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Evidence-Based Recommendations for the Oral Health of Patients with Parkinson’s Disease

Abstract

Introduction

Patients with Parkinson’s disease (PD) present a variety of oral disease that can be worsened by xerostomia and sialorrhea. The patients’ physical limitations, for example rigidity and tremor, add to the difficulty of oral care by the general dental surgeon. The objective of the present review was to organize a list of evidence-based recommendations for the oral care of patients with PD.

Methods

A systematic review of the literature was carried out by specialists who selected the relevant papers and created a list of recommendations based upon the literature.

Results

Fourteen papers (data reported in 16 articles) were included in this review. Patients with PD had reduced quality of oral health and hygiene, and high prevalence of gingival recession, periodontal disease, dental calculus, tooth decay, tooth mobility and loss, drooling, xerostomia, dysphagia and temporomandibular disorders. Most studies offered class IV evidence, while one paper had class II evidence.

Conclusion

Patients with PD present poor oral health with conditions that are mostly preventable.

FormalPara Key Summary Points
Patients with Parkinson’s disease (PD) present a variety of oral disease that can be worsened by xerostomia and sialorrhea.
A systematic review of the literature was carried out and a list of recommendations has been created.
Patients with PD present poor oral health with conditions that are mostly preventable.
Routine consultations with dental surgeons may improve the quality of life of patients with PD.

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Introduction

Parkinson’s Disease (PD) is one of the most frequent neurodegenerative diseases, characterized by motor, autonomic, cognitive and behavioral symptoms [1]. Patients with PD will live with this condition from its onset until death, undergoing a variety of pharmacological and/or non-pharmacological treatments. At disease onset, often concerned with mobility limitations, the patient and the physician will focus on this aspect of the disease. Subsequently, cognitive and behavioral symptoms may add to the disease burden, while superimposed autonomic dysfunction makes PD management particularly challenging [2]. Faced with these myriad disabling symptoms, it is not unexpected that oral health may become a secondary aspect of the patients’ lives.

The interdisciplinary approach to patients with PD is highly recommended, but it is not common to have a dentist in the group [3]. Oral care of these patients is often neglected by the patients and their caregivers and physicians [4]. Some diseases reported in patients with PD include increased prevalence of caries and periodontal disease, sialorrhea and drooling, xerostomia, orofacial pain, bruxism and taste impairment [4]. The physiopathology of oral disorders in patients with PD is complex and is not fully understood. Drooling, for example, can be caused by dopamine-induced increased speed of salivary excretion, increased salivary flow rate swallowing dysfunction, hypomimia, lingual bradykinesia and abnormal flexed posture in a patient with reduced salivary production [5]. Although the association between xerostomia and drooling may seem paradoxical, in PD these two conditions may often occur together [5]. In addition, chronic oral inflammation by Porphyromonas gingivalis, a keystone pathogen in periodontitis, causes microbial dysbiosis typical of the neuroinflammation [6]. Periodontal disease has been considered a feature of PD due to poor motor and cognitive control, leading to poor oral health maintenance [7, 8]. However, the association between the two conditions may be two-sided. Chronic neuroinflammation is consistently associated with the pathophysiology of PD and is one of the contributing factors for neurodegeneration [8]. P. gingivalis may be associated with the development of PD and may be more frequent in patients with periodontal disease [7].

The objective of the present study was to review different aspects of oral health in PD and to establish evidence-based recommendations for the prevention and treatment of oral cavity diseases.

Methods

Eligibility Criteria for Including Studies

Clinical trials and observational studies assessing different aspects of oral health among patients with PD were included in this review. These involved associations between different aspects of PD and oral cavity diseases, along with any type of treatment or preventive strategies. Case reports, reviews, guidelines and experimental studies were excluded. This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

Search Strategies for Identifying Studies

A comprehensive and sensitive search was conducted first on 24 March 2020 and then updated on 23 November 2020, in the following electronic databases: MEDLINE (via PubMed), Embase (via Elsevier), Cochrane Central Register of Controlled Trials (CENTRAL), Latin American & Caribbean Health Sciences Literature (LILACS) (via Biblioteca Virtual em Saúde, BVS) and Brazilian Bibliography of Odontology (BBO) (via BVS). We also hand-searched the reference lists of relevant studies to identify any potentially eligible study. The full search strategies are presented in Supplementary File 1. There were no language or date restrictions.

