Neurodegenerative Diseases

Question 1

What is dysphagia?

Answer 1

Difficulty swallowing +/- pain

Question 2

What causes dysphagia?

Answer 2

Associated with damage to CN IX - XII

Oral/pharyngeal pain, dryness, irritation

Tumours

Irradiation

Infection

Any condition that damages or weakens nerves or muscles involved

Question 3

Who most commonly gets dysphagia?

Answer 3

Neurodegenerative conditions

Head and neck cancer

Question 4

What are the potential complications of dysphagia?

Answer 4

Malnutrition/dehydration

Increased risk of aspiration (majority of people get some aspiration but more common in people with dysphagia)

Question 5

How does dehydration lead to increased risk of dental caries?

Answer 5

Dehydration causes increased mucosal dryness and mucosal fragility. Mucosal dryness and decreased salivation cause an increased risk of dental caries

Dehydration also causes malnutrition which causes increased consumption of sugars which icnreases risk of dental caries.

Question 6

Why does dysphagia cause patients to use more sugar?

Answer 6

Aerated drinks help in swallowing

Syrup is used for medications high in sugar

Thicker liquids are often used

Tablets are crushed and added to pureed fruit

Fruit juice used to breakdown thick saliva

Food pouching

Question 7

What thickening agents are used for dysphagic patients?

Answer 7

Methyldextrose

Xanthan gum (lower caries risk)

Question 8

How are patients with dysphagia managed?

Answer 8

Oral debridement

Reduced saliva/xerostomia

Oral pain management

Dietician (High sugar thickening agents)

Speech pathologist

Medical doctors

Multidisciplinary team approach

Question 9

What is aspiration pneumonia?

Answer 9

Foreign material originating from either oral cavity or oropharynx descends into the bronchial tree and alveoli with colonisation of bacteria resulting in an infective process.

Dependent on amount and type of aspirant, frequency, and host immune response.

Question 10

What is the burden of aspiration pneumonia?

Answer 10

Leading cause of death and hospitalisation in nursing homes.

Represents 1% of Australian deaths

Question 11

Is dysphagia the main cause of aspiration pneumonia?

Answer 11

No, it is a risk factor but insufficient to be a sole cause.

Question 12

What are the risk factors for aspiration pneumonia?

Answer 12

Immobile patients

Altered consciousness

Dysphagia

Comorbidities

Increased age

Oral health (may be a predictor of resp related deaths)

Nocturnal denture wearing (2 - 3x increase in risk)

Perio disease increases risk by 3.9x

Improved oral hygiene could prevent 1 in 10 deaths.

Question 13

Can dentists make a difference in risk of ventillator associated pneumonia?

Answer 13

8-hourly oral hygiene reduced the incidence of ventillator associated pneumonia to 0 in stroke and neurologic ICU.

Cochrane review of 38 RCTs found chlorhex mouthwash or gel reduced ventilator associated pneumonia in critically ill patients from 24 - 18% no difference found for toothbrushing.

43 survivors of mild to moderate stroke had poorer periodontal condition on discharge from hospital after six months.

Question 14

What should the dentist do for the patient with dysphagia?

Answer 14

Should aim to remove plaque from teeth

Increase protective factors against dental disease.

Question 15

How often should oral hygiene practices be done in patients with dysphagia?

Answer 15

Should be completed at least daily after the last meal of the day

This includes the removal and cleaning of dentures daily.

Question 16

How should mechanical cleaning be done for patients with dyspahagia?

Answer 16

Same as healthy patients.

Clean teeth and oral soft tissues including the tongue.

Brush around teeth at the gum level and in between teeth and chewing surface.

Use toothbrush, floss, interdental brushies, oral swabs, and gauze

Use less toothpaste (pea size)

Use higher fluoride products

Question 17

How can protective factors be increased against oral disease?

Answer 17

Increased fluoride exposure

Address dry mouth issues

Use chlorhexidine based products for periodontal disease

Question 18

How should patients with mild to moderate dysphagia be treated?

Answer 18

Where possible encourage normal oral hygiene: 2x a day brush. 1x interdental

If physical limitations supervise/assist, electric toothbrush, modified dental appliances, and suction/swab oral cavity to remove excess once completed.

Question 19

How should patients with severe dysphagia be treated?

Answer 19

Risk is lower for decay but much higher for perio

Mechanical cleaning is still essential with brushing, interdental cleaning, and chlorhexidine + fluoride are useful.

Where maintaining some oral intake should complete oral hygieve after each meal.

Question 20

Which people most commonly get MS and how slow does it progress?

Answer 20

usually females between 20 - 50 years of age and progresses for 15 years.

Question 21

What are the common symptoms of MS?

Answer 21

Depends on region of the brain affected:

Bladder problems

Fatigue

Weakness

Muscle hypotonicity

Loss of sensation

Dizziness

Visual disturbances

Depression and emotional instability

Question 22

How is MS treated?

Answer 22

Symptomatic management:

Interferon

Corticosteroids

Immunosuppressants (methotrexate)

Question 23

What are the dental implications of interferon use for MS?

Answer 23

Can cause flu like symptoms, xerostomia, neutropenia, thrombocytppenia)

Question 24

What are the dental implications of corticosteroid use for MS?

Answer 24

Affects healing of infections, can cause adrenal crisis (very low risk)

Question 25

What are the dental implications of immunosuppressant use for MS?

