16 minute read
Special needs CPD paper
Neurodegenerative conditions and oral health
Self-record CPD hours for the time spent in reading this article (DHAA recommends 0.5 CPD hour clinical/scientific)
By the DHAA Special Needs Dentistry SIG – Margie Steffens – Aileen Lewis – Angie Ioannidis – Amelia Roff
Neurones are the building blocks of the nervous system which includes the brain and spinal cord. Neurones normally do not reproduce or replace themselves, so when they become damaged or die they cannot be replaced by the body. Neurodegenerative conditions through this destruction of cells cause problems with movement (ataxias) or mental functioning (dementias).
Neurodegenerative conditions affect many activities, such as balance, movement, talking, breathing, and heart function. Many of these diseases are genetic. Sometimes the cause is a medical condition such as alcoholism, a tumor, or a stroke. Other causes may include toxins, chemicals, and viruses. Sometimes the cause is unknown. Neurodegenerative conditions can be serious or lifethreatening. It depends on the type. Most of them have no cure. Treatments may help improve symptoms, relieve pain, and increase mobility.
Neurodegenerative conditions can have a profound impact on a patient’s oral health. As clinicians it is important to understand the ways in which these conditions impact oral health so we can reduce the barriers patients with neurodegenerative conditions face when receiving dental treatment or advice.
This article outlines the main areas that impact the oral health of people with neurodegenerative disorders, and discuss management strategies for health professionals and carers.
Limited mobility/ coordination
Neurodegenerative conditions often affect areas of the brain that control motor function of the extremities. Patients end up with muscle weakness, uncontrolled movements, and a lack of coordination; all issues in maintaining an effective oral home care routine.
Some neurodegenerative conditions, for example Friedreich’s ataxia, can render a patient non-ambulatory by as young as 15.5 years of age (Parkinson et al 2013). Given that many patients with neurodegenerative conditions may be relying on wheelchairs for mobility, it is important to plan ahead and ensure that your surgery is wheelchair accessible. This includes ensuring no steps, and that doorways are wide enough to accommodate the width of the chair.
Dysphagia/orofacial dysfunction
The same mechanisms that impact the declining coordination of the limbs and extremities can also impact the muscles in the head and neck. This often leads to dysphagia, tongue stiffness, impaired speech, and difficulty swallowing/ coughing (Nakayama et al 2017). This presents issues for both dental practitioners and carers as there needs to be strategies in place to reduce the risk of aspiration. Patients often have issues with food retention after swallowing due to either dysphagia or reduction in ‘purposeful lingual searching activity’ (Rae et al 2015).
Because of issues with the function of the orofacial region, patients with motor neurone disease have a higher instance of mortality related to bronchial pneumonia and aspiration pneumonia (Burkhardt et al 2017).
Patients with ataxia will often struggle to keep their mouth open due to muscle weakness so the use of a mouth prop is recommended (Camm et al 1987).
Patients with amyotrophic lateral sclerosis have limited mouth opening. This limited opening has a negative impact on general health outcomes, hastening mortality and increasing the need and duration of ventilation (Nakayama et al 2017). Limited mouth opening also provides a difficult situation for the management of oral health conditions by caregivers and dental practitioners and an increased risk of aspiration. There has been some suggestion that exercise therapy in the initial stages of the disease can reduce the impacts of limited mouth opening (Lui et al 2009).
Salivary function
Xerostomia is not itself a side effect of neurodegenerative conditions, but medication induced xerostomia is commonly associated with neurological disorders. Co-morbidities of depression and anxiety are very common with neurological conditions. The medications used to treat these conditions leave patients with reduced salivary function and xerostomia.
Hyposalivation tends to be present in patients with Parkinson’s disease, Lewy body dementia and amyotrophic lateral sclerosis (Srivanitchapoom et al 2014, Lakraj et al 2013). The use of antipsychotic medication to treat comorbidities can also increase the chances of developing hyposalivation (Maher et al 2016). Hyposalivation reduces a patient’s quality of life as patients often feel a sense of stigma related to the condition. Hyposalivation can also increase the risk of aspiration (Yuruyen et al 2017).
Dental caries
The incidence of dental caries in patients with neurodegenerative conditions is not as straightforward as a simple increased risk of dental caries. As with any patient, the risk is determined by many factors such as saliva quality medications, diet, and home care.
Many patients rely on a carer for their home care routine, so if a patient is reliant on a carer it is important to educate them on how best to manage a patients home routine. As there is an increased risk of aspiration and difficulty with opening, please refer to the ‘Mouth c are for people with neurological Conditions’ section of this article for management strategies. Due to these barriers to care, patients with Alzheimer’s were found to have had lower rates of brushing, flossing and dental visits compared to their healthy counterparts (Aragón et al 2018).
