21/2/2017 ManagementoftheDentalPatientWithNeurologicalDisease:Overview,Epilepsy,Stroke

Thissiteisintendedforhealthcareprofessionals

ManagementoftheDentalPatientWith
NeurologicalDisease
Updated:Nov09,2015
Author:JeffBurgess,DDS,MSDChiefEditor:ArlenDMeyers,MD,MBAmore...

OVERVIEW

Overview
Patientswithneurologicaldiseaserequirespecialmanagementconsiderations.Theseinclude
pretreatmenttreatmentplanning,therapeutictechniques,andposttreatmentrequirements.Neurologic
conditionsfacingthedentistincludeabnormalitiesassociatedwiththecranialnerves,facialsensory
loss,facialparalysis,andconditionssuchasepilepsy,Parkinsondisease,multiplesclerosis,stroke,
andmyastheniagravis.Inthisarticle,strategiesformanagingpatientswithsomeoftheseconditions
arepresented.[1]

Epilepsy
Epilepsydescribesasetofconditionsassociatedwithparoxysmalneurologicfunctionobservedas
seizuresthatincludeconvulsiveandotherneurosensorydisturbances.About10%ofthepopulationis
estimatedtohaveepilepsy.Theclinicalsignsassociatedwithtonicclonicconvulsionsarequite
distinctiveandcanbedisconcertingtodentalpersonnelwhenconfrontedwiththesituationwhilethe
patientisinthedentalchair.Toeliminatepotentialtreatmentissues,guidelinesarepresentedbelow.
[2,3,4,5,26]

Priortoandduringdentaltreatment
Ensurethepatienthasbeencompliantwithmedicationcoverage.Ifthereareanyquestionsregarding
compliance,contactthepatientsphysician.

Ascertainthatthepatienthasnotoxicitywiththemedicationtakenandthatmentalfunctionisnormal.

Patientstakingvalproicacid(Depakene)mayhaveincreasedbleedingduringprocedures.Ifthereare
acknowledgedproblems,orderableedingtimeassessmentpriortotreatmentandconsultwitha
physicianifthevaluesarequestionable.

Duringdentaltreatment,beawarethatagrandmalseizurecouldoccur.Ifaseizureoccurs,placethe
chairbacktoasupineposition,turnthepatienttotheside,andkeepthepatientcomfortablewithout
restraintuntilithaspassed.Placementofatonguebladeisnotrecommendedunlessthepatientis
awareofanimpendingseizureandcanassistinitsplacement.

Ifinjurytotheliportongueoccursduringaseizure,appropriatetreatmentsuchassuturingof
lacerations,localizationofpotentialfractures,removaloffragments,andfollowupdentaltreatmentis
required.

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Ifdentaltreatmentnecessitatesthereplacementofoneormoremissingteeth,restorationofthe
missingteethusingfixedappliancesispreferableoverremovaltypeprosthetics.Inaddition,the
clinicianneedstobecognizantofpotentialfractureofanteriorfullcoveragerestorationssuchas
completeporcelaincrowns.Itmaybepreferabletousethreequartergoldcrownswithporcelain
veneersifconcernexistsregardingthefrequencyofseizures.

Oralmedicineaspects
Monitorgingivalhyperplasiasecondarytotheuseofanticonvulsantmedication(eg,phenytoin).

Monitororalhygieneandprovideeducationalinformationandtrainingtofacilitatethepatientsability
tomanagehisorheroralhealtheffectivelyevidencesuggestsmeticulousoralhygienemayreduceor
preventgingivalhyperplasia.

Subluxationofthetemporomandibularjointcanoccurduringseizureepisodes.Nospecifictreatment
isnecessaryunlessthisresultsinjointhypermobilityandsubsequentfrequentnonseizure
subluxation.

Stroke
Aneurovascularaccident(stroke)isoftenfatalbutmaybeprecipitatedbymultiplenonlife
threateningeventsthatifidentified,canreducetheriskofanacuteandseriousoutcomewhenthe
patientisindentaltreatment.Knowingtheclinicalsignsandsymptomsofastrokeisimportantin
managingolderpatientswithlongstandingcardiovasculardisease.[6,7,8,9,10]

Priortoandduringdentaltreatment

Theclinicianshouldbeawarethatpatientswithlongstandinghypertensionandcerebrovascular
diseaseareatincreasedriskofacerebrovascularaccident.Strokeisthethirdmostcommoncauseof
deathintheUnitedStates.

Thesignsofastrokecanbequitesubtle.Amajoreventmaybeassociatedwithmanytransient
ischemicattacks(TIAs),orminorstrokes,thatlastforafewminutes.InaTIA,dizziness,diplopia,
hemiplegia,andalteredspeechmayoccur.Athoroughhistoryofpossiblepatientsymptomspriorto
treatmentmayprovideusefulinformationregardingthepossibilityofanimpendingmajoreventduring
treatment,asseveralTIAsoccurringclosetogetheroftenprecedeamajorstroke.Thisisimportant
becausetheclinicianshouldbeawarethatapatientexperiencingaminoreventintheofficemay
haveamajoreventafterleavingtheoffice,leadingtomortality.