Selection of Studies and Data Extraction

Two authors independently reviewed the title and abstracts recovered through the search using the Rayyan platform [3]. References identified as “potentially eligible” were analyzed in full text. Any disagreement was resolved by a third reviewer.

Data extraction from the studies included was performed by four independent reviewers using a pre-established data extraction form. The data gathered comprised the main characteristics of the studies included (study design, sample size, participant characteristics, intervention and comparator groups, outcomes assessed, follow-up and results). Any disagreement was resolved by two other review authors.

Data Synthesis

The results from the studies included were presented narratively in accordance with the hierarchy of evidence levels [4].

Results

Through the search strategies, a total of 121 references were retrieved. After removed 17 duplicates, 104 were screened using their titles and abstracts, and out of these, 41 potentially eligible references were analyzed in full text. Twenty-two studies did not meet the inclusion criteria and were excluded (reviews and case reports). Two other studies were excluded because they dealt with oral-related risk factors associated with the development of PD in previously healthy individuals. One study was excluded because it only discussed the reduction in the risk of developing PD when an individual underwent dental scaling [5]. This study compared two populations: 4765 adults with PD and 19,060 age-matched individuals without PD. Another study [6] investigated data from 20,175 individuals who were free from PD in 1973 and 1974, regarding the evolution of their health up to 2012. Among men, use of tobacco was associated with a lower risk of developing PD, but their number of teeth and the presence of plaque were not associated with having PD after 28 years of follow-up.

Thus, 14 studies (reported in 16 papers) were included in this review [7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22]. Figure 1 shows the study selection process. Table 1 shows a summary of the data retrieved from the 16 articles that were included in the systematic review, along with the level of evidence for each of them. In summary, the studies pointed out that patients with PD had reduced quality of oral health and hygiene. Presence of PD was associated with gingival recession, periodontal disease, dental calculus, tooth decay, tooth mobility and loss, drooling, xerostomia, dysphagia and temporomandibular disorders. Except for one study with class II evidence [7], all the papers had class IV evidence.

Fig. 1
figure 1

Flowchart of article selection for the systematic review

Table 1 Summary of the studies included in the systematic review

Discussion

There is no question that oral health is important for everyone. Although oral diseases are largely preventable, they are among the most prevalent diseases globally, thus creating a public health problem [23].

Despite the relatively low level of evidence in studies on oral health among patients with PD, the data retrieved for this systematic review allowed us to create a set of simple guidelines. We thus created a list of practical, evidence-based recommendations for all neurologists and dentists who treat patients with PD.

General Dental Care

  1. o

    During neurological consultations, the physician needs to introduce the issue of visits to a dentist.

  2. p

    Should the patient not have regular dental appointments, the neurologist should refer this individual to an oral health care center.

  3. q

    Teeth brushing needs to be done regularly and should be performed alternating the right and the left hands, since rigidity and tremor may be more disabling in one limb as PD progresses. Therefore, the patient should learn to use either hand for oral hygiene.

  4. r

    Individualized instructions regarding oral hygiene, together with chewing and lip exercises, can improve oral health in PD cases [7].

Salivation

  1. o

    PD is associated with hyposalivation or xerostomia (autonomic and anticholinergic drugs), drooling (motor or dysphagia) and halitosis. [11,12,13, 16]. The neurologist and the dentist should assess these conditions and establish the best possible approach to control them.

  2. p

    Low salivary flow can be relieved through artificial saliva spray [24].

  3. q

    Botulinum toxin applied to the parotid and submandibular glands can relieve drooling [25]. However, this procedure may increase xerostomia, and the risk/benefit ratio must be assessed carefully (Fuster Torres et al. [26]).

  4. r

    Photodynamic therapy on the tongue surface may be a good option for halitosis [27].

