|Year : 2022 | Volume
| Issue : 1 | Page : 24-30
Removable prosthodontic considerations for patients having neurologic and neuromuscular disorders
Aryen Kaushik1, Anurag Bhatnagar2, Taranjeet Kaur3
1 Department of Prosthodontics, ITS Dental College, Greater Noida, Uttar Pradesh, India
2 Department of Periodontics, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, India
3 Department of Prosthodontics, College of Dental Sciences, Davangere, Karnataka, India
|Date of Submission||01-Sep-2020|
|Date of Decision||14-Jan-2021|
|Date of Acceptance||19-Apr-2021|
|Date of Web Publication||4-Jul-2022|
Dr. Aryen Kaushik
CW-57, 1st Floor, Malibu Towne, Sector 47, Gurugram, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
This review provides an updated synopsis and documentation of various modified approaches for planning as well as fabricating removable prosthesis for patients suffering from commonly reported neurological and neuromuscular disorders. An increase in life expectancy and comparative decline in the number of newborns has led to a sharp growth in elderly population, a large number of which suffer from age-related disorders. Among these, neurological and neuromuscular disorders are the most common age-related diseases, which greatly affect the functioning as well as adaptability of any intraoral removable prosthesis. To address the above needs, a rich profusion of clinical reports have been published, which include modified conventional techniques of prosthesis fabrication, as per the symptoms and requirement of the patient. We included the Medline and Google database search using the mentioned keywords to congregate the literature.
Keywords: Denture stability, modified removable prosthesis, neurological, neuromuscular disorders, oral hygiene
|How to cite this article:|
Kaushik A, Bhatnagar A, Kaur T. Removable prosthodontic considerations for patients having neurologic and neuromuscular disorders. J Int Clin Dent Res Organ 2022;14:24-30
|How to cite this URL:|
Kaushik A, Bhatnagar A, Kaur T. Removable prosthodontic considerations for patients having neurologic and neuromuscular disorders. J Int Clin Dent Res Organ [serial online] 2022 [cited 2022 Aug 14];14:24-30. Available from: https://www.jicdro.org/text.asp?2022/14/1/24/349756
| Introduction|| |
The estimated population of elderly (60 plus) in India for 2021 is around 10.7 percent, as compared to 7.4 percent reported in 2001. The neuromuscular system being a part of peripheral nervous system, which includes all the body muscles and the nerves serving them, is a requisite for all voluntary or involuntary motor activity. Hence, it is apparent that any pathology in nerves causing an associated muscle impairment (weakness, wasting, cramps, spasticity, or pain) will impede the serviceability of dentures and thereby mandates modification in traditional therapeutic techniques, selection of dental materials as well as posttreatment care.
This review tries to cover all the modified approaches advocated while planning and fabricating removable prosthesis for patients suffering from neurological or neuromuscular disorders.
| Rationale for Oral Rehabilitation by Removable Prosthesis|| |
Most of the neurological and neuromuscular disorders occur in later stages of life (6th or 7th decade), by which time most of the patients become partially or completely edentulous. It has been shown that degradation of brain function is averted and cognitive functions are improved by mastication, due to enhancement of blood flow as well as the activity of cerebral cortex. Therefore, prosthetic rehabilitation in these patients is critically important, as it has shown to greatly improve the patient's appetite, nutrition, and masticatory efficiency. Although implant-supported prosthesis must be planned to aid in stability and retention whenever the clinical conditions permit, less invasive approach like removable prosthesis should be considered in the late stages of these disorders as they are easy to clean and maintain by the caregivers.
| General Prosthodontic Considerations|| |
- In patients with progressive neurological disorders, it is best to restore the oral cavity as early as possible, because the patient's cooperation decreases as functional and cognitive competence decline with time. Patient's physician should always be consulted as and when required
- As most of these disorders are commonly associated with depression, the anxiety in such patients may be alleviated by relaxation and diversion methods, allowing caregiver to sit next to the patient as well as by scheduling a short appointment time (30–45 min), preferably early morning. While communicating, direct eye contact with a gentle smile and short simple sentences should be used. A continuous reassurance should be given along the course of treatment,
- For patients having poor neuromuscular control and irregular jaw movements, use of the most consistent measurement after repeated swallow and relax maneuver for measuring vertical dimension at rest (in upright position), and Dawson's bimanual manipulation technique for recording centric relation (in supine position), has been advocated. The various occlusal schemes suggested in these patients to aid in prosthetic stability have been mentioned in [Table 1].
