The NobleDentist Blog

Our dentists have once again put together a paper to assist you. This time on Parkinson’s Disease.

New York University (Medicine Faculty) has made observations over 3 years on more than 100 people with Parkinson’s Disease. Findings suggest an urgent need for dental treatment for people with Parkinson’s Disease.

Dental Health Findings

• Dental cavities and the build up of dental plaque do increase. This is associated with the increase in gum inflammation, gum disease, tooth mobility, and pain. All of which are due to the diminishing ability to brush teeth and the reduction of hand-to-mouth mobility associated with Parkinson’s Disease.
• The fit of removable partial or complete dentures can be poor and usually there is a loss of bite stability (particularly when worn for a long time). The dentures generally have inappropriate chewing contacts when the upper and lower teeth bite against each other. This irregular bite loosens the fit of the dentures, can break both natural and artificial teeth, and often causes ulceration and pain in the supportive gum tissue.

Recommended Treatment

• Dental examinations at least twice a year to find and treat dental cavities, plaque accumulation, gum disease, ‘bad bite’, missing teeth, defective bridges and breakdown of restorations.
• Preventative care every 6 months or if necessary every 3 months. A dentist or dental hygienist should provide preventaive care and a home-care regime.
• Clear instructions and demonstrations of home oral hygiene are essential. This includes information about choice of toothpaste, tooth-brushing, dental flossing, mouth rinses and saliva control. There are electric toothbrushes and electronic devices available. These are all helpful for people with limited hand skills.


• It is important to have a care-giver (partner, child, aide, nurse) assume responsibility for oral hygiene on a daily and regular basis when people are in an advanced stage of Parkinson’s disease. The dentist should give thorough advice to this care-giver and follow up the care during professional clinic visits. The care-giver should also be instructed to wear gloves and told how to maintain an infection-free environment.


• It may be possible to arrange limited home dental care by a private dentist when unable to attend the dental practice.
• Dental care treatment options for people with Parkinson’s Disease should be aimed at maximising oral health and function. This will reduce the risk of requiring extensive maintenance as the person’s physical condition deteriorates and their oral hygiene and access to dental care become difficult. The care also includes cancer screening and review of other oral functions and their oral hygiene.

Quality of Life & Dental Care

It is critical for people with Parkinson’s Disease to consider dental issues relating to oral functions in order to have a better quality of life. These include the following:

• Swallowing disorders.
• Nutrition disorders.
• Language and communication disorders.
• Loss of self esteem.
• Impairment of job and vocational function.
• Impairment of social communication.

Swallowing Disorders

Swallowing difficulties may relate to any of the 3 stages of the swallowing process that takes place sequentially in 3 chambers.

Stage 1 – The Mouth

• The mouth and teeth compose the first chamber. The act of swallowing is initiated by the closure of the lips after chewing and preparation of food. When the lips close, the food is propelled backwards toward the throat by pressure of the tongue tip against the hard palate and the teeth. The food at this stage is at the person’s voluntary control. If the food particles are perceived as too large, the food can be chewed further. If the food is too dry, it can be moistened with either saliva or more fluid such as water or an artificial moistener fluid.
• It is during the first stage of swallowing that dental care can be most effective in assisting swallowing. If the lip and face muscles are weak because of the disease, or if food cannot be chewed adequately because teeth are missing, dental care can both strengthen the lip action and restore chewing efficiency so that food particles can be prepared for swallowing.
• Another factor in swallowing difficulty is pain caused by inflamed dental pulp and gum tissues. Pain caused by pressure on the teeth or by hot or cold foods can cause difficulties in swallowing. The dentist can always relieve pain caused by gum inflammation, decayed teeth, faulty fillings, crowns, dental bridges or removable dentures.
• The final consideration in the mouth and facial part of the swallowing process is the stability of the bite when the opposing teeth close together during chewing. This preparation for swallowing is all voluntary and usually dependent on intact teeth, or their replacement, to be most effective. When teeth are missing or faulty, the tongue becomes a more dominant swallowing agent. In these cases the tongue braces the jaws for swallowing by being pushed between the opposing jaws. This abnormal swallowing pattern requires a more fluid and softer diet.

