Neurological Diseases PDF

Neurological Diseases  Seizure Disorders Cerebrovascular Diseases Parkinson Disease Myasthenia Gravis Multiple Sclerosis Alzheimer’s Disease  Intro Diseases affecting the neuromuscular system have a collective lifetime prevalence rate of 3% to 5% Thus, ever...

Neurological Diseases  Seizure Disorders Cerebrovascular Diseases Parkinson Disease Myasthenia Gravis Multiple Sclerosis Alzheimer’s Disease  Intro Diseases affecting the neuromuscular system have a collective lifetime prevalence rate of 3% to 5% Thus, every oral health-care provider will encounter a patient who has had, or presently has, a neuromuscular disease diagnosis The signs and symptoms as well as the complications and implications of these disorders or their treatment can have significant impact on oral health as well as dental management decisions  Epidemiology & Etiology Seizure Clinical Manifestations Disorders Diagnosis & Treatment Oral Health Considerations  Seizures Disorder – Epidemiology & Etiology Epilepsy is a brain disorder characterized by excessive neuronal discharge that can produce seizures, unusual body movements, and loss or changes in consciousness. Transient episodes of motor, sensory, or psychic dysfunction, with or without unconsciousness or convulsive movements may be present Prevalence is around 1% in the general population 75% no known etiology Higher frequency in males  Seizures Disorder – Clinical Features Can be classified into two major categories: Partial seizures Generalized seizures  Seizures Disorder – Clinical Features Partial seizures affects only part of the brain: Simple – may be subtle, with awareness intact Complex – involves impairment of awareness, variable presentation: may have autonomic symptoms, abnormal sensation, hallucinations  Seizures Disorder – Generalized Seizures Generalized seizures – affects entire cortex: Absence – impaired consciousness, staring, and eye blinking Atonic – abrupt loss of muscle tone, loss of consciousness, and sudden collapse Myoclonic – sudden jerking of arms and/or legs and impaired consciousness Tonic-clonic – loss of consciousness, repetitive jerking, sustained stiffening, post- seizure amnesia, and possibly cyanosis  Seizures Disorder – Diagnosis Needs to see a neurologist Detailed neurological history and examination MRI CT Electroencephalogram (EEG)  Seizures Disorder – Management Pharmacologic therapy is considered the mainstay of epilepsy treatment The goal is to choose an antiepileptic drug (AED) that is most appropriate for the specific type of seizure activity Which can achieve control of seizure activity with minimal side effects  Seizures Disorder – Oral Health Considerations Patients with Epilepsy are at an increased risk for: Dental caries Oral trauma Laceration, including bite injuries to tongue Ulcerations and glossitis as a result of medication-induced B-12 deficiency Trauma-induced TMJ disc dislocation requiring reduction Trauma-induced tooth avulsion – if tooth cannot be located, chest imaging indicated to rule out aspiration to lungs Medication-induced gingival hyperplasia, bleeding gums, and delayed healing  Seizures Disorder – Oral Health Considerations Obtain thorough medical history-including seizure triggers and seizure frequency/level of control. Ask patient (or caregiver) for medication updates at each appointment. Medication changes can affect the appropriate care of the patient from a medical and/or appointment management standpoint. Monitor patient for anti-epileptic medication-induced gingival hyperplasia. Meticulous oral hygiene is the best prevention. In severe cases, surgical reduction may be needed.  