|Table 1: Types of occlusal schemes suggested in neuromuscular deficit patients|
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| Commonly Encountered Neurological and Neuromuscular Disorders|| |
The various documented palliative modifications aiding in prosthodontics treatment for these disorders are briefed in [Table 2].
|Table 2: Prosthodontics treatment modifications for various neurological and neuromuscular disorders|
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Crude Incidence for Alzheimer's disease in India is 15.54 cases per 1000 population per year (for more than 65 years), and the prevalence rate is 1.5% for those aged 65 years and above in the country. Females are more susceptible than males, and the mean age of onset is mostly in mid-60 (late onset) compared to early onset (30 to mid-60).
It is a neurological disorder which mainly affects the cholinergic synaptic transmissions in the brain, hence leading to progressive deterioration in cognitive abilities such as awareness, recognition, learning process, and communication along with motor skills. It is the most common cause of dementia in the elderly. Prosthodontic treatment concerns in these patients include poor hygiene maintenance of the prosthesis, xerostomia (due to anticholinergic medications and disease itself), dyskinesia (in severe form of disease only), and impaired ability to adapt to new prosthesis. Therefore, to ensure minimal changes in previous prosthesis, either refabrication of new prosthesis can be avoided by relining or the cameo surface contour of the new denture should be simulated in accordance to the old one. For managing severe dyskinesia, successful use of magnet retained overdentures and recording dynamic impression with tissue conditioners followed by indirect denture base relining procedure has been suggested for these patients. The caregivers should be asked to encourage the patient to wear their dentures, especially in unfamiliar environment like health-care centers where the dentures may be lost or exchanged, and the patient may lose the ability to adapt to new prosthesis. Labeled dentures may be fabricated for patients with severe dementia [Figure 1].
|Figure 1: labeled prosthesis (prosthetic modification for Alzheimer's disease)|
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Incidence of Parkinson's disease in India is 70 cases per 100,000 people per year, and the crude prevalence rate is 27–328.3 per 100,000 people (varies in different parts of India). Males are twice more commonly affected than females, and although the age of onset for Juvenile type is below 21 years and for young is less than 40 years, the probability increases with advancing age.
It is a progressive disorder having an insidious onset, in which deficiency of dopamine occurs due to degeneration of neurons in catecholamine nuclei of midbrain, like locus coeruleus and substantia nigra pars compacta. Midmorning or early afternoon appointments are usually preferred and patients are advised to visit the clinic 1 to 1.5 h after administration of medications as well as urinate before the procedure due to bladder incompetency., The dental chair should be slowly raised to avoid orthostatic hypotension. Challenges faced by a prosthodontist during treatment may be due to resting tremors (jaw, head, or tongue fasciculations), bradykinesia, inability to keep the mouth open, muscle rigidity (inability to swallow and close mouth completely), and saliva dribbling from corner of the mouth., All these factors may affect the denture stability and retention. Therefore, the dental chair should be reclined up to 45° (semi-Fowler's position) to aid in swallowing movements, extraoral molt mouth prop can be used to aid mouth opening, quick setting dental materials should be used, and facial exercises can be advised which have been shown to improve hypomimia and facial muscle coordination in these patients.,
Due to poor dexterity (dyssynergia and dysmetria), there is an increased possibility of falling of the prosthesis as well as difficulty in maintaining its hygiene. Hence, metal denture bases or high impact resins with glass fiber reinforcement may be used for fabricating dentures, and patient's caregivers can be instructed to mechanically clean the prosthesis regularly using nonabrasive pastes or the patient can be given a brush with a foam ball for ease in gripping [Figure 2]a. Moreover, prolonged use of dopaminergic medications causes xerostomia which may increase the chances fungal overgrowth intraorally. After consulting the physician, if the drug causing xerostomia cannot be changed, use of artificial salivary substitute or fabricating a functional salivary reservoir in prosthesis can be considered [Figure 2]b. Planning a precision attachment or any prosthesis with unconventional path of insertion or removal should be refrained. To counter this, use of magnet retained prosthesis (avoided in pacemaker carrier) and flexible denture base materials have been advocated., Adding notches on labial flange may assist in removal, and outline of the prosthesis framework should be planned to add teeth easily if required. To aid in denture retention, the use of moisture-based denture adhesives is also indicated in conditions such as myasthenia gravis, Alzheimer's disease, and Parkinson's disease. While designing partial dentures, the major connectors should be large enough to circumvent the accidental aspiration of the prosthesis.
