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Earn 1 CE credit This course was written for dentists, dental hygienists, and assistants. Clinical Considerations for Treating the Dental Patient with ALS A Peer-Reviewed Publication Written by Kimberly M. Parsons, MEd, CDA, EFDA, RDH and Amy J. Schneider, LDH, CDA, BS Abstract Amyotrophic lateral sclerosis (ALS) is a progressive degenerative disorder that affects the nervous system, particularly the motor neurons. It may affect either spinal or bulbar neurons, which classifies how an individual’s symptoms present. The prognosis for individuals with ALS is not promising, usually resulting in death within three to five years of diagnosis. Most management of amyotrophic lateral sclerosis focuses on palliative care, determined by the affected individual’s ongoing symptoms. An essential component of palliative care is management of the individual’s oral conditions. Manifestations of ALS may affect the dental practitioner’s care of patients with this disease. These modifications will be dependent upon the individual’s current symptoms and needs. Educational Objectives At the conclusion of this educational activity participants will be able to: 1.Describe amyotrophic lateral sclerosis (ALS) and the manner(s) in which it may present 2.Recognize common types of palliative care offered to individuals with ALS 3.Describe the symptoms associated with spinal and bulbar degeneration 4.Integrate appropriate modifications into the dental treatment of patients with ALS Author Profile Kimberly M. Parsons, MEd, CDA, EFDA, RDH, is the dental assisting program chair and an assistant professor of dental assisting/dental hygiene at the University of Southern Indiana. Her scholarly activities include research in the areas of educational technologies and dental education. Ms. Parsons has been a dental hygienist for 13 years, practicing in Arizona, Indiana, Kentucky, and Michigan. She can be reached at [email protected]. Amy J. Schneider, LDH, CDA, BS is an instructor of dental assisting/dental hygiene at the University of Southern Indiana. She has been practicing dental hygiene for 18 years in the state of Indiana. Ms. Schneider has personal experience with individuals with ALS. Author Disclosure Kimberly M. Parsons and Amy J. Schneider have no commercial ties with the sponsors or providers of the unrestricted educational grant for this course. Go Green, Go Online to take your course Publication date: June 2014 Expiration date: May 2017 Supplement to PennWell Publications PennWelldesignatesthisactivityfor1continuingeducationalcredit. DentalBoardofCalifornia:Provider4527,courseregistrationnumberCA#01-4527-14016 “ThiscoursemeetstheDentalBoardofCalifornia’srequirementsfor1unitofcontinuingeducation.” ThePennWellCorporationisdesignatedasanApprovedPACEProgramProviderbythe AcademyofGeneralDentistry.Theformalcontinuingdentaleducationprogramsofthis programproviderareacceptedbytheAGDforFellowship,Mastershipandmembership maintenancecredit.Approvaldoesnotimplyacceptancebyastateorprovincialboardof dentistryorAGDendorsement.Thecurrenttermofapprovalextendsfrom(11/1/2011)to (10/31/2015) Provider ID# 320452. This educational activity was developed by PennWell’s Dental Group with no commercial support. This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content. Requirements for Successful Completion: To obtain 1 CE credit for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products or services discussed in this educational activity. Heather can be reached at [email protected] Educational Disclaimer: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. Image Authenticity Statement: The images in this educational activity have not been altered. Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents the most current information available from evidence based dentistry. Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient and improvements in oral health. Registration: The cost of this CE course is $20.00 for 1 CE credit. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives At the conclusion of this educational activity participants will be able to: 1. Describe amyotrophic lateral sclerosis (ALS) and the manner(s) in which it may present 2. Recognize common types of palliative care offered to individuals with ALS 3. Describe the symptoms associated with spinal and bulbar degeneration 4. Integrate appropriate modifications into the dental treatment of patients with ALS Abstract Amyotrophic lateral sclerosis (ALS) is a progressive degenerative disorder that affects the nervous system, particularly the motor neurons. It may affect either spinal or bulbar neurons, which classifies how an individual’s symptoms present. The prognosis for individuals with ALS is not promising, usually resulting in death within three to five years of diagnosis. Most management