Download Parkinson`s Disease Oral Health: Interprofessional

Parkinson’s Disease Oral Health: Interprofessional Coordination of Care
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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.
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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.
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Let’s begin with an Introduction to Parkinson’s disease.
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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.
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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.
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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.’
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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.
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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.
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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.
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We will now discuss the link between oral and systemic health, and the importance of
the interprofessional health care team.
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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.
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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.
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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.
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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).
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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.
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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.
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Now to conclude.
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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.
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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."
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