1. Provide general descriptions of dental hygiene care for patients with neurologic and sensory deficits
+ these patients have inability to perform self-care caused by motor coordination problems, generalized muscle weakness and fatigue, and oral side effects
+ review client's pharmacological history
+ consult with client's physician
+ assess client's capabi
2. Discuss dysfunctions of the motor system, including characteristics, treatment and prognosis, oral clinical findings, special considerations, and oral self-care instructions
1) Tremors
2) Parkinson's disease
3) Cerebral palsy
4) Multiple sclerosis
+ Disorders that affect the cells of the cerebellum and the basal ganglia may result in disturb movements and produce abnormalities of muscle tone, abnormal posturing and tremors
2-1. Tremors
involuntary rhythmic repetitions or oscillations of movement at regular intervals
+ can start at any age - more common 30's and 40's
+ can be temporarily suppressed by alcohol, phenobarbital, and diazepam, a benzodiazepine
+ tremor is most prominent durin
2-2. Parkinson's disease
chronic progressive disorder of the motor system that eventually causes muscle rigidity, impaired movement (akinesia) and tremors
+ caused by loss of dopamine producing tremors
+ common during middle and old age - higher among men
2-2. Parkinson's disease - characteristics
+ may result from genetic susceptibility, and exposure to environmental factors (toxins/viruses) may trigger the disease
+ depression is common, and dementia is sometimes present
+ have difficulty with movement, getting up from sitting position, starting/
2-2. Parkinson's disease - treatment
includes dopamine replacement (levodopa) - side effects (nausea, vomiting, low blood pressure)
2-2. Parkinson's disease- clinical findings
+ oral manifestations: lack of expression, fly catcher tongue, tongue thrusting, lip pursing, swallowing muscles
+ muscle rigidity (stiffness), akinesia (impaired muscle movement) and tremor
+ Akinesia or bradykinesia (movement slowness) leads to infreque
2-2. Parkinson's disease - special considerations
+ client may have involuntary muscle movement - create a safety concern for DHG
+ may need dental treatment under general anesthesia
+ client may be susceptible to orthostatic hypotension/dizziness...DHG cautious with moving chair
2-2. Parkinson's disease - oral self-care instructions
+ have difficulty caring for their oral health
+ become dependent on caregivers
+ include the use of adaptive aids, power toothbrush and saliva substitutes
2-3. Cerebral palsy
a chronic, non-progressive neuromuscular disorder caused by damage to motor areas of the immature brain, primarily affecting the ability to control posture and movement
** second most common neurologic impairment in chlidhood
2-3. Cerebral palsy - characteristics
+ affects muscle movement, the brain's ability to control movement and posture
+ symptoms vary from mild to severe
+ other conditions may be associated such as hearing and vision problems, impairment of other senses, and intellectual and developmental cha
2-3. Cerebral palsy - oral manifestations
+ clients taking phenytoin for a convulsive disorder - look for gingival overgrowth
+ fractures of the maxillary anterior teeth are commonly caused by falls
+ attrition and bruxism may result from involuntary grinding
+ the enamel defect of hypoplasia is
2-3. Cerebral palsy - risk factors
+ premature birth
+ multiple births
+ maternal infections or exposure to toxic substances
+ blood type incompatibility
+ acquired cases arise from traumatic brain damage in first few months or years of life
2-3. Cerebral palsy - special considerations for DHG care
+ power brushes are good for the client if they have the strength to hold the brush for an appropriate amount of time and capable of adapting the brush to all areas of the mouth
+ floss aids are effective, but it depends on the client/caregiver
+ rinsing
2-3. Cerebral palsy - conditions and their management
+ abnormal muscle reflexes are often triggered by changing the client's head or neck position in the dental chair
+ tonic labyrinthine reflex: this caused by tilting the patient with CP backward so the head loses support -> their body goes into full exten
asymmetric tonic neck reflexes
this is caused by turning a patient with CP head to one side away from the midline
+ their response is arm and leg that extend, opposite arm and leg flex