Stage 2 – The Pharyngeal Chamber

• When food is passed into the throat, the lower jaw must be fixed in position (stabilised) so the floor of the mouth can be elevated. This allows the laryngeal valve (vocal folds) to be closed, preventing food from being aspirated into the lungs. Associated with the elevation or tucking forward of the larynx is the control over head posture.
• It is advisable for people with Parkinson’s Disease to sit upright when eating so that gravity does not cause food to pass into the pharynx before one is ready to initiate the second phase of swallowing. People should not eat or drink lying on their backs. If people are bedridden, they should drink lying on their sides with the head elevated as high as possible.
• Another factor is that it is normal to swallow up to 2,000 times a day, which makes it a full-time activity during the waking day. Since many people with Parkinson’s Disease salivate excessively, they should sit forward when watching TV for a long period of time. A pillow behind the back to move the trunk forward when they have to swallow usually facilitates this function. Aspiration of saliva into the larynx and lungs can cause coughing spasms which sometimes are very debilitating. It is also advisable not to speak when chewing or swallowing, since doing several things at once is difficult for people with Parkinson’s Disease.
• The second phase of swallowing is under only partial voluntary control, so the precautions about type of fluid, body posture and healthy teeth are essential for effective swallowing.

Stage 3 – The Oesophagus

• In this stage food passes from the oesophagus to the stomach; the third stage of swallowing relates to the oesophagus and its upper valve, from pharynx to oesophagus, and the lower valve from the oesophagus to the stomach. When these valves don’t function properly, reflux or regurgitation of gastric fluid can cause heartburn.
• Difficulty with this part of swallowing is a medical problem and should be investigated by a physician or speech pathologist. Some hospitals have a swallowing clinic to assist people with the second and third phase of swallowing disorders.

Summary

Healthy teeth and gums and controlled posture can provide an effective swallowing function for people with swallowing disorders. Sometimes a speech pathologist trained in oral and dental aspects of swallowing co-operates with the dentist to improve and maintain effective swallowing.

Nutrition Disorders

Nutritional deficiency may occur with progressive loss of motor skills and diminished dental health care in people with Parkinson’s Disease.

As Parkinson’s Disease progresses, or if the teeth are defective, food intake may become a problem. People may no longer be able to eat the foods they prefer. Since protein and other dietary requirements are altered as the disease progresses, it is essential that dental health be considered a major factor in nutritional management for people with Parkinson’s Disease. Their physician and dietitian should inquire into their dental health status and make the appropriate referral to their own dentist. If they do not feel experienced enough about treating people with movement disorders like Parkinson’s Disease, they may contact the Australian Dental Association.

Speech and Language Disorders

Speech impairment often accompanies Parkinson’s Disease. It has been estimated that 70 per cent of people with Parkinson’s Disease show signs of speech impairment but that only 5 per cent receive speech therapy. One of the main contributing factors to speech problems is poor dental health, especially loose teeth, missing teeth and defective dentures.

The teeth are the principal skeletal support for the pronunciation of many consonant sounds (e.g. labials like F and V, lingual dental sounds like T, D, R and L, and continuant sounds like S, Th and Ch). When the anterior teeth are missing or defective, the absence or distortion of these consonants causes speech to be less intelligible. In people with Parkinson’s Disease whose muscle movements are unco-ordinated, the speech may be totally incoherent.

When dentures are ill-fitting, their looseness distorts not only the consonants but also the vowel sounds, making the person fearful of speaking. This looseness and anxiety magnifies the speech difficulty. People with Parkinson’s Disease often reduce their breathing energy and their speech becomes inaudible. Appropriate bite allows more effective diaphragmatic breathing to give a supportive breath stream for speech. Furthermore, when dentures are loose many people with Parkinson’s Disease who salivate excessively cannot swallow their saliva effectively, and either drool or spray their saliva when attempting to talk.

Faulty breathing patterns also prevent a long enough stream of air to be exhaled when a person is speaking. The breathing patterns have to be co-ordinated with an appropriate head and jaw posture for speech. A dentist can check the bite to see if it prevents or assists in proper air exhalation and inspiration for speech.

Faulty tooth alignments and gross irregularity of bite between the upper and lower jaws cause poor lip approximation to produce faulty labial sounds like P and B.

Associated with lip difficulties in speech is the distortion of lip form which causes excessive creasing and folding of the muscles around the mouth and lips. Routine dental examination, tooth replacement, denture repairs and properly restored teeth will improve speech.