|Figure 2: prosthetic modifications for Parkinson's disease. (a) Modified brush handle, (b) Salivary reservoir denture|
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Incidence of Epilepsy in India is 0.2–0.6 cases per 1000 population per year, and the prevalence rate is 3.0–11.9 per 1000 population. Predilection of this disorder is equal in both sex, but mortality rate is slightly higher in males. The mean age of onset is 4.78 years.
It is chronic neurological disorder, identified by repetitive episodes of nonsynchronous discharge of neuronal assemblies, and thus eliciting varying seizure activity depending on the part of the brain involved. Frequent seizures can cause injury to teeth as well as prosthesis. No special prosthodontic considerations have been advised for patients having seizures, which do not involve masticatory apparatus and occur less than once a year. If the seizure causes grinding of teeth, twitching of the facial and masticatory muscles (grand mal epilepsy) or occurs more frequently (once or more than once a year), certain treatment modifications need to be incorporated. In such cases, incisal restorations should be avoided and fixed prosthetic options must be preferred over loose removable prosthesis due to seizure-induced injury or aspiration. Even if removable prosthesis is planned, use of large metal base [Figure 3]a, flexible denture bases (if undercuts present), or telescopic overdentures should be considered.,
|Figure 3: prosthetic modifications for epileptic patients. (a) Metal reinforced denture base, (b) Modified implant abutment|
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Successful use of modified implant abutment [Figure 3]b, Lew passive attachment bar (to securely lock the prosthesis), and locator attachment used for implant-retained overdentures have been documented for these patients., However, chronic use of commonly prescribed epileptic drugs such as phenytoin, phenobarbital, carbamazepine, and primidone has been associated with reduced bone density as they interfere with bone metabolism and clearance of Vitamin D, and hence, careful treatment planning for removable or fixed implant prosthesis should be done after considering the drug history and host response to the same.
The incidence in Indian population has been reported to be 20–30 cases per 100,000 per year (for Bell's palsy). Either sex is affected equally, and the median age of onset is 40 years.
The most common causes of facial paralysis include Bell's palsy (most common cause globally), cerebrovascular accident (stroke), progressive bulbar palsy, resection of tumors like acoustic neuroma, and amyotrophic lateral sclerosis.,,, Prosthodontic challenges faced during treatment may be due to the loss in tonicity of facial muscles (buccinator, orbicularis oris, and levator anguli oris), excessive salivary flow, cheek biting as well as inconsistent mandibular movements (difficulty in making impression, recording jaw relations, and compromised denture stability). To counter the unequal forces exerted by buccinators and tongue musculature on the affected side, various authors have used neutral zone technique by encouraging functional movements (sucking, swallowing, pronouncing vowels, and sipping water) on softened compound rim and arranging the teeth accordingly [Figure 4]a. Moreover, the cameo surface of the denture is contoured according to the varying intraoral muscle forces (peculiar to each individual), augmenting the stability of the denture. Successful use of hollow prosthesis has been shown to improve denture retention as well as patient comfort [Figure 4]b. To counter the facial asymmetry as well as weakened perioral muscles, various removable prostheses like combination palatal prosthesis and cheek plumper have been suggested [Figure 5]a and [Figure 5]b. For patients who provide an inconsistent VD or centric relation position, a systematic stepwise approach can be used, in which lower posterior teeth from both the side of final prosthesis are replaced with a flat platform made of self-cure resin. The patient is expected to increase the maximum possible continuous tapping movements on this platform (up to 40) as well as clear indentations of the upper palatal cusp on the platform over a period of time, before final bite registration and remounting. It is usually difficult to guide the jaw of patients having hemifacial paresis due to stroke, in centric relation. In addition, they mostly present with a reverse articulation scheme where the mandibular teeth are more buccal than maxillary teeth.