of amyotrophic lateral sclerosis focuses on palliative care, determined by the affected individual’s ongoing symptoms. An essential component of palliative care is management of the individual’s oral conditions. Manifestations of ALS may affect the dental practitioner’s care of patients with this disease. These modifications will be dependent upon the individual’s current symptoms and needs. Introduction Amyotrophic lateral sclerosis (ALS), commonly referred to as Lou Gehrig’s disease, is a progressive degenerative disorder that affects the nervous system, particularly the motor neurons.1, 2 It may affect either spinal or bulbar neurons, which classify how symptoms present in the individual.1 Currently, the cause of ALS is unknown, although research indicates the possibility of genetic and environmental factors affecting its incidence.3 It is important for health care practitioners to understand amyotrophic lateral sclerosis to enable them to make modifications to patient care as needed. Epidemiology and Prognosis The sporadic form of amyotrophic lateral sclerosis, characterized by motor neuron degeneration and premature death, comprises the majority of all ALS cases.4 Juvenile-onset ALS, where disease onset occurs before age 30, comprises only five percent of all ALS cases. Familial ALS occurs only five to ten percent of the time. The more common sporadic form comprises the vast majority of cases. The average onset of sporadic ALS occurs between 55 and 65 years, with a median age of 64 years.4 There is a slightly higher incidence of sporadic ALS in men than women, with a ratio of 1.5:1.4 The age of onset of familial ALS occurs approximately ten years earlier than sporadic ALS, with males and females equally affected. The prognosis for individuals with amyotrophic lateral sclerosis is not promising. Although there are possible treat- 84 06. 2014 | www.DENTALECONOMICS.com | @dentalmagazine ments on the horizon, they are still in early developmental stages. This rapidly progressive disease usually results in death within three to five years of diagnosis, primarily from respiratory complications.5 Slower disease progression can occur in younger individuals and those whose disease first presents in the extremities. Only ten percent of individuals with ALS live longer than eight years.5 Management of the Disease Currently, management of ALS patients primarily focuses on palliative care.6,7,8,9 Palliative care is a philosophy of care that addresses the prevention and relief of suffering.6 Symptoms of ALS greatly impact an individual’s quality of life and, therefore, must be continually managed.8 A multidisciplinary approach to care provides the individual with ALS with the most optimal care choices, thus enhancing their quality of life.6 The National Consensus Project Clinical Practice Guidelines for Quality Palliative Care (NCPQPC) outline eight domains of palliative care.6 These include: (1) physical care, such as pain management and physical symptoms; (2) psychological care that addresses depression, loss, grief, and other symptoms experienced by both the patient and his/her loved ones; (3) social systems available for the patient; (4) faith-based beliefs; (5) cultural norms that are integrated into patient care; (6) ethical and legal choices for the patient and family to define; (7) designation of property and other legal aspects of care for the imminently dying patient; and (8) structure and processes associated with the outcomes of ALS.6,8 The affected individual’s ongoing symptoms determine the type of palliative care provided.7 Some common types of palliative care offered to individuals with amyotrophic lateral sclerosis may include medication for the following symptoms: depression or anxiety, drooling, bronchial secretions, pain, pathological laughing, constipation, gastro-esophageal reflux, sleep disturbances, and venous thrombosis or pulmonary embolism. In addition, dietary changes, increased hydration, physiotherapy, and/or stretching may be utilized to address other symptoms.7 Management of oral conditions may be required as part of the palliative treatment of an individual with ALS. Oral conditions may arise due to the effects of medication, sialorrhea caused by ineffective clearance of saliva, thickened mucus, and/ or xerostomia that arises from mouth breathing.10 Management of these oral conditions is essential for patient comfort. Adequate hydration and the use of a room humidifier can be effective in decreasing xerostomia from mouth breathing during sleep.10 In addition, an expectorant or beta-adrenergic blocking agents, such as propranolol or metoprolol may be effective in 75% of patients experiencing thickened secretions.10 To address sialorrhea, an anticholinergic, such as glycopyrolate can be 90% effective.10 Another option for sialorrhea is the injection of botulinum