As it is difficult for patients with neurodegenerative conditions to achieve sufficient caloric intake, often dietary advice includes the consumption of highcaloric, but high sugar, foods which can increase caries risk (Rae et al 2015).
Medication induced xerostomia can increase a patients’ risk of decay, but conversely hyposalivation may possibly have a positive correlation on decay rates, with one small study finding no increase in decay in patients with Motor Neurone Disease, most likely due to hyposalivation (Tay et al 2014).
Periodontal disease
Some neurodegenerative conditions seem to have a negative correlation between periodontal disease bacteria and adverse or exacerbated disease outcomes. Though a causal link has not been established, there is a growing body of evidence suggesting a link between periodontal disease and Alzheimer’s disease. It is evident that periodontal disease in patients with Alzheimer’s disease can exacerbate the condition. Chronic low-grade infection can alter the immune response to invasive organisms and virulence factors that invade the central nervous system through the blood-brain barrier (Harding et al 2017, Kramer et al 2008, Matsushita et al 2020). Serum antibody levels against P. gingivalis are found to have increased in Alzheimer’s disease patients compared to non- Alzheimer’s disease controls’ ( Scherer et al 2020).
Mouth care for people with neurodegenerative disorders
Encompassing Motor Neurone/ Amyotrophic Lateral Sclerosis, dementia, cerebral palsy, epilepsy, multiple sclerosis, Parkinsons Disease, Alzheimers disease, Ataxia, Bell’s Palsy, Guillain-Barre Syndrome,Muscular Dystrophy, strokes, Huntington Disease.
Many people who have neurological conditions have limited mobility, dexterity, swallowing (dysphagia) problems, dry mouth complications and/ or reduced cognitive abilities.
It is important that people with these conditions maintain good oral hygiene and have a healthy diet to prevent caries, halitosis, inflammation of the gums and reduce the risk of infection in the mouth and the rest of the body.
It is recognised that good oral care is pivotal in maintaining the mouth and body health connection in reduction of complications such as aspiration pneumonia, exacerbation of heart disease, strokes and to reduce infection and complications relating to diabetes.
Frequently different aids are required to assist independence and to encourage ease of oral care, for example:
Modified toothbrushes: Bending toothbrushes: a soft toothbrush can be bent for better access to the mouth. Bending a toothbrush forward can help with inner surfaces of upper and lower teeth. A backward bent toothbrush can be used to pull the cheek away while using another brush to clean the teeth.
Toothbrush adaptors may help the person or carer to brush when they have poor grip or limited movement. Using a foam or rubber handle, a cut tennis ball or commercial adaptors will help those who can brush by themselves but need extra help.
Three sided toothbrushes are designed to brush all the surfaces of the teeth. They ‘hug’ the teeth to clean the three tooth surfaces and gumline at the same time. For example the ‘Collis Curve’ toothbrush.
An electric toothbrush is very effective if the person can accept the noise and vibration. Again useful for those with limited manual dexterity but like to be independent.
Where mouth care is provided by a carer, they can introduce the electric brush on the fingers first, then the lips and occasionally touch the front teeth until the person accepts the vibration and noise.
Interproximal brushes that have extension handles with thicker grips, are efficient tools to remove food debris and plaque. They are good for carers to clean areas that are hard to reach such as dental bridges and implants.
Suction toothbrushes e.g PlakVak are suitable for brushing teeth for people who are unconscious, tube fed or have dysphagia. It is used with a portable pump or wall suction and is used generally in nursing homes. It is very important for people that are unconscious, non-orally fed or have difficulty swallowing to have their oral hygiene kept to a high standard. Thus reducing the risk of chest infections (e.g. Aspiration Pneumonia) if plaque is left on their teeth and gums.
Tooth rests and mouth props are used when either a person is not cooperative with opening their mouth or for those who cannot keep their mouth open for long periods of time.
Mouth props such as: a tightly rolled up flannel slightly dampened, toothbrush with a padded handle, padded tongue depressors and commercial props. They are not suitable for everyone.
There are commercially made soft plastic props available.
Many people with neurological conditions also experience a dry mouth or hyposalivation. Some medications can affect the salivary glands and reduced saliva can increase the risk of caries, gingival diseases and infections. Ulcers can appear under poorly fitting dentures as the dry mouth reduces the ability for the denture to adhere to the soft tissues. The denture then moves when the person is trying to eat or talk causing friction ulcers and sores. Oral thrush is also a problem with a dry mouth and angular cheilitis (dry, cracked corners of the mouth) can be an uncomfortable condition that reduces the person’s ability to eat and talk.
Some people also experience hyposalivation where there is too much saliva and swallowing can be difficult. It is best to have more than one carer to help in these situations and a suction toothbrush is ideal.
