D3 Case ReportPatient JSTable of ContentsIntroduction of Clinical QuestionBackgroundSignificancePurposePatient’s Presentation of Condition or RiskLiterature ReviewPICOClinical QuestionSearch StrategyArticle AnalysisSynthesis of the FindingsDescription of the PatientDemographicsSocial, Personal and Family History Including Risk FactorsReview of Medical HistoryResults of a Physical Exam Including Vital SignsEthical DilemmaDiscussion of Positive FindingsConclusions and Recommendation  Introduction of Clinical QuestionBackground Parkinson’s Disease is one of the most common conditions that present with orofacial dystonia and dyskinesia (Packer, M. E. 2018).This leads to patients with the disease having trouble performing everyday activities such as eating, speaking and maintaining oral hygiene (Heckmann, S. M., Heckmann, J. G. and Weber, H. 2000). Parkinson’s Disease is more often seen in men than women and affects every 120 out of 100,000 people. There are two modes of this disease. The first is a genetic form which only consists of 5% of people with Parkinson’s and occurs at a young age. The second occurs around the age of 57 and is deemed idiopathic as it has a more complex etiology where there is a familial and environmental component (Bollero, et al., 2017). Secondary Parkinsonism can be drug-induced. Parkinson’s disease is caused by the death of dopaminergic neurons in the substantia nigra and locus coruleus. It is caused by the presence of Lewy bodies in the nerve cells in areas as such (Drummond, Newton, & Yemm, 1995).These neurons, which are subsequently destroyed, are necessary for the control of movement and coordination. Patients begin to experience symptoms once there is about a 65% reduction in functioning dopaminergic neurons (Bollero, et al., 2017).The symptoms are categorized into non-motor, motor and behavioral. The cardinal motor symptoms, which are the most overt, include tremors, bradykinesia, akinesia, and postural instability. Tremors are typically present at limbs as well as most orofacial muscles. Bradykinesia explains slow movement while akinesia is the impairment of voluntary movement. Postural instability is a major component of the appearance of Parkinson’s Disease. This is where the patient has difficulty with balance and walks with their trunk and head more forward. Non-motor symptoms include, autonomic nervous system dysfunction, insomnia and olfactory dysfunction. Behavioral symptoms include depression, dementia and psychosis (Bollero, et al., 2017). The main treatment of Parkinson’s disease is levodopa with peripheral dopa-decarboxylase inhibitor. Despite being widely used, one in six patients fail to respond to Levodopa and those who respond to it lose the response after about four years. Because of this, it is mainly used once symptoms are shown to be significantly debilitating. A selective MAOB-inhibitor, Selegiline, inhibits the degradation of dopamine in the central nervous system. Selegiline can be used to treat Parkinson’s disease in its early stages due to the fact that it delays the progression of the disease and its levodopa-sparing effects (Drummond, Newton, & Yemm, 1995).SignificanceAll of these symptoms make it more difficult for patients to practice proper oral hygiene. Patients with Parkinson’s Disease have difficulty brushing their teeth, chewing, swallowing, along with many more essential aspects of maintaining oral health. Due to their motor and behavioral symptoms, they tend to make fewer visits to the dentist. As their akinesia affects the jaw, their chewing ability is compromised and therefore this leads to retention of food (Bollero, et al., 2017).The standard treatment for the symptoms of Parkinson’s Disease is Levodopa and other dopamine agonists. Anticholinergic drugs are also used and can cause side effects such as gingival hyperplasia, bruxism and xerostomia. These side effects make patients with Parkinson’s Disease more susceptible to dental fractures and carious lesions. Pharmacologic management of symptoms could provide therapy for the first 5-10 years of use. There is an increase in symptoms after long-term pharmacological use. Recently there has been an alternative treatment called deep brain stimulation surgery which allows for relief of symptoms and a decrease of medication use (Liu, Su, You, & Wu, 2015).Purpose The purpose of this paper is to compare the success rate of dental implant in patients with Parkinson’s Disease with the general population. Parkinson’s disease reduces the patient’s ability to perform proper oral hygiene. Along with poor oral hygiene, these patients have tremors that affect their oral cavity as well as reduced ability to chew and perform normal orofacial movements. It is important to know the proper treatment for patients in this situation and whether dental implants is a recommended treatment as opposed to alternative prostheses and treatments.Patient’s Presentation of Condition or Risk Patient JS presented to NYU Dental’s 1A clinic for comprehensive care on July 13th with a chief complaint; “I want a full check-up and cleaning.” The patient was seen in clinic 5AB-A where a comprehensive examination and treatment plan