Evaluation of oral conditions in patients with neurodegenerative diseases treated in geriatric centers

Objetivo: Comparar as condicoes sistemicas e orais, alem de avaliar as proteses removiveis, associadas aos portadores de Doenca Alzheimer e Doenca Parkinson, atendidos em dois centros geriatricos situados no municipio de Fortaleza - Ceara. Metodos: Foram analisados 70 pacientes (entre 57 a 91 anos) com Doenca Alzheimer e Doenca Parkinson, por meio de avaliacao de prontuarios neurologicos e exame clinico oral. Tendo sido observadas variaveis de sexo, idade, raca, comorbidades, condicoes orais e proteticas. Um total de 20 pacientes idosos sem doencas neurologicas consistiu no Grupo Controle. Foi utilizado teste exato de Fischer como analise estatistica. Resultados: Em ambos os grupos estudados, a Hipertensao arterial foi a comorbidade mais frequente. Quanto ao exame oral, no grupo com Doenca Alzheimer, foi observado que 54.2% apresentou doenca periodontal, 34.2% doenca carie. Achados semelhantes foram encontrados em pacientes com Doenca Parkinson (31,4%; 22,8% - respectivamente). Entretanto, nao foi observada diferenca entre os grupos estudados, quanto as manifestacoes sistemicas e orais nos dois centros geriatricos (p>0.05). Foi identificado que mais da metade dos pacientes avaliados nesse estudo (57,7%), utilizavam alguma protese removivel, sendo que 86,5% dessas apresentavam-se mal adaptadas, com algum tipo de defeito, principalmente nos idosos Institucionalizados (p= 0.034). Verificou-se, tambem, diferenca estatistica na presenca de estomatite protetica, entre os grupos demencia e grupo controle (p= 0.0213). Conclusao: Idosos portadores de Doenca Alzheimer e Doenca Parkinson tem deficiente saude bucal, assim como aqueles sem as doencas neurodegenerativas. No entanto, apresentam mais imperfeicoes e patologias associadas ao uso de proteses removiveis.

(levodopa, parkidopa) used in treating those diseases.Increased spasms of the masticatory muscles can lead to temporomandibular disorders and difficulty in adapting prostheses.Infections caused by Candida spp.can also be found, resulting in stomatitis of various causes, in addition to gingivitis, periodontitis, tooth decay and premature loss of teeth units [13][14] .
This study aims to evaluate the clinical and oral condition in patients with Alzheimer's and Parkinson's disease, providing the establishment of epidemiological data of oral conditions.This knowledge will enable the effective treatment of these patients' real dental needs.

METHODS
It is a cross-sectional descriptive study with a sample of 90 elderly of both sexes, which included residents of Lar Torres de Melo Institute, and volunteers who attend the Care Center for the Elderly at Walter Cantídio University Hospital (HUWC), both located in the city of Fortaleza, Ceará.The test group consisted of 70 elderly and the control group, 20.Prior to the study, all subjects of the test group were diagnosed with neurodegenerative disease such as Alzheimer's and/or Parkinson's by a neuropsychiatrist by means of the Mini Mental State Examination (MMSE).
The subjects in the control group had an average age of 68.80 ± 5:45 (13 women and 7 men).In the test groups, the average age of subjects comprised 74.18 ± 5:59 years, with the youngest aged 57 and the oldest, 91 (38 men and 32 women) in different stages of neurodegenerative diseases.
In the Care Center for the Elderly, volunteers were randomly selected according to demand having a total of 46 seniors.It was filled out a clinical form containing medical history, personal data and possible changes seen during the oral exam.The data were collected with the help of caregivers and the elderly themselves when possible.
At Lar Torres de Melo Institute, 44 seniors were selected from consultations to archived medical records, which were also used to fill out the clinical form, with subsequent oral exam.From 240 elderly living in this institution, only 34 had been diagnosed with Alzheimer's and/or Parkinson's.
On clinical examination, material as a probe, mouth retractors, mouth mirror and flashlight were used to evaluate the mucous membranes (lips, cheeks, floor of the mouth), alveolar mucosa (ventral surface of the tongue, vestibule and soft palate), mastication (hard

