Parkinson's Toolkit

 General considerations that all dentist should know:

• PD has motor and non motor symptoms, both of which may affect dental evaluation and treatment.
• Tremor and bradykinesia are common motor symptoms. Non motor symptoms may include cognitive decline, depression, orthostathic hypothension, impulse control disorders, dysphagia and urinary dysfunction. All these symptoms should be considered in the dental office by all members of the staff.
• Caregivers should be always considered when treating a PD patient. Obtaining consent from a caregiver is recommended when PD patients have cognitive decline.
• Peak effectiveness of most PD medications begins within 60 to 90 minutes after administration
• Since many PD patients have drooling, many physicians use anticholinergic medications such as glycopyrrolate and benztropine, or injections with botulinum toxin into the salivary glands to decrease salivary flow.
• Levodopa, dopamine agonists, anticholinergics, MAO-B inhibitors, COMT inhibitors are the main group of medications used to treat PD patients.

 Clinical considerations:

• Restoration of oral health is best completed as early as possible in the PD process because of the patient’s ability to cooperate.
• PD patients should be scheduled for appointments no longer than 45 minutes, preferably early in the morning when they usually are the least bothered by their symptoms and when their medication is most effective.
• Before entering the dental operatory, PD patients should empty their bladders because PD is often associated with urinary urgency and incontinence.
• To facilitate the patient’s swallowing, the dentist should avoid inclining the chair more than 45°.
• PD patients may have difficulty in keeping their mouth open, managing saliva and restricting head and tongue movements. Using an extra oral ratchet-type prop or intraoral rubber bite block can help in keeping the mouth open.
• An aspirator tip placed under a rubber dam and stabilized by an assistant will assist the patient in managing saliva while the dam prevents contamination of the restoration placement. The dam also provides protection of the airways which is important in PD patients because their higher risk of aspiration.
• Be careful when using local anesthetic agents containing epinephrine in patients being treated with levodopa and entacapone because these patients may experience an exaggerated effect on blood pressure and heart rate. It is prudent to administer no more than 0.05 mg of epinephrine – as is found in three cartridges of 2% lidocaine with 1:100,000 epinephrine – per 30 minute period, with careful aspiration to avoid intravascular administration.
• The dental chair should be slowly raised to allow the patient to adapt to the upright position and prevent syncopal episodes.
• To reduce the likelihood of a fall from dental chair, the patient should be assisted to and from the chair.
• Parkinsonian tremors of the orofacial musculature and the use of levodopa containing medications may cause bruxism. Therefore, the dentist should look for excessive loss of tooth structure.
• Glass ionomers and resin-modified glass ionomers are most appropriate for the restoration of carious lesions in PD patients, including lesions that involve the root surfaces, because they bond to both dentin and cementum and release floride.
• In advanced PD, care could be better offered by using intravenous sedation or general anesthesia (with a trained anesthesiologist).
• PD patients may have difficulties in brushing their teeth and flossing therefore the use of mechanical or electric brushes, specialized toothbrush – e.g. Collis curve toothbrush -and Clorhexidine rinses are recommended for better results.
• Dental recalls should be scheduled more frequent to maintain adequate oral health.
• High Fluoride toothpaste topical Fluoride should be considered for use in dentate patient with xerostomia to prevent root caries.
• Personal care providers should be educated about their role in assisting the oral hygiene.
• In patient is taking MAOB inhibitors such as selegiline or rasagiline, avoid meperidine.
• Encourage caregivers to check PD relative’s teeth if they are living in a long term care facility to ensure plaque is adequately removed.