Additional information for carers
• Clean the person’s teeth morning and night, preferably after every meal therefore lunchtime brushing is advised.
• Use a toothbrush and method that is suitable for that person, making it comfortable for the person and the carer.
• May need two carers to be effective.
• In group settings, keep each person’s oral hygiene equipment separate and labeled to prevent cross contamination.
• Use fluoride toothpaste. Choose a non-foaming toothpaste for those who gag.
• High fluoride toothpastes, antiplaque agents and other products may be prescribed by a dental practitioner for people with a high risk of dental disease.
• Dentures need to be cleaned with warm soapy water not toothpaste and stored in a clean dry container to air when not in use.
It is important that the mouth is kept clean by swabbing or brushing the gums and tongue and wetting the denture before placing it back into the mouth.
If the person is not able to do this the carer must care for the denture and the mouth everyday.
When living in supported care it is essential dentures are labeled correctly - The dental technician can embed the label into the acrylic appliance when being made. The person’s name or any identifier should never be scratched on the denture as this causes microscopic scratches which can retain plaque/bacteria that contribute to fungal infections and inflammation in the mouth
Dietary advice
• Limit sweet, sticky foods and drinks between meals.
• Limit acidic drinks such as sodas, energy/sports drinks, fruit juices and cordials.
• Encourage drinking or rinsing with water to help remove food debris after a meal.
Methods for carers to assist in good oral hygiene:
• Toothbrush positioning must provide support for the head and neck and be comfortable and safe for all. A good lighting is needed and the positioning should allow a clear view inside the mouth.
• The ‘Cuddle position’ is best where the carer stands behind and to the side of the person. Their head is rested against the side of the carer›s body and arm and supporting the chin gently with the index finger and thumb (pistol grip). This is a supportive position and provides greater head control.
• People with swallowing difficulties risk choking if the head is tilted too far back.
• Use a smear or pea size amount of fluoride toothpaste on a soft bristled toothbrush.
• Use a show, tell, do approach so that the person is aware of what the carer is about to do. The carer moves to the side/behind the person and places the bristles at a 45 degree angle to the gum. Brush in a gentle, circular motion.
• Encourage use of a toothpaste without sodium laurel sulphate.
• Rinse the toothbrush thoroughly, tap off excess water and allow it to dry.
• Replace the toothbrush every 3 months or after any illness.
For oral health professionals
Spit don’t rinse is recommended for most healthy patients in general. However when working with people with specific medical conditions and polypharmacy, or chemical allergies, it is advisable to either swab the mouth out or have a very light rinse with water. There are possible contraindications with other medications, chemicals causing dry mouth or possible allergic reactions or even asthma attacks.
Medications commonly used in neurodegenerative conditions
Many medications used in the management of neurodegenerative disorders cause dry mouth and other gastrointestinal adverse effects. Oral health practitioners may need to address them to maintain oral hygiene.
Dementia and Alzheimers: A number of drugs are currently available in Australia for use by people with dementia. These drugs fall into two categories, cholinergic treatments and memantine.
Cholinergic treatments offer some relief from the symptoms of Alzheimer’s disease for some people for a limited time. Drugs known as acetylcholinesterase inhibitors work by blocking the actions of an enzyme called acetylcholinesterase which destroys an important neurotransmitter for memory called acetylcholine.
Memantine targets a neurotransmitter called glutamate that is present in high levels when someone has Alzheimer’s disease. Memantine blocks glutamate and prevents too much calcium moving into the brain cells causing damage.
These medications may cause drug mouth, nausea and vomiting.
Multiple Sclerosis: The two main aims of the drugs that are available for people with MS are to either ease specific symptoms (symptomatic therapies), or reduce the risk of relapses and disease progression (these are known as ‘disease-modifying therapies.’) Acute relapses are also sometimes treated using steroids to help shorten the attack and reduce its severity. The types of drugs used in treatment depend on a number of factors, including the person's type of MS.
Drug treatment may include immunotherapies, steroids and immunosuppressants, many may lead to nausea and vomiting.
Amyotrophic Lateral Sclerosis (ALS) and Progressive Bulbar Palsy (PBP): Drug treatment may involve riluzole which could cause nausea or vomiting and stomach ache.
Parkinsons Disease: Most drug treatment options focus on restoring the balance of dopamine and other neurotransmitters by Dopamine replacement or dopamine agonist therapy.
These agents may either cause dry mouth or excessive salivation.
Other drugs: These include antidepressants such as fluoxetine and sertraline; antipsychotics such as quetiapine, risperidone and olanzapine; mood stabilisers such as volproate and carbamazepine; as well as monoamine depletors tetrabenazine and amantadine. Most of them may cause a degree of dry mouth and other gastrointestinal side effects. n
Are you interested in getting involved with the DHAA Special Needs Dentistry Special Interest Group? Please email contact@dhaa.info .