Loss of Self Esteem

The impairment of speech, coupled with changes in facial contour and salivary drool, often undermines the self-esteem and self-image of people with Parkinson’s Disease. They often choose to eat alone and thereby avoid embarrassment. One of the more critical aspects is the effect on their psychosexual feelings. They often feel their general disability makes them less desirable as a connubial partner. This feeling of inadequacy is heightened where the face and lips are distorted, and when the teeth are decayed or filled with plaque and gums bleed easily. Appropriate and sustained dental care and prophylaxis may alleviate the stress on their libido and sex drive.

Job and Vocational Status

Many people with Parkinson’s Disease are still employed in a wide variety of vocations. Often their ability to continue gainful employment depends on their oral and facial appearance and their ability to communicate. Dental care to improve their appearance and speech and diminish salivary drool may be a critical factor in continued employment. A dentist, often in co-operation with other professional associates, can solve these problems.

Socialisation and Community Activity

People with Parkinson’s Disease often become dependent on their care-givers. They tend to withdraw, eat alone and become socially isolated. Caring for their facial and oral needs often facilitates and/or improves socialisation. Improving the arrangement of teeth, cleaning the gums of plaque and stains and replacing missing teeth and dentures give people more confidence to socialise and to be a part of community activity.

Summary

People in all stages of Parkinson’s Disease can play an active role in maintaining or improving their oral and dental health. The following points are very important.

• Regular oral hygiene by a dentist or hygienist at least every 6 months.
• Regular periodic dental examination at least every 6 to 12 months if oral hygiene is maintained.
• Use of special-handle toothbrushes to facilitate hand grasp.
• Training in home care for care-givers in advanced cases.
• Monitoring of changes in oral function such as changes in speech, swallowing or nutritional habits.
• Home care, if necessary, for both emergency and routine care for home-bound people may also be available.

Choosing a Dentist

Keep in mind that many dentists are not equipped professionally or psychologically to treat people with moderate to severe Parkinson’s Disease. If you do require assistance, you could contact the Australian Dental Association. They may be able to identify a dentist in your area that could assist you.

To learn how to save hundreds and even thousands of dollars at the dentist, click on NobleDentist.

According to the Australian Dental Association, mouthguards are a must for children participating in contact sports. It is also important that parents, teachers, and sporting coaches are aware of the potential dangers for children’s mouths if the children are risking collision or contact during sports and activities.

Dr Don Wilson said, ‘Dentists are seeing too many cases of dislodged or chipped teeth following sports-related accidents. ‘Although mouthguards are compulsory in many schools and sporting clubs, there are still too many incidents occurring because a mouthguard hasn’t been used or doesn’t fit securely,’ Dr Wilson said.

The Australian Dental Association makes the following points:

• If contact is a part of the game then mouthguards should be compulsory and their use closely monitored by parents, teachers, and sporting coaches. This would apply to sports such as rugby, rugby league, aussie rules, and boxing.
• Where contact is not permitted but it can occur then mouthguards are highly recommended. This would apply to sports such as basketball, squash, hockey, and soccer. Where contact is considered rare then mouthguards are not necessary. This would apply to such sports as tennis.
• Mouthguards should be a top priority for a parent with a child participating in sports where contact is likely. A custom-fitted mouthguard for a child costs less than a pair of sporting shoes. This is very little when compared with the cost of repairing broken teeth with bonding, root canal treatment, a crown, a bridge or implant work, not to mention the heartache and inconvenience.
• It is recommended that custom mouthguards be fitted by a dentist rather than the over-the-counter variety found at the chemist. Custom-fitted mouthguards are moulded by a dentist to the shape of the child’s teeth making them more comfortable and the most effective means of preventing injuries. Custom-fitted mouthguards are more secure and clear speech is much easier than when using an over-the-counter type of mouthguard.

‘This is not an advertisement for dental services. It is a well-researched fact that the custom-fitted mouthguard gives significant benefits over the self-applied one.’ Dr Wilson said.

To learn how to save hundreds and even thousands of dollars on dentist fees, click on NobleDentist.

Only several hours ago, we decided to change our name NobleHealth to NobleDentist.

It was felt that this name change would decrease the number of times we are asked, “Are you an insurance company?” or “Do you cover optical?”

It also made us chuckle at possible reactions from dentists when people enquire, “Are you a NobleDentist?”

Well, we estimate this change to take roughly a week. Your NobleHealth card will continue to be accepted.

To learn how to save hundreds and even thousands of dollars at the dentist, click on NobleDentist.