were rendered. After proper examination, it was determined that the patient needed an extraction on tooth #20 due to the extensive carious lesion. Tooth #15 had an existing crown that has open margins and therefore it was determined that it would need to be re-done. After being given the option, the patient requested to receive an implant supported crown to replace the tooth. Teeth #8, #9 and #10 required restorations on the MI surfaces. Patient JS presented with severe plaque and halitosis which corresponds to his lack of manual dexterity and ability to take care of his oral hygiene. After assessing the patient’s tremors and areas of contact on those teeth, it was determined that the restorations would not last and it would be best to try to arrest the demineralization at each visit. Patient JS presented with Parkinson’s disease at a moderate severity. The patient had noticeable tremors and anxiety about his oral health. He elaborated having limitations such as not being able to use his dominant left hand for writing anymore. He also mentioned that he has mild anxiety. The patient is taking medications, Amantadine, Selegiline and Pramipexole, to help treat his symptoms for Parkinson’s disease.Literature ReviewPICOPopulation: Patients with dental implantsIntervention: Parkinson’s DiseaseComparison: Patients without Parkinson’s DiseaseOutcomes: Dental implant successClinical Question:In patients seeking dental implants, does having Parkinson’s Disease lower the success rate than the general population?Search Strategy:The initial search in PubMed began as “Parkinson’s Disease AND dental implant*” My search presented 13 articles. I conducted another search of “Parkinson’s Disease AND dental implant* OR Parkinson’s AND dental implant*” which presented the same 13 articles. I found five of the articles useful for this paper, two of which did not have the full text available. Two of the articles are systematic reviews and the other is a clinical report.Article Analysis:1) “A review of the outcome of dental implant provision in individuals with movement disorders.” Mark Edward Packer. 2018. This article was chosen as it is a systematic review that discusses the survival of dental implants in patients with movement disorders such as Parkinson’s Disease that patient JS exhibits. The purpose of this paper was to “establish whether implant success in patients suffering from movement disorders is similar to the general population, identifying risk factors and noting recommendations that may aid maintenance programmes” (Packer. 2018. 1). This search primarily yielded patient case reports. Other studies rendered were patient case series observational studies. In the patient case reports, the ages of the participants from the studies ranged from 19-83 years old. Most of the implants were placed using a two-stage-process or delayed loading and were followed up for two years or less. During the observational period, the majority of reports showed a 100% survival rate. Cobalt-Chromium strengthen design was the main material selected across the articles for the implants. All early failures were due to integration as opposed to mechanical failures. In the observational studies, the ages of the participants from the studies ranged from 12-834, similar to that of the patient case reports. Parkinson’s Disease studies generally treated an older age group of  54-81 years old. Most of the implants were placed using a two-stage-process. The studies following patients with Parkinson’s Disease, implant survival rates of 77%-86% were reported. Most studied followed up with patients for at least four years. The majority of implant failures were reported in the early stages although in patients with Parkinson’s Disease, later failures were noted. This paper discussed the outcome of dental implants placed in patients with movement disorders compared to in the general population. One study reviewed in the paper concluded a 91% implant survival rate after four years in the patients with movement disorders, compared to a 100% survival rate in the control group. In patients with Parkinson’s Disease, it is suggested to provide IV-sedation, midazolam can be beneficial to reduce the risk of cardiovascular issues from the catecholamines. The early implant failures noted in some patients with the disease could have been due to a lack of elimination of motor symptoms. In one study with patients with Parkinson’s disease, from the nine subjects, there was an 82% success rate of the implants whereas another study including three subjects presented a 100% success rate. In the study with nine subjects, there was another follow-up after five years showing late implant failure in four of the patients. This is most likely linked to their parafunctional symptoms leading to implant fracture. It is suggested to add an additional “sleeper” implant when placing a two implant mandibular overdenture. This will stabilize the denture. There were three studies reviewed in this paper that dealt specifically with patients with Parkinson’s Disease. I was concluded that the quality of life for these patients were improved with the addition of dental implants to support