title: Parkinson disease: systemic and orofacial manifestations, medical and dental management.
abstract: BACKGROUND
  More than 1.5 million Americans have Parkinson disease (PD), and this figure is expected to rise as the population ages. However, the dental literature offers little information about the illness.
  
  
  METHODS
  The authors conducted a MEDLINE search using the key terms "Parkinson's disease," "medical management" and "dentistry." They selected contemporaneous articles published in peer-reviewed journals and gave preference to articles reporting randomized controlled trials.
  
  
  RESULTS
  PD is a progressive neurodegenerative disorder caused by loss of dopaminergic and nondopaminergic neurons in the brain. These deficits result in tremor, slowness of movement, rigidity, postural instability and autonomic and behavioral dysfunction. Treatment consists of administering medications that replace dopamine, stimulate dopamine receptors and modulate other neurotransmitter systems.
  
  
  CONCLUSIONS
  Oral health may decline because of tremors, muscle rigidity and cognitive deficits. The dentist should consult with the patient's physician to establish the patient's competence to provide informed consent and to determine the presence of comorbid illnesses. Scheduling short morning appointments that begin 90 minutes after administration of PD medication enhances the patient's ability to cooperate with care. Inclination of the dental chair at 45 degrees, placement of a bite prop, use of a rubber dam and high-volume oral evacuation enhance airway protection. To avoid adverse drug interactions with levodopa and entacapone, the dentist should limit administration of local anesthetic agents to three cartridges of 2 percent lidocaine with 1:100,000 epinephrine per half hour, and patients receiving selegiline should not be given agents containing epinephrine or levonordefrin. The dentist should instruct the patient and the caregiver in good oral hygiene techniques.
authors.affiliation: VA (Department of Veterans Affairs) Greater Los Angeles Healthcare System, Los Angeles, Calif. 90073, USA. arthur.friedlander@med.va.gov
authors.forename: Arthur H
authors.initials: AH
authors.lastname: Friedlander
authors.forename: Michael
authors.initials: M
authors.lastname: Mahler
authors.forename: Keith M
authors.initials: KM
authors.lastname: Norman
authors.forename: Ronald L
authors.initials: RL
authors.lastname: Ettinger
mesh_terms: D000779:Anesthetics, Local / Q000008:administration & dosage; D000978:Antiparkinson Agents / Q000627:therapeutic use; D003299:Cooperative Behavior; D017742:Dental Care for Chronically Ill; D003812:Dentist-Patient Relations; D004347:Drug Interactions; D006801:Humans; D009909:Oral Health; D009910:Oral Hygiene; D010300:Parkinson Disease / Q000188:drug therapy / Q000503:physiopathology*
chemical_list: D000779:Anesthetics, Local; D000978:Antiparkinson Agents