Please self record CPD hours for the time spent in reading this article (DHAA recommends 0.5 CPD hour clinical/scientific)
References Aragón, F., Zea-Sevilla, M. A., Montero, J., Sancho, P., Corral, R., Tejedor, C., Frades-Payo, B., Paredes-Gallardo, V., & Albaladejo, A. (2018). Oral health in Alzheimer’s disease: a multicenter case-control study. Clinical Oral Investigations, 22(9), 3061–3070. https://doi. org/10.1007/s00784-018-2396-z Burkhardt, C., Neuwirth, C., Sommacal, A., Andersen, P. M., & Weber, M. (2017). Is survival improved by the use of NIV and PEG in amyotrophic lateral sclerosis (ALS)? A post-mortem study of 80 ALS patients. PloS One, 12(5), e0177555–e0177555. https://doi. org/10.1371/journal.pone.0177555 Camm, J. H., & Carpenter, J. V. (1987). Dental treatment of a patient with Friedreich’s ataxia. Special Care in Dentistry, 7(3), 117–119. https://doi.org/10.1111/j.1754-4505.1987. tb00619.x Harding, A., Gonder, U., Robinson, S. J., Crean, S., & Singhrao, S. K. (2017). Exploring the Association between Alzheimer’s Disease, Oral Health, Microbial Endocrinology and Nutrition. Frontiers in Aging Neuroscience, 9, 398–398. https://doi.org/10.3389/ fnagi.2017.00398 Kamer, A. R., Craig, R. G., Dasanayake, A. P., Brys, M., Glodzik-Sobanska, L., & de Leon, M. J. (2008). Inflammation and Alzheimer’s disease: Possible role of periodontal diseases. Alzheimer’s & Dementia, 4(4), 242–250. https://doi.org/10.1016/j.jalz.2007.08.004 Lakraj, A. A., Moghimi, N., & Jabbari, B. (2013). Sialorrhea: Anatomy, pathophysiology and treatment with emphasis on the role of botulinum toxins. Toxins, 5(5), 1010–1031. https://doi.org/10.3390/toxins5051010 Lui, A. J., & Byl, N. N. (2009). A Systematic Review of the Effect of Moderate Intensity Exercise on Function and Disease Progression in Amyotrophic Lateral Sclerosis. Journal of Neurologic Physical Therapy, 33(2), 68–87. https://doi.org/10.1097/ NPT.0b013e31819912d0 Maher, S., Cunningham, A., O’Callaghan, N., Byrne, F., Mc Donald, C., McInerney, S., & Hallahan, B. (2016). Clozapineinduced hyposalivation: an estimate of prevalence, severity and impact on quality of life. Therapeutic Advances in Psychopharmacology, 6(3), 178–184. https:// doi.org/10.1177/2045125316641019 Matsushita, K., Yamada-Furukawa, M., Kurosawa, M., & Shikama, Y. (2020). Periodontal Disease and Periodontal Disease-Related Bacteria Involved in the Pathogenesis of Alzheimer’s Disease. Journal of Inflammation Research, 13, 275–283. https://doi.org/10.2147/JIR.S255309 Nakayama, R., Nishiyama, A., Matsuda, C., Nakayama, Y., Hakuta, C., & Shimada, M. (2017). Oral health status of hospitalized amyotrophic lateral sclerosis patients: a single-centre observational study. Acta Odontologica Scandinavica, 76(4), 1–298. https://doi.org/10.1080/00016357.2017.142 0228 Rae, D., & Manley, G. (2015). Oral Health Care in People with Huntington’s Disease. In Diet and Nutrition in Dementia and Cognitive Decline (pp. 1125–1133). https://doi. org/10.1016/B978-0-12-407824-6.00105-1 Scherer, R. X., & Scherer, W. J. (2020). U.S. state correlations between oral health metrics and Alzheimer’s disease mortality, prevalence and subjective cognitive decline prevalence. Scientific Reports, 10(1), 20962–20962. https://doi.org/10.1038/s41598-020-77937-8 Srivanitchapoom, P., Pandey, S., & Hallett, M. (2014). Drooling in Parkinson’s disease: A review. Parkinsonism & Related Disorders, 20(11), 1109–1118. https://doi. org/10.1016/j.parkreldis.2014.08.013 Yuruyen, M., Gokturk, A., Yavuzer, H., Döventas, A., & Erdincler, D. S. (2017). Applied botulinum neurotoxin injection in a patient with dementia to reduce hyposalivation. Geriatrics & Gerontology International, 17(6), 1028–1029. https://doi. org/10.1111/ggi.12994
