BDS13021 Neurological Disease Lecture Notes PDF

BDS13021 Neurological disease Dr. Maha Zakaria Date : 11/ 11 / 2020  AIM: The educational aims of this lecture are: To describe the potential impact of common neurological disorders upon oral health and oral health care (dentistry). Epilepsy, multiple sclerosis and Parkinson’s disease are us...

BDS13021 Neurological disease Dr. Maha Zakaria Date : 11/ 11 / 2020  AIM: The educational aims of this lecture are: To describe the potential impact of common neurological disorders upon oral health and oral health care (dentistry). Epilepsy, multiple sclerosis and Parkinson’s disease are used as examples. INTENDED LEARNING OBJECTIVES: On completion of this lecture, the student should have an understanding of: 1. The oral disease that may arise in patients with common neurological disease 2. The impact of common neurological disorders upon the delivery of oral health care  Neurological disease Disorders Of Central & Peripheral Nervous Systems Neurological tissues (white or grey matter) Meninges and Meningeal spaces Blood supply &Others Causes of Huntington’s chorea, Tuberous sclerosis, Many others Neurological Genetic diseases Degenerative Example: Acquired Parkinson’s disease; dementia Vascular example:Arteriosclerosis (stroke) Neoplastic: primary or secondary Infective: encephalopathies e.g. herpes, measles, mump) Inflammatory disease: Example: multiple sclerosis) Epilepsy and seizures may be a feature of several of the above] Neurological disease: common disease relevant to dental practice Epilepsy Multiple Parkinson’s Sclerosis disease  Epilepsy and seizures – definitions Epilepsy – A paroxysmal dysfunction of brain neurophysiology (EEG) – Accompanied by a paroxysmal dysfunction in brain action (cognitive / behavioural/sensory/experiential) – TENDENCY TO RECUR Seizure – A TRANSIENT occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain Epilepsy and seizures: Basic Background Affects 50M in the world; possible prevalence of 1% in some populations. Causes : Young age group Old(er) age groups Cerebro-vascular Idiopathic Tumour Developmental lesion Head injury Tumour Alzheimer’s disease Head injury Medications Metabolic disturbance (alcohol/drug)  Epilepsy – the basic clinical features Highly varied For purposes of simplicity, and relevance to oral health care, epilepsy can be considered to be an absence or a “grand mal” episode that comprises: ▪ Aura (variable features – see below) ▪ Tonic phase ▪ Clonic phase ▪ Recovery Epilepsy – What is AURA? Epilepsy: Management Patient information – Lifelong prophylactic treatment – Driving – Avoid triggers – Safety aids ID jewellery / cards, Protective headgear Safety pillows Seizure alert dogs  Epilepsy: Management Medical Anti-epileptic drugs (AEDs) ex. Phenytoin, valproate Diet (in children a ketogenic diet may be helpful) Surgery Deep brain stimulators Vagus nerve stimulation Neurosurgery Implications of Epilepsy on oral health care access to care Risk Assessment consider Risk of seizure (and resultant trauma) Risk of a sharps injury communication Unlikely to be an issue Risk of triggers – e.g. lighting consent Unlikely to be an issue unless seizure occurs education Risk of phenytoin-induced gingival enlargement hence a need to ensure good oral hygiene (as this lessens the risk of this drug-related effect occurring). There is also a risk that dental pain may induce seizures  Implications of Epilepsy on oral health care surgical Anaesthesia: There are no significant concerns with LA/inhalation or intravenous sedation GA is not contraindicated Dental procedures: Dental trauma may cause loss of teeth and hence replacements should where possible be with FIXED APPLIANCES as REMOVABLE may compromise the airways in seizures Orofacial manifestations: Oral features are principally phenytoin-induced gingival enlargement and possible dental trauma with seizures  Implications of Epilepsy on oral health care surgical In the event of seizures: Ensure the patient does not harm/injure themselves (Gently limit patient movement, remove any sharp objects) Consider buccal or intranasal midazolam if status epilepticus likely Do not try to clear the mouth with your fingers spread No risks Neurological disease: common disease relevant to dental practice Epilepsy Multiple Parkinson’s Sclerosis disease  Multiple sclerosis: Basic Epidemiology Not uncommon – affects 2.5M people across the globe More common in non-equatorial countries; Most common in those of Northern European ancestry More common in Caucasians