+ prevention: use rear operating position, stabilize head in midline position
+ management: place the
2-4. Multiple sclerosis
MS is a CNS disorder in which there is myelin sheath destruction of specific axons causing multiple neurologic symptoms that accrue over time
+ MS is the most common progressive and disabling neurologic condition affecting young adults - mean onset age of
2-4. Multiple sclerosis - risk factors
+ caused by a combination of genetic and environmental factors
+ being susceptible to MS may be inherited
+ Deficiency in vitamin D is known to be a risk factor
+ Epstein Barr virus infection and cigarette smoking can also be risk factors
2-4. Multiple sclerosis - characteristics
+ the main problem is the presence of demyelinated nerve axons in the brain and spinal cord
+ MS causes the sheath around the nerve to degenerate thus interfering with nerve impulse transmission
+ demyelination results from autoimmune related inflammation
2-4. Multiple sclerosis - treatment and prognosis
+ the natural progression of MS is unpredictable
+ in most MS patients, the disease is initially exacerbating-remitting, and after several years there is a transition to a slow and relentless chronic progression
+ management includes treating the acute ex
2-4. Multiple sclerosis - clinical findings
+ clients with MS exhibit extraoral complications such as facial pain and TMJ and muscle dysfunction along with trigeminal neuralgia
+ with MS progression, the client will lose muscular coordination
+ oral hygiene care becomes difficult
+ the involvement
2-4. Multiple sclerosis - special considerations
+ frequent DHG appointments
+ short appts scheduled in mornings
+ comfortable, quiet, relaxed environment may reduce stress
+ client may be sensitive to heat
+ may have incontinence problems - give them bathroom breaks
3. Discuss peripheral neuropathies (facial neuropathy, Bell's palsy, trigeminal neuralgia), including characteristics, treatment and prognosis, oral clinical findings, special considerations, and oral self-care instructions
1) Bell's Palsy
2) Trigeminal neuralgia
3-1. Bell's palsy
Bell's palsy is most common neurologic disorders affecting the cranial nerves and is the most common cause of an acute facial paralysis
+ involves the facial nerve (CN VII)
+ facial nerve becomes swollen, inflamed, or compressed...interrupting communicati
3-1. Bell's palsy - oral clinical findings
+ numbness affect the individual's ability to chew or to feel oral trauma such as cheek biting
+ debris on the affected side of the mouth may cause gingivitis/caries
+ xerostomia, glossitis, candidiasis
3-1. Bell's palsy - characteristics
+ bell's palsy occurs abruptly
+ client's face becomes distorted and they think they have had a stroke
+ pain behind the ears
+ drooling
altered taste
+ tearing from the eyes
+ numbness or paralysis on the affected side of the face
3-1. Bell's palsy - treatment and prognosis
+ includes steroids and sometimes antiviral agents, acupuncture, and eye protection with lubricants, artificial tears
+ other treatments include 7th cranial surgical decompression and stimulation of paralyzed facial muscle
+ most patients recover without
3-1. Bell's palsy - special considerations
+ client should wear protective eyewear to keep foreign material from entering the eye on the affected side - cannot close their eyelid
+ sensation loss causes the client's inability to feel what they are doing while brushing
+ establish a brushing patter
3-2. Trigeminal neuralgia
trigeminal neuralgia is a mononeuropathy of the trigeminal nerve (CN V) that results in severe pain
+ the condition is seen more often in females and most cases occur over the age of 40
+ seen more often in patients with multiple sclerosis
3-2. Trigeminal neuralgia - etiology
o Usually caused by nerve compression
o Pressure causes wear of the protective myelin sheath around nerve -> abnormal signals to brain resulting in pain
3-2. Trigeminal neuralgia - characteristics
+ characterized by sudden, brief, severe, shooting or sharp stabbing pains
+ The symptoms are usually unilateral
+ occur most often in the mandibular division
+ occur more often on the right side of the face
+ The pain usually lasts less than a minute
+ c
3-2. Trigeminal neuralgia - treatment and prognosis
+ The first treatment of choice is drug therapy
+ surgical procedures are done if drug treatment is not tolerated or is ineffective
3-2. Trigeminal neuralgia - oral clinical findings
