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Parkinson’s Disease Oral Health: Interprofessional Coordination of Care 1 Regarding his battle with Parkinson’s disease, actor Michael J. Fox remarked, “Acceptance doesn’t mean resignation; it means understanding that something is what it is, and that there’s got to be a way through it.” As members of the interprofessional health care team for patients with Parkinson’s disease, we can serve our patients by showing them the way. 2 This presentation will focus on the oral health concerns and care of patients with Parkinson’s disease, with a particular focus on the role of the interprofessional health care team. We will begin with a background on Parkinson’s disease and describe its constellation of symptoms. Second, we will discuss how oral health and systemic health are linked and stress the consequent importance of each member of the interprofessional health care team. Next, we will review four prevalent oral symptoms of Parkinson’s disease and highlight the role of various clinicians. Finally, we will offer advice for oral care in patients with Parkinson’s disease to ensure optimal dental appointments and home oral hygiene. 3 Let’s begin with an Introduction to Parkinson’s disease. 4 Parkinson’s disease is a progressive, neurodegenerative disorder well known for its motor symptoms. Patients experience head tremors and a lack of facial expressions, tremor of the extremities, a shuffling gait with short steps, rigidity with stooped posture, and bradykinesia, which is slowness of movement. Parkinson’s disease also produces non-motor symptoms encompassing multiple body systems. Examples of non-motor symptoms include loss of smell, urinary incontinence, swallowing difficulty, and cognitive decline, all of which negatively affect the quality of life of these patients. 5 The severity of Parkinson’s disease can be ranked in one of 5 stages according to the Hoehn & Yahr scale. Understanding how the different stages affect a patient can aid health professionals in adapting appointments, examinations, and treatment plans to the needs of the patient. In stage I, there is no, or minimal, functional impairment. In stage II, posture and balance are normal though now both sides of the body are affected. Stage III brings imbalance upon standing or walking, but the patient remains independent. In stage IV, imbalance is now disabling and the patient requires assistance. In stage V, the patient is cachectic (wasting muscles and loss of weight), restricted to bed or a wheelchair and needs complete assistance for activities of daily living. 6 Parkinson’s disease affects 1 in 100 people over the age of 60. More than 60,000 new cases are diagnosed every year. Parkinson’s disease can begin before the age of 50, as in the case of Michael J. Fox, and is then called ‘early onset.’ 7 With 7 million people suffering Parkinson’s disease worldwide, it is ranked as the second most common neurodegenerative disorder after Alzheimer’s disease. With a growing aging population, caring for patients with Parkinson’s disease will be increasingly important and challenging for health professionals. The disease is often referred to as idiopathic because the majority of cases have no known cause and only a small percentage of them can be associated with a genetic origin. For example, just 15% of patients have a first-degree relative with the disease and only 5% of patients have a gene mutation known to cause Parkinson’s disease. Although most studies linking environmental factors to Parkinson’s disease have been inconclusive, head injuries and exposure to pesticides may increase an individual’s risk. The current view suggests that both genetic and environmental factors affect important cellular processes leading to a constellation of motor and non-motor symptoms. Management of the disease becomes challenging, because not every patient develops the same set of symptoms. 8 The consistent feature of Parkinson’s disease is the death of neurons containing the neurotransmitter dopamine in the substantia nigra pars compacta of the brain, a structure involved in the regulation of voluntary movement. Thus, progressive death of these neurons leads to the characteristic parkinsonian motor symptoms: bradykinesia, resting tremor, rigidity, and postural/gait instability. Another important pathological feature of Parkinson’s disease is the accumulation of abnormally folded alpha-synuclein protein into inclusions called Lewy bodies. Lewy pathology is used as a biomarker for neurodegeneration in Parkinson’s disease, and these protein aggregates may have a role in neuronal death. 9 Besides the characteristic motor symptoms of Parkinson’s disease, patients may also present with a variety of non-motor symptoms that further burden daily life. These include behavioral and cognitive dysfunctions, autonomic system dysfunctions, sleep related dysfunctions, sensory dysfunctions and medication side effects. Note that symptoms can appear years before a patient receives the diagnosis of Parkinson’s disease. During the later stages of Parkinson’s disease, both motor and non-motor symptoms become drug resistant, worsen, and lead to rapid deterioration in quality of life and even death. For example, a freezing gait may lead to falls; and dysphagia may lead to choking or aspiration pneumonia. 