Clinical Scenario

An 81‐year‐old female presents to the dental clinic, accompanied by her daughter and carer. The patient reports that she finds it increasingly embarrassing to communicate, socialise and go to public places. In part, she feels that this is related to her excessive drooling and the fact that food persistently accumulates in her mouth (Figure 14.2.1).

Structured Learning

1. Following further questioning regarding the haematoma on the right side of the patient’s forehead, you determine that she fell over in the bathroom at home that morning. What additional questions would you ask and why?
   

   

   

   • In view of the risk of a traumatic brain injury, it is important to enquire if there was any loss of consciousness, any amnesia before or after the injury, persistent headache, drowsiness or any vomiting episodes since the injury; the patient may require urgent referral to the emergency services if any of these are present; this patient is particularly at risk of an intracranial bleed as she is anticoagulated (see Chapter 10.3) and hence should be alerted that if any of these signs do appear later, she should seek urgent medical attention
   • Further details regarding how the fall occurred are also important as these may highlight safeguarding issues (inadequate support/supervision in the bathroom, possible non‐accidental injury)

2. Following further assessment of the patient, you determine that she appears stable (Glasgow Coma Scale 15) and there are no safeguarding concerns. The patient wishes to proceed with the dental appointment and asks what could be causing the worsening of her drooling. What would you discuss?
   • Up to 85% of patients experience sialorrhoea (drooling) in advanced PD
     

     

   • This is in relation to reduced muscle control, which results in swallowing dysfunction, oropharyngeal dysphagia, poor oral musculature control and forward flexed positioning of the head
   • Treatment options include botulinum toxin injected to the parotid and submandibular glands usually through ultrasound guidance or palpating the gland; the duration of its effects can range from 6 weeks to 6 months with the usual side‐effect being xerostomia. Speech therapy and physical therapy may also be helpful
3. In addition to drooling, what other factors make it difficult for the PD patient to communicate and socialise in public?
   • A mask‐like facial appearance and reduced movements of the small muscles of the face (hypomimia) are perceived by others as staring blankly or responding flatly
     

     

   • The quality of speech deteriorates along with disease progression, with hypophonia and even whispering in the later stages
   • Patients may fear not being understood or interrupted in a conversation with several people
   • The patient may also experience altered emotions or mood swings that vary day to day and may be associated with depression

4. The patient also asks why food is accumulating in her mouth and if this is causing the deterioration in her oral health. What would you discuss?
   • Bradykinesia can affect chewing, slowing down the clearance of food in the oral cavity
   • Poor bolus formation with reduced tongue movement make propulsion of food down the oral cavity difficult
   • In the latter stages of disease, there is weakened pharyngeal motor control, causing dysphagia and making swallowing certain foods more difficult, if not impossible, causing them to remain in the oral cavity
   • A forward/drooped head position can also make swallowing worse
   • Tremors, loss of fine muscle control and impaired manual dexterity make it increasingly difficult for the patient to brush her teeth efficiently; an electric toothbrush/adapted brush with suction may help
   • Depression also contributes to the low motivation in self‐care and difficulty in performing oral hygiene care regularly
5. The patient reports that #34 is not painful, although there was a gingival swelling in the adjacent gum for which the doctor prescribed antibiotics 3 months ago. Why is this of particular concern in this patient?
   • The tooth should be managed urgently as it is grossly carious, with further episodes of infection likely
   • There may be associated bacteraemia with the associated risk of infective endocarditis as the patient has a prosthetic heart valve (see Chapter 8.5)
6. What other factors do you need to consider in your risk assessment when planning extraction of #34?
   • Social
     • Escort availability
     • Consider positioning the chair to accommodate the patient’s forward bent position
     • Access and transfer from the wheelchair (a wheelchair recliner may be required)
     • Particular caution if transferring the patient due to history of frequent falls
   • Medical
     • PD‐associated complications such as tremor, communication and swallowing problems
     • Prosthetic heart valve/infective endocarditis risk (see Chapter 8.5)
     • Bleeding risk related to INR range (see Chapter 10.3)
     • Osteoporosis: hyperkyphotic posture, increased fragility of bone (see Chapter 7.1)
     • Drug interactions/side‐effects: benzodiazepines used in conscious sedation may reduce effect of levodopa/carbidopa; antihypertensive medication may increase the risk of orthostatic hypotension
   • Dental
     • Antibiotic prophylaxis prior to invasive dental surgery (see Chapter 8.5)
     • Medication‐related osteonecrosis of the jaw risk due to denosumab (see Chapter 16.2)
     • Haemostatic measures to control bleeding after surgery and at home
     • May require assistance for oral care
7. Following stabilisation of her oral health, the patient returns to you 6 months later for a routine review. She informs you that she has had a deep brain stimulator (DBS
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