Neurology for dentistry

Question 1

What is Bell’s Palsy?

Answer 1

Inflammation or viral inflammation of the facial nerve that causes one sided weakness or the entire face.

Slow onset of symptoms

Question 2

What is multiple sclerosis?

Answer 2

A neuromuscular disorder that results in uncoordinated movement.

It is caused by the damage of myelin sheath on brain/spinal cord.

Occurs over the course of days-weeks relapses an occur.

Question 3

What is myasthenia gravis?

Answer 3

Chronic condition that relapses

It is an autoimmune condition with the production of autoantibodies against Acetylcholine receptors at NMJ, meaning there is less stimulation of muscles by ACh which increases fatiguability of muscles and causes them to be weak.

• symptoms can include - eyes moving slowly, tongue movement disordered.

Question 4

Does bells palsy affect lower motor neurones or upper motor neurones?

Answer 4

Lower motor neurones (facial nerve)

Question 5

What is fasciculation?

Answer 5

involuntary twitching of muscle fibres

Question 6

What does damage to an upper motor neurone cause? (muscle tone, weakness, reflexes)

Answer 6

Causes an increased in reflex firing as they are no longer under inhibitory control.

Causes an increase in spasticity and pyramidal weakness.

Pyramidal weakness is weak extensors in arms and weak flexors in legs.

Question 7

What may LMN damage to a nerve which is supplying the tongue cause?

Answer 7

Fasciculation
Atrophy
Weakness
Wasting

Question 8

How can we test for damage in trigeminal (v) cranial nerve?

Answer 8

open mouth (control muscles of mastication)

Question 9

How can we test the function of facial (VII) cranial nerve?

What is the disease called when facial nerve is damaged and what is its effects?

Answer 9

Smile (controls muscles of facial expression)

Bells palsy is when VII is damaged and it causes unilateral paralysis of one side of the face.

Question 10

How can we test the function of the vagus (X) cranial nerve?

Answer 10

Cough, swallow (motor to muscles of soft palate).

Question 11

How can we test the function of the hypoglossal nerve?

Answer 11

Move tongue (motor to tongue muscles)

Question 12

What will happen to someone with damaged trigeminal nerve when they are trying to open their mouth and protrude their jaw?

Answer 12

Their jaw will move towards the side where there is a damaged trigeminal nerve as the pterygoid muscles won’t be contracting on the damaged side so the chin will deviate.

Question 13

What will happen to someone with a damaged vagus nerve when they try to swallow, cough or say ‘aaaa’?

Answer 13

Uvula will be pulled up unequally towards the side which is functioning correctly.

Question 14

What will happen to someone with a damaged hypoglossal nerve when they go to protrude their tongue?

Answer 14

It will turn toward the damaged side as there will be no protrusion on that side.

Question 15

How may we, as dentists, manage pts with myasthenia gravis?

Answer 15

Dental treatment early in day when not fatigued.

Do not use procaine antibiotics.

Question 16

How can we manage a pt with bells palsy as a dentist?

Answer 16

Protect eye (eye protection) during dental treatment as can’t move.

Question 17

How may we manage pts which have had a stroke as a dentist?

Answer 17

Stroke may cause dysphagia (TACS) which may cause aspiration risk/drooling.

Question 18

What is epilepsy?

Answer 18

People who are prone to having frequent recurrent seizures.

Question 19

What is the main type of seizure seen in younger people?

Answer 19

Generalised seizures

Question 20

What is the main type of seizure seen in older people?

Answer 20

focal seizures

Question 21

What are the main two types of focal seizures?

Answer 21

Aware (simple) and impaired consciousness (impaired awareness).

Question 22

How do we diagnose epilepsy?

Answer 22

Take history, consider differential diagnosis.

MRI brain scan to look for lesions.

EEG (electroencephalogram) - records brain electrical activity.

Question 23

How can we manage epilepsy?

Answer 23

If just single seizure - not medicated unless it’s likely there is going to be a recurrent seizure.

Anti-epileptic drugs
- lamotrigine, carbamazepine, valproate.
(choice based on efficacy, tolerability, safety (teratogenic effects, cost).

Question 24

What are some common dental side effects of common anti-epileptic drugs? (valproate, phenytoin, carbamazepine)?

Answer 24

valproate = affects platelets which can increase bleeding during procedures.

phenytoin - causes gingival hyperplasia

carbamazepine = causes xerostomia

Question 25

When may neurosurgery be good for patients with epilepsy?

