Dental Encounter

Key Facts:

  • Oral health may decline in PD patients because symptoms impair self-care.
  • Dental appointments should be scheduled at least every six months.
  • Drug interactions, especially use of local anesthetic agents, should be considered when conducting dental procedures on PD patients.
  • PD patients may have difficulty in keeping their mouth open, managing saliva and restricting head and tongue movements.
  • PD patients may have difficulties in controlling and retaining dentures.

Clinical Best Practices:

  • Consult with patient’s physician before initiating dental treatment in a PD patient.
  • Scheduled your PD patient for short appointments, preferably early in the morning.
  • Be careful when administering anesthesia to PD patients, especially if using agents containing epinephrine.
  • Don’t prescribe meperidine hydrochloride to PD patients taking MAOIs.

 

The motor and non-motor symptoms of Parkinson's disease can affect patients’ dental health. Assessing for symptoms that could be barriers to maintaining proper dental health is important. Every dentist should be informed of and familiar with his/her patient's symptoms and medications.  Patients or care partners should be reminded to schedule routine dental cleanings and evaluations.

 General considerations that all dentist should know:

 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.
References: 

 

Friedlander A, Mahler M, Norman K, Ettinger R. Parkinson Disease Systemic and orofacial manifestations, medical and dental management. Jour. Of the American Dental Association. 2009; 140:658-668

Little, James W.. Dental Management of the Medically Compromised Patient, 7th Edition. Mosby, 072007. p. 477-478