Stroke and Seizure Management Quiz

Neurological Disorders

• Neurological disorders impact the nervous system, causing a range of impairments.

Cerebrovascular Accident (CVA)

• CVA, commonly known as stroke, results from disrupted blood flow to a brain region.
• Two main types of strokes exist: ischemic and hemorrhagic.
• Ischemic stroke occurs when a blood vessel supplying the brain is blocked by a clot.
• Hemorrhagic stroke happens when a cerebral artery ruptures.

Ischemic Stroke Signs and Symptoms

• Ischemic strokes are often harder to detect.
• This type of stroke can cause weakness in one side of the body.
• Facial drooping can be a sign.
• Numbness or tingling sensations may arise on one side of the body.
• Problems with language.
• Vision disturbances.

Hemorrhagic Stroke Signs and Symptoms

• Hemorrhagic stroke symptoms often include a sudden, intense headache.
• Visual problems.
• Nausea and vomiting.
• Neck and back pain.
• Sensitivity to light.
• Weakness on one side of the body.

FAST Stroke Assessment

• A pre-hospital stroke screen.
• Face: Facial drooping check.
• Arm: Arm weakness.
• Speech: Speech difficulties.
• Time: Time of onset.

Face Assessment

• Ask the patient to smile or show teeth.
• Normal: Both sides of the face move equally.
• Abnormal: One side of the face droops or doesn't move.

Arm Assessment

• Have the patient close their eyes and lift both arms.
• Normal: Both arms stay level.
• Abnormal: One arm drifts downward compared to the other.

Speech Assessment

• Ask the patient to say "You can't teach an old dog new tricks."
• Normal: Clear and understandable speech.
• Abnormal: Slurred speech or inability to speak.

Time of Onset

• The critical window for effective stroke treatment is 3 hours (180 minutes).
• This time window may, sometimes, be extended to 4.5 hours.
• Knowing the patient’s "last known well state" is crucial.

Abnormal Speech

• Slurred speech
• Trouble forming words
• Inapropriate words
• Expressive aphasia (inability to speak words)
• Receptive aphasia (inability to understand words)

Right-Brain Damage (Stroke on Right Side)

• Paralyzed left side (hemiplegia)
• Neglect of the left side
• Spatial-perceptual difficulties
• Minimization of problems
• Quick performance, short attention span
• Impulsivity, safety issues
• Impaired judgment
• Impaired time concepts

Left-Brain Damage (Stroke on Left Side)

• Paralyzed right side (hemiplegia)
• Impaired speech/language (aphasias)
• Impaired right/left discrimination
• Slow performance, cautiousness
• Awareness of deficits: potential depression or anxiety
• Impaired understanding related to language or math.

Dental Management of Patient With Stroke

• Avoid procedures increasing blood pressure.
• Minimize stress.
• Elective dental treatment is not advised until 6 months after stroke, but preventive measures should start sooner.
• Treatment can be done in short, smaller increments due to possible weakness/impairments
• Four-handed dental hygiene is required.

Dental Management of Patient With Stroke (continued)

• The affected side of the face tends to sag, and the tongue may be less active.
• Reduced sensation can elevate the risk of biofilm buildup and oral complications.
• Rinsing may be challenging for stroke patients.
• Daily fluoride treatments like gels or trays are beneficial for affected patients.

Seizure Disorders

• Genetic factors
• Missed medication
• Stress (emotional/physical)
• Sleep disturbances
• Hypoglycemia
• Alcohol withdrawal

Questions to Ask For Seizure Patient

• Time since last seizure.
• Type of seizure.
• Frequency of seizures
• Medication for seizure control.
• How the seizure started.
• Warning signs before each seizure.
• How the patient can communicate during a seizure.
• If the patient feels confused or tired after the seizure.
• When was the last seizure.

Dental Treatment Considerations of Epileptic Patient

• Complete medical history intake.
• Medication verification
• Scheduling proper oral hygiene routines.
• Avoid any bright lights or strong light sources.
• Periodontal and surgical treatment to manage hyperplasias and minimize damage to the teeth.

Management of Patient During Seizure

• Clear instruments away from the patient.
• Position the chair in a supine position.
• Position the patient on their side.
• Do not restrain the patient.
• Call emergency if seizure lasts more than 3 minutes.
• Call emergency if cyanosis occurs.
• Administer oxygen at 6-8 L/min..
• If a seizure lasts >1 min or repeated administer 10 mg diazepam (IM or IV).

Post-Seizure

• No dental treatments that day.
• Assess level of consciousness.
• Don't let patient leave if awareness is not restored.
• Contact family/caregivers if needed.
• Do brief oral assessment.

Sensory Processing Disorders (SPD)

• A neurological condition impacting the ability to interpret sensory information.
• Affects how the body receives/interprets sensory messages into appropriate motor/behavioral responses.

Multiple Sclerosis (MS)

• An inflammatory/demyelinating disease.
• Causes inflammation in the nervous system, damaging the myelin sheath (protective covering for nerves).
• This leads to the formation of scar tissue.