Tooth Decay and Loss

  1. o

    Patients with PD have a higher frequency of untreated caries [19, 20]. This can be corrected through regular dental appointments.

  2. p

    Tooth loss can be successfully corrected through osseointegrated implants, as shown in nine patients with PD and tooth loss in an open, uncontrolled study [22]. Partial and complete prostheses have also been presented as an alternative to tooth loss [14, 15, 28]. However, it needs to be kept in mind that placing dentures and keeping them functional may be a burden for patients with tremor, rigidity, xerostomia and drooling. In addition, denture stomatitis and inflammatory fibrous hyperplasia have been reported in patients with PD using dentures [8]. Therefore, whenever possible, osseointegrated implants are recommended.

Periodontal Disease

  1. o

    PD is associated with gingival recession and bleeding, plaques, dental calculus and tooth mobility [8, 18,19,20]. Improved hygiene may ultimately lead to lower rates of periodontal disease and, consequently, less tooth loss. Regular visits to a periodontist should be encouraged.

Temporomandibular Disorder (TMD)

  1. o

    Patients with PD showed a higher prevalence of TMD, particularly women [9, 21]. While around 20% of patients with PD show signs and symptoms of TMD, the elderly population generally has a 12% prevalence of temporomandibular dysfunction [29]. Less than 4% of elderly subjects have severe TMD [30].

  2. p

    Untreated TMD may add to the burden of PD, by generating greater pain and orofacial dysfunction. TMD needs to be investigated and treated.

Burning Mouth Syndrome (BMS)

  1. o

    Although the prevalence of BMS is not higher than 4% among patients with PD, this condition has been correlated with poor oral conditions [17]. Therefore, to avoid adding a burden of BMS to individuals already presenting with disability, good oral health needs to be maintained among patients with PD.

Conclusions

Patients with PD have a variety of oral diseases that needs to be prevented, diagnosed and treated. The present paper provides a list of evidence-based recommendations for neurologists and dentists caring for these patients.

References

  1. 1.

    Armstrong MJ, Okun MS. Diagnosis and treatment of Parkinson disease: a review. JAMA. 2020;323(6):548–60. https://doi.org/10.1001/jama.2019.22360.

    Article  PubMed  Google Scholar 

  2. 2.

    Reich SG, Savitt JM. Parkinson’s disease. Med Clin N Am. 2019;103(2):337–50. https://doi.org/10.1016/j.mcna.2018.10.014.

    Article  PubMed  Google Scholar 

  3. 3.

    Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev [Internet]. 2016;5(1):210.

    Article  Google Scholar 

  4. 4.

    - OCEBM Levels of Evidence Working Group*. “The Oxford Levels of Evidence 2”. Oxford Centre for Evidence-Based Medicine. https://www.cebm.ox.ac.uk/resources/levels-of-evidence/ocebm-levels-of-evidence. (Accessed on Nov 26, 2020).

  5. 5.

    Chen CK, Huang JY, Wu YT, Chang YC. Dental scaling decreases the risk of Parkinson’s disease: a nationwide population-based nested case-control study. Int J Environ Res Public Health. 2018;15(8):1587. https://doi.org/10.3390/ijerph15081587.

    Article  PubMed Central  Google Scholar 

  6. 6.

    Liu Z, Roosaar A, Axéll T, Ye W. Tobacco use, oral health, and risk of Parkinson’s disease. Am J Epidemiol. 2017;185(7):538–45. https://doi.org/10.1093/aje/kww146.

    Article  PubMed  Google Scholar 

  7. 7.

    Baram S, Karlsborg M, Bakke M. Improvement of oral function and hygiene in Parkinson’s disease: a randomised controlled clinical trial. J Oral Rehabil. 2020;47(3):370–6. https://doi.org/10.1111/joor.12924.

    Article  PubMed  Google Scholar 

  8. 8.

    Zarpelon C, Regina Stahl Melchiors N, Adalberto Rodrigues-Junior S, da Silva Corralo V, Gassen Kellermann M. Oral health condition of elderly people with Parkinson disease. RFO UPF. 2019;24(2):211–9 (maio/ago. 2).

