Neurological Disorders PDF

NEUROLOGICAL DISORDERS CEREBROVASCULAR ACCIDENT (CVA) CVA –commonly referred to as stroke is a neurological impairment caused by a disruption in blood supply to a region of the brain. TWO MAJOR CATEGORIES Ischemic strokes occurs when a blood vessel supplying the brain is occluded b...

NEUROLOGICAL DISORDERS CEREBROVASCULAR ACCIDENT (CVA) CVA –commonly referred to as stroke is a neurological impairment caused by a disruption in blood supply to a region of the brain. TWO MAJOR CATEGORIES Ischemic strokes occurs when a blood vessel supplying the brain is occluded by a clot. Hemorrhagic stroke occurs when a cerebral artery ruptures. Signs and Symptoms Ischemic Stroke Harder to detect Weakness in one side Facial drooping Numbness and tingling Language disturbance Visual disturbance Hemorrhagic Stroke Aneurysm – weakened area in artery Congenital Younger population younger than 40 years “worst headache in my life” Spontaneous Hypertensive Bleed BP 200/100 Older patients Malformed Artery 50% younger than 30 years Signs and Symptoms Hemorrhagic Sudden and dramatic Violent explosive headache Visual disturbance Nausea and vomiting Neck and back pain Sensitivity to light Weakness on one side FAST Stroke Assessment Pre-Hospital Stroke Screen Face Arm Speech Time of onset FACE Look for Facial Droop Have the patient smile or show his/her teeth NORMAL Both sides of the face move equally ABNORMAL One side of the patient’s face droops or does not move ARMS Motor Weakness: Look for arm drift by asking the patient to close eyes and lift arms NORMAL- arms remain extended equally or drift downward equally ABNORMAL – One arm drifts down compared to the other Speech Ask the patient to say “You can’t teach an old dog new tricks” NORMAL –Phrase repeated clearly and plainly ABNORMAL – Words slurred, abnormal or unable to speak Time of Onset The window of opportunity to effectively treat STROKE is 3 hours (180 minutes) May be extended to 4 ½ hours Need to know “ last known well-state”. Difficult when Patient lives alone Woke up with symptoms Abnormal Speech Slurring of speech Unable to think of words Inappropriate words Expressive aphasia – unable to speak words Receptive aphasia – unable to understand words DENTAL MANAGEMENT OF PATIENT WITH STROKE Avoid procedure that may lead to increase blood pressure. Minimize stress Elective dental treatment is usually not advised until 6 months or more after a stroke, but preventive measures and biofilm control procedures are introduced or reinstated as early as possible. Because of weakness, treatment may best be accomplished in shorter appointments and small increments of instrumentation. The application of four-handed dental hygiene during instrumentation is necessary DENTAL MANAGEMENT OF PATIENT WITH STROKE The paralyzed side of the face tends to sag or droop and the tongue is less active, which lessens self-cleansing action. Lack of sensation hinders the patient from realizing that dental biofilm may be collecting, which increases the risk for gingival inflammation and demineralization leading to dental caries. Rinsing may be difficult or impossible. Daily fluoride can be applied with a gel tray by the caregiver or by brushing the teeth with a fluoride gel. When xerostomia is present, substitute saliva can be recommended. SEIZURE DISORDERS CAUSES: GENETIC/CONGENITAL FORGETTING TO MEDICATION STRESS – EMOTIONAL/PHYSICAL SLEEP DISTURBANCE HYPOGLYCEMIA ALCOHOL WITHDRAWAL DENTAL TREATMENT CONSIDERATIONS OF EPILEPTIC PATIENT Take complete health history. Ensure medications have been taken. Schedule proper frequency of oral hygiene and provide good oral hygiene instruction. Ensure no light directly in eyes. Perform proper periodontal and surgical treatment of gingival hyperplasia to minimize damage to teeth and to maintain the aesthetics. MANAGEMENT OF PATIENT DURING SEIZURE 1. Clear all instruments away from the patient. 2. Place the dental chair in a supine position as near to the floor as possible. 3. Place the patient on his or her side (to decrease the chance of aspiration of secretions or dental materials in the patient’s mouth). 4. Do not restrain the patient. 6. Call emergency number if the seizure lasts longer than 3 minutes. 7. Call emergency number if the patient becomes cyanotic from the onset. 8. Administer oxygen at a rate of 6–8 L/minute. 9. If the seizure lasts longer than 1 minute or for repeated seizures, administer a 10-mg dose of diazepam (IM) or (IV). POST SEIZURE Do not undertake further dental treatment that day. 2. Try to talk to the patient to evaluate the level of consciousness. 