toxin into the parotid and submandibular glands. However, this type of care may result in temporary side effects, such as bulbar and masseter muscle weakness.10 Table 1 Dental Treatment Modifications ALS Symptom Treatment Modification Advanced disease Care provider to learn oral home care Dysphagia Semi-supine treatment position Dysphagia Nutritional counseling Excessive saliva Additional practitioner to assist with HVE Muscle weakness/spasticity Shorter appointment time or frequent breaks during appointment Muscle weakness/spasticity Bite block/assistance with holding mouth open Currently, the only medication approved to slow the course of the amyotrophic lateral sclerosis disease process is riluzole.3, 11 Riluzole, originally developed as an anti-epileptic drug, inhibits the release of glutamate. However, this drug’s mechanism of action in ALS is currently unknown.3 Presently, the use of riluzole prolongs the life of an individual with ALS by approximately four months. Its safety and efficacy have been established for individuals with ALS, including those with advanced disease and in elderly patients.3 More than half of ALS patients in the United States utilize it.3 Symptoms Associated with Spinal Degeneration Individuals that experience degeneration of the spinal neurons usually exhibit weakness or spasticity of the lower limb muscles. As a result, they may also experience disturbances in gait.1 Initial presentation of symptoms in an individual with spinal neuron involvement includes changes in the functional strength and coordination of lower extremity muscles. Eventually this progresses to muscles of the upper extremities, and finally to the bulbar muscles.1 Symptoms Associated With Bulbar Degeneration Individuals with involvement of the bulbar neurons present initially with speech problems resulting in dysarthria (motor speech disorder), deterioration of respiratory function, and weakness of the muscles of deglutition, which results in dysphagia.1 Dysphagia occurs in each ALS patient with bulbar involvement and eventually occurs in all ALS patients, regardless of the time of disease onset. Dysphagia in ALS patients is characterized by impairment of the oral and pharyngeal phases of swallowing. Patients with amyotrophic lateral sclerosis present with abnormal lingual movement. This abnormality makes the act of swallowing effortful, inefficient, and fatiguing.1,12 Decreased tongue strength may also result in decreased frequency of swallowing. This leads to accumulation of saliva in the oral cavity, which can result in drooling, aspiration, and coughing.9 Salivary control, along with other secretions, is a common challenge for patients with ALS.1 Dental Treatment Modifications Manifestations of amyotrophic lateral sclerosis affect the dental practitioner’s care of patients with ALS (Table 1). Due to the high occurrence of dysphagia in individuals with ALS,1,12 modification of patient treatment in the dental chair is often necessary. First, the dental practitioner may need to modify patient positioning. Since pooling of saliva can occur in the oral cavity, the patient may be more comfortable in a semi-supine position to help control aspiration of excess saliva. In addition, the dentist and dental hygienist may need another practitioner present to assist him/ her with high volume evacuation to help keep saliva from pooling and interfering with dental work, and to make the patient more comfortable. Third, shorter appointments, or appointments with built in breaks, may be necessary for the patient with ALS. Since individuals with ALS experience muscle weakness and spasticity,1 it can be difficult for them to keep their mouths open for the time necessary to complete treatment during a regular appointment. Treatment may need to be broken down into smaller divisions to allow for shorter appointment times. Frequent breaks may also need to occur during the appointment. In addition, a bite block may be necessary to hold the mouth open for the duration of the dental procedure. Many ALS patients have difficulty swallowing,9 which can affect an individual’s intake of food. As a result, nutritional counseling by the dental practitioner may be warranted. Oral health education regarding nutrition and its effects on the oral cavity is important in emphasizing how food intake can affect the health of an individual’s intraoral tissues. The health of the intraoral tissues can also influence the individual’s food choices and nutrient intake. This important cycle should be addressed with ALS patients so that the dental professional and patient can work together to devise a nutritional plan that will complement the patient’s current physiological needs. Lastly, oral health education may need to address modification of home care due to loss of muscular function.1 These alterations will include