Neurology For Dentists Flashcards
Name a few types of common neurological complaints
Headaches/Orofacial pain Meningitis Cerebrovascular accidents Parkinsonism MS Epilepsy
What is the most common neurological complaint
Headaches (often chronic)
What are headaches usually caused by
- Local Disease (tumour maybe)
- Vascular Disease
- Referred Pain
- Neurological disorders
- Psychogenic disorders
What are migraines most commonly caused by
Intra and extra cranial blood vessels dilatation and inflammation
What are some triggers for migraines
Stress, caffeine, alcohol, weather, certain foods (choice/cheese), low blood sugar, bright light, lack of sleep
What are the clinical features of a migraine
Headache usually unilateral and throbbing
Associated Sx = nausea, vomiting, photophobia and phonophobia
What management options are there for migraines
Avoid the triggers
Acute attacks with triptans
Frequent attacks with B-blocker i.e. propranolol
What are the clinical features of migrainous neuralgia/cluster headaches
- Unilateral pain around the eye, frontal, cheek and temporal area
- Ipsilateral lacrimation, photophobia, nasal stuffiness and rhinorrhorea
- Recurrent in separate bouts with daily or almost daily attacks for weeks/months
What are the management options for migrainous neuralgia/ cluster headaches
- High flow oxygen
- Triptans
- Verapamil
How does triptans work to reduce migraines
- Releases Serotonin in the brain that reduces inflammation and constricts the blood vessels
What serious conditions can cause a headache
- Acute glaucoma
- Acute hypertension
- Brain tumours
- Giant cell arteritis
- Meningitis
- Subarachnoid haemorrhage
- Subdural or epidural haemorrhages
What are the indicators of seriousness in headaches
- Abrupt, severe/bilateral headache
- Confusion, neck stiffness, diplopia, weakness/numbness
- Disruption of normal life and over age of 55
- Preceded head injury
What are some of the clinical features of giant cell arteritis
- Fever
- Temporal headache
- Pain in the jaw and chewing
- Tenderness of the temporal artery
- Recurrence in children
- Worsening after coughing or exertion
What does a strokes onset like
Rapidly developing symptoms/signs of loss of focal CNS function - like unilateral weakness in the arm
How long do stroke symptoms last for
More than 24 hours or they lead to death
What are the 2 types of stroke
Ischaemic
Haemorrhagic
What causes ischaemic stroke (most common)
Atheroma formation in the carotid artery or intracerebral artery or an emboli that comes from the heart and travels to the brain and blocks a blood vessel
What causes haemorrhagic stroke
Burst blood vessels in the brain
What are the risk factors for a stroke
- Hypertension
- Diabetes Mellitus
- Hyperlipidaemia
- Heart Disease
- Atrial Fibrillation
- Excess alcohol
- Smoking
- Carotid artery occlusion
- Polycythaemia vera
What changes in lifestyle factors can be made to reduce the risk of stroke
- Maintain a healthy weight
- Eat healthily
- Regular exercise
- Reduce alcohol intake
- Stop smoking
What targets of drug treatment can be used to reduce the risk of stroke
- Treat hypertension
- Treat high cholesterol (diet and statins)
- Atrial fibrillation (beta blockers and anticoagulants
- Keep good glycemic control if diabetic
What do the clinical manifestations of a stroke depend on
On the vascular territory affected
What are some typical clinical features of stroke
- Facial weakness or numbness
- Hemiplagia (unilateral leg or arm weakness of both)
- Speech disturbance
- Sudden visual deterioration
- Dysphagia
What investigations would be done if you suspect a stroke
- Assess the patients risk factors - hypertension and ECG, smoking, drinking etc.