3. Do not allow the patient to leave the office if his or her level of awareness is not fully restored. 4. Contact the patient’s family, if he or she is alone 5. Do a brief oral examination for sustained injuries. SENSORY PROCESSING DISORDERS Sensory processing disorder (SPD) is a neurological condition that interferes with the body’s ability to receive messages from the senses, and convert those messages into appropriate motor and behavioral responses. MULTIPLE SCLEROSIS It is an inflammatory and demyelinating disease. Inflammation: body’s own immune cells attack the nervous system. Demyelination: myelin (protective covering of the nerves) is destroyed leaving areas of scar tissue or sclerosis. DENTAL MANAGEMENT OF PATIENT WITH MULTIPLE SCLEROSIS Transfer assistance from wheel chair to dental chair Management of swallowing difficulty Management of spastic/involuntary movements Management of facial pain Management of dry mouth and other oral side effects of medications dysphagia DENTAL MANAGEMENT OF PATIENT WITH MULTIPLE SCLEROSIS assess gag reflex meticulous suctioning all procedures done with high volume suction presence of saliva ejector protect the airway position patient to minimize flow of fluids into throat for all compromised laryngeal reflex diminished cough strength  Extra effort chewing or swallowing Eating very slowly Packing foods into the cheeks Drooling Fluid leaking from the nose after swallowing Increased congestion in the chest after eating ASPIRATION RISK ASPIRATION PNEUMONIA CONTROL OF INVOLUNTARY MOVEMENT extra-oral mouth props intra-oral mouth prop rubber bite block, extended foam handle physical, gentle hand-holding stabilization of head MS ORAL/FACIAL PAIN Trigeminal Neuralgia Facial Palsy may be the first manifestation of MS “electric shock” by touching cheek, tooth brushing or chewing pain lasts for seconds, severe; returns several times/day numbness of lower lip/chin, with or without pain weakness/paralysis of facial muscles Dental management rule out dental etiology occlusal orthotics, trigger point injections Surgical management peripheral nerve block/ablation, gasserian ganglion procedures, MD consult re: disease progression  Meticulous plaque control is mandatory Caries likely anywhere plaque can accumulate Reinforce instruction at frequently (q 3 mos) Antibacterial rinses Maximize fluoride strategies Patient applied rinse before bedtime brush, swab Professionally applied fluoride varnish  Tips for the caregiver: In later stages of MS the patient may lose muscle control of the cheeks and tongue. These muscles, when strong, work to propel food and liquid from the front of the mouth to the back and eventually to the throat for swallowing. When these muscles become too weak to function properly, food can become trapped in the vestibule (the area between the cheek and teeth). Food that stays in this area for long periods of time can cause offensive odors as well as breakdown and speed the process of decay to the neighboring teeth. If the patient wears full or partial dentures, they should be removed in order to clean the vestibule properly. To clean the vestibule, pull open the cheek to increase visibility. Using a moist cloth, finger, cotton swab, or a large sponge-tipped swab (Toothette), sweep from the back of the vestibule forward to remove large particles of debris. Like natural teeth, dentures must be brushed daily to remove food deposits and plaque. Brushing helps prevent dentures from becoming permanently stained and helps your mouth stay healthy. It's best to use a brush designed for cleaning dentures. A toothbrush with soft bristles can also be used. Avoid using hard-bristled brushes that can damage dentures. Dentures may lose their shape if they are allowed to dry out. When they are not worn, dentures should be placed in a denture cleanser soaking solution or in water. MS ORAL HYGIENE STRATEGIES Adaptive equipment electric toothbrush cord on toothbrush if drops cuffs or utensil holders suctioned denture brush one handed flosser MS ORAL HYGIENE MANAGEMENT Early comprehensive oral rehab Frequent professional visits Monitor caries/periodontal disease risk Monitor salivary function Educate care givers Prevent Infection Pain SPECIAL CARE PATIENT The term "Special Patient" is used in the oral health field to describe an individual with special needs, including physical, medical, developmental and/or cognitive conditions, resulting in limitations in their ability to receive dental services and prevent oral diseases by maintaining daily oral hygiene. DISABILITIES Physical disabilities Intellectual disabilities Learning disabilities Syndromes ( e.g. Down syndrome) Cerebral palsy Muscle atrophy Autism BARRIERS Lack of funding for training Cost of specialist services & facilities Unwillingness of some general dental practitioners to provide dental treatment for such groups General Aspects of oral status in impaired patients Poor cooperation Resistance to mouth cleaning Challenging behavior Limited access to dental services ORAL HYGIENE STATUS Poor cooperation Resistance to mouth cleaning Challenging behaviour Limited access to dental services Dental caries prevalence in patients with impairments is higher More untreated decay More missing teeth  PREVENTING HYPERSALIVATION Excessive drooling especially in poor neuromuscular control (cerebral palsy or cerebro-vascular accident) Prevention & management: Surgical Pharmacological Radiotherapy Palatal training aids ( Hyoscine patch /anticholinergic ) Behavior modification Hyoscine patch is used to prevent nausea and vomiting caused by motion sickness. Managing The Challenging Patient Premedication This is prescribed to calm the patient and put him or her at ease before treatment. Nitrous oxide–oxygen This method of mild sedation that can help calm a patient for treatment. Physical restraint Restraints are used to prevent injury to the child and dental team. Autism Autism is a complex developmental disability that impairs communication and social, behavioral and intellectual functioning. Some people appear distant, aloof, or detached from other people or from their surroundings. Others do not react appropriately to common verbal and social cues, such as a parents’ tone of voice or smile. Autism Obsessive routines, repetitive behaviours, unpredictable body movements, and self-injurious behaviour may all be symptoms that complicate dental care. Consultation with physicians, family, and caregivers is essential to assembling an accurate medical history. Also determine who can legally provide informed consent for treatment. Treatment –plan modifications: Communicate at a level the patient can understand. Use a “tell-show-do” approach. Keep dental instruments out of sight and light out of patients’ eyes. Make the appointment short and positive. Praise and reinforce good behaviour after each step of procedure. Ignore inappropriate behaviour as much as you can. Use immobilization techniques only when absolutely necessary. Down Syndrome This disorder is also called trisomy 21 Down syndrome is a chromosomal disorder resulting in certain abnormal physical characteristics and mental impairment. Mental impairment may range from mild to moderate retardation. A person with Down syndrome is affected by low muscle strength and weak muscle tone. Heart conditions are possible. An affected child may exhibit abnormalities in dental development. Periodontal problems are possible Treatment-plan modifications ―Schedule appointments early in the day if possible. ―Listen actively and show whether you understand. ―Use simple, concrete instructions, and repeat them often to compensate for any short-term memory problems. ―Try to be consistent in all aspects of providing oral health care. ―Use immobilization techniques only when absolutely necessary to protect the patient and staff during dental treatment. ―Be prepared to manage a seizure. Cerebral Palsy This non-progressive neural disorder is caused by brain damage that occurred prenatally, during birth, or postnatally before the central nervous system reaches maturity. Characterized by: Paralysis Muscle weakness Lack of coordination Other disorders of motor function Poor oral hygiene Types of Cerebral Palsy Spastic palsy Stiff or rigid muscles on one side of the body or in all four limbs, sometimes including the mouth, tongue, and pharynx. Dyskenitic or athetoid palsy Characterized by hypotonia and slow, uncontrolled writhing movements. Ataxia palsy (rare) Marked by problems with balance and depth perception, an unsteady gait. Also my include hypotonia and tremors. Combined palsy Reflects a combination of these types. Treatment-plan modifications All cerebral palsy patients have problems with movement and posture. Observe each patient, then tailor your care accordingly. ―Make the environment calm and supportive ―Do not force arms and legs into unnatural positions. Allow the patient to settle into a position that is comfortable and will not interfere with dental treatment. ―Try to keep appointments short with frequent breaks. ―Minimize distractions in the treatment setting. ―Tell the patient about any movements, lights, sounds before it appears. e.g. tell the patient before moving the dental chair. ―Place patient in slightly upright position.