+ Oral ulcerations/xerostomia because of meds
+ Patient may avoid oral hygiene owing to the fear that it may trigger pain, causing the likelihood of plaque related diseases
3-2. Trigeminal neuralgia - special considerations
+ allow patient extra time to express their feelings about pain
+ Full supine position needed to relieve pain
+ Locals may need to be administered to relieve tissue pain resulting from manipulation during treatment
+ Referral to a pain management physicia
4. Discuss spinal cord dysfunction, including characteristics, treatment and prognosis, oral clinical findings, special considerations and oral self-care instructions
+ Spinal cord injury may occur from trauma or from diseases such as spinal bifida, polio, MS, and cancer
+ The major causes of SCI are motor vehicle accidents, acts of violence, falls, and sports, especially diving
+ Most victims are males between the age
4-1. Spinal cord injury - characteristics
+ The effect of SCI depends on the level and type of injury
+ Clients with SCI also may have problems with temperature, blood pressure control, chronic pain and inability to sweat below the level of injury
4-1. Spinal cord injury - treatment and prognosis
+ Even though the spinal cord remains intact, most people with SCI have a loss of function
+ Only in rare cases do individuals with SCI recover full functioning
+ People who use ventilators are at risk for respiratory infection and pneumonia
+ Decubitus a
4-1. Spinal cord injury - DHG care
+ Oral clinical findings, DHG care, and oral self-care instructions depend on the level and type of SCI
+ Wheelchair bound patients may be more easily treated in the wheelchair with a headrest and reclines
+ For clients without the use of their hands: the
5. Discuss seizures, including characteristics, treatment and prognosis, oral clinical findings, special considerations, and oral self-care instructions
+ A brief disturbance of cerebral function caused by excessive abnormal neuronal discharge
+ High fevers can cause seizures in about 1% of children during the first 15 years of life
+ Seizures in the elderly are related to cerebrovascular disease
5-1. Seizures - etiology
+ result from primary CNS dysfunction or an underlying systemic or metabolic disorder
+ The specific cause is unknown in most cases
epilepsy
a seizure disorder in which excessive abnormal discharges occur in the brain
5-1. Seizures - characteristics:
Tonic-clonic seizures
+ the most common type and are divided into phases
+ A vague prodromal symptoms (aura) happen hours to days before the convulsion
+ Tonic phase includes contractions (stiffening) that begin in the trunk of body and progress
+ Clonic phase (convulsion) beg
5-1. Seizures - characteristics:
typical absence (petit mal)
+ almost exclusively in childhood between the ages of 3 and 12 years
+ Seizures consist of brief (10 to 30 second) episodes of altered states of consciousness during which the child has a vacant stare and sometimes eyelid blinking or lip smacking
+ Muscle
5-1. Seizures - characteristics:
Generalized status epilepticus
+ defined as a single seizure lasting for at least 20 minutes or
+ recurrent generalized seizures without regaining of consciousness between the seizure episodes
+ this is life threatening medical emergency and requires prompt therapy
5-1. Seizures - treatment
Anticonvulsant medications such as phenytoin (Dilantin) are effective in preventing most seizures
5-1. Seizures - clinical findings
+ accidents resulting during the seizures and the medications may be evident in the oral cavity
+ Bruising, scars, and severe gingival enlargement or overgrowth caused by phenytoin
5-1. Seizures - DHG care
+ Prevention of seizures in the dental chair and preparations for managing seizures if they occur
� Do not use nitrous oxide sedation it can cause epileptic seizure
� Fatigue can cause seizures - morning appointments
+ scheduling appointments based on the
6. Discuss disorders of higher cortical function (dementia, Alzheimer disease), including characteristics, treatment and prognosis, oral clinical findings, special considerations, and oral self-care instructions
1) Dementia
2) Alzheimer's disease
6-1 Dementia
+ Characterized by a progressive intellectual decline that eventually leads to deterioration of occupational, social, and interpersonal functions
+ frequently attributed to the normal aging process
+ Dementia differs from the decline of physiologic proces
6-1 Dementia - etiology
