Clinical Protocols for Dental Settings: A Guide to Managing Parkinson’s Disease

Introduction

What are the different protocols in the clinic that your dentist would need to follow and manage in a patient suffering from Parkinson's neurologic disease, where there is a lack of oral motor coordination? Read on now in detail.

What Is the Pathology of Parkinsons Disease?

There is a broad range of orofacial manifestations in patients of Parkinson's neurologic disease (short form - PD), which makes the in-clinical or in-hospital dental management quite challenging as well as critical. Before considering treatment protocols as well as surgery or dental procedures in patients with PD, dentists or oral surgeons must first collaborate with the physician or the neurosurgeon in charge of the patient. As per the information enlisted in the recent clinical practice guidelines, in patients suffering from PD, there would be degeneration of dopaminergic as well as non-dopaminergic neurons in the substantia nigra (SN, a small midbrain structure essential for motor control, reward processing, and various brain functions). This would be because of the pathophysiologic consequences occurring as a result of the presence of Lewy bodies (clumps of protein particles), subsequently resulting in the afflicted patients of PD experiencing the main clinical features of impaired motor control.

Though current medical research is extensively investigating and also focusing on the cause or occurrence of this idiopathic Lewy body responsible for causing these pathophysiologic changes leading to motor control loss, the evidence so far or research is still elusive. The Lewy body aggregates are however thought to be the most common initiators that aid in the loss of motor control in patients who have progression of Parkinson's disease. Research also takes into consideration the possible etiologies related to genetic and environmental factors that may also play a role in both the initiation and eventual progression of PD. The genetic onset of PD would contribute as per current global prevalence rates to around three to five percent of PD cases, involving in fact different types of monogenic forms that are pathologically mutated. They would be either single mutations in an inherited dominant or recessive gene that would make up for a familial pattern of Parkinson's disease as well.

What Steps Should Dentists Follow to Manage a Parkinsons Patient?

Given that several different and common orofacial manifestations would cause both oral and facial discomfiture in Parkinson's patients, it is important to obtain physician consent or the neurologist's consent before operating on the patient.

Here are the enlisted guidelines or general protocols and techniques that should be followed keeping in mind the safety of PD patients. These protocols can ensure that managing patients with Parkinson’s disease in the dental environment would prove to be not only safe but also successful in oral rehabilitation and restoration of their dental or orofacial functions by the operating dentist or oral surgeon.

1. Dentists first need to obtain and update the complete medical history of the PD patient. Records of the same can be maintained by ensuring that medical history is up to date. The prescriptions of the PD patient are also to be updated regularly.

2. Care should be always taken to avoid any possible drug interactions with the systemic drugs prescribed by the patient's physician or neurologist. The dental drugs or agents used in the clinic should not ideally interfere with the patient's systemic drugs in any way. Further, the dentist can also possibly note the progression of the PD disease by collaborating or taking the advice from the neurologist, to analyze the changes or additions to the patient's medications list if any, with passing time or in the dental recall appointments.

3. Dentists should be familiar with or well-educated about the symptoms of Parkinson’s disease. They should also be capable of recognizing common orofacial manifestations such as dry mouth (xerostomia) and dysphagia (difficulty swallowing), which are common symptoms in patients who may exhibit poor motor control. In fact, this is where the dental surgeon can further play an important role in referring the patient to a neurologist especially when they can detect these symptoms that have been left untreated in possible cases of PD.

4. It is important for dental surgeons to be well aware of the medico-legal and the potential informed-consent issues by discussing the treatment strategies dentally with the physicians first and also tuning into the patient's needs, family members, and/or guardians and caregivers who have their power of attorney.

5. Preventive oral hygiene is always an awareness factor that should be imparted to the person in charge of the PD patient. For instance, not only should the emphasis of the dental surgeon be on imparting proper oral care and strict hygiene regimens at home by mechanical or chemical plaque control and remineralizing tooth measures, but also patients, family members, and/or caregivers should be instructed on how to take care of the PD patient in question pertaining to the daily oral hygiene techniques.

6. Dental visits should always be kept short for PD patients ideally in the mornings when patients can be more active in terms of motor control or coordination and care should be taken during the course of dental or oral surgical procedures to avoid any operator-induced or iatrogenic errors or potential for aspiration of dental objects or burs, as patient lacks motor control usually.

7. Care should be taken to manage any case of orthostatic hypotension (sudden drop in blood pressure when moving from a sitting or lying position to standing) or the dental chair should be raised very slowly during the course of a procedure. Patients should be well seated comfortably in the dental chair with suitable assistance from the dental personnel.

8. Conscious sedation is one of the common modes of management for complex dental or surgical procedures for the completion of treatment successfully and to facilitate operating efficiency. This should be done under the instructions and guidance of the physician or neurologist.