Answer 25

When pt is suffering from unstable epilepsy with recurring seizures even whilst receiving medication.

Surgery may be used to remove lesion seen on MRI scan.

Question 26

What are some potential complications of seizures?

Answer 26

Accidents/suicide

Status epilepticus
- seizure persisting longer than 5 minutes - need status epilepticus treatment.

Prolonged neuronal activity >30mins may cause irreversible neurological damage and death.

SUDEP - sudden unexpected death in a patient with epilepsy (with no structural or toxic cause)

Question 27

As a dentist what can we do if a pt has seizure in our chair?

Answer 27

Call for help

Damage limitation(recover position, pillows to limit fall damage, remove objects)

Oxygen

Look at clock as most seizures will terminate <3 mins

Question 28

What is the pathophysiology of idiopathic Parkinson’s disease?

Answer 28

Destruction of dopaminergic neurones of substantia nigra (so no dopamine production)

Causes the basal ganglia to have reduced domaine levels because dopamine in the basal ganglia is responsible for preparing the brain to be in a ready state to allow movement to happen easily and effortlessly.

This causes poverty of motion (bradykinesia) - the body isn’t in a ready state to move quickly so there is more effort required for any given movement.

Question 29

What are some other causes of parkinsons disease apart from ideopathic parkinsons disease?

Answer 29

Anti-psychotic drugs (dopamine blockers)

/ Head injury

post encephalitis (inflammation of the CNS may have caused damage to dopaminergic neurones).

Question 30

What are the micro and macro ways we can identify parkinsons disease in the midbrain?

Answer 30

Macro:
Reduced melanin pigment in substantia nigra
- dopamine if made from a precursor of melanin. so reduced melanin = reduced dopamine.

Micro:
- degeneration of dopaminergic neurones from the substantia nigra to the basal ganglia.

Question 31

What is the clinical history if iPD?

Answer 31

Insidious onset
Resting tremor (pill rolling motion with hands).
Slowness of movement (bradykinesia).
Smaller handwriting ( as hands more effort to move).
insomnia

Question 32

What would we expect to see whilst examining someone with iPD?

Answer 32

Pill rolling resting tremor
Rigidity
Bradykinesia

Question 33

What are some non motor signs of iPD?

Answer 33

Hyposmia (impaired smell)
Constipation
Sleep disturbance
Depression/dementia (executive dysfunction).

Question 34

How can we investigate & treat iPD?

Answer 34

Clinical diagnosis (investigations rule out other diagnosis)

We treat using trials of medications:
initially
- lovodopa + dopa decarboxylase inhibitor (stop breakdown of dopamine)
- dopamine agonists

Advanced therapies
- dopamine directly into duodenum
Continuous s/c apomorphine (which is a dopamine agonist)
Deep brain electrical stimulation of the basal ganglia.

Question 35

How is parkinsons related to dentistry?

Answer 35

Dry mouth

Tooth wear due to bradykinesia

Lack of muscular control (may be difficult to brush due to bradykinesia, difficulty with dentures)

Lack of facial expression - need to use limb/eye movement to signal comfortability etc.

Question 36

What affect does dopamine have on the basal ganglia?

Answer 36

Increases the readiness potential for the brain for movement allowing for quicker, easier movement.

Normally the pallidum is spontaneously active and other parts of the basal ganglia inhibit the pallidum to allow controlled movement.

Dopamine allows the release of the pallidum from inhibition to allow movement to occur.

Question 37

Name some differential diagnosis for epilepsy

Answer 37

Cardiogenic syncope, psychogenic

Question 38

What is the parkinsonism clinical triad?

Answer 38

Bradykinesia, resting tremor, rigidity.

Question 39

What is a side effect of tx with dopamine?

Answer 39

uncontrolled or excess dopamine can cause dyskensia - uncontrolled movement.

Question 40

Give an example of some drugs to treat parkinsons disease?

Answer 40

Lovadopa or dopa decarboxylase inhibitor

Augment effects of existing dopamine (dopamine agonists - apomorphine)

Question 41

What are some advanced therapies to treat dopamine?

Answer 41

Dopamine directly into duodenum

Deep brain stimulation

Continuous subcutaneous apomorphine

Question 42

What are some differential diagnosis for parkinsons disease?

Answer 42

thyroid

structural brain lesions.

Question 43

What are some differential diagnosis for parkinsons disease?

Answer 43

thyroid

structural brain lesions.