a fixed prosthesis or an overdenture. This allowed them to have improved chewing, moderate body weight gain and improved GI symptoms as well as overall oral well-being. Implant supported prosthesis should be considered as first line treatment as it has the best overall prognosis as the disease advances. It is important to take into consideration their inability to maintain proper oral hygiene, however it cannot be concluded that a lack of oral care will cause more issues in patients with Parkinson’s Disease or any movement disorder as opposed to the general population of patients with no movement disorder. This paper is at the top of the hierarchy of evidence as it is a systematic review. The review only included published studies and English language studies. A strength of this review is that it presented articles with control groups. Another strength was that many movement disorders were assessed and compared to one another to further gain a better understanding for the differences of each and the success of dental implants for each disorder. Regarding the weaknesses, it was not clear how many assessors took part in the analysis and organization of the study. No quantitative analyses were conducted to show the statistical significance of the articles. 2): “Oral Health and Implant Therapy in Parkinson’s Patients: Review.” Bollero et al., 2017. The purpose of this review was to review the oral health of patients with Parkinson’s Disease and factors such as caries and periodontal disease, as well as, dental implants, compared to the general population. The researches made a search of Medline consisting of the keywords: “Parkinson’s Disease and dental management.” The search resulted in 50 articles, 15 of which were used since they dealt with dental implants as well. Articles considered in this review had to have been published from 2000 and on. Most of the articles found DMFT and Periodontal disease to be greater in patients with Parkinson’s disease than the general population. Generally DMFT is greater in the patients, however, two studies in the review showed a lower DMFT in patients with Pakrkinson’s disease. This was thought to be due to the hypersalivation that these patients experience. In order to help these patients with their oral hygiene, it was proposed to see patients in the morning in a 45 degree armchair to prevent extra loss of saliva and help with swallowing. The medications cause xerostomia and subsequently burning mouth syndrome in about 55% of cases. The studies showed that patients with Parkinson’s disease have worse oral health than the general population and have higher risk of caries and periodontal disease. One article from the review showed that the implant survival rate in patients with Parkinson’s disease, after 12 months, for the maxilla was 85% and for the mandible was 81% compared to 90% in patients without Parkinson’s Disease. In cases with dental implants, patients reported better chewing ability and better quality of life. It is recommended to provide dental implants for these patients in earlier in the disease if possible. Progression of the disease increases caries and periodontal disease risk. This is due to lack of proper oral hygiene, xerostomia, and a great presence of streptococcus mutans bacteria in the oral cavity. Stannous fluoride toothpaste and an electric toothbrush is recommended to help with oral hygiene. Due to difficulty chewing, many patients have gastrointestinal issues and this review shows that mobile prosthesis  improves these symptoms. Implant therapy to support the mobile prosthesis is favorable to allow for better retainment. Although the implant survival rate is lower in patients with Parkinson’s disease when compared to the general population, it is still a great therapy for these patients due to the benefits it provides. This is a systematic review and therefore is at the top the hierarchy pyramid. This review has a few strengths, one of which is the fact that the articles reviewed had control groups. A strength of this paper is that it included oral hygiene and DMFT as well as dental implant success. This was interesting to see how each category relates to one another since Parkinson’s disease affects patient’s ability to maintain oral hygiene. The articles also had a large number of subjects per group which allows for greater accuracy in the results. Some shortcomings in the article were that there was no scoring system mentioned nor was there any heterogeneity tests to compare the results of the articles. Quantitative results were not conducted to assess the statistical significance of the results.3) “Critical appraisal of evidence supporting the placement of dental implants in patients with neurodegenerative disease” Faggion. 2017. The objective of this study was assess the available studies on the effectiveness and difficulty when using dental implants in patients with neurodegenerative diseases. Studies on dental treatment with implants in patients with neurodegenerative diseases were included. Randomized controlled trials and other controlled trials were used in this systematic review. Studies of lower hierarchy were included in the incident that there would not be enough high hierarchic studies found. The lower hierarchy studies that were included were retrospective and prospective cohorts, case series, and clinical reports. “Neurodegenerative diseases were defined as ‘hereditary and sporadic conditions characterized by progressive nervous system dysfunction” (Faggion, C. M. 2016. 