10 We will now discuss the link between oral and systemic health, and the importance of the interprofessional health care team. 11 Patients and caregivers may be tempted to believe that the ravages of motor symptoms require all of their attention. Yet, oral health problems arise directly and indirectly from the progression of Parkinson’s disease and require attention as well. Neuronal deterioration leads directly to dysphagia, whereas tremors indirectly affect a patients’ oral health by reducing their ability to floss and brush their teeth. Compounding the problem, depression and dementia reduce the patient’s willingness or memory to perform oral hygiene tasks. Dry mouth is a direct medication side effect. Because many patients may be seen regularly by a primary care physician or nurse practitioner, it is important for these clinicians to assess the oral cavity and make the necessary referrals to dentists. Further, these clinicians should also provide basic oral health education as a preventive measure. 12 We just discussed how Parkinson’s disease is a systemic disease with impacts on oral health. Oral health, in turn, influences systemic health. Three primary mechanisms underscore this connection. Bacteria found in periodontal pockets may enter the bloodstream through lacerations of inflamed tissue and cause bacteremia. If bacteria persistently enter the bloodstream, they may eventually be able to avoid host defense mechanisms and travel to other areas of the body. Second, is chronic inflammation. Inflammation is a mechanism body tissues use to clean the remains of injury and start tissue repair. Gum damage can be caused by bacterial toxins. In response, the body routes macrophages to the site to clean up cellular debris. If not resolved, the macrophages secrete chronic inflammatory mediators that can circulate beyond the oral cavity. These mechanisms can lead to systemic problems including sinusitis, atherosclerotic plaque and aspiration pneumonia. Third, is immune response. The immune system creates antibodies against alien pathogens and their toxins in the body. This is a protective mechanism; however, cross-reactivity of some antibodies may cause lesions in the arterial walls. Because there is evidence for an oral health link to diseases like diabetes, cardiovascular disease, and respiratory tract disease, all providers must be aware of the relation and play a role in educating patients. The Smiles for Life oral health curriculum website is an invaluable resource for the integration of oral health and primary care. 13 The diversity of symptoms seen in patients with Parkinson’s disease cannot be treated by a single health care provider. An interprofessional health care team is needed. Initially, a patient typically visits his or her primary health care physician or nurse practitioner. As symptoms progress, these clinicians may refer patients to other health care providers, such as a neurologist to manage motor symptoms, a physical therapist to address activities of daily living, a speech therapist to manage voice and swallowing problems, and a dietician to prevent malnutrition in those patients with swallowing problems. An effective interprofessional health care team stays attentive to the patient’s changing health and alerts other team members through consultation, communication, and referral. All team members have a responsibility to educate patients about the oral manifestations of Parkinson’s disease, recommend prevention strategies, and refer to a dentist. 14 We will review four common oral health symptoms of Parkinson’s disease. These include tooth and gum loss, xerostomia (dry mouth), drooling and sialorrhea (excess saliva in the mouth), and dysphagia (swallowing difficulty). 15 As motor symptoms become more severe and interfere with daily oral hygiene routines, patients with Parkinson’s disease can develop caries and periodontal disease. Caries, commonly known as cavities, are a form of tooth decay due to an imbalance in the biofilm that coats teeth, leading to acidification, tooth demineralization, and erosion. Periodontal disease encompasses immuno-inflammatory disorders that destroy the structures supporting teeth. They include gingivitis (gingival inflammation) and periodontitis (gingival inflammation, elimination of periodontal ligament and alveolar bone). One study found that about 50% of patients with Parkinson’s disease report having some degree of trouble brushing their teeth. Research reports conflict, though, as to whether patients with Parkinson’s disease have more caries than healthy individuals. Investigations of periodontal disease are more consistent. Six independent studies from different countries found that patients with Parkinson’s disease have a higher rate of periodontal disease than the control population, suggesting that patients with Parkinson’s disease are indeed in need of oral health intervention. Whereas the time of onset of caries and periodontal disease in patients with Parkinson’s disease varies, studies agree that these worsen with Parkinson’s disease severity and its associated cognitive decline. 16 An individual’s quality of life is closely related to his or her oral health. Tooth and gum loss lead directly to difficulties chewing, speaking and maintaining self-esteem. These, in turn, contribute to nutritional imbalance, fatigue and depression. As discussed, periodontal disease is associated with a higher risk of systemic diseases, such as cardiovascular problems and arthritis. 