Thewarningsignsofaseverestrokeeventincludesuddenortemporaryweaknessornumbnessof
thefaceandotherbodyparts,lossofspeechordifficultyspeakingorunderstandingspeech,visual
changes,andunexplainedlossofbalanceordizziness.

InpatientswithanidentifiedincreasedriskofstrokepretreatmentorwhoexhibitsignsofamildTIA
occurringduringtreatment,afollowupphonecallisrecommended.Anypatientexhibitingsignsor
symptomsofaTIAorstrokerequiresimmediatemedicalreferral.

Ifanobviousstrokehasoccurredduringadentalprocedure,thepatientsairwaymustbemaintained
untilemergencymedicalpersonnelarrive.

Dentaltreatmentofpatientswithstrokeresidual

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Inpatientswhohaveexperiencedphysicaldeficits(eg,handeyecoordinationproblems,armorhand
deficit,masticatorymuscleweakness),personaloralhygieneeffortsmaybecompromised.Treatment
planningshouldincludethefollowing:

Comprehensiveoralhygieneinstructionthatmayincludeinstructiononuseofanelectric
toothbrushoralargehandheldtoothbrushorwaterirrigationinstrumentcoupledwithplaque
revealingtabletsrunningawashcloththroughthevestibulecanhelptoreduceaccumulationof
foodmatter
Recommendationregardinganticariespreparations,includingrinsescontainingfluorideand
xylitolortheuseofxylitollozenges(eg,XyliMelts)tohelpreducetheoralbacterialburdenof
Streptococcusmutans
Thepossibleneedforanantifungalprescription,astheaccumulationofsalivainpatientswith
facialpalsymaybeproblematicatthecornersofthemouthandcanpredisposethepatientto
fungalinfection
Awarenessthatdependingonthetypeofstroke,thepoststrokepatientmayhavebeen
prescribedanticoagulantmedication

ParkinsonDisease
Parkinsondisease,resultingfromthedegenerationofcellsinthesubstantianigra,causesanumber
ofmotorsymptomsthatcancomplicatedentalmanagement.Theseincludetremors,involuntary
movements,facialandlimbrigidity,bradykinesia(particularlyasitrelatestoswallowing),and
akathisia(ie,restlessness).Duringdentaltreatment,thesedisabilitiesmustbetakeninto
consideration.Followingisalistofspecificrecommendationsformanagingthedentalpatientwith
Parkinsondisease.[10,11,12,13,14,15]

Predentaltreatment
ThesameoralhygieneinformationshouldbeofferedtotheParkinsondiseasepatientasthestroke
patient.Recommendtheuseofanelectrictoothbrushoralargehandheldtoothbrushorwater
irrigationinstrumentcoupledwithplaquerevealingtablets.Runningawashcloththroughthevestibule
canhelptoreduceaccumulationoffoodmatter.

PatientswithParkinsondiseasemaynotbeabletoeffectivelycommunicatetheirneeds,soafamily
memberorcaregivershouldbepresentwhenthetreatmentplanispresentedtothepatient.Ifthereis
cognitivedecline,thisisparticularlyimportanttoensureunderstandinginfulloftherisksandbenefits
ofproposedintervention(eg,multipleextractions,periodontaltreatment).

Dentaltreatmentrecommendations

Severetremorsandinvoluntaryjawandlimbmovementscanpresentdifficultyinthemanagementof
thepatient.Thisisparticularlytrueforthepatientinwhomthemedicationdosageisincorrectorin
whommedicationhasnotbeencompletelyeffective.Togainthemaximumbenefitfromprescribed
drugs,patientsshouldbeinstructedtotakeprescribedmedicationasscheduled,anddentistry
appointmentsshouldbemadewithinashorttimeframefollowingtheiruse.

SincefacialmusculaturetonicityassociatedwithParkinsondiseasecanleadtothepatientsinability
toexpressemotion,itisimportantforthetreatingcliniciantobesympatheticandattentivetoeyeor
otherlimbmovementsthatcouldsuggestpainduringaprocedure.

BradykinesiathatcausesswallowingdifficultyisalsoapotentialproblemforParkinsondisease
patientsduringtreatment.Adequatesuctionoffluidisimperativeduringdentalprocedures,including
thoseinvolvingdentalhygiene.
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TemperatureregulationmaybecompromisedifthepatienthascomorbidShyDragerdisease(an
abnormalityoftheautonomicnervoussystem)placementofablanketoverthepatientmayhelp
maintainwarmth.

Dentalreconstructionthatinvolvestheocclusalsurfacesneedstobetailoredtothefactthatbruxism
maybesevereinpatientswithParkinsondisease.Theocclusionofplacedrestorationsshouldbe
keptasflataspossibletoavoidbreakageoftherestorationorteeth.