    Google Scholar 

  9. 9.

    Silva PF, Biasotto-Gonzalez DA, Motta LJ, Silva SM, Ferrari RA, Fernandes KP, Bussadori SK. Impact in oral health and the prevalence of temporomandibular disorder in individuals with Parkinson’s disease. J Phys Ther Sci. 2015;27(3):887–91. https://doi.org/10.1589/jpts.27.887.

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    van Stiphout MAE, Marinus J, van Hilten JJ, Lobbezoo F, de Baat C. Oral health of Parkinson’s disease patients: a case-control study. Parkinsons Dis. 2018;8(2018):9315285. https://doi.org/10.1155/2018/9315285.

    Article  Google Scholar 

  11. 11.

    Tiigimäe-Saar J, Tamme T, Rosenthal M, Kadastik-Eerme L, Taba P. Saliva changes in Parkinson’s disease patients after injection of Botulinum neurotoxin type A. Neurol Sci. 2018;39(5):871–7. https://doi.org/10.1007/s10072-018-3279-4.

    Article  PubMed  Google Scholar 

  12. 12.

    Barbe AG, Bock N, Derman SH, Felsch M, Timmermann L, Noack MJ. Self-assessment of oral health, dental health care and oral health-related quality of life among Parkinson’s disease patients. Gerodontology. 2017;34(1):135–43. https://doi.org/10.1111/ger.12237.

    Article  PubMed  Google Scholar 

  13. 13.

    Barbe AG, Deutscher DHC, Derman SHM, Hellmich M, Noack MJ. Subjective and objective halitosis among patients with Parkinson’s disease. Gerodontology. 2017;34(4):460–8. https://doi.org/10.1111/ger.12293.

    Article  PubMed  Google Scholar 

  14. 14.

    Ribeiro GR, Campos CH, Garcia RC. Oral health in elders with Parkinson’s disease. Braz Dent J. 2016;27(3):340–4. https://doi.org/10.1590/0103-6440201600881.

    Article  PubMed  Google Scholar 

  15. 15.

    Ribeiro GR, Campos CH, Rodrigues Garcia RCM. Influence of a removable prosthesis on oral health-related quality of life and mastication in elders with Parkinson disease. J Prosthet Dent. 2017;118(5):637–42. https://doi.org/10.1016/j.prosdent.2016.12.018.

    Article  PubMed  Google Scholar 

  16. 16.

    Barbe AG, Heinzler A, Derman S, Hellmich M, Timmermann L, Noack MJ. Hyposalivation and xerostomia among Parkinson’s disease patients and its impact on quality of life. Oral Dis. 2017;23(4):464–70. https://doi.org/10.1111/odi.

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Pradeep AR, Singh SP, Martande SS, Raju AP, Rustagi T, Suke DK, Naik SB. Clinical evaluation of the periodontal health condition and oral health awareness in Parkinson’s disease patients. Gerodontology. 2015;32(2):100–6. https://doi.org/10.1111/ger.12055.

    Article  PubMed  Google Scholar 

  18. 18.

    Cicciù M, Risitano G, Lo Giudice G, Bramanti E. Periodontal health and caries prevalence evaluation in patients affected by Parkinson’s disease. Parkinsons Dis. 2012;2012:541908. https://doi.org/10.1155/2012/541908.

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Müller T, Palluch R, Jackowski J. Caries and periodontal disease in patients with Parkinson’s disease. Spec Care Dentist. 2011;31(5):178–81. https://doi.org/10.1111/j.1754-4505.2011.00205.x.

    Article  PubMed  Google Scholar 

  20. 20.

    Bakke M, Larsen SL, Lautrup C, Karlsborg M. Orofacial function and oral health in patients with Parkinson’s disease. Eur J Oral Sci. 2011;119(1):27–32. https://doi.org/10.1111/j.1600-0722.2010.00802.x.

    Article  PubMed  Google Scholar 

  21. 21.

