Brain Training Matters

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Brain Training Matters

• Prosthetic Management of the Parkinsonian Patient
• Thomas J Clifford

Friday 13th June Belfast
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I woke up to find a message in my left hand. It
had me trembling. It wasn't a fax, telegram,
memo, or the usual sort of missive bringing
disturbing news. In fact, my hand held nothing at
all. The trembling was the message.
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Parkinsons Disease

• A progressive neurodegenerative condition
  resulting from the death of the
  dopamine-containing cells of the substantia
  nigra.
• There is no consistently reliable test that can
  distinguish PD from other conditions that have
  similar presentation.
• The diagnosis is primarily clinical, based on
  history and examination.
• People with suspected PD should be referred
  untreated to an expert in the differential
  diagnosis.
• Should be suspected in people presenting with
  tremors, stiffness, slowness, balance problems
  and/or gait disorders.

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Parkinsons DiseaseDemographics

• Affects 1 of adults over age 60
• Onset between 55 and 60
• 5 cases in adults under 40
• Men Women 3 2

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Parkinsons DiseaseDemographics

• 100-180 people per 100,000 of population
• 6-11 people per 6,000 in UK
• Annual incidence of 4-20 per 100,000

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Parkinsons DiseaseDemographics

• Ireland 6,000 adults have disease
• U.K. in excess of 120,000

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Parkinsons Disease
In coming years Parkinsons disease will become
increasingly more prevalent as the population
gets older. Diagnosis is often complicated and
requires careful consideration of symptoms and
neurological findings. Optimal symptomatic
treatment of Parkinsons disease involves an
individualised approach and ongoing evaluation of
benefits versus side effects
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Clinical Features of Parkinsons Disease

• T remor
• R igidity
• A kinesia and bradykinesia
• P ostural instability
• S soft speech

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Typical signs of Parkinsons Disease

• Blank mask-like facial expression
• Reduction in spontaneous blink rate
• Soft monotonous voice
• Difficulty initiating walking
• Walking with small slow shuffling steps
• Walking with rapid small steps
• Freezing occurs on turning/changing direction
• Voluntary movements slow and reduced amplitude
• Resting tremor, pill rolling of opposed thumb and
  fingers

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The Face in PD From combination of bradykinesia,
loss of postural reflexes and rigidity
Absence of blinking Dribbling of
saliva Expressionless Monotonous, soft
speech Sweatiness, sialorrhoea Weakness of upward
gaze Glabellar tap
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Non-motor Features of Parkinsons Disease

• Cognitive impairment dementia
• Psychiatric depression
• Autonomic disturbances
• urgency frequency
• constipation
• hypotension orthostasis
• sweating disorders
• sexual dysfunction
• Dysarthria
• Dysphagia
• Dyspneoa

• Limb paraesthesias
• Restless legs syndrome
• Sleep disturbances
• insomnia
• fragmented sleep
• daytime drowsiness
• REM sleep behaviour
• Impaired sense of smell
• Visual disturbances
• diplopia
• impaired colour contrast
• Weight loss

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Depression in PD

• Cross-sectional studies have shown that
  depression affects around 40 of patients with PD
  and has a major impact on quality of life.
• In most cases depression is mild to moderate in
  severity.
• May be missed by clinician because the clinical
  features of depression overlap with the motor
  features of PD

NICE PD Diagnosis and management in primary and
secondary care 2006
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Depression in PD

• Sad mood, diminished ability to enjoy things
• Poor appetite,sleeping, reduced energy levels
• Slowed movement, poor concentration
• Usually diagnosed when symptoms present every day
  for at least two weeks
• Leading factor contributing to reduced QOL

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Oral Problems and Parkinsons Disease

• Xerostomia and root caries
• Dysphagia and drooling
• Muscle control and dentures
• Maintenance and oral hygiene
• Burning sensation

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PD diagnosis and management in primary and
secondary careKey priorities for implementation

• Referral to expert for accurate diagnosis
• Diagnosis and expert review
• Regular access to specialist nursing care
• Access to physiotherapy
• Access to occupational therapy
• Access to speech and language therapy
• Palliative care

NICE 2006
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Assessing health related QOL in patients with PD
in a prospective longitudinal study
This study did not consider the impact of dental
health on quality of life.
Reuther et al. Parkinsonism and Related Disorders
200713108-114
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An innovative education programme for people with
PD and their carers
This study did not include any advice on dental
health
Simons et al. Parkinsonism and related disorders.
200612478-485
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Parkinsons and dental health John Finnerty BDS
MMed Sci Parkinsons Disease Society
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The dental awareness and needs of a PD population.
Dental problems were reported often. Xerostomia
and burning sensation at least twice that of
general population. Satisfaction with dental care
was high. Reduced satisfaction in those with
loose dentures and burning sensation.
Clifford and Finnerty. Gerodontolgy 1995 12
99-103
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PD Common Dental Complaints

• Xerostomia 51
• Dysphagia 48
• Loose dentures 31
• Poor denture control 28
• Sore gums 23
• Ulcers 17
• Bleeding gums 11.5
• Burning sensation 9.7
• Loose teeth 8
• Sore teeth 5

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Recommendations

• Dentists need to be made aware of the needs of PD
  patients
• Dentists should be involved early in the
  management of PD patients
• Dental health educators should establish contact
  with PD groups
• Dentists should target PD groups for dental
  health awareness

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Prosthetic need in Greek patients with
Parkinsons Disease

• Chewing problems 39
• Swallowing difficulty 29
• Nausea 14
• Occlusion difficult to evaluate 24
• Preference for soft diet
• Oral hygiene 57
• Brush dentures 12

Anastassiadu et al Eur J Prosthodont Rest Dent
2002 10 63-68
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Burning Mouth in PD
Clifford et al. Gerodontology 1998 15 73-78
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Burning Mouth in PD

• Burning mouth affected 24 of PD
• Females more than males
• None reported burning before onset of PD
• 96 of BM taking levodopa
• No relationship with dental status