INTRODUCTION
Dementia syndromes are often degenerative and progressive comorbidities involving great mental, physical and psychological disorders.Deficits of cognitive function are commonly accompanied, and occasionally preceded by a deterioration of emotional control, social behavior or motivation.The most common cause of dementia is Alzheimer's Disease (AD) accounting for 60% to 70% of cases, followed by vascular dementia, dementia with Lewy bodies, and frontotemporal dementia [1][2] .According to Burlá et al. 3 , the Brazilian average prevalence of this disease is higher than the one in the world.Projections for the Brazilian population indicate a slight increase in the prevalence of dementia in the population aged 65 or over, from 7.6% to 7.9% between 2010 and 2020, that is, 55.000 new cases per year.
In April 2012, WHO published the document "Dementia: a Public Health Priority", showing concern for this problem which affects the quality of life of older people, especially in developing countries.It is estimated at 35.6 million the number of people with dementia in 2010, projecting a doubling of this number every 20 years, that is, 65.7 million in 2030 and 115.4 million in 2050 4 .
Alzheimer`s disease is characterized by progressive decline in cognition, learning ability and memory, in addition to apraxia, such as difficulty in language and carrying out daily tasks.In the progressive stage of disease, Alzheimer causes loss of motor function, leading to starvation and immobility, which may be fatal 5 .It has idiopathic origin, although genetic alterations might be involved in increasing its risk [6][7] .
Parkinson's disease (PD) is one of the most common and intriguing neurological diseases today.The etiology of the disease is still unclear and controversial, and it is characterized by the degeneration of neurons.Such degeneration results in reduced production of dopamine, an essential neurotransmitter in the control of movement, leading to disturbances in tone, adoption of abnormal posture and involuntary movements [8][9] .Dementia is a common manifestation of PD generally associated with rigidity, bradykinesia and tremor, classic signs of the disease [10][11] .
Due to old age, AD and PD carriers usually present several systemic complications such as visual and hearing impairment, oral problems, hypertension, diabetes, hypothyroidism, arthropathy and depression 12 .
Several side effects such as dry mouth and symptomatic ulcers are related to the main drugs Oral condition of patients with neurodegenerative diseases

RESULTS
It was evaluated 90 elderly, 70 of them were part of the test group, 35 patients with AD and PD 35 (06 patients had both diseases).The remaining 20 corresponded to the control group, who were randomly evaluated in the two institutions.
Among the systemic diseases associated with AD, it was observed that hypertension, stroke, diabetes and infarction had a higher incidence in the two evaluated centers (Table 1).It has also been observed lower incidence of pathologies such as seizures, pulmonary emphysema and cancer.In PD the most associated systemic diseases were hypertension, stroke and depression in both geriatric centers.It was also registered infarction, pulmonary emphysema, epilepsy and renal dysfunction.In the control group the most prevalent disease was hypertension, followed by diabetes and cancer.There were no statistical differences between the analysed centers, in relation to the systemic disease in patients with dementia and control group (p> 0.05).palate and gingiva) and specialized (back of the tongue).Structures such as teeth and dentures of each subject and the presence of oral diseases, as ulceration and denture stomatitis, were checked as well.This research is based on the study of Ericson et al. 15 which suggested four oral categories to be investigated in people with dementia, such as the ability to chew and eat, oral problems, hygiene independence and dental conditions.The results were analyzed using Fisher's exact test, with statistical power of 80% and 5% significance level.
Dentures and removable partial dentures were analyzed inside and outside the mouth.The evaluation was recorded for stability, occlusal retention, vertical height and defects.
The study was submitted to the Ethics Committee of the Federal University of Ceará and was approved under number 301/09.It was also obtained the approval of the Research Council of Lar Torres de Melo Institute.Caregivers of the elderly or the elderly themselves signed an Informed Consent Form for the research, in cases where the elderly could not or did not sign their fingerprint was collected.As for the oral manifestations, it was observed a higher incidence of periodontal disease (periodontitis) and caries in both neurodegenerative diseases (AD and PD) and control group in both evaluated geriatric centers (p> 0.05).Other changes were identified as angular cheilitis, abscesses, presence of residual roots and crown fractures, besides fibrous hyperplasia and bruxism (Table 2).group (p = 0.0467).Lack of stability and retention, occlusal disadjustment and vertical height were analyzed between groups (p> 0.05), as well as the presence of pathology associated with the prosthesis, denture stomatitis, p = 0.0213 between dementia and control groups (Table 3).
When evaluated the presence and condition of dentures among patients treated at the Care Center for the Elderly and the ones living at Lar Torres de Melo, a greater presence of prostheses under suitable conditions was detected in the outpatient setting at HUWC (p = 0.034).
Data were analyzed using Fisher's exact test, which showed no statistically significant difference between the test and control groups for the presence of systemic diseases and oral manifestations, between the analysed centers (p> 0.05).
Among the studied patients, more than half of them wore some type of dental prosthesis (52 elderly).The analysis related to their conditions identified that 86.5% were ill-fitting and/or were in very poor condition, for instance, the presence of fractures, excessive calculus and foul odor when compared to those found in the control

