Management of the Dental Patient With Neurological Disease

Updated: Nov 09, 2015
  • Author: Jeff Burgess, DDS, MSD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Overview

Overview

Patients with neurological disease require special management considerations. These include pretreatment treatment planning, therapeutic techniques, and posttreatment requirements. Neurologic conditions facing the dentist include abnormalities associated with the cranial nerves, facial sensory loss, facial paralysis, and conditions such as epilepsy, Parkinson disease, multiple sclerosis, stroke, and myasthenia gravis. In this article, strategies for managing patients with some of these conditions are presented. [1]

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Epilepsy

Epilepsy describes a set of conditions associated with paroxysmal neurologic function observed as seizures that include convulsive and other neurosensory disturbances. About 10% of the population is estimated to have epilepsy. The clinical signs associated with tonic-clonic convulsions are quite distinctive and can be disconcerting to dental personnel when confronted with the situation while the patient is in the dental chair. To eliminate potential treatment issues, guidelines are presented below. [2, 3, 4, 5, 26]

Prior to and during dental treatment

Ensure the patient has been compliant with medication coverage. If there are any questions regarding compliance, contact the patient’s physician.

Ascertain that the patient has no toxicity with the medication taken and that mental function is normal.

Patients taking valproic acid (Depakene) may have increased bleeding during procedures. If there are acknowledged problems, order a bleeding time assessment prior to treatment and consult with a physician if the values are questionable.

During dental treatment, be aware that a grand mal seizure could occur. If a seizure occurs, place the chair back to a supine position, turn the patient to the side, and keep the patient comfortable without restraint until it has passed. Placement of a tongue blade is not recommended unless the patient is aware of an impending seizure and can assist in its placement.

If injury to the lip or tongue occurs during a seizure, appropriate treatment such as suturing of lacerations, localization of potential fractures, removal of fragments, and follow-up dental treatment is required.

If dental treatment necessitates the replacement of one or more missing teeth, restoration of the missing teeth using fixed appliances is preferable over removal-type prosthetics. In addition, the clinician needs to be cognizant of potential fracture of anterior full-coverage restorations such as complete porcelain crowns. It may be preferable to use three-quarter gold crowns with porcelain veneers if concern exists regarding the frequency of seizures.

Oral medicine aspects

Monitor gingival hyperplasia secondary to the use of anticonvulsant medication (eg, phenytoin).

Monitor oral hygiene and provide educational information and training to facilitate the patient’s ability to manage his or her oral health effectively; evidence suggests meticulous oral hygiene may reduce or prevent gingival hyperplasia.

Subluxation of the temporomandibular joint can occur during seizure episodes. No specific treatment is necessary unless this results in joint hypermobility and subsequent frequent nonseizure subluxation.

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Stroke

A neurovascular accident (stroke) is often fatal but may be precipitated by multiple non–life-threatening events that if identified, can reduce the risk of an acute and serious outcome when the patient is in dental treatment. Knowing the clinical signs and symptoms of a stroke is important in managing older patients with longstanding cardiovascular disease. [6, 7, 8, 9, 10]

Prior to and during dental treatment

The clinician should be aware that patients with longstanding hypertension and cerebrovascular disease are at increased risk of a cerebrovascular accident. Stroke is the third most common cause of death in the United States.

The signs of a stroke can be quite subtle. A major event may be associated with many transient ischemic attacks (TIAs), or minor strokes, that last for a few minutes. In a TIA, dizziness, diplopia, hemiplegia, and altered speech may occur. A thorough history of possible patient symptoms prior to treatment may provide useful information regarding the possibility of an impending major event during treatment, as several TIAs occurring close together often precede a major stroke. This is important because the clinician should be aware that a patient experiencing a minor event in the office may have a major event after leaving the office, leading to mortality.

The warning signs of a severe stroke event include sudden or temporary weakness or numbness of the face and other body parts, loss of speech or difficulty speaking or understanding speech, visual changes, and unexplained loss of balance or dizziness.

In patients with an identified increased risk of stroke pretreatment or who exhibit signs of a mild TIA occurring during treatment, a follow-up phone call is recommended. Any patient exhibiting signs or symptoms of a TIA or stroke requires immediate medical referral.

If an obvious stroke has occurred during a dental procedure, the patient’s airway must be maintained until emergency medical personnel arrive.

Dental treatment of patients with stroke residual

In patients who have experienced physical deficits (eg, hand-eye coordination problems, arm or hand deficit, masticatory muscle weakness), personal oral hygiene efforts may be compromised. Treatment planning should include the following:

  • Comprehensive oral hygiene instruction that may include instruction on use of an electric toothbrush or a large hand-held toothbrush or water irrigation instrument coupled with plaque-revealing tablets; running a washcloth through the vestibule can help to reduce accumulation of food matter
  • Recommendation regarding anticaries preparations, including rinses containing fluoride and xylitol or the use of xylitol lozenges (eg, XyliMelts) to help reduce the oral bacterial burden of Streptococcus mutans
  • The possible need for an antifungal prescription, as the accumulation of saliva in patients with facial palsy may be problematic at the corners of the mouth and can predispose the patient to fungal infection
  • Awareness that depending on the type of stroke, the poststroke patient may have been prescribed anticoagulant medication
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Parkinson Disease

Parkinson disease, resulting from the degeneration of cells in the substantia nigra, causes a number of motor symptoms that can complicate dental management. These include tremors, involuntary movements, facial and limb rigidity, bradykinesia (particularly as it relates to swallowing), and akathisia (ie, restlessness). During dental treatment, these disabilities must be taken into consideration. Following is a list of specific recommendations for managing the dental patient with Parkinson disease. [10, 11, 12, 13, 14, 15]

Predental treatment

The same oral hygiene information should be offered to the Parkinson disease patient as the stroke patient. Recommend the use of an electric toothbrush or a large hand-held toothbrush or water irrigation instrument coupled with plaque-revealing tablets. Running a washcloth through the vestibule can help to reduce accumulation of food matter.

