Tips on How to Maintain Dental Care & Oral Hygiene In Parkinson’s Patients: By Dr. De Leon

“Be true to your teeth, or they will be false for you.” Soupy sales

It is true that Parkinson’s in rare instances has been diagnosed by very astute
dentists who saw tale tell signs and referred them to a specialist who confirmed
diagnosis but this is the exception rather than the rule. So, it is up to all of
us who suffer with or care for someone with Parkinson’s (PD) to educate other health
professionals about our symptoms including our dentists.

This education begins with a thorough medical review of medications, symptoms. Your dentist
should as a routine monitor your blood pressure and other vitals and always discuss
any medical issues and changes to your medical regimen which might impact your dental care
in any shape or form.

For you see, as many of you have already figured out, having Parkinson’s can present a very complex
and unique set of challenges to you and your dentist when it comes to providing routine and not so routine care.
Plus, the fact that you have PD alone can cause problems with your mouth, gums, and
teeth due to multiple factors.

Therefore, it is important that you are aware of what the issues are and how to
be proactive in preventing problems. By being knowledgeable, you can be
instrumental in helping your physician(s) and dentist to work together to
provide the best possible care for you in order to continue to maintain the best
quality of life for as long as possible which includes maintenance of your teeth for
a healthy dentition but also a pain free mouth.

It is estimated that about 25% of patients with PD experience a syndrome known as
“Burning Mouth Syndrome.” This problem can result due to multiple factors. The main cause is ultimately
the tissues in the mouth becoming dry. These occur as a result from things like
vitamin D deficiencies (or insufficiencies)-which are extremely common in PD; multiple medication intake
(especially PD meds like Artane -[trihexyphenidyl] or [amantadine]- Symmetrel which
cause dry mouth or decrease saliva input by blocking choline receptors). Other conditions which lead to mouth
dryness is known as Xerostomia (dry mouth from insufficient saliva production). Poor oral hygiene,
poor nutrition and even infections can also be some of the reasons patients with PD have mouth and oral
mucosa dryness. The dryness can subsequently cause pain.

However, before a dentist gives you a diagnosis of ” Burning Mouth Syndrome” make sure you check with your
Neurologist to exclude other causes of pain and burning in face and mouth which are
unrelated to Parkinson’s like trigeminal neuralgia, shingles, atypical face
pain, bruxisim (grinding of teeth) and are much more common especially in older populations.

Once other causes of pain have been thoroughly excluded and pain is related to Parkinson’s due to multiple factors above
it is the job of the dentist to help sort out which is the main culprit in the pain -whether infections, or lack of saliva,
or poor nutrition or hygiene …thus make a formal treatment plan to alleviate symptoms.
treatment plan can include things like:
Use of artificial saliva to help with dry mouth, for sailorrhea consider a
couple of alternatives sucking on hard candy of course sugar free…but don’t
want or increase cavities and increase diabetes so if drooling severe discuss
medication options like levsin or Botox Injections into salivary glands. Botox
injections are still the recommended treatment for bruxisim which causes severe
jaw pain ….this is most effective …guards do not worK! & are Expensive!
And usually break !

Also to prevent decay, make sure you brush regularly. It can be hard to brush
and maintain hygiene especially as Parkinson’s symptoms progress due to poor
dexterity, Loss of fine motor control, increase rigidity , tremors and
dyskenesias to name a few things so consider investing in a good electric tooth
brush. Also get a long handle for it to make it easier to maneuver.(I have had to switch because
my rigidity was preventing me to be able to brush properly my whole mouth …one side is stronger than another!)
This solved my problem and if you have trouble flossing use mouth rinse 3 times a day!
Some dentist have suggested putting a regular grip brush inside a bike handlebar grip or a
tennis ball for stability and dexterity.
Also, try a ” one handed” technique using the stronger side of your body. Brush
after every meal, if not able to do so at least rinse your mouth with water or
mouth rise. You should replace your brush at least every 3 months or if bristles
are worn.
Also avoid irritating products like alcohol, tobacco, acidic and spicy foods.

Because Vitamin D is so compromised in PD patients, 1/2 showing Vitamin D insufficient, while a 1/4 have
clear deficiency, according to Archives of Neurology report.
Therefore, I recommend, that all PD patients have their Vitamin D levels checked at least once a year by their
Neurologist or MDS. The Endocrine Society Recommends the following guidelines for blood levels in adults and children.
Vitamin D deficiency-20ng/ml or less
Vitamin D insufficiency- 21-29ng/ml
Vitamin D sufficiency – 30ng/ml or greater (NL)

Of course when you have dryness and take a lot of meds you are more prone to
dental sensitivity and tooth decay….I know that since I was diagnosed With PD,
I have had lots of tooth sensitivity that fortunately
responds well to Proenamel Sendodyne.