Answer 25

Causes oral ulcerations, xerostomia, gingivitis, candidiasis, mucositis, anaemia, leukopaenia, thrombocytopaenia, and increased infections)

Question 26

What are the oral manifestations of MS?

Answer 26

Trigeminal neuralgia (>40 year old females) can be bilateral or unilateral Sensory neuropathy (Paraesthesia, dysaesthesia, and anaesthesia) Paralysis (Similar to Bell's Palsy - Usually a late symptom)

Question 27

Why is it important to understand MS?

Answer 27

Patient may present with initial symptoms to the dentist

Question 28

How can dentist help early detection of MS? What signs should a dentist look out for?

Answer 28

Question suspicious complaints about abnormal facial pains (20 - 35 year olds): Mimicking trigeminal neuralgia Numbness of extremities Visual disturbance Muscle weakness Afternoon tiredness If there is relapsing remitting pattern Refer for neurological assessment

Question 29

When should patients with MS be treated?

Answer 29

Ideally when in remission With mild disease routine dental care is a good idea When more severe: Transfer to clinic/dental chair, ensure good oral hygiene, prosthetic/reconstructive treatment, use short morning appointments.

Question 30

What are the side effects of medications that commonly are used for MS?

Answer 30

Dry mouth Some may cause bleeding problems

Question 31

What should be considered for treatment of MS patients?

Answer 31

Stage of disease Advice from other health professionals in multidisciplinary team Implications of medications Oral hygiene, risk factors Access to dental clinic, transfer to chair Short appointments in morning Rational treatment planning

Question 32

What brain regions are affected by parkinson's disease?

Answer 32

Dopamine producing neurons in the substantia nigra.

Question 33

Who most commonly has parkinson's disease?

Answer 33

Men and more common with older ages. over 75 1 in 100 people

Question 34

What are the symptoms of parkinson's disease?

Answer 34

Abnormal shuffling gates. Difficulty initiating movements and stopping movements. Arms carried in front of body. Bradykinesia (stiffer and slower movements) Pill rolling tremor. Mask like face due to difficulty creating facial expressions Dementia Orthostatic hypotension

Question 35

How is Parkinson's disease treated?

Answer 35

Generally symptom management Monoamine oxidase inhibitors used to improve early symptoms Levodopa or dopamine agonists which are most effective and widely used. They replenish dopamine and improve motor functions. Anticholinergics NMDA receptor inhibitors (amantadine) COMT inhibitors

Question 36

What side effects are commonly seen in medications used to treat Parkinson's disease?

Answer 36

Weight loss: Undernutrition Altered speech: Slow, slurred, monotone Abnormal swallowing/dysphagia Change in taste sensation Dementia Angular cheilitis predisposition due to drooling.

Question 37

When should dental treatment ideally be done for parkinson's?

Answer 37

Earlier treatment is preferable because the condition does progress

Question 38

What should be done to prevent discomfort caused by dysphagia?

Answer 38

High volume suction, patients come in the morning

Question 39

What is huntington's disease?

Answer 39

Progressive neurodegenerative disorder affecting the CNS. Characterised by unwanted choreatic movements, cognitive decline and psychiatric disturbances.

Question 40

Who does Huntington's disease typically affect?

Answer 40

Males and females equally 6 -7 per 100000 in Australia

Question 41

What causes mortality in people with Huntington's typically?

Answer 41

Mortality is typically aspiration pneumonia and suicide

Question 42

How is Huntington's disease diagnosed?

Answer 42

Clinical sign with known history Confirmed with genetic testing.

Question 43

What are the symptoms of Huntington's disease?

Answer 43

Triad of clinical symptoms: Motor impairment (dysphagia and dysarthria) Cognitive impairment (decline in cognition and memory) Personality and psychiatric disorders (emotional) (Dysphoria, anxiety, sleep disturbances)

Question 44

How is Huntington's disease managed?

Answer 44

Symptom based and often moved to long term care in nursing homes and specialist unit daycare services.

Question 45

Why is dental treatment so important to treat for patients with Huntington's disease?

Answer 45

Aspiration pneumonia is a common method of death so dental treatment is important.

Question 46

How is dental treatment applied to patients with Huntington's?

Answer 46

Aggressive preventative measures and restorative treatment in the early stages. Later stages: Domiciliary care and palliative care. Oral hygiene techniques: Allow to maintain independence, carer assistance, individual tailoring of strategies, reminder posters.

Question 47

What is motor neurone disease?

Answer 47

A quick neurodegenerative disease caracterised by selective degeneration of upper and lower motor neurones. Also referred to as ALS or Lou Gehrig's disease. 1900 affected in Australia

Question 48

What are the challenges to dental care people with motor neurone disease face?

Answer 48

Patients with this condition require non-invasive ventillation meaning they might have a mouthpiece. Nasally delivered NIV is the only one that allows dental care. Salivation and drooling with dry mouth and increased viscosity. Dysphagia Communication Cognitive and behavioural changes (Can go from verbal to non-verbal)

Question 49

What arrangements for dental management is required for patients with motor neurone disease?

Answer 49

Access to care: accessible facilities vs domiciliary visit. Patient positioning: Upright and support head/body with cushions. Communication Treatment planning appropriate to disease High volume suction for treatment Appropriate oral hygiene and preventive measures

Question 50

What should be discussed with other specialists involved in the treatment of patients with motor neurone disease?

Answer 50

Management of saliva issues (drooling and dry mouth) Oral hygiene Collaboration with speech pathologist regarding dysphagia management Consultation with dietician regarding diet