CareshouldbetakentonotoverstressthepatientwithParkinsondisease.Shortappointmentsare
helpful.

ThepatientwithParkinsondiseasemayhavedifficultyplacinganoralsleepapneaappliance.This
approachtothemanagementofsleepapneaisdiscouraged.Ifapneaisaconfoundingproblem,
medicalconsultationisrequiredanduseofacontinuouspositiveairwaypressure(CPAP)device
shouldbeconsidered.

SomeParkinsonpatientsdeveloptemporomandibularjointproblems,particularlyhypermobilityofthe
mandibleandfrequentsubluxation.Thisisadifficultproblemtotreatifthepatientalsohascomorbid
severebruxism.Insomecases,patientsbenefitfromHerbstapplianceswithstrongelasticswornat
night.However,theproblemofpatientplacementinthefaceofmusclerigidityandbradykinesiais
alsoaconcerninthesecases.

MyastheniaGravis
Myastheniagravisresultsingeneralizedmuscleweakness,includingthemusclesoftheface,tongue,
andneck.Patientswithmyastheniagravismayholdtheirjawsinaslackpositionwiththemouth
open.Theproblembecomesworsetowardstheendofthedayandwithfatigueorstress.[16,17,18,19,
20]

Dentalconsiderations
Dentaltreatmentshouldbescheduledatatimewhenthepatientisnotfatigued,andpreferablyduring
remissionofthedisease.Appointmentsneedtobemade12hoursafterthepatienthastakenhisor
hermedication(ananticholinesterase,eg,pyridostigmine),preferablyinthemorning.

Considerationshouldbemadeforreducingstresspriortoandduringthedentalappointment.Anxious
patientsmaybenefitfromalowdoseofananxiolyticbenzodiazepinesuchassuchasdiazepam
(Valium)orlorazepam(Ativan)takenpriortotreatment.

Procaineanestheticsshouldnotbeusedforlocalanesthesia.

Inthepatientwithadentalabscess,onlytheantibioticspenicillinorerythromycincanbesafelyused
totreatinfection.Drugstobeavoidedincludethetetracyclines,clindamycin,lincomycin,
sulphonamides,andaminoglycosides.Forpain,paracetamolcoupledwithanarcotic(eg,codeine)
maybehelpful.Aspirinhasbeenassociatedwithcholinergiccrisisinpatientstaking
anticholinesterases,soitshouldbeavoided.

Sincepatientswithmyastheniagravisoftenhaveimpairedrespiration,specialconsiderationneedsto
betakenformaintainingoxygenationduringproceduresinvolvingconscioussedation.Infact,itisbest
totreatthesepatientsinaninpatienthospitalsetting.Thedrugsoftenusedinconscioussedation(eg,
opioids,barbiturates)maypotentiateoraggravatebreathingdifficultyinmyastheniagravispatients.

FacialParalysis
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Conditionscausinglossoffunctionoftheseventhcranialnerveincludemultiplesclerosis,infection
(eg,syphilis,HIVdisease,Lymedisease,leprosy),sarcoidosis,cholesteatoma,Bellpalsy,andseveral
intracranialproblems(eg,tumor,trauma).Upperandlowermotorneuronabnormalitycanbe
differentiatedbytheresultinglossoffunction.Manyoftheseconditionsaffectoralhealth.[21,22,23,24,
25,27]

Dentalconsiderations
Lossoftastecanoccurandisassociatedwithabnormalityofthechordatympani.

IncasesinvolvingBellpalsy,thecorneasshouldbeprotectedduringdentaltreatment.

Inothercasesoffacialpalsy,theremaybeaccumulationoffooddebris,potentiallyincreasingdental
plaque.Patientsshouldbeinstructedintechniquestobeusedaftereatingaimedateliminatingthe
material.

Leakingofsalivaatthecornersofthemouthmaypredisposethepatienttoangularcheilitis.An
antifungalcreamappropriatelyplacedmaybeusefuliffungalinfectionemerges.

Placementofasplintmaybehelpfulinimprovingfacialaesthetics.Otherapproachesmayinclude
appliancesanchoredtotheteeth.Suturingmayalsobeuseful.

Painintheregionoftheear/temporomandibularjointmaybetheresultofinflammationofthe
geniculategangliaofthefacialnerve.Avoidanceofmisdiagnosis(temporomandibularjointpathology)
isimportant.

Facialdyskinesiascanleadtotongueorjawmovementthatcanconfounddentaltreatment.Bruxism
canleadtotoothwearorfracture.Patientswithfacialdyskinesiasmaybenefitfrompredental
treatmentprescriptionofabenzodiazepine.

Sensorydeficitsassociatedwithconditionsinvolvingthefifthcranialnervemaybetheresultof
conditionssuchasPagetdiseaseorperipherallesionsinvolvingthebonesandthecanals.

Brainstemlesionscanaffectmasticationandcausemouthopeningdifficulty.

Facialparalysiscanresultfromalveolarnerveblocks.Insomecases,thiscanbepermanent.

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