Aside from the issues of dryness, pain and sensitivity there are many other reasons why it is difficult
for both patients and dentists alike to deal with oral hygiene.
First of all tremors have a tendency to increase during stressful
situations and what can be more stressful than going to the dentist! Tremors can
be present in the tongue and head (although head tremors are not typical of PD
but more pathogneumonic of ET but there may be some overlap in some patients).
These tremors are involuntary movements and can be present as dyskenesias or
dystonias of the neck which make a routine cleaning extremely difficult much less any other dental work.
Another big problem PD patients encounter is salivary control or excessive drooling (sailorrhea).
Patients can also have excessive neck rigidity or stiffness including that of the facial
muscles making it difficult to open their mouth and or weakness causing problems with
swallowing or biting down during X-rays or cleaning.
PD patients by nature are anxious and can become even more so increasing their levels of fatigue
during their visits to the dentists. These symptoms are both caused by the illness itself and can be a
consequence of the medications patients are on. The combination of anxiety, fatigue can at times make it
very difficult for them to tolerate being seated upright for long or awake to be cooperative.
Along the same lines, some patients, especially in moderate to advance stages may suffer from
orthostatic hypotension[OH] again making it extremely difficult to sit for any significant length of
time or tolerate change in position in body or neck movements without
causing them to feel faint, dizzy, or pass out.
One way to compensate for [OH]is follow some of the maneuvers I suggested in my blog on [OH]….wear Ted hoses,
make SLOW body movements and talk to doctor about medication changes consider new medication Northera …

Finally, Tips to help ease your anxiety and make your visit at your dentist easier :
1) Make appointments when you are at your best whether in am or in pm…. Most
Parkinson’s patients have trouble getting going early in am…
2) Ask your doctor to give a sedative like Xanax or Valium to relax you and stop
or decrease the tremors. ( have a driver)
3) If need to then schedule general anesthesia …if you do need general anesthesia…may
not be able to take your oral meds especially Azilect
or other MAO inhibitors. Avoid or limit meds like Demerol OTC cold / cough meds, dextromethorphan,
pseudo ephedrine, phenylephrine, nausea meds
Antidepressants -MAO -a , ssri’s , Snri, tricyclics- all of these have potential of making PD symptoms worse
Also minimize narcotics and pain medications.

But you can still take
NEUPRO patch and take oral dissolvable sinemet (Parcopa) your neurologist can
prescribe this….you can also have IV amantadine and can have scopolamine patch
to decrease nausea and vomiting but of course if you are going to have any kind
of procedure whether you have general anesthesia or mild sedatives ( conscious
sedation) like Xanax need to have someone accompany you because you will not be
able to drive on your own. For pain Tylenol plus an anti-inflammatory usually works well.
4) request to be seated more upright to reduce aspiration risks.
5) make more frequent appointments ( every -3 months if you have gum disease), and of smaller
duration to avoid fatigue, pain, dystonia …
(I know that my dystonia really kicks in if my cleaning lasts longer than 30
minutes then I have pain for few days which then triggers migraines…I avoid by
asking for 5 minute breaks…if you are not feeling well DO NOT be afraid to reschedule!)

if you need to have work done [Consider restoration of old fillings, ill filling dentures,
replace crowns and bridges if needed in early PD when things are a lot easier with a lot less need
more anesthetics or suspension or alteration of medications or risk of
complications because difficulty owning mouth etc. also consider dental implants
for over dentures before Parkinson’s gets severe].

References:

Arthur H.Friedlander, DMD, Michael Mahler, MD, Keith M. Norman,BA, Ronald L.
Ettinger, BDS, MDS,DDSc,DABSCD, “Parkinson’s Disease, Systemic and Orofacial
Manifestations, Medical and Dental Management”, JADA, Vol.140, June 2009

Devere Ronald, MD FAAN, “Cognitive Consequences of Vitamin D Deficiency”, Practical Neurology,
Vol. 13, No.1,January/February2014.

James M. Noble, MD, MS, CPH. ” Dental Health and Parkinson’s Disease”,
Parkinson’s Disease Foundation, winter 2009

“Low Vitamin D levels Associated with Parkinson’s Disease’, Parkinson’s Disease Foundation News & Review, winter 2009

Michaell A. Huber, DDS. ” Parkinson’s Disease and Oral Health,” The American
Parkinson Disease Association, Inc. 2007

Satbir Grover, BDS, MS, Nelson L. Rhodus, DMD, MPH, Dental Implications of
Parkinson’s Disease, Northwest Dentistry Journal, 2000-2013.MN Dental Assoc.

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Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at http://www.facebook.com/defeatparkinsons101 you can also learn more about Parkinson’s disease at www.pdf.org or at www.wemove.org; http://www.aan.org, http://www.defeatparkinsons.blogspot.com
may also contact me at
deleonenterprises3@yahoo.com