    Packer ME. Are dental implants the answer to tooth loss in patients with Parkinson’s disease? Prim Dent J. 2015;4(2):35–41. https://doi.org/10.1308/205016815814955091.

    Article  PubMed  Google Scholar 

  22. 22.

    Peres MA, Macpherson LMD, Weyant RJ, Daly B, Venturelli R, Mathur MR, Listl S, Celeste RK, Guarnizo-Herreño CC, Kearns C, Benzian H, Allison P, Watt RG. Oral diseases: a global public health challenge. Lancet. 2019;394(10194):249–60. https://doi.org/10.1016/S0140-6736(19)31146-8.

    Article  PubMed  Google Scholar 

  23. 23.

    Spirk C, Hartl S, Pritz E, Gugatschka M, Kolb-Lenz D, Leitinger G, Roblegg E. Comprehensive investigation of saliva replacement liquids for the treatment of xerostomia. Int J Pharm. 2019;25(571):118759. https://doi.org/10.1016/j.ijpharm.2019.118759.

    CAS  Article  Google Scholar 

  24. 24.

    Jocson A, Lew M. Use of botulinum toxin in Parkinson’s disease. Parkinsonism Relat Disord. 2019;59:57–64. https://doi.org/10.1016/j.parkreldis.2018.12.002.

    Article  PubMed  Google Scholar 

  25. 25.

    Javed F. Halitosis and photodynamic therapy. Photodiagnosis Photodyn Ther. 2020;17:102006. https://doi.org/10.1016/j.pdpdt.2020.102006.

    Article  Google Scholar 

  26. 26.

    Fuster Torres MA, Berini Aytés L, Gay Escoda C. Salivary gland application of botulinum toxin for the treatment of sialorrhea. Med Oral Patol Oral Cir Bucal. 2007;12(7):E511–7.

    PubMed  Google Scholar 

  27. 27.

    Farrow-Hamblen A. Prostheses in Parkinson’s disease. Br Dent J. 2019;227(5):329. https://doi.org/10.1038/s41415-019-0759-8.

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    Carlsson GE, Ekbäck G, Johansson A, Ordell S, Unell L. Is there a trend of decreasing prevalence of TMD-related symptoms with ageing among the elderly? Acta Odontol Scand. 2014;72(8):714–20. https://doi.org/10.3109/00016357.2014.898787.

    Article  PubMed  Google Scholar 

  29. 29.

    Unell L, Johansson A, Ekbäck G, Ordell S, Carlsson GE. Prevalence of troublesome symptoms related to temporomandibular disorders and awareness of bruxism in 65- and 75-year-old subjects. Gerodontology. 2012;29(2):e772–9. https://doi.org/10.1111/j.1741-2358.2011.00558.x.

    Article  PubMed  Google Scholar 

  30. 30.

    Yadav S, Yang Y, Dutra EH, Robinson JL, Wadhwa S. Temporomandibular joint disorders in older adults. J Am Geriatr Soc. 2018;66(6):1213–7. https://doi.org/10.1111/jgs.15354.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

Funding

No funding or sponsorship was received for this study or publication of this article.

Authorship

All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.

Disclosures

The authors Ana Luiza Cabrera Martimbianco, Fabio Cesar Prosdocimi, Camillo Anauate-Netto, Elaine Marcílio dos Santos, Gustavo Duarte Mendes and Yara Dadalti Fragoso have no conflicts of interest to declare. Yara Dadalti Fragoso is a member of the journal’s Editorial Board.

Compliance with Ethics Guidelines

This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

Data Availability

Data sharing is not applicable to this article as no data sets were generated or analyzed during the current study.

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Correspondence to Yara D. Fragoso.

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Martimbianco, A.L.C., Prosdocimi, F.C., Anauate-Netto, C. et al. Evidence-Based Recommendations for the Oral Health of Patients with Parkinson’s Disease. Neurol Ther 10, 391–400 (2021). https://doi.org/10.1007/s40120-021-00237-4

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Keywords

  • Dentistry
  • Movement disorders
  • Neurology
  • Oral health
  • Parkinson