than Hispanics or African Americans; rare among Asians Usually diagnosed between 20 and 50 - occasionally in young children and older adults Affects both genders  Multiple sclerosis: Basic Pathology Demyelination (usually in the CNS) Dissemination of the development of disease in time and space: – Space: evidence of scarring (plaques) in at least two separate areas of the CNS – Time: evidence that the plaques occurred at different points in time There must be no other explanation for the changes Multiple Sclerosis: Basic Clinical Features  Multiple Sclerosis: Basic Clinical Features Fatigue (most common) Pain (including trigeminal neuralgia) Vision problems (various) Cognitive problems (memory, Bladder / bowel dysfunction attention,processing,planning Numbness and tingling Emotional disturbances (depression + anxiety,mood Muscle spasms, stiffness and swings) weakness Speech and swallowing problems Tremor Heat sensitivity Sexual problems Mobility problems Multiple Sclerosis: 4 5% Types 65% 15% 85% Multiple Sclerosis: Therapies Modify the disease Azathiorpine Methotrexate Mitoxantrone Monthly administration of methylprednisolone IVIgG Cladribine Cytoxan Bone Marrow Transplantation Others: The treatment has greatly changed in recent years in view of the availability of many biological agents Multiple Sclerosis: Treatment plan Team Treatment involves many specialties Neurologist Dentist Speech/language Neuropsychologist Psychotherapist Physical therapist Urologist Occupational therapist Social worker MS Nurse  Implications of multiple sclerosis Education Surgery There are no significant concerns with LA/inhalation or intravenous sedation. There is no good evidence that amalgam restorations cause or worsen MS. GA is not contraindicated Oral features are principally those associated with drug-induced oral dryness Orofacial features may include: Trigeminal neuralgia Trigeminal neuropathy (i.e. paraesthesia or anaesthesia) Facial nerve weakness (rare) Loss of mastication function (very rare) Spread No risks Implications of Multiple Sclerosis on oral health care access to care Mobility – vision; wheelchairs; limited movement; balance issues; attendance at many other clinics; fatigue; pain; mood changes; complete inability to attend dentist communication Possibly compromised by vision, dementia (with severe disease), Mood, possible dysarthria consent Possibly compromised by mood (with severe disease); dementia education Risk of oral dryness with many agents (e.g. Antidepressants, agents to modify bladder function and anti-fatigue agent (amantadine) requires focus upon preventative dental care Motor defects may require a modification in oral hygiene methods Implications of Multiple Sclerosis on oral health care surgical There are no significant concerns with LA/inhalation or intravenous sedation. There is no good evidence that amalgam restorations cause or worsen MS. GA is not contraindicated Oral features are principally those associated with drug- induced oral dryness Orofacial features may include: Trigeminal neuralgia Trigeminal neuropathy (i.e. paraesthesia or anaesthesia) Facial nerve weakness (rare) Loss of mastication function (very rare) spread No Risk Neurological disease: common disease relevant to dental practice Epilepsy Multiple Parkinson’s Sclerosis disease  Parkinson’s Disease: Basic Epidemiology Worldwide, 1 in every 3000 (currently ~6.3 million). 8.7-9.3 million worldwide by 2030 Prevalence increase with age Ratio in genders: Male to female ratio of 1.46 Becoming more common  Parkinson’s Disease: Basic Pathology Progressive neurodegenerative disease Degeneration of dopaminergic neurons in the Substantia Number of potential causes and protections suggested: Risk factors: – Genetics – Trauma to the head – Boxing, Muay Thai etc. – Toxin exposure e.g. pesticides and herbicides Protective factors: – Smoking – Coffee – Black tea  Parkinson’s Disease: Basic clinical Features: Motor Motor features – Dyskinesia – Akinesia – Bradykinesia – Postural instability and gait disturbance Others: – Dysphagia, speech changes, drooling – Scoliosis, leg deformities etc. Parkinson’s Disease: Basic clinical Features: Non Motor Non-motor features Autonomic dysfunctions: Orthostatic hypotension, sweating, gastrointestinal disturbances, weight loss Sensory disturbances: Visual hallucination, anosmia, chronic pain Neurological deficits: Cognitive impairment, dementia, psychosis, hallucinations, affective disorders Sleep disturbances: REM sleep behavioural disorders, vivid dreams, insomnia, daytime