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A number of relatively uncommon but significantly neuromuscular conditions may affect dental treatment, particularly elderly patients
Inability to carry out proper oral hygiene may result in an increased caries rate and greater incidence and severity of periodontal disease, causing these patients to seek dental care for chronic and acute disorders.
PARKINSON’S DISEASEAlso known” as shaking palsy”
A progresssive neurodegenerative disorder of neurons that produce dopamine
Caused by death and depletion of doparminergic neurons, wch are manufactured in the substantia nigra and released in the caudate nucleus and putamen (the niagrostriatal pathway)
MANIFESTATIONS Chronic progressive combinations of resting
tremor Cogwheel rigidity Bradykinesia( slownesss of voluntary
movement) Facial impassiveness Falls Mood disturbances Insomia Fatigue
POTENTIAL MEDICAL PROBLEM RELATED TO DENTAL CARE Patients may be unable to perform oral
procedures Patients may have severe tremor or may be
unable to coperate during dental treatment
ORAL MANIFESTATIONS Excessive salivation and drooling Muscle rigidity and repetitive muscle
movements contribute to poor oral hygiene Antiparkinson’s drugs may cause xerostomia,
nausea, tardive dykinesia
PREVENTION OF PROBLEMS Provide frequent dental recall and specialized
toothbrushes (e.g. Collis curve toothbrush, mechanical brushes) to maintain adequate oral hygiene
Salivary substitutes and topical fluoride are beneficial
Personal care providers should be educated about their role in assisting and maintaining the oral hygiene if these patients.
MULTIPLE SCLEROSIS Most common autoimmune disease of the
nervous system Characterized by chronic and continuous
demyelination of the cortico-spinal tract of the brain and spinal cord
Affects the white matter in the cns and spares the pns with the exception of the optic nerve
MS is a Demyelinating Disease
Myelin – provides insulation to nerve processes (axons)
Blood vessel
Blood vessel
Blood vessel
Inflammation
Inflammation
Inflammation
Myelin – provides insulation to nerve processes (axons)
Blood vessel
Blood vessel
Blood vessel
Blood vessel
Blood vessel
Blood vessel
Inflammation
Inflammation
Inflammation
Inflammation
Inflammation
Inflammation
CLINICAL MANIFESTATIONS Disturbances in visual function Abnormal eye movements(nystagmus and
double vision) Incordination Spaticity Difficulty in walking Loss of balance Vertigo Tremor or paralysis of the limbs
ORAL COMPLICATIONS AND MANIFESTATIONS Dysarthria produces slow , irregular speech
with unusual separation of words referred to as scanning speech
Facial Parethesia Numbness of orofacial structures Trigeminal neuralgia wch can be relieved by
carbamezapine, clonazepam or amitripytline or surgery
TREATMENT PLANNING MODIFICATIONS Patients with stable disease and little motor
spasticity or weakness can receive routine dental care
With more advanced disease may require help in transferring to and from the dental chair, may have difficulty maintaining oral hygiene, and may be poor candidates for reconstructive and prosthetic procedures
Short morning are advised because fatigue is often worse in the afternoon
PATHOPHYSIOLOGY Normally impulses travel along the nerve to the ending and
release the neurotransmitter substance acetylcholine
Acetylcholine travels through the neuromuscular junction and binds to acetylcholine receptors, which are activated, and generate a muscle contraction
In myasthenia gravis, person’s own antibodies block, alter, or destroy the receptors for acetylcholine at the neuromuscular junction, preventing muscle contraction
S & S'S
In most cases, the first noticeable symptom is weakness of the eye muscles
Diplopia (blurred or double vision)Ptosis (drooping of one or both eyelids)
ALSO COMMON …
Majority also have weakness of face and throat muscles
Dysphagia (difficulty in swallowing)
Dysarthria (slurred speech)
Dysphonia (voice impairment )
Therefore, RISK of choking + aspiration
ALWAYS A B CS …
The degree of muscle weakness involved in MG varies greatly among patients
Within a year of onset, approximately 85–90% will develop Generalized myasthenia gravis, which is characterized by weakness in the trunk, arms, and legs
May lose muscle strength for breathing and need ventilator
DENTAL IMPLICATIONS Crisis rarely occurs suddenly and patients with
crisis do not present for dental treatment For routine dental care, awareness of
immunosuppressive medications and the potential for increased respiratory and oral secretions is mandatory
May antibiotics may worsen MG e.g. imipenem, fluoroquinolones
Ester local anesthetics may be toxic because they are hydrolyzed more slowly
Patients are very sensitive to non depolarizing muscle relaxants
WHAT IS MUSCULAR DYSTROPHY?
Genetic disease affecting skeletal muscles
Characterized by progressive muscle weakness and wasting, and loss of motor skills
X-linked recessive most common: Duchenne and Becker
More than 1 in 3500 males born Onset age from infancy to adulthood Most end up wheelchair-bound
DUCHENNE MUSCULAR DYSTROPHY
Most common type: 1 in 3500 Early onset: signs appear before 6
years of age Delayed development of motor skills Weakness/fatigue Difficulty in keeping balance Pseudohypertrophy Contractures Wheelchair dependent by ~12 years of
age
BECKER MUSCULAR DYSTROPHY
Milder form of Duchenne 1 in 18,518 males Onset age: 5 to 15 years of age Loss of muscle mass and motor skills Weakness/fatigue Pseudohypertrophy Contractures Wheelchair dependent by 25-30
OTHER CONDITIONS CAUSED Scoliosis
Curvature due to contractures and muscle weakness
Cardiac Dilated cardiomyopathy Arrhythmia Shortness of breath and fatigue
Respiratory Progressive weakening of the diaphragm
Cognitive (non-progressive)
DENTAL CONSIDERATIONS Patients can often have conventional care in a
dental office that is wheelchair accessible Increased risk of toxicity to LA Slower onset of drug actions Increased duration of drug actions Poor candidates for intramuscular sedation Caution with nitrous oxide if respiration is
impaired May not tolerate supine position Consider steroid supplementation exogenous
prednisone