2). The neurodegenerative diseases covered in this review are Dementia, Parkinson’s and Huntington’s disease. The databases searched for the articles were PubMed, EMBASE, Biosis Citation Index, CINAHL, Web of Science and LILACS. The search did not have a language restriction. The studies that were included were categorized by the type of study. A risk of bias tool was used for randomized control trials to assess the risk of bias. The methodological quality of the articles were assessed whenever applicable. In the end, 11 papers were included in the review, compared to 58 which were initially chosen. Outcomes with dental implants in patients with Parkinson’s disease were assessed. Three case reports discussed the process of using mandibular overdentures for an elderly patient. In one of these reports, a 12 year follow up was conducted where the patient expressed his satisfaction with the overdenture. In another article, a patient with moderate Parkinson’s disease received an implant which was reported as successful. In another clinical case, a patient aspirated the dental implant screwdriver during the implant placement. One case series involved patients with severe Parkinson’s disease. These patients received mandibular over dentures and after a year and a half follow up, they reported a great increase in chewing function. Some issues that these patients faced were maintaining their oral hygiene. They experienced gingival hyperplasia under their overdentures. Other reports included concerned patients with Huntington’s disease as well as Dementia. Overall Their quality of life was improved with the addition of dental implants. Due to the fact that no randomized control trials were found, the findings were less than expected. They show low evidence for the use or disuse of dental implants in these patients. Most of the papers dealt with patients living with Parkinson’s disease. The added dental implants greatly improved their chewing capabilities and quality of life. Contrary to popular belief, many of the patients from these studies presented with better gingival index scores after the insertion of the dental implants. This review had many strengths due to the fact that it was done in a more precise manner. Risk of bias was prevented with the risk of bias tool. Many online databases were searched which shows a wide array of studies taken into account. This is a systematic review which is at the top of the hierarchy pyramid. There were no quantitative results to show any statistical significance.Synthesis of the Findings Overall, these articles present that dental implants are indicated in patients with Parkinson’s disease. Dental implants provide the structural support for these patients to enhance their ability to chew. The articles used in the systematic reviews generally showed positive results in the use of dental implants for patients with Parkinson’s disease. Although the survival of implants may be slightly less in these patients, the benefits are too great to oversee. Generally, oral hygiene was a main issue in the patient’s overall dentition but did not seem to affect the dental implant survival as much as expected. Between the three articles, it was agreed upon that these patients need continuous dental care and assistance with their oral hygiene in order to help increase their quality of life. There are a few recommendations for future research on the topic that would greatly benefit the answer to the clinical questions. Researches would focus more on randomized control trials in order to properly asses the oral health after implant placement. There should be further recommendation on how to assist patients suffering with Parkinson’s disease on ways to maintain oral hygiene.Description of the patientDemographics Age: 57 Sex: Male Race: Caucasian Marital status: Married Language: EnglishSocial, Personal and Family History Including Risk Factors Patient JS presented to clinic 5AB-A at 10:30 am on June 28th 20018. At our first appointment his chief complaint was that he wanted a “complete examination and cleaning.” He had some anxiety about past dental work and did not trust what his previous dentist had told him. He expressed that it had been difficult for him to floss. He brushes twice a day but it is difficult for him to reach his posterior teeth and some other areas while brushing his teeth. Patient JS was concerned about his dental health and wanted to make sure he keeps his natural teeth if possible. Due to his disease he clenches and bruxes his teeth. He had a recent life stressor of losing his job. His family history includes his paternal grandfather having had diabetes, his mother and father both had cancer as well as his maternal grandfather. His paternal grandfather had high blood pressure.Review of the Medical History Patient JS takes three medications; Amantadine HCl Dose: 100mg TID, Selegiline HCl Dose: 5mg BID and Pramipexole Dose: 3.0g 4 TS D. Patient has Parkinson’s disease. At the most recent visit, he presented with swollen ankles and when asked if he has seen his primary care physician about it he said that he had and she did not recommend any treatment. Due to the disease, he experiences difficulty with balance , tremors, muscle weakness, and limited range of motion. Patient JS also has frequent abdominal pain. Amantadine is an anti-Parkinson agent and Dopamine agonist. Key adverse effects are related to xerostomia and orthostatic hypotension. Selegiline is another anti-Parkinson agent and MAO Type B inhibitor.  