hyper-somnolence Parkinson’s Disease: Medical Management Levodopa and combinations (carbidopa) Dopamine agonist MAO-B inhibitor COMT inhibitors Anticholinergics (for tremors)  Parkinson’s Disease: Medical Management Deep brain stimulation: – Subthalamus nucleus (STN) – Globus Pallidus interna (GPi) Lesioning: – Thalamus (for tremors) – Globus Pallidus (for drug-induced dyskinesia)  Parkinson’s Disease: Supportive management Physical therapy > motor symptoms – E.g. general, treadmill, dance, martial arts, cuing Strength training > motor symptoms – e.g. weight machines, resistance cycling Occupational therapy > dysphagia, motor symptoms – e.g. CBT approach, utensils Speech and language therapy > dysarthria, dysphagia – e.g. compensatory and rehabilitative approaches Implications of Parkinson’s disease on oral health care access to care Mobility – wheelchairs; limited movement; balance issues; attendance at many other clinics; fatigue; slowness of movement, mood changes; complete inability to attend dentist communication Possibly compromised dementia (with severe disease), mood, slowness of talking, volume of voice consent Possibly compromised by dementia; dementia Risk of oral dryness with many agents education Motor defects may require a modification in oral hygiene methods – see additional slides Implications of Parkinson’s disease on oral health care surgical In general there are no significant concerns with LA/inhalation or intravenous sedation. GA is not contraindicated – but recall that Parkinson’s disease comes with an increased of pneumonias Oral features are principally those associated with drug-induced oral dryness Orofacial features may include: Dyskinesias Drooling Others (see following slides) spread No risks Some aids to improving the access of patients with Parkinson’s disease (or indeed others with mobility issues) Mobility Reduce risks of falls with anti-slip floors, handrails Good wheel chair access Additional clinical time Dental chair 45° reclined: aspiration & orthostatic hypotension Knee-break chairs Appointments: – “On” and “Off” periods – Post-DBS surgery period – Morning appointments best to reduce tremors – 60-90mins after medications – Short and stress-free sessions – Lavatory-use Oral manifestations of Parkinson’s disease Dry mouth Caries and periodontal disease risk Drooling Altered sense of taste and smell Orofacial pain syndromes Medication-related oral features Oral motor features: Dysphagia Facial dyskinesia and bradykinesia Vocal and speech changes Bruxism Oral manifestations of Parkinson’s disease Altered taste & smell Drooling Causes: Initial hyposmia Causes: Dry mouth Incompetent lips, mouth breathing Medications Reduced rate and volume of swallow Management: No known effective treatment Management: Treat dry mouth & halitosis Head positioning, reminders Alteration of medications Botulinum toxin A/B; scopolamine patches* Possible olfactory training Radiation therapy Surgery, relocation of ducts *probably the most useful Common Neurological disease – key points Epilepsy has many causes but the likelihood of a patient having a seizure during oral health care delivery is small – and the main issues are to ensure that the patient does not injure themselves and that any status epilepticus is identified and managed Multiple sclerosis is increasing in prevalence and has the potential to impact considerably upon access to oral health care. Parkinson’s disease may greatly compromise access to oral health care. Attending staff require to consider the layout of the clinic to minimise risks to the patient and must give consideration of the timing of appointments Good communication between all clinicians involved in the management of patients with neurological disease is essential  Reading material Students are advised to review any relevant teaching provided in the second and fourth years. In addition a useful textbook is: Scully C, Diz Dios, P, Kumar N. Special Care Dentistry: handbook of oral healthcare. Churchill Livingstone 2007  AIM: The educational aims of this lecture are: To describe the potential impact of common neurological disorders upon oral health and oral health care (dentistry). Epilepsy, multiple sclerosis and Parkinson’s disease are used as examples. INTENDED LEARNING OBJECTIVES: On completion of this lecture, the student should have an understanding of: 1. The oral disease that may arise in patients with common neurological disease 2. The impact of common neurological disorders upon the delivery of oral health care Thank you