modification of the daily homecare regimen, such as modified toothbrushes or brushing techniques. In addition, the introduction of auxiliary aides may enable the patient to enhance biofilm removal. Individuals who have lost substantial motor function or who experience severe spasticity may need to bring a care provider, such as a family member, to their dental appointment to assist in the nutritional and homecare planning. Conclusion Amyotrophic lateral sclerosis, a degenerative neural disorder, ultimately affects multiple body systems. Its poor prognosis and rapid progression lead to quick, visible symptoms.5 The initial symptoms vary according to the type of neural involvement in the individual. All patients afflicted with ALS show signs of dysphagia and other oral complications. The dental implications of ALS span both home and professional clinical care. As such, it is important for the dental practitioner to have an understanding of the disease and the modifications needed to treat patients with ALS. @dentalmagazine | www.DENTALECONOMICS.com | 06.2014 85 References 1. Easterling C, Antinoja J, Cashin S, Barkhaus PE. Changes in tongue pressure, pulmonary function, and salivary flow in patients with amyotrophc lateral sclerosis. Dysphagia 2013; 28(2): 217-225. 2. Paris G, Martinaud O, Petit A, Cuvelier A, Hannequin D. Oropharyngeal dysphagia in amyotrophic lateral sclerosis alters quality of life. J Oral Rehabil 2013; 40(3): 199-204. 3. Gordon P. Amyotrophic lateral sclerosis: pathophysiology, diagnosis, and management. CNS Drugs 2011; 25(1): 1-15. 4. Escuro AA. Nutrition support in amyotrophic lateral sclerosis: from diagnosis through terminal phase. Support Line 2012; 34(2): 8-19. 5. Fallon L. Amyotrophic lateral sclerosis. Gale Encyclo Neurol Disor 2005. Available at: http://www.encyclopedia.com/topic/amyotrophic_lateral_sclerosis.aspx 6. Davis M, Lou JS. Management of amyotrophic lateral sclerosis (ALS) by the family nurse practitioner: A timeline for anticipated referrals. J Am Acad Nurse Pract 2011; 23(9); 464472. 7. Corcia P, Meininger V. Management of amyotrophic lateral sclerosis. Drugs 2008; 68(8); 1037-1048. 8. Gardner DD. Amyotrophic lateral sclerosis in the older adult. AARC Times. November 2011; 35(11): 22-25. 9. Britton D., Cleary S., Miller R. What is ALS and what is the philosophy of care? Perspect Swallow Swallow Disorders 2013; 22: 4-11. 10. Valente SM. Life with Lou Gehrig’s disease: managing ALS symptoms. The Nurs Pract 2007; 32(12); 26-34. 11. Blackhall LJ. Amyotrophic lateral sclerosis and palliative care: where we are, and the road ahead. Muscle Nerve 2012; 45(3): 311-318. 12. Fattori B, Grosso M, Bongioanni P, et al. Assessment of swallowing by oropharyngoesophageal scintigraphy in patients with amyotrophic lateral sclerosis. Dysphagia 2006; 21(4): 280-286. Author Profile Kimberly M. Parsons, MEd, CDA, EFDA, RDH, is the dental assisting program chair and an assistant professor of dental assisting/dental hygiene at the University of Southern Indiana. Her scholarly activities include research in the areas of educational technologies and dental education. Ms. Parsons has been a dental hygienist for 13 years, practicing in Arizona, Indiana, Kentucky, and Michigan. She can be reached at [email protected]. Amy J. Schneider, LDH, CDA, BS is an instructor of dental assisting/ dental hygiene at the University of Southern Indiana. She has been practicing dental hygiene for 18 years in the state of Indiana. Ms. Schneider has personal experience with individuals with ALS. Author Disclosure Kimberly M. Parsons and Amy J. Schneider have no commercial ties with the sponsors or providers of the unrestricted educational grant for this course. Online Completion Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page. Questions 1.What is the name for the progressive degenerative disorder that affects the nervous system, particularly the motor neurons? a. Amyotrophic latent sclerosis b. Amyotrophic lateral spasticity c. Amyotrophic lateral sclerosis d. Alveolar lateral sclerosis 2.What form of ALS comprises the majority of ALS cases? a. Juvenile onset b.Sporadic c.Familial d. Geriatric onset 3.Which of the following groups is most often inflicted with sporadic ALS? a.Men b.Women c.Children d. Men and women are equally inflicted 4.Death in patients with ALS occurs primarily from which of the following complications? 86 a.Cardiac b.Skeletal c.Nervous d.Respiratory 5.What determines the type of palliative care provided to individuals with ALS? a. Length of time afflicted with ALS b. Individual’s current financial situation c. Individual’s ongoing symptoms d. Individual’s prognosis 6.Which of the following oral conditions may arise as a result of medications used for ALS patients? a. Thickened mucus b.Xerostomia c.Sialorrhea d. All of the above 7.Management of sialorrhea may be achieved through which of the following? a. Use of an anticholinergic b. Chewing medicinal gum c. Use of a room humidifier d. Adequate hydration 06. 