If it is taken in doses of 10mg a day or less than it does not require any vasoconstriction precautions. Key adverse effects include xerostomia and dysphagia. Pramipexole is an anti-Parkinson agent and dopamine agonist. Key adverse events include xerostomia (Lexicomp. 2019).              .Results of a physical exam including vital signs The patient’s extra-oral examination was within normal limits. Intra-oral findings included halitosis, dental erosion and attrition and mandibular lingual tori. Vitals at the initial visit were 140/87 and pulse was 70 bpm. The patient was visibly anxious which added to his blood pressure. At the next visits his blood pressure was 116/84 and 117/80 with a common pulse of 75 bpm.Ethical Dilemma During the oral examination, dental decay was detected on teeth #8, #9 and #10 on the MI surfaces. After hearing this the patient wanted to get them restored. After diagnostic casts were taken and hand articulated, it was determined that these restorations, if done, would fail due to the anterior incisal contact. Not only did they contact at the area where the restoration would be, but the patient experiences orofacial tremors that would cause the restoration to fracture. Because of this I did not feel that it was ethical to proceed with treatment planning the restorations. Therefore, I told the patient that I would be able to apply fluoride varnish to the lesions, which were not extensive yet, and try to arrest the process.Discussion of Positive Findings Patient JS presented with extensive decay on tooth #20 and heavy generalized plaque. An extraction of tooth #20 was treatment planned and complete in the periodontal clinic. An implant and implant supported crown has also been treatment planned and will be done in the periodontal clinic as well. Tooth #15 was also treatment planned for a replacement of the crown due to open margins.Conclusions and Recommendations The purpose of this case report is to assess the literature in order to properly answer the clinical question: “In patients seeking dental implants, does having Parkinson’s Disease lower the success rate than the general population?” After reviewing the articles it can be concluded that the success rate may be slightly lower in patients with Parkinson’s disease. Regardless of the lower success rate, there are more benefits than not which indicate that, when creating a dental prosthesis, dental implants should be the first line of choice for patients with Parkinson’s disease. Regarding the treatment for this patient, phase 1 is OHI, phase 2 is adult prophylaxis, extraction of tooth #20 and fluoride varnish application, phase 3 is implant placement on #20, phase 4 is implant supported crown on #20 and the crown on tooth #15, and phase 5 is maintenance and re-care. After having a discussion with the patient we decided that it is best to have him come in for cleanings every three months as his risk is high and cannot maintain his oral hygiene.ReferencesBollero, P., Franco, R., Cecchetti, C., Miranda, M., Barlattani, A., Jr., Dolci, A., & Ottria, L. (2017). Oral Health And Implant Therapy In Parkinson’s Patients: Review. Oral & Implantology, 10(2), 105-111. doi:10.11138/orl/2017.10.2.105Drummond, J. R., Newton, J. P., & Yemm, R. (1995). Color atlas and text of dental care of the elderly. Retrieved from https://bookshelf.vitalsource.com/#/books/0-8151-9751-9/cfi/6/2!/4/10/22/2@0:0Faggion, C. M. (2016). Critical appraisal of evidence supporting the placement of dental implants in patients with neurodegenerative diseases. Gerodontology, 33(1), 2–10. https://doi-org.proxy.library.nyu.edu/10.1111/ger.12100Heckmann, S. M., Heckmann, J. G. and Weber, H. (2000), Clinical outcomes of three Parkinson’s disease patients treated with mandibular implant overdentures. Clinical Oral Implants Research, 11: 566-571. doi:10.1034/j.1600-0501.2000.011006566.xLexicomp. 2019. Retrieved from https://online.lexi.com/lco/action/homeLiu, F., Su, W., You, C., & Wu, A. Y. (2015). All-on-4 concept implantation for mandibular rehabilitation of an edentulous patient with Parkinson disease: A clinical report. The Journal of Prosthetic Dentistry, 114(6), 745-750. doi:10.1016/j.prosdent.2015.07.007Packer, M. E. (2018). A review of the outcome of dental implant provision in individuals with movement disorders. European Journal of Oral Implantology, 11, S47–S63. Retrieved from http://proxy.library.nyu.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=ddh&AN=131347945&site=ehost-live