Patients with Parkinson disease may not be able to effectively communicate their needs, so a family member or caregiver should be present when the treatment plan is presented to the patient. If there is cognitive decline, this is particularly important to ensure understanding in full of the risks and benefits of proposed intervention (eg, multiple extractions, periodontal treatment).

Dental treatment recommendations

Severe tremors and involuntary jaw and limb movements can present difficulty in the management of the patient. This is particularly true for the patient in whom the medication dosage is incorrect or in whom medication has not been completely effective. To gain the maximum benefit from prescribed drugs, patients should be instructed to take prescribed medication as scheduled, and dentistry appointments should be made within a short time frame following their use.

Since facial musculature tonicity associated with Parkinson disease can lead to the patient’s inability to express emotion, it is important for the treating clinician to be sympathetic and attentive to eye or other limb movements that could suggest pain during a procedure.

Bradykinesia that causes swallowing difficulty is also a potential problem for Parkinson disease patients during treatment. Adequate suction of fluid is imperative during dental procedures, including those involving dental hygiene.

Temperature regulation may be compromised if the patient has comorbid Shy-Drager disease (an abnormality of the autonomic nervous system); placement of a blanket over the patient may help maintain warmth.

Dental reconstruction that involves the occlusal surfaces needs to be tailored to the fact that bruxism may be severe in patients with Parkinson disease. The occlusion of placed restorations should be kept as flat as possible to avoid breakage of the restoration or teeth.

Care should be taken to not overstress the patient with Parkinson disease. Short appointments are helpful.

The patient with Parkinson disease may have difficulty placing an oral sleep-apnea appliance. This approach to the management of sleep apnea is discouraged. If apnea is a confounding problem, medical consultation is required and use of a continuous positive-airway pressure (CPAP) device should be considered.

Some Parkinson patients develop temporomandibular joint problems, particularly hypermobility of the mandible and frequent subluxation. This is a difficult problem to treat if the patient also has comorbid severe bruxism. In some cases, patients benefit from Herbst appliances with strong elastics worn at night. However, the problem of patient placement in the face of muscle rigidity and bradykinesia is also a concern in these cases.

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Myasthenia Gravis

Myasthenia gravis results in generalized muscle weakness, including the muscles of the face, tongue, and neck. Patients with myasthenia gravis may hold their jaws in a slack position with the mouth open. The problem becomes worse towards the end of the day and with fatigue or stress. [16, 17, 18, 19, 20]

Dental considerations

Dental treatment should be scheduled at a time when the patient is not fatigued, and preferably during remission of the disease. Appointments need to be made 1-2 hours after the patient has taken his or her medication (an anticholinesterase, eg, pyridostigmine), preferably in the morning.

Consideration should be made for reducing stress prior to and during the dental appointment. Anxious patients may benefit from a low dose of an anxiolytic benzodiazepine such as such as diazepam (Valium) or lorazepam (Ativan) taken prior to treatment.

Procaine anesthetics should not be used for local anesthesia.

In the patient with a dental abscess, only the antibiotics penicillin or erythromycin can be safely used to treat infection. Drugs to be avoided include the tetracyclines, clindamycin, lincomycin, sulphonamides, and aminoglycosides. For pain, paracetamol coupled with a narcotic (eg, codeine) may be helpful. Aspirin has been associated with cholinergic crisis in patients taking anticholinesterases, so it should be avoided.

Since patients with myasthenia gravis often have impaired respiration, special consideration needs to be taken for maintaining oxygenation during procedures involving conscious sedation. In fact, it is best to treat these patients in an inpatient hospital setting. The drugs often used in conscious sedation (eg, opioids, barbiturates) may potentiate or aggravate breathing difficulty in myasthenia gravis patients.

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Facial Paralysis

Conditions causing loss of function of the seventh cranial nerve include multiple sclerosis, infection (eg, syphilis, HIV disease, Lyme disease, leprosy), sarcoidosis, cholesteatoma, Bell palsy, and several intracranial problems (eg, tumor, trauma). Upper and lower motor neuron abnormality can be differentiated by the resulting loss of function. Many of these conditions affect oral health. [21, 22, 23, 24, 25, 27]

Dental considerations

Loss of taste can occur and is associated with abnormality of the chorda tympani.

In cases involving Bell palsy, the corneas should be protected during dental treatment.

In other cases of facial palsy, there may be accumulation of food debris, potentially increasing dental plaque. Patients should be instructed in techniques to be used after eating aimed at eliminating the material.

Leaking of saliva at the corners of the mouth may predispose the patient to angular cheilitis. An antifungal cream appropriately placed may be useful if fungal infection emerges.

Placement of a splint may be helpful in improving facial aesthetics. Other approaches may include appliances anchored to the teeth. Suturing may also be useful.

Pain in the region of the ear/temporomandibular joint may be the result of inflammation of the geniculate ganglia of the facial nerve. Avoidance of misdiagnosis (temporomandibular joint pathology) is important.

Facial dyskinesias can lead to tongue or jaw movement that can confound dental treatment. Bruxism can lead to tooth wear or fracture. Patients with facial dyskinesias may benefit from predental treatment prescription of a benzodiazepine.

Sensory deficits associated with conditions involving the fifth cranial nerve may be the result of conditions such as Paget disease or peripheral lesions involving the bones and the canals.

Brain stem lesions can affect mastication and cause mouth-opening difficulty.

Facial paralysis can result from alveolar nerve blocks. In some cases, this can be permanent.

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