MS Main Symptoms

• Central: Fatigue, cognitive impairment, depression, unstable mood.
• Visual: Nystagmus, optic neuritis, diplopia. Speech: dysarthria.
• Throat: Dysphagia.
• Musculoskeletal: weakness, spasms, ataxia.
• Sensation: pain, hypoaesthesia, paraethesia.
• Bowel: incontinence, diarrhea, constipation.
• Urinary: incontinence, frequency or retention.

Oral Manifestations of MS

• Oral/facial pain
• Swallowing difficulty
• Medication side effects
• Caries/periodontal disease (related to poor oral hygiene)

Dental Management of Patient With MS

• Transfer assistance from a wheelchair to the dental chair.
• Manage swallowing difficulties
• Manage issues with spastic/involuntary movements.
• Manage facial pain and other oral side effects of medication.
• Dental management of dysphagia needs to be considered.

Dental Management of Patient With MS (continued)

• Assess gag reflex.
• Employ meticulous suctioning during procedures.
• Ensure access to saliva ejectors.
• Protect the patient's airway.
• Position the patient in a way that reduces the flow of fluids into the throat.
• Consider any compromised laryngeal reflex. Note any diminished cough strength.

Swallowing Problems in MS Patients

• Extra effort chewing/swallowing
• Slow eating
• Food packing into cheeks
• Drooling
• Fluid leakage from nose after swallowing
• Increased chest congestion after eating
• Aspiration risk
• Aspiration pneumonia (related risk)

Oral Health Strategies For Swallowing Problems (MS and other patients)

• Daily oral hygiene care (with assistance if needed).
• Assessment of dentures for proper fit and stability.
• Routine professional dental checkups.
• Address dental hygiene and periodontal issues.
• Reducing loss of teeth.
• Semi-supine to upright dental chair positioning.
• Limit water use during appointments.
• Use short-lasting anesthetic/local anesthetic.

Control of Involuntary Movement

• Extra/intra-oral mouth props
• Rubber bite block; extended foam handle.
• Gentle hand-holding.
• Head stabilization

MS Oral/Facial Pain

• Trigeminal neuralgia; facial palsy,
• Possible early symptom of MS
• Described as an electric shock-like pain in the face.
• Can occur with tooth brushing or chewing.
• Pain may occur several times per day.
• Numbness in lower lip or chin.
• Facial weakness or muscle paralysis may accompany the pain.

Dental Management for MS Oral/Facial Pain

• Rule out dental etiology.
• Occlusal orthotics management
• Trigger point injections
• Surgical management.
• Peripheral nerve block/ablation.
• Gasserian ganglion procedures.
• MD consult: disease progression monitoring.

Xerostomia Management

• Patient advice.
• Water misting.
• Let ice melt in the mouth.
• Avoid mouth rinses with alcohol.
• Humidify sleeping areas.
• Limit caffeine intake.
• Reduce tobacco use.
• Use lip balm or sugar-free sweets/lozenges.

Meticulous Plaque Control

• Mandatory for special needs patients
• Caries prevention crucial
• Plaque control instruction reinforcement (q3 mos).
• Maximize fluoride rinse use.
• Apply fluoride before bedtime
• Professional fluoride varnish applications.

Tooth Brushing and Flossing Tips for Impaired Patients

• Use toothbrushes with handles (for weak grip)
• Consult a dentist for toothbrush modification.
• Consider electric toothbrushes or other aids.
• Assess the patient's need for adjusted flossing strategies..

Tooth Brushing and Flossing for Tired/Weak Patients

• Sit while brushing and flossing
• Start with water before introducing the toothpaste into the mouth).
• Use weighted toothbrushes if trembling.
• Consider weighted gloves to aid brushing.

Tooth Brushing Techniques.

• Collis Curve
• Twin Brush
• Plaque Vac
• Radius toothbrushes
• Rotary toothbrushes
• Ultrasonic toothbrushes (modified or adapted versions).

Flossing Techniques:

• Waxed/Unwaxed floss.
• Dental tape
• Yarn/gauze strips.
• Tufted/Superfloss.
• Floss threaders.
• Holders.
• Rubber tips.
• Interdental brushes.

Denture Care

• Remove dentures daily.
• Clean the oral vestibule.
• Use a damp cloth, finger, cotton swab, or a large sponge to clean the vestibule.
• Brush and clean dentures daily.
• Remove from mouth before bed and place in suitable denture cleansing solution.

Tips for Caregivers of Patients with MS

• Monitor for muscle decline in the cheeks and tongue.
• Carefully assist with moving food to the back of the mouth to ensure swallowing
• Removing dentures can ensure proper cleaning of the vestibule.
• Denture brushing similar to natural teeth.
• Do not force extremities into uncomfortable positions.
• Use techniques to control movement and reduce any distractions during treatment.
• Place patient in a slightly upright position.
• Monitor for any signs of mouth/facial pain.

MS Oral Hygiene Strategies

• Employ adaptive equipment for oral hygiene.
• Electric toothbrushes, cords on toothbrushes.
• Cuffs or utensil holders.
• Suctioned denture brushes.
• One-handed flossers.