Seizures Disorder – Oral Health Considerations Powered toothbrushes may be too stimulating for some adults and should be recommended only after determining if the adult will tolerate one If prosthetic restorations are considered, insure they are appropriate for the rate, level, and frequency of seizures, and they are resistant to damage or displacement during an epileptic seizure to reduce choking hazards Fixed prosthetics are preferable to removable prosthetics because choking and aspiration of appliances are of concern Determine if mouth guard could provide potential benefit  Seizures Disorder – Oral Health Considerations Some individuals with epilepsy are tube fed, therefore they typically have low caries, rapid accumulation of calculus, GERD (Gastro-esophageal Reflux Disease), oral hypersensitivity, and are at high risk for aspiration in the dental chair Position the patient in as upright a position as possible and utilize low amounts of water and high-volume suction to minimize aspiration  Seizures Disorder – Oral Health Considerations As needed for patients with xerostomia: Educate on proper oral hygiene (brushing, flossing) and nutrition Recommend brushing teeth with a fluoride containing dentifrice before bedtime After brushing, apply neutral 1.1% fluoride gel Instruct patient to spit out excess gel and NOT to rinse with water, eat or drink before going to bed Recommend xylitol mints, lozenges, and/or gum to stimulate saliva production and caries resistance  Epidemiology & Etiology Cerebrovascular Clinical Manifestations Disease Diagnosis & Treatment Oral Health Considerations  Cerebrovascular Disease – Epidemiology & Etiology Cerebrovascular disease refers to disorders that result in damage to the cerebral blood vessels leading to impaired cerebral circulation A cerebrovascular accident (CVA), or complete stroke, is a sudden impairment in cerebral circulation resulting in death or a focal neurologic deficit lasting more than 24 hours Transient ischemic attack (TIA), defined as a reversible, acute, short-duration, focal neurologic deficit (“mini stroke”) resulting from transient (reversible within 24 hours)  Cerebrovascular Disease – Epidemiology & Etiology Stroke is considered the second leading cause of death and the third leading cause of disability in the world The incidence of stroke in Saudi Arabia is 43.8 per 100,000 Bakraa R, Aldhaheri R, Barashid M, Benafeef S, Alzahrani M, Bajaba R, Alshehri S, Alshibani M. Stroke Risk Factor Awareness Among Populations in Saudi Arabia. Int J Gen Med. 2021;14:4177-4182 https://doi.org/10.2147/IJGM.S325568  Cerebrovascular Disease – Clinical Features Sensory and motor deficits Weakness Visual defects Sudden headache Altered mental status Dizziness Nausea Seizures impaired speech or hearing neurocognitive deficits such as impaired memory, reasoning, and concentration  Cerebrovascular Disease – Diagnosis & Management Brain Imaging (CT scan followed by MRI) Risk factor stratification (Check for diabetes, and hyperlipidemia) Acute treatment may contain thrombolysis with intravenous tissue plasminogen activator (t- PA) Chronic treatment may contain daily aspirin and other antiplatelet medications  Cerebrovascular Disease – Oral Health Considerations When providing care to patients who have had a stroke, dental providers should assess the patient’s risk for complications before providing any dental care Items to consider include the timing of the stroke and type and magnitude of dental procedure Patients who are taking Warfarin should report their international normalized ratio (INR) a theraputic range is between 2-3 Metronidazole and tetracycline interact with warfarin which can increase the INR. Little JW, Miller CS, Rhodus NL. Dental Management of the Medically Compromised Patient, 9th Ed. St. Louis, MO. Elsevier. 2018.  Cerebrovascular Disease – Oral Health Considerations Effective pain control during the procedure and post-operative will reduce stress and the risk for complications Local anesthesia should have a limited amount of vasoconstrictor (epinephrine) Patients can be safely given local anesthesia with epinephrine 1:100,000 or 1:200,000 The amount of vasoconstrictor should be ≤ 0.04 mg.  