DISCUSSION
This study evaluated the oral health of individuals with AD and PD in light, moderate and severe stages of the disease in both geriatric centers in the city of Fortaleza, Brazil.There were no statistical differences in the control group and the group of voluntary patients, carriers of AD and PD as their systemic and oral manifestations.
In a study by Paulson & Stern 8 systemic diseases such as diabetes, hypertension, convulsions, renal dysfunction were found in patients with PD, like those identified in this one.These changes were also reported to be more frequent in patients with AD in a study by Friedlander et al. 13 .
Study by Adam & Preston 16 determined that the decrease or loss of functional motor skills is a risk factor for oral diseases.It was shown the impairment of oral health due to several changes, often resulting from loss of cognitive and motor skills, related to age or illness.
In Parkinson's disease, tremor is one of the early signs and it usually affects the hands, lips and tongue.Bradykinesia is another common factor and it often involves the facial muscles.These factors may induce orofacial pain, discomfort in the temporomandibular joint (TMJ), dental fracture, trauma of soft tissues, restoration detachment and lack of salivary control, which makes it difficult the prosthetic rehabilitation of these patients 17 .The presence of these changes, such as pain, bruxism and tooth fracture were also found in this study.
The main oral manifestations found in AD were periodontal disease, denture stomatitis and caries, data corroborated by several authors [18][19] .The use of ill-fitting and worn dentures, the presence of mucosal lesions are also extremely common and described in the literature [20][21] .
According to Frenkel (2004) traumatic ulcers caused by ill-fitting dentures and fractured teeth are common in these patients, changes that were not identified in this study.As fractured teeth, roots and poorly fitting dentures were diagnosed, it is possible that the ulcers had already been healed.
Finally, it is highlighted the percentage in the use of upper and/or lower prosthetics reaching more than half of patients (57.7%), while 86.5% of the dentures were poorly adapted.The prostheses of patients attending the outpatient setting of the Care Center for the Elderly at HUWC held better hygiene conditions, perhaps by greater availability of access to specialized dental treatment, since this service is located in the health campus of university.However, most of the prostheses of the elderly living at Lar Torres de Melo had bad conditions, leading to the appearance of associated diseases.
The denture stomatitis showed was present in most patients with removable dentures, with statistical significance as it was found in the group of patients with AD or PD.Probably a result of increased cognitive and motor difficulties in relation to the cleaning of these devices, combined with factors, as mentioned before, such as drugs and systemic associated diseases 21 .
In the final stages of both neurodegenerative alterations, it is questionable the use of ill-fitting and poorly sanitized prostheses are of, recommend not using them 22 .The non-use of prostheses should provide favorable oral health condition and prevent the occurrence of possible accidents such as aspiration or swallowing due to neuromuscular disorders such as spasms 23 .
As well as treatment, it should also be considered the prevention of certain factors that may be correlated with the emergence or worsening of such degenerative diseases.The role of periodontitis as a risk factor for many systemic diseases is widely accepted and there is increasing evidence for an association between periodontitis and early Alzheimer's disease.Recent epidemiological, microbiological and inflammatory findings strengthen this association, indicating that periodontal pathogens are possible contributors to neural inflammation 24 .According to Kaur et al. 25 , so far there is no direct evidence implying an effect of periodontitis in the pathogenesis of Parkinson's disease; therefore, it is believed the need for more studies about population-based case-control of or cohort design.
The minimum oral health condition of patients with neurodegenerative diseases should be prioritized, because, as reported, there is a relation of dental infection and its possible impact on general health as well as deaths related to aspiration pneumonia, often for lack of favourable oral health 26 .Considering that, it is essential the inclusion of dental surgeon in the preparation of the plan of prevention, treatment and maintenance of oral health condition of these patients.

CONCLUSION
The main systemic comorbidities present in the elderly in control group and test groups were cardiovascular diseases (infarction and hypertension), diabetes, stroke, depression and cancer.Also, there were no differences in the occurrence of oral diseases between the groups.Periodontal disease, tooth decay and denture stomatitis were the most incidents, the latter presenting higher statistical incidence in patients with removable devices and some type of dementia.
Differences in the quality of dental prostheses (total or partial) were found in institutionalized patients, i.e., residents of Lar Torres de Melo and patients treated at the Care Center for the Elderly at HUWC.Fractures, maladaptation, poor hygiene conditions were identified in the analysed prostheses.
Collaborators BMD FROTA participated in the clinical assessment of patients and writing of the article.SN HOLANDA contributed to the analysis of the results, acquisition of materials and writing of the article.FB SOUSA performed the statistical analysis and participated in writing of the article.APNN ALVES was responsible for the project and participated in the writing of the article.

Table 1 .
Systemic diseases identified in both evaluated centers in subjects carriers of AD, PD and Control Group.(n = 90), p > 0.05 .Fortaleza, 2013.

Table 3 .
Frequency (%) of conditions of removable dental prosthesis and presence.
AD, Alzheimer Disease; PD, Parkinson Disease