- CT head scan to distinguish ischaemic and haemorrhagic and other differentials like tumours or hematomas
How does a haemorrhage appear in a CT scan
Dense and white
How does ischaemia appear in a CT scan
Darker
What treatments are there for stroke
- Admission to a stroke unit for rapid clinical assessment
- Aspirin (300mg) should be given as soon as possible after the onset of stroke symptoms once a diagnosis of primary haemorrhage has been excluded
- Thrombolysis (intravenous tissue plasminogen activator) - eligible for ischaemic stroke and ineligible for haemorrhagic stroke - risk of haemorrhage
How fast should treatment be given after the onset of stroke symptoms
4 hours
What are the dental aspects of treating someone who has had a stroke in the past
- Impaired mobility and communication - speak slower and simply
- Oral hygiene deterioration on paralysed side - suggest electric toothbrush or manual with adapted holder
- Modifications during dental treatment- treatment in upright position and good suction to prevent foreign objects from entering the pharynx
- Monitor BP and anticoagulation status
What is a Transient Ischaemic Attack (TIAs)
Mini strokes commonly caused by thromboembolism from an atheroma in the carotid vessels
What symptoms of Transient Ischaemic Attacks (TIAs) are there
Sudden loss of focal CNS function
Speeh disturbance
Weakness and numbness in limbs
How long do the clinical manifestations of Transient Ischaemic Attacks last for
Minutes/hours that fully resolve within 24 hours
What are some risk factors for Transient Ischaemic Attacks (TIAs)
- Smoking/alcohol
- Hypercholesterolaemia
- Atrial fibrillation/valvular disease
- Hypertension
- Diabetes Mellitus
What are some preventative measures for Transient Ischaemic Attacks (TIAs)
- Stop drinking/smoking
- Reduce cholesterol by diet or drugs (statins)
- Anticoagulant (warfarin, NOAC)
- Antiplatelet (aspirin, clopidogrel)
- Treat hypertension
- Keep blood sugar under control
What does Parkinson’s disease affect the most
The substantia nigra of the basal ganglia where dopamine is the neurotransmitter
What is Parkinson’s caused by
Gradual and progressive death of neutrons in the substantial nigra - loss of dopamine leads to less stimulation of the motor cortex and slower onset of movements
When do symptoms for Parkinson’s appear
When 60-80% of dopaminergic neurones are lost
What does the substantia nigra normally do
Sends dopamine releasing signals to the cordic nucleus? basal ganglia and this sends signals to the motor cortex and neurones to do movement
What are the clinical features of Parkinson’s
Akinesia: - Bradykinesia - Poverty of facial expression - Difficulty changing position - Quiet monotonous speech Gait: - Flexed or stooped posture - Reduced arm swing on walking - Postural instability Tremor/Rigidity
How does dopamine replacement therapy work for Parkinson’s
L-Dopa + Carbidopa = Co-careldopa
L-Dopa is broken down into Dopamine and travels in a vesicle to the synapse where dopamine is released and will bind to receptors and stimulate motor cortex to move
How does dopamine agonist therapy work for Parkinson’s, include named examples
Bromocriptine, Pergolide, Ropinirole
These binds directly to the dopamine receptors
What does selegiline do to treat parkinson’s
Inhibits dopamine metabolism by inhibiting monoamine oxidase type B
What does entacapone do to treat parkinson’s
Inhibits Dopamine and L-dopa breakdown by inhibiting Cathechol-O-methyl transferase
Name some anticholinergic drugs and how they help to treat Parkinson’s
Procyclidine and benzotropine
These reduce tremors at rest but have side effects like dry mouth
Why can’t L-dopa be given alone
As 97%+ will only be present in the peripheral circulation and can’t enter the brain and this will cause a lot of side effects like nausea, vomiting, arrhythmia and postural hypertension
Why do we give carbidopa along with L-dopa for dopamine replacement
It inhibits the DOPA decarboxylase enzyme so less Dopamine is released into the peripheral circulation so less side effects
What are the dental aspects relating to Parkinson’s disease
- Lack of expression doesn’t mean lack of reaction or intelligence
- Minimise anxiety as it increases tremor that may affect the tongue/lip
- Avoid LA with epinephrine that can interact with L-dopa + Dopa decarboxylase inhibitor and COMT inhibitors
- Anticholinergic drugs - dry mouth and hallucinations
What can be caused by the interaction between epinephrine and L-Dopa + Dopa decarboxylase inhibitor and COMT inhibitors
Tachycardia
Arrhythmias
Hypertension
Why might you need to protect the airways of a patient with Parkinson’s