Cerebrovascular Disease – Oral Health Considerations Oral manifestations associated with a stroke include unilateral paralysis of the face, loss of sensory stimuli or oral tissues, a flaccid tongue with multiple folds, and dysphagia You may also notice that patients neglect oral self-care on one side of their mouth. This is associated with the brain damage that has occurred Increased caries, periodontal disease, and halitosis is also common due to challenges with oral self-care Dental providers should recommend rigorous preventive measures such as 3-month recall appointments and application of topical fluoride  Epidemiology & Etiology Parkinson Clinical Manifestations Disease Diagnosis & Treatment Oral Health Considerations  Parkinson Disease – Epidemiology & Etiology Parkinson disease (PD) is a chronic, progressive, neurodegenerative disorder PD results from degeneration of the dopaminergic cells in the substantia nigra, leading to depletion of the neurotransmitter dopamine in the basal ganglia The prevalence of PD in Saudi Arabia has been estimated to be 27 per 100,000 population Alyamani AM, Alarifi J, Alfadhel A, et al. Public knowledge and awareness about Parkinson's disease in Saudi Arabia. J Family Med Prim Care. 2018;7(6):1216-1221. doi:10.4103/jfmpc.jfmpc_335_18  Parkinson Disease – Clinical Manifestations Resting tremor (in hands, arms, legs, jaw, and face) Rigidity or stiffness (limbs and trunk) Bradykinesia (slowness of movement) Postural instability or impaired balance and coordination Dementia Behavioral/psychiatric symptoms (depression, anxiety, apathy, and irritability) Autonomic dysfunction (orthostatic hypotension, constipation, urinary frequency and urgency, and abnormal sweating)  Parkinson Disease – Diagnosis & Management Clinical diagnosis Genetic testing in cases of hereditary patterns No cure for PD, only symptomatic treatment Dopamine replacement therapy using levodopa (used by neurons to synthesize dopamine) combined with carbidopa (delays the conversion of levodopa into dopamine until it reaches the brain) remains the initial gold standard Various medications are used in conjunction for different symptoms  Parkinson Disease – Oral Health Considerations Patients with PD present several challenges to the dental health-care team Patients with PD often must be treated in a relatively upright position Dysphagia and impaired gag reflex increase the risk for aspiration of oral and irrigation fluids, and high-speed evacuation of fluids is important in reducing the risk for aspiration pneumonia Levodopa and dopamine agonists can lead to both orthostatic hypertension and, rarely, severe hypertension (Monitor BP in long visits and tell the patient to stand up from the chair slowly and over many stages)  Epidemiology & Etiology Myasthenia Clinical Manifestations Gravis Diagnosis & Treatment Oral Health Considerations  Myasthenia Gravis – Epidemiology & Etiology Myasthenia gravis (MG) is a chronic neuromuscular disease caused by autoimmune destruction of the skeletal neuromuscular junction MG is characterized by episodic weakness of the skeletal muscles that increases during periods of activity and improves after periods of rest The most common autoantibody is anti-acetylcholine receptor (AChR) The estimated prevalence rate for MG is 15 to 20 cases per 100,000 population in western countries  Myasthenia Gravis – Clinical Features diplopia and/or ptosis Oropharyngeal, facial, and masticatory muscle weakness dysphagia, asymmetry, and dysarthria The clinical course of disease is variable but usually progressive  Myasthenia Gravis – Diagnosis & Management The clinical examination and history are highly suggestive of MG Tensilon (edrophonium) challenge (rapid resulting in immediate elevation of available Ach) serum anti-AChR antibodies Treatment is with plasma exchange and high-dose intravenous immunoglobulin in addition to symptomatic treatment  Myasthenia Gravis – Oral Health Considerations Aspiration risks can be high and can be reduced by adequate suction, the use of a rubber dam, and avoiding bilateral mandibular anesthetic block Prolonged opening might be hard to maintain MG patient may also be at risk for a respiratory crisis from the disease itself or from overmedication If this is a concern, dental procedure should happen in a hospital setting where intubation is available  Myasthenia Gravis – Oral Health Considerations Avoid prescribing drugs that may affect the neuromuscular junction, such as narcotics, tranquilizers, and barbiturates Certain antibiotics, including tetracycline, streptomycin, sulfonamides, and clindamycin, can affect neuromuscular activity and should be avoided or used with caution Esther anesthetics which are metabolized by plasma cholinesterase should be avoided in MG patients on anticholinesterase therapy