17 Patients with Parkinson’s disease may suffer several motor and non-motor symptoms that can impair their ability to brush their teeth. It is recommended that dental professionals test a patient’s ability to perform oral hygiene using the Toothbrushing Ability Test or the Oral Hygiene Performance Test. The most basic diagnostic methods for caries are the visual-tactile methods, in which the dentist probes inside the mouth with different dental instruments. This method is inexpensive and does not expose the patient to radiation; however, it is a subjective evaluation as some lesions may go undetected. X-ray methods are used more frequently. The most popular one is bitewing radiography, which can be coupled with digital radiography. Tuned aperture computed tomography is a newer method with better diagnostic accuracy, but the equipment is prohibitively expensive for most private practices. X-ray methods can be used to see hidden lesions and assess the depth of the lesion, however, they expose the patient to low-levels of radiation and some of these methods involve subjective interpretation of images. Light based diagnostic methods include laser light induced fluorescence, which works on the premise that caries, plaque and microorganisms contain fluorescent substances different from those of enamel and dentin. Fiberoptic transillumination is a qualitative diagnostic method that transilluminates teeth to expose shadows associated with caries. Finally, electronic caries monitors work by measuring the electrical conductance of the tooth and detecting demineralized sites in enamel, because it is more conductive 18 than sound tissue. Diagnosis of periodontal disease begins by asking the patient questions about key symptoms. 1. Do your gums bleed overnight or upon brushing? 2. Are any of your teeth loose? 3. Can you chew all foods you want to? 4. Do you suffer from pain, swelling or blisters? Measuring pocket depth with a periodontal probe can identify the patient’s ability to maintain soft tissue health. Probing depth that exceeds 3 mm should be considered for periodontal treatment. Probing depth can be coupled with radiography and periodontal pocket depth must be recorded and followed in every visit to note the evolution of the treatment or worsening of the problem. 18 Xerostomia is the subjective complaint of dry mouth. Over half of patients with Parkinson’s disease complain of xerostomia, a rate that is more than double the rate in control individuals. For 10-20% of patients with Parkinson’s disease, xerostomia precedes motor symptoms of the disease. For all patients, prolonged treatment and increasing dosage of levodopa or carbidopa can lead to drug-induced dry mouth. Paradoxically, 30% of patients with Parkinson’s disease report both xerostomia and sialorrhea, which is excessive pooling of saliva in the mouth. This may stem from autonomic dysfunction and medication side effects paired with an inability to properly clear saliva from the mouth by swallowing. 19 Patients with xerostomia may also complain of bad breath, a burning mouth and difficulties articulating speech. Demineralization of tooth enamel, severe oral infections like candidiasis, and dehydration of the gingiva make xerostomia a risk factor for tooth and gum loss. Because saliva is not only an oral lubricant, but also contains digestive enzymes and antimicrobial protection, dry mouth can alter taste perception and oral bacterial growth. Impaired swallowing occurs because a lack of saliva may impede bolus formation. Subsequently, patients can develop aspiration pneumonia, drooling, and malnutrition. 20 Proactive clinicians must carefully listen for patient complaints of dryness of the mouth. These include symptoms like chewing, swallowing or speech difficulty. Persistent dry mouth can cause the oral mucosa to stick to teeth, while salivary glands may swell and create oral pain. Patients may report drinking fluids to aid swallowing dry foods and avoiding spicy or crunchy foods. These all may be taken as warning signs of xerostomia and clinicians can use available surveys to ask about the duration and frequency of symptoms and medications used. Upon oral examination, the provider may note frothy saliva that does not pool, a loss of tongue papillae and altered gingiva. The tongue and lips may be cracked or fissured. Salivary flow rate can be objectively measured by a variety of methods. To battle symptoms, patients can be encouraged to take frequent sips of water, eat moist foods, and use lip balms and artificial saliva. Patients can select alcohol-free mouthwash, chew sugar-free gum or take medications to stimulate salivation. 21 Drooling occurs when saliva uncontrollably spills out of the mouth. Sialorrhea is a closely related term for saliva that excessively pools inside the mouth. This pooling may be due to overproduction of saliva, or the inability to properly clear it from the oral cavity by swallowing. In either case, drooling is a common sequela. The number of patients with Parkinson’s disease affected by drooling is 5 times higher than in the control population. The onset of drooling and sialorrhea depends on each case and history of symptoms. For example, drooling is seen in about 86% of patients with Parkinson’s disease who also suffer from dysphagia, but only in 44% of patients without dysphagia. Drooling becomes more severe with disease severity. 