Parkinson's disease: 5 Tips on seeing the dentist and dental care
We receive tons of questions about the dentist and dental care with Parkinson’s disease. It turns out that there are important aspects to care every person with Parkinson’s should have access to. In this month’s blog we provide 5 tips on the dentist and dental care with Parkinson’s.
What do we know about dental care and Parkinson’s?
Is it safe, should I get it?
There was a recent article summarizing challenges with dental care and Parkinson’s by Prete and colleagues including Aviv Ouanounou, MSc, DDS, FICO who is a dentist at University of Toronto.
The main point they make is that dental care is safe in Parkinson’s. Here are the issues Prete and others have highlighted as important. You should be seeing the dentist at least once a year with Parkinson’s.
There are many symptoms dentists encounter in people with Parkinson’s. There can be weakened facial musculature, gaunt appearance, tremors of the tongue, lips and eyes, erratic mandibular movements, bruxism (grinding of the teeth), xerostomia (dry mouth), sialorrhea (drooling), dysphagia (swallowing issues), dysgeusia (taste issues) and glossitis (tongue issues).
Consequences of dental issues can include angular cheilosis (issues arising at the far right or left side of the lips), burning mouth syndrome, hyposmia (smell issues) and hypophonia (speech issues).
Some of the dental issues, if left unaddressed, can lead to poor nutrition, weight loss and a worsened quality of life.
Some persons with Parkinson’s may have heart valves requiring anticoagulation (blood thinners), devices or other issues the dentist must be prepared to manage. If you have atrial fibrillation this is another common reason to be on a blood thinner.
What is the consequence of drying the mouth with
anticholinergics and or botulinum toxin, if I have
drooling?
It is really important that all persons with Parkinson are aware that any medication that dries the mouth can lead to cavities and to dental issues. It is important if you are on any of the following medications to brush your teeth multiple times a day, especially before bedtime; and brush in the mornings after you awaken from sleep.
Anticholinergics can include drugs like benadryl, trihexyphenidyl, artane, parsitan and others. Check with the pharmacist to make sure you are aware if any of your drugs are classed as anticholinergics.
Remember also that anticholinergics can hide as components in other drugs such as amantadine, eye drops and bladder drugs.
Some folks will give atropine eye drops under the tongue to dry the mouth; and this medication is an anticholinergic.
All botulinum toxins can dry the mouth and lead to issues.
AVIV OUANOUNOU, MSC, DDS, FICO IS A DENTIST AT UNIVERSITY OF TORONTO WHO WROTE A RECENT REVIEW ARTICLE. HE REVIEWED SOME OF THE GUIDELINES.
What if I have deep brain stimulation, do I need to
take antibiotics for dental procedures?
It is important to check with your doctor, however in most cases prophylactic antibiotics are not required if you have deep brain stimulators implanted. If you are immunosuppressed, or for example have a heart valve, in many cases your doctor will recommend a course of antibiotics prior to and after dental procedures.
The last American Dental Association guidelines (2012) suggested that prophylactic antibiotics are not routinely recommended.
Also, if you have deep brain stimulation you can use electric toothbrushes.
AVIV OUANOUNOU, MSC, DDS, FICO IS A DENTIST AT UNIVERSITY OF TORONTO WHO WROTE A RECENT REVIEW ARTICLE. HERE ARE SOME OF HIS TIPS.
What if I am on a blood thinner, can I have dental
procedures with Parkinson’s?
The short answer is, it will probably be ok. If you are on a blood thinner like coumadin or other blood thinners, you should always check with your doctor and have the doctor communicate directly with the dentist. Depending on the type of procedure, there may be a need to be temporarily come “off” a blood thinner; and this could introduce risk if you have a heart valve or atrial fibrillation (as two examples). Many small dental procedures can be performed when on a blood thinner, however it is always best to have the dialogue and to assess the risks and benefits; and to plan accordingly.
Are regular X-rays safe in Parkinson’s disease?
Plain film (and panoramic films) old fashioned X-rays which are obtained in the dental office are in most cases safe in persons with Parkinson’s disease.
Bonus Information on Deep Brain Stimulation and
dental visits.
PAM ZEILMAN ARNP EXPERT DBS PROGRAMMER @UF @FIXELINSTITUTE
Pam Zeilman is our nurse practitioner for deep brain stimulation adjustments at the University of Florida @Fixelinstitute and she has assembled this information (below) for our persons with DBS.
Deep Brain Stimulation Medical Safety Issues – or things to know!
EKG / ECG (cardiac rhythm checks)
- If your doctor wants to do an EKG you should turn the DBS off so that it will not cause interference in your doctor interpreting the EKG tracing.
Surgery or procedures
- For surgical procedures you should turn the DBS off as well. We can provide a letter to your doctor regarding surgical procedures and your DBS device if needed.
- Electrocautery (used to stop bleeding in surgeries) - DBS needs to be turned off. The surgeon needs to be aware regarding guidelines. Ideally, only bipolar electrocautery should be used. If needed, the grounding pad can be placed on the lower extremities.