|Figure 4: prosthetic modifications for hemifacial palsy. (a) Neutral zone, (b) Hollow denture fabrication using thermoform beads|
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|Figure 5: prosthetic modifications for hemifacial palsy. (a) Cheek plumper prosthesis, (b) Combination palatal prosthesis|
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Incidence of myasthenia gravis in India is 2.1–5 cases per 100,000 people per year, and the prevalence is 20 per 100,000 people. Male: female ratio of this disorder is 2.7:1, and the median age of onset has been reported to be 48 years (males – 53 years and females – 34 years).,
It is an autoimmune disorder (70% patients having antibodies for acetylcholine receptors) affecting neuromuscular junction, thereby abnormally lowering the nerve impulse duration and amplitude. Paroxysmal weakness of the muscles of tongue (weak protrusive movement), soft palate, masticatory, and facial muscles are the prosthodontic challenges faced. The clinician must examine the posterior palatal seal (PPS) carefully in these patients before adjusting it, as the PPS region of denture appears overextended and thick due to a static low hanging soft palate, and there is always a possibility of under extending this region in the final prosthesis. Overextended and thick flanges of the upper denture base must be avoided as it interferes with the Stensen's duct opening and drastically decreases the salivary flow in these patients. Many patients have reported a large amount of saliva pooling in the mouth after they removed the dentures, which might precipitate myasthenic crisis (swallowing and respiratory difficulty)., Therefore, after every meal, the dentures should be removed for at least 30 min and for extended time during the day whenever feasible. A palatal lift prosthesis may additionally be fabricated to counter the velopharyngeal incompetency. Medications like anticholinesterase drugs (as prescribed by physicians) improve the symptoms and may enhance the prosthetic treatment outcome.
The Annual incidence of Oromandibular dystonia is 3.3 cases per million, and the prevalence rate is 6.9 per 100,000 cases. Females are twice more commonly affected than males, and the mean age of onset is 57 years (45–70 years).
It is an involuntary, intermittent, and patterned forceful cocontraction of agonist and antagonist muscle groups, mainly involving the face, jaw, and/or tongue. A possible dysfunction in basal nuclei causes loss of motor control (muscular spasms and abnormal muscle posture), which may impede the prosthetic treatment procedure as well as its final outcome. With time, these patients usually acquire their own peculiar “sensory tricks” which attenuate these atypical muscle movements. These sensory tricks or “gestes-antagonistes” may vary from tongue thrusting, clenching on an object, and lip biting to applying pressure under chin. Various modified removable prosthesis have been reported to be capable of mimicking these sensory tricks. Hence, apart from rehabilitating the patient, removable prosthesis plays a unique therapeutic role in this movement disorder.
Intramuscular use of botulinum toxin A has been shown to reduce muscle spasms, especially in patients having mandibular dystonia while closing the jaw. In addition, a periodic recall after delivering the prosthesis is required as chronic ill-fitting dentures have been associated with development of orofacial dystonia and atypical trigeminal neuralgia like symptoms in some susceptible patients.,
| Conclusion|| |
In some cases, the dental clinician may be the first to recognize symptoms of the disorders mostly affecting the geriatric patients, if early stage of its onset affects the oral environment or patient complaints of functional disturbances in old prosthesis. Therefore, apart from the treatment aspects, a trained prosthodontist must have a thorough understanding of the systemic conditions which may affect the manipulation of the prosthesis. A detailed medical and drug history as well as thorough clinical examination of previous prosthesis aids in implementation of correct treatment plan and thereby modify the procedure as per the severity of the condition and in harmony to neuromusculature. Moreover, a multidisciplinary work involving physician, prosthodontist, nutritionist, and a speech therapist would provide a sound health care to these patients. As the symptoms presented by different neurological and neuromuscular disorders vary largely, various documented techniques discussed above can be carefully applied for other disorders having symptoms similar to the one mentioned in this review.
| Acknowledgments|| |
I would like to thank Department of Prosthodontics, College of Dental Sciences, Davangere, for providing the guidance for managing clinical cases as well as the dental equipment and materials required.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]