MS Oral Hygiene Management

• Early comprehensive oral rehabilitation.
• Frequent professional visits.
• Monitor caries/periodontal issues.
• Monitor salivary function.
• Educate caregivers on proper oral care routines.
• Prevent infection and pain.

Special Needs Patient

• Patients with physical, medical, developmental and/or cognitive conditions needing special considerations.
• Daily oral care routines essential.
• Prevent oral diseases.

Disabilities Overview

• Physical disabilities
• Intellectual disabilities
• Learning disabilities
• Syndromes (e.g., Down syndrome )
• Cerebral palsy
• Muscle atrophy
• Autism

Congenital vs Acquired Disabilities

• Congenital disabilities are present at birth.
• Acquired disabilities develop during a person's lifespan due to illness, injury, or other events.

Barriers to Treating Special Needs Patients

• Lack of funding for training and facilities.
• Cost of specialist services and facilities.
• Unwillingness of some general dental practitioners to treat special needs patients.

Physical Disability Considerations

• Countries implementing special dental units or chairs for patients in wheelchairs.
• Wheelchair platforms for better access and cheaper service options for special-needs patients.

General Oral Status

• Patients may exhibit poor cooperation in oral hygiene.
• Resistance or challenging behaviors common.
• Limited access to dental services possible.
• Oral hygiene prevalence higher in patients with impairments.
• More untreated decay and missing teeth common.

Preventing Dental Caries in Special Needs Patients

• Employ topical fluorides (high doses).
• Use high fluoride toothpastes.
• Utilize fluoride mouthwashes/alternatives
• Employ dietary oral medications and constituents.
• Utilize chlorhexidine gel or varnish treatments.

Tooth Wear in Special Needs Patients

• Neurological impairments can cause clenching or grinding.
• Cerebral palsy can lead to gastroesophageal issues causing tooth wear from vomiting.
• Other factors might cause abrasion (bizarre oral habits).

Preventing Tooth Wear in Special Needs Patients

• If patients cannot tolerate extensive dental treatments, remove badly worn teeth.
• Use sedation if needed
• Provide full coverage on affected teeth and molars.
• Use non-erosive cleaning aids/techniques.

Gingivitis in Special Needs Patients

• Poor oral hygiene leads to plaque buildup and gingivitis common
• Down syndrome prevalence of periodontal disease and early tooth loss.
• Epilepsy medications commonly associate with gingival hypertrophy.
• Oral care support systems crucial.

Preventing Gingivitis in Special Needs Patients

• Difficult/ill patients might employ care routines in bed or with a caregiver.
• Use mouthwash/chlorhexidine dipped toothpaste.
• Sustained chlorhexidine varnish may be used (up to 6 months) for affected patients.
• Handle behavioral challenges with modification and desensitization.

Self-Inflicted Trauma

• Self mutilation involving oral tissues in syndromes is common.
• Teething sometimes triggers such behaviors.
• Lip/tongue biting can cause pain, swelling, mouth soreness, dehydration, and hospitalizations.

Preventing Hyper-salivation

• Excessive drooling prevalent in patients with poor neuromuscular control (from cerebral palsy, stroke).
• Prevention & management includes surgical, pharmacological (e.g., hyoscine patch), and behavioral modification strategies.

Managing Challenging Patients in Dentistry

• Employ premedication to calm patients.
• Nitrous oxide-oxygen for mild sedation.
• Physical restraints for safety considerations.

Autism

• A complex developmental disability impacting communication, social, behavioral, and intellectual functioning.
• Characterized by unpredictable body movements/repetitive behaviors/self-injurious behaviors.
• Consultations with physicians, families and caregivers mandatory.
• Gaining valid legal consent essential.
• Patients may exhibit challenging behaviors, causing difficulty in daily communication/relation.

Autism Treatment modifications

• Communicate/use a "tell-show-do approach" in simple terms.
• Use/keep instruments and bright/stark lighting out of patient's visual field.
• Keep appointments short and positive.
• Praise/reinforce good behavior and ignore inappropriate behaviors.
• Use immobilization techniques only when necessary.

Down Syndrome

• Also known as trisomy 21.
• Chromosomal disorder affecting physical characteristics and intelligence.
• Low muscle tone and strength.
• Heart conditions possible.
• Dental development anomalies possible.
• Periodontal problems can occur as well.

Cerebral Palsy

• Non-progressive neural disorder often caused by prenatal, birth, or postnatal central nervous system damage.
• Characterized by motor function impairments (paralysis, muscle weakness, lack of coordination).
• Poor oral hygiene commonly affects patients with Cerebral palsy.
• Various types exists (e.g., spastic, ataxic, dyskinetic .

Types of Cerebral Palsy

• Spastic palsy: muscle stiffness/rigidity affecting limbs.
• Dyskinetic palsy: uncontrolled/writhing movements.
• Ataxia palsy: balance/depth perception problems.
• Combined palsy: a combination of these types.

Cerebral Palsy Treatment Modifications

• Focus on creating a stable/calm environment.
• Avoid forcing unnatural extremity positions.
• Make appointments and treatment short.
• Minimize distractions.
• Informing the patients prior to treatment about any planned movements.
• Place in a slightly upright position.