Dementia may be caused by the following factors
+ age, genetics, and family history
+ metabolic disorders, anemia, brain tumor, trauma,
+ infections, deficiency diseases, toxins, and medications
6-1 Dementia - characteristics
� Early stages include diminished energy enthusiasm, interest in things, emotional instability and heightened anxiety levels
� Disease progression involves impaired m cognition, difficulties with orientation, language, perceptions, ability to learn new sk
6-2. Alzheimer's disease
+ a brain degenerative disorder that gradually destroys the ability to remember, reason, learn and imagine
*Alzheimer's disease is the most common form of dementia, affecting approximately 50% of those older than age 85
6-2. Alzheimer's disease - etiology and risk factors
o Genetics which influence susceptibility to AD
o Smoking
o Alcohol use
o Atherosclerosis
o Down syndrome
o Insulin resistant -according to new research
6-2. Alzheimer's disease - characteristics
** characterized by the presence of abnormal clumps or amyloid plaques, and irregular knots (tangles) that destroy the areas of the brain associated with intellectual functions
6-2. Alzheimer's disease - treatment and prognosis
+ There is no cure for AD, treatment is aimed at prevention, slowing progression of the disease and improving quality of life for the patient
+ Acetylcholine drugs are used to improve cognition but the effects are not permanent
+ The period from the earli
6-2. Alzheimer's disease - clinical findings
+ Patients with AD have more gingival disease and caries than the normal elderly population - poor OHI and neglect
+ Clients forget to brush, forget how to brush, may not want to brush or may be resistant to a caregiver brushing teeth
6-2. Alzheimer's disease - DHG care
� Frightened and frustrated AD clients may demonstrate uncooperative even combative behavior - approach with a caring and understanding demeanor
� Schedule appointments in morning
� Caregiver should accompany the client to discuss special client managemen
6-2. Alzheimer's disease - Oral self-care instructions
� In early stages of AD, encourage client to be self-sufficient
� Instructions should be given slowly, step by step in simple, language
� As the disease progresses the caregiver needs to be familiar with these procedures
� *Powered toothbrushes would seem
7. Discuss cerebrovascular disease (stroke), including characteristics, treatment and prognosis, oral clinical findings, special considerations, and oral self-care instructions
+ Cerebrovascular accident/stroke is an abrupt onset of neurological deficits caused by either ischemia or hemorrhage
+ It is the major cause of serious disability in adults
7-1. Cerebrovascular accident (stroke) - risk factors
o Recent stroke
o Hypertension...major factor because it is treatable
o Cigarette smoking
o Cardiac disease
o Diabetes mellitus
o Possible risk factors: oral contraceptives, obesity, physical inactivity, alcohol, pregnancy
7-1. Cerebrovascular accident (stroke) - characteristics
+ A CVA results from a lack of O2 supply to the brain due to an occlusion of blood supply
+ The ischemia leads to infarction of brain tissue supplied by the affected artery
+ Hemorrhage or rupture of a brain vessel causes leakage of blood into the brain e
7-1. Cerebrovascular accident (stroke) - common impairments
+ Motor impairments involving the face, arm, leg on one side
+ Sensory deficits - vision, pain, temperature, touch
+ Language and cognition disturbances
+ Depression - most common affective disturbances after a stroke
7-1. Cerebrovascular accident (stroke) - Treatment and prognosis
+ Prescribing anticoagulants, antihypertensive agents
+ Oral findings of the CVA survivor depends on the areas of the brain affected and the type of CVA as well as the resultant dysfunction
7-1. Cerebrovascular accident (stroke) - DHG care
� A stroke survivor should not undergo elective dental care within 6 months of the episode
� Pain and anxiety add to stroke risk - manage by creating a safe and comfortable environment
� Blood pressure should be monitored
� anticoagulant therapy - predisp
7-1. Cerebrovascular accident (stroke) - oral self-care instructions
+ Initially post stroke - the caregiver performs all the daily hygiene functions
+ give complete instructions and demonstrations of tooth brushing/flossing to caregiver
+ Clients with residual physical deficits may need assistance performing oral hygiene