22 Excessive drooling can impede eating, speaking, and effective oral hygiene. It causes perioral dermatitis, bad breath, increased amounts of oral bacteria, and a higher risk for silent aspiration of saliva leading to respiratory tract infections and death. Sialorrhea forces drooling patients to adopt the undignified practice of relentlessly spitting into a cup. Patients who suffer from prolonged social embarrassment or isolation may develop depression. 23 Salivary flow rate can be measured objectively or subjectively. Objective measures employ techniques including saliva collection in a cup, suctioning, the Lashley disk, patient self-swallow counts, and cotton pads weighed before and after absorbing saliva. Subjective measures of drooling and sialorrhea employ any number of patient and clinical surveys. Objective methods can be time consuming and uncomfortable for the patient. Moreover, they neither quantify how drooling and sialorrhea affect quality of life nor distinguish the root cause as dysphagia from overproduction of saliva. Subjective measures can be administered quickly by a trained health professional. Importantly, they rate the impact of drooling and sialorrhea on quality of life of the patient. 24 Dysphagia is difficulty in swallowing that may include delayed oral transit time, tongue festination, altered bolus control, impaired laryngeal, pharyngeal and esophageal motility and reflux. Swallowing requires voluntary and involuntary sensory and motor behaviors. As many as 87% of patients with Parkinson’s disease suffer from dysphagia compared to up to half of the normal population. This wide range of incidence among studies is most likely due to age differences in the study populations, as well as the methods of dysphagia diagnosis. Studies using self-report of dysphagia suggest the symptom arises late in the disease, approximately 10-12 years after Parkinson’s disease diagnosis. However, studies that directly and objectively measure dysphagia report that this symptom may start earlier, less than 6 years after diagnosis. 25 Dysphagia negatively affects quality of life and oral health. The simple act of holding food in one’s mouth for minutes, waiting for the ability to swallow, can lead to infections of soft and hard oral tissues. Patients with dysphagia progress from regular diets to soft foods and then liquid diets. Impaired bolus flow and retention of food material along the swallowing tract promotes bacterial growth, tooth and gum loss. Without the advice of a dietician, the sugary content of high caloric liquid diets can adversely affect a patient’s nutrition and oral health. Impaired swallowing of saliva leads to drooling, often making patients feel self-conscious, withdraw from social interactions, and deepen into depression. Aspiration pneumonia is a leading cause of death in patients with Parkinson’s disease. Tragically, the average time to death is just two years after dysphagia develops. 26 Screening for dysphagia typically proceeds in two steps. Distinguishing between symptoms of dysphagia and normal age-related swallowing complaints may be challenging, especially if patients present concomitant cognitive problems. Daily questions, interactions and observation of habits of the patient by caregivers, may be the first clue that dysphagia is a problem. Health care providers should pay attention to the eating habits of the patient (have they changed? Is the patient having trouble with hard foods?, is the patient coughing or choking more often while eating? Does the patient avoid eating in front of others?). Of the sensitive and reliable surveys available, the Munich Dysphagia Test has been validated for early screening of dysphagia in patients with Parkinson’s disease. The advantages of initial screening methods are that they are easy to administer, brief, noninvasive methods that avoid distress to the patient. They may, however, produce inconclusive results and only identify dysphagia when it has already become a problem in daily life. Secondary screening is done by specialized health professionals that can make a more accurate diagnosis, and include assessment by observation, videography or endoscopy. 27 The complete interprofessional health care team for patients with Parkinson’s disease should comprise a host of members with complementary expertise. Caregivers are often the first to report symptoms to the patient’s primary care physician or nurse practitioner. The neurologist will confirm the diagnosis and provide treatment options. A speech and language pathologist can assess swallowing ability and provide techniques to retain speech and swallowing. Nurses have the unique and frequent opportunity to educate patients about the importance of oral health. A dietitian can create a non-cariogenic diet for patients with mastication and swallowing difficulties who have switched to soft diets. Dentists must create a preventive oral health plan and proactively manage oral symptoms as they present. Finally, a psychologist may be able to help the patient cope with social and mental distress. This team works most effectively by conferring and communicating with each other. 