2014 | www.DENTALECONOMICS.com | @dentalmagazine 8.A medication currently approved to slow the course of ALS is: a.Metoprolol b.Warfarin c.Riluzole d. There is no approved medication 9.Individuals with degeneration of the spinal neurons initially exhibit: a. Difficulty maintaining control of the head and neck b. Weakness or spasticity of the lower limb muscles c. Problems with speech d. Tingling or numbness of the hands 10. Individuals with degeneration of the bulbar neurons initially exhibit: a. Difficulty maintaining control of the head and neck b. Weakness or spasticity of the lower limb muscles c. Problems with speech d. Tingling or numbness of the hands ANSWER SHEET Clinical Considerations for Treating the Dental Patient with ALS Name: Title: Specialty: Address:E-mail: City: State:ZIP:Country: Telephone: Home ( ) Office ( Lic. Renewal Date: ) AGD Member ID: Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 1 CE credit. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822 If not taking online, mail completed answer sheet to Educational Objectives Academy of Dental Therapeutics and Stomatology, 1. Describeamyotrophiclateralsclerosis(ALS)andthemanner(s)inwhichitmaypresent P.O. Box 116, Chesterland, OH 44026 or fax to: (440) 845-3447 2. Recognize common types of palliative care offered to individuals with ALS A Division of PennWell Corp. 3. Describe the symptoms associated with spinal and bulbar degeneration 4. Integrate appropriate modifications into the dental treatment of patients with ALS Course Evaluation 1. Were the individual course objectives met? Objective #1: Yes No Objective #2: Yes No Objective #3: Yes No Objective #4: Yes No For IMMEDIATE results, go to www.ineedce.com to take tests online. Answer sheets can be faxed with credit card payment to (440) 845-3447, (216) 398-7922, or (216) 255-6619. Payment of $20.00 is enclosed. (Checks and credit cards are accepted.) Pleaseevaluatethiscoursebyrespondingtothefollowingstatements,usingascaleofExcellent=5toPoor=0. 2. To what extent were the course objectives accomplished overall? 5 43210 3. Please rate your personal mastery of the course objectives. 5 43210 4. How would you rate the objectives and educational methods? 5 4 3210 5. How do you rate the author’s grasp of the topic? 5 4 3210 6. Please rate the instructor’s effectiveness. 5 4 3210 7. Was the overall administration of the course effective? 5 4 3210 8. Please rate the usefulness and clinical applicability of this course. 5 43210 9. Please rate the usefulness of the supplemental webliography. 5 4 3210 10. Do you feel that the references were adequate? YesNo 11. Would you participate in a similar program on a different topic? If paying by credit card, please complete the following: MC Visa AmEx Discover Acct. Number: ______________________________ Exp. Date: _____________________ Charges on your statement will show up as PennWell Yes oN 12. Ifanyofthecontinuingeducationquestionswereunclearorambiguous,pleaselistthem. ________________________________________________________________ 13. Was there any subject matter you found confusing? Please describe. _________________________________________________________________ 14. H ow long did it take you to complete this course? _________________________________________________________________ 15. What additional continuing dental education topics would you like to see? AGD Code 754 _________________________________________________________________ PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. COURSE EVALUATION and PARTICIPANT FEEDBACK We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: [email protected]. INSTRUCTIONS All questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be mailed within two weeks after taking an examination. COURSE CREDITS/COST All participants scoring at least 70% on the examination will receive a verification form verifying 1 CE credit. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00. PROVIDER INFORMATION PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, not does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP ar www.ada. org/cotocerp/ The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to (10/31/2015) Provider ID# 320452 RECORD KEEPING PennWell maintains records of your successful completion of any exam for a minimum of six years. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt. Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. CANCELLATION/REFUND POLICY Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. IMAGE AUTHENTICITY The images provided and included in this course have not been altered. © 2014 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell Customer Service 216.398.7822 ALS614DE