- EEG (electroencephalogram) tracing. Turn off DBS until monitoring is completed
- No lithotripsy (treatment for kidney stones). This may damage the neurostimulator circuitry. If lithotripsy must be used, do not focus the beam within 15 cm (6 in) of the neurostimulator
- Cardioversion – turn the device off. Some older devices need to be turned down to 0V.
- For Colonoscopy: Provider will follow electrocautery guidelines. The DBS may need to be turned off during the procedure to allow for monitoring of EKG.
- For Cataract surgery: Cataract surgery is considered safe and your DBS device can remain “on”.
If the ophthalmologist uses phaecoemulsification (“ultrasound”, most common), they should work from the top of the head down. The surgeon should not lay anything across the chest
If they use laser, the surgeon should use caution to not direct anything towards the DBS equipment.
Dentistry:
- Dental x-rays and Panoramic dental x-rays are okay
- You may use electric toothbrushes
- Prophylactic Antibiotics: As of 2012, the American Dental Association (ADA) and the American Association of Orthopedic Surgeons no longer recommend antibiotic prophylaxis for everyone with orthopedic implants. Based on these guidelines, we no longer recommend antibiotics for everyone with DBS. However, your dentist may rely more on your personal medical history to determine when antibiotics are appropriate.
Radiology
- CT Scan and x-rays are okay
- Regular ultrasounds are okay. For example: ultrasounds of the heart, kidney etc.
- For mammograms, the radiology technician should be experienced with doing mammograms on cardiac pacemakers as the devices are similar. The pads should be positioned/ rotated so as not to pull/place pressure on the device or lead extenders (wires)
- DEXA scans okay
MRIs
- depends on company and type of battery. Ask your DBS provider
- For all companies and batteries the imaging center has to be certified to do imaging in DBS patients.
- Medtronic Soletra / Kinetra – brain only conditional, impedance within range, 1.5T only, DBS set to 0 volts and off. Cannot do MRI impedance check with patient remote – has to be done by DBS provider or Medtronic representative.
- Medtronic Activa SC, Activa PC, Activa RC – Full body conditional, impedance within range, 1.5T only, DBS set to off if monopolar setting and either side, DBS set on if biplar setting on both sides. Cannot do MRI impedance check with patient remote – has to be done by DBS provider or Medtronic representative.
- Medtronic Percept PC – full body conditional, impedance within range, 1.5T or 3T, DBS set to off if monopolar setting and either side, DBS set on if bipolar setting on both sides. Can do MRI check with patient remote or be done by DBS provider or Medtronic representative.
- Abbott Libra - not FDA approved of MRI brain. Brain only with special consent. 1.5T with DBS 0 mA and off. Cannot do MRI check with patient remote – has to be done by DBS provider.
- Abbott Infinity – brain only conditional, impedance within range (has to be done by DBS provider or Abbott representative), 1.5T only, DBS set to MRI mode with patient remote.
- Boston Scientific Vercise, Vercise PC - not FDA approved of MRI brain. Brain only with special consent. 1.5T with DBS 0 mA and off. Cannot do MRI check with patient remote – has to be done by DBS provider.
- Boston Scientific Vercise Gevia – brain only conditional, impedance within range (has to be done by DBS provider or Boston Scientific representative), 1.5T only, DBS set to MRI mode by DBS provider or Boston Scientific representative.
- Boston Scientific Vercise Genus – brain only conditional, impedance within range (can be checked with patient remote or done by DBS provider or Boston Scientific representative), 1.5T only, DBS set to MRI mode by patient remote
What to avoid:
- No Diathermy (heated ultrasound or therapeutic ultrasound) Physical therapist or Chiropractors use diathermy. Can cause neurostimulation system or tissue damage and can result in severe injury or death
- No Transcranial Magnetic Stimulation (TMS)
- Patients should not dive below 10 meters (33 feet) of water or enter hyperbaric chambers above 2.0 atmospheres absolute (ATA) as this could damage the neurostimulation system, before diving or using a hyperbaric chamber, patients should discuss the effects of high pressure with their clinician.
Precautions:
- Loss of coordination in activities such as swimming may occur. Have a swim buddy.
Airport security:
- Bring your DBS identification card to the airport with you to present to airport security personnel prior to being screened.
- Security devices will NOT harm your DBS; however, they may cause stimulation to switch ON or OFF and some patients may experience a momentary increase in perceived stimulation when passing through theft detectors and security screening devices.
- Security personnel at most airports will conduct a “pat-down” security check instead of requiring the DBS patient to go through the security gate.
- Always bring your patient programmer with you when you travel.
Mental Health:
- Depression, suicidal ideations and suicide have been reported in patients receiving Medtronic DBS Therapy for Movement Disorders, although no direct cause and effect relationship has been established. Please contact your DBS provider immediately if you note any change in your mental health
Physical Activities:
- After incisions have completely healed, it is ok to perform all physical activities, except for those that may result in repeated hard blows to the device, e.g., American football, ice hockey, and boxing. Wear helmets for the activities you would normally have a helmet for, e.g., bicycling, skiing, snowboarding, and horseback riding
- If you have Parkinson's or essential tremor – both diagnoses can cause problems with balance. Because of this symptom we recommended avoiding the use of ladders.
Disclaimer: This is a partial list of safety concerns. Please review each companies DBS website for a more complete list of safety concerns.