They may have dysphagia and trouble swallowing so might need rubber dam or some shit
What is multiple sclerosis and who is it common in
- Chronic relapsing neurological disorder affecting young adults, thought to be autoimmune
- More common in females than males
- Can develop at any age
- Usually presents between 20 and 40 years
- More common in temperate areas than tropical climate
What parts of the body are affected by multiple sclerosis
Affects the white matter of the brain, spinal cord and optic nerves
- Forms multiple foci of inflammatory demyelination (plaques) and scarring (sclerosis)
What are the consequences of multiple sclerosis
Reduction in conduction velocity, loss of information conveyed by impulse traffic along various pathways
What is the most common form of multiple sclerosis and how does the level of disability develop over time
Relapsing-remitting MS
Unpredictable attack that may or may not leave permanent deficits followed by periods of remission
What is the 2nd most common form (10-20%) of MS and how does the level of disability develop over time
Primary progressive MS
Steady increase in disability without attacks
What is the 3rd most common form of MS and how does the level of disability develop over time
Secondary progressive MS
Initial relapsing-remitting MS that suddenly begins to have decline without periods of remission
What is the least common form of MS and how does the level of disability develop over time
Progressive relapsing MS
Steady decline since onset with super-imposed attacks
What are some clinical features of MS
Central - Fatigue, depression, unstable mood
Visual - optic nerve inflammation, diplopia
Musculoskeletal - weakness, spasms, ataxia
Bowel - incontinence, diarrhoea or constipation
What is done to manage acute relapses of MS
High dose corticosteroids e.g. methylprednisolone
What drugs can be given to modify the number of relapses
Immunosuppressants - azathioprine, methotrexate and cyclophosphamide
Disease Modifying Therapies 0 Beta-interferons, glatiramer, natalizumab and mitoxantrone
What can be done to treat the depression, spasms and bladder dysfunction of MS
Depression - SSRIs, tricyclics
Spasms - Muscle relaxants - benzodiazepine
Bladder dysfunction - anticholinergic drugs
What symptoms are likely manifestations suggestive of advanced MS
Trigeminal neuralgia - often bilateral
Facial para/anaesthesia - numbest of lower lip and chin
- Facial Palsy
Abnormal facial or intraoral pain and discomfort
Difficulty swallowing
Lhermitte phenomenon - tingling sensation (arms or legs) on neck flexion
What are the dental aspects to consider of MS
- Shorter appointments - unable to keep mouth open for long
- Treat in morning - fatigue is less pronounced
- Treat in semi-supine position - respiratory problems
- Emphasis on preventative care
What does motor neurone disease do
Leads to progressive paralysis and eventual death, gradually muscles under voluntary control are affected
What are the clinical features of Motor neurone disease
Limb weakness - usually affects the upper limbs and/or lower limbs
Bulbar onset - Slurred speech, dysphagia, accompanying emotional liability
Respiratory onset - dyspnoea and orthopnoea
What’s done to diagnose motor neurone disease
Clinical examinations
EMG/nerve conduction studies
CT/MRI brain and spinal cord - excludes other pathologies
What can be done to manage motor neurone disease
- No cure
- Supportive care, MDT + management of symptoms
- Drug: riluzole - disease modifying efficacy
What dental aspects are there relating to motor neurone disease
- Impaired oral hygiene
- Poor mobility and co-ordination
- Protection of airway may be impaired
What happens to the grey matter in epilepsy
Recurrent occasional, sudden, excessive, rapid and local discharges of the nerve cells in grey matter
What kind of disorder is epilepsy and what characterises it
It is a paroxysmal disorder characterised by intermittent, stereotyped attacks of altered consciousness, motor or sensory function, behaviour or emotion
What happens in a grand-mal/tonic clonic seizure and who is this most common in
Aura - becomes irritable and loses consciousness
Tonic phase - rigidity
Clonic phase - jerking movements, lots of salivation
Recovery phase - confused and stuff
Common in adults
What happens in a petit-mal/absence seizure and who is this most common in
Common in children
Presents with repetitive rapid blinking, child stares into space
What is status epilepticus
Medical emergency where the seizure lasts more than 5 minutes or patient gets 2 or more seizures within 5 minutes with no regain of consciousness