28 Over half of patients with Parkinson’s disease will experience oral health problems. All healthcare professionals play a key role in educating patients on the importance of oral health in the progression of Parkinson’s disease. Prevention plans that include proper oral hygiene, a low-sugar diet and regular visits to the dentist can help maintain tooth and gum health. Dentists should encourage patients to come twice yearly, or more often as needed, for oral check-ups. Oral symptoms can be a threat to quality of life and survival in patients with Parkinson’s disease. Thus, early diagnosis is vital, and can be achieved with the aid of initial and secondary screenings. The Toothbrushing Ability Test and Oral Hygiene Performance Test can assess a patient’s motor ability to complete the fine motor skills of flossing and brushing their teeth. The successful interprofessional healthcare team must keep open communication channels with patients and one another. Consultation and referral can prevent progression of insidious oral symptoms. Finally, this teamwork can offer a comprehensive treatment plan to ensure the health of the patient with Parkinson’s disease. 29 In the next few slides, we offer advice for oral care of patients with Parkinson’s disease, both at the dental appointment and at home. 30 When scheduling an appointment for oral care or otherwise, several accommodations should be made. First, because patients with Parkinson’s disease have the most energy in the morning, appointments should be scheduled at the beginning of the day, 60-90 minutes after taking their medication. Short, frequent appointments with adequate breaks help the patient remain comfortable. For those in advanced stages of the disease, consider offering care in the patient’s home. Finally, for procedures requiring changes in medication, consult with the patient’s neurologist. 31 During a dental appointment, take a detailed medical history. Fluoride varnish is recommended in every visit to help minimize decay. Caregivers should be invited to join the patient, who may need assistance into the dental chair. Patients with Parkinson’s disease can have difficulty thermoregulating or become dizzy, so a blanket and slow chair adjustments can help a patient remain relaxed. Patients with instability and significant tremors can be offered restraints, mouth props, or bite blocks to protect the dental professional from unexpected jaw closures. Stress can increase tremors, so ensure adequate pain management. When movements are severe, the dental team may recommend procedures be under general anesthesia for safety. Stay cognizant that a patient’s lack of facial expressions may impair nonverbal communication with the dental professional. Patients should not be left alone at any moment during the dental visit. 32 There are special considerations for dental care of patients with dysphagia. Use of powered scaling devices and polishers is not recommended as they may cause choking. Further, patients with dysphagia may need to be seated in an upright or 45 degree angle to avoid choking and aspiration. Water flow should be reduced and optimal suctioning used. Caution patients against using fluoride rinses as they can initiate choking. Consider the use of fast setting dental materials that are not moisture sensitive. Finally, use caution with local anesthesia, as the loss of sensation in the mouth and throat may exacerbate dysphagia. 33 Though all Activities of Daily Living are slowed for patients with Parkinson’s disease, it is important patients maintain home oral hygiene routines. Clinicians can encourage this through patient education and written instructions. Patients become partners with their providers by reporting oral symptoms when they appear and diligently keeping dental visits. Special oral hygiene products are available to break down the barriers to brushing and flossing. 34 Now to conclude. 35 Parkinson’s disease is characterized by motor and non-motor symptoms. Both classes of symptoms can lead to poor oral health, such as caries and periodontal disease. As Parkinson’s disease progresses, a majority of patients will battle additional symptoms like dry mouth and dysphagia. Dysphagia not only has a bidirectional relationship with oral symptoms, but also can lead to drooling and failure to thrive. Excess saliva can aggravate oral symptoms, as well as make a dysphagic patient at higher risk for aspiration pneumonia. Unsightly drooling and prolonged eating duration resulting from tremors and dysphagia may lead a patient to refrain from social interaction. A resulting sense of helplessness can compound the physical and mental toll of existing non-motor symptoms. 36 Fortunately, patients with Parkinson’s disease can have hope. Each member of their interprofessional health care team has the expertise to diagnosis, manage and treat features of the disease. Further, patients can be encouraged to know their health care providers are working compassionately as team – consulting, collaborating, and conferring to design a holistic treatment plan for each patient with Parkinson’s disease. The importance of the interprofessional health care team is summarized well by the World Health Organization. “It is no longer enough for health workers to be professional. In the current global climate, health workers also need to be interprofessional." 37 38 39 40 41 42 43