Oral Health in Elders with Parkinson's Disease

Abstract

This study aimed to evaluate objectively and subjectively the oral health of elders with Parkinson's disease (PD), using clinical oral assessments and the General Oral Health Assessment Index (GOHAI). Subjects included 37 removable prosthesis wearers, 17 with PD (mean age 69.59±5.09 years) and 20 without PD (mean age 72.00±5.69 years). The objective assessment included an evaluation of oral characteristics, including the number of remaining teeth, decayed, missing and filled teeth (DMFT), visible plaque index (VPI), salivary flow rate and removable prosthesis conditions. The subjective assessment included self-perception of oral health collected using the GOHAI index. The number of remaining teeth, DMFT, VPI, salivary flow rate and GOHAI data were compared between the groups using t-tests. Removable prosthesis conditions were analyzed using χ2 tests (p<0.05). There were no group differences in the number of remaining teeth, DMFT, VPI or salivary flow rate (p>0.05). Greater maxillary prosthesis defects were observed in the control group (p=0.037). GOHAI scores were low for the PD group and moderate for controls, yielding a group difference (p=0.04). In conclusion, elders with PD have similar oral health to controls. Although all elders had few remaining teeth, high DMFT and high VPI, PD elders had more negative self-perceptions of their oral health than did the controls.

Key Words:
Parkinson's disease; oral hygiene; oral health; removable dental prosthesis.

Resumo

Este estudo teve como objetivo avaliar objetiva e subjetivamente a saúde bucal em idosos com doença de Parkinson (DP), usando avaliações clínicas bucais e do General Oral Health Assessment Index (GOHAI). Os participantes foram 37 indivíduos usuários de prótese removível, 17 com DP (idade média 69,59±5,09 anos) e 20 sem DP (idade média 72,00±5,69 anos). A avaliação objetiva incluiu avaliação de características bucais,incluindo número de dentes remanescentes; dentes cariados, perdidos e obturados (CPOD); índice de placa visível (IPV), a taxa de fluxo salivar e as condições das próteses removíveis. A avaliação subjetiva incluiu autopercepção da saúde bucal, coletada usando o índice GOHAI. O número de dentes remanescentes, CPOD, IPV, fluxo salivar e os dados GOHAI foram comparadas entre os grupos utilizando o teste t . As condições das próteses removíveis foram analisadas utilizando o teste χ2 (p<0,05). Não houve diferenças entre os grupos no número de dentes remanescentes, CPOD, IPV ou fluxo salivar (p>0,05). Maiores defeitos na prótese superior foi observada no grupo controle (p=0,037). As pontuações do GOHAI foram baixa para o grupo DP e moderada para os controles, com diferença entre os grupos (p=0,04). Como conclusão, os idosos com doença de Parkinson tem saúde bucal semelhante aos controles. Embora todos os idosos tenham poucos dentes remanescentes, alto CPOD e alto IPV, os idosos com DP apresentaram autopercepção mais negativa da sua saúde bucal em relação aos controles.

Introduction

Parkinson's disease (PD) is the second most common neurodegenerative disorder. It is characterized by intracellular α-synuclein-positive inclusions called Lewy bodies and by nigrostriatal cell loss, which cause motor and non-motor symptoms 11. Alves, G; Forsaa, EB; Pedersen, KF; Dreetz, Gjerstad M; Larsen JP. Epidemiology of Parkinson's disease. J Neurol 2008;255:18-32.. Cardinal motor symptoms include resting tremor, bradykinesia, rigidity and postural instability 22. Hoehn, MM; Yahr, MD. Parkinsonism: onset, progression and mortality. Neurology 1967;17:427-442., and diagnosis requires the presence of at least two of these symptoms, coupled with asymmetric symptom onset and a good response to levodopa 11. Alves, G; Forsaa, EB; Pedersen, KF; Dreetz, Gjerstad M; Larsen JP. Epidemiology of Parkinson's disease. J Neurol 2008;255:18-32.. Non-motor symptoms occur in over 90% of patients across all stages and include neuropsychiatric and autonomous dysfunction, such as depression, anxiety, apathy, cognitive and sleep disturbances, sensory symptoms, fatigue and pain 33. Chaudhuri, KR; Odin, P; Antonini, A; Martinez-Martin P. Parkinson's disease: the non-motor issues. Parkinsonism Relat Disord 2011;170:717-723..

Motor symptoms may interfere with automated small hand movements 44. Schwarz, J; Heimhilger, E; Storch A. Increased periodontal pathology in Parkinson's disease. J Neurol 2006;253:608-611., causing impairment in toothbrushing ability, which is considered a primary risk factor for deteriorated oral health in PD patients 55. Müller, T; Palluch, R; Jackowski J. Caries and periodontal disease in patients with Parkinson's disease. Spec Care Dentist 2011;31:178-181.. In addition to non-motor symptoms, such as dementia or apathy, altered motor behavior and particularly motor fluctuations may influence the quality and frequency of daily oral hygiene care by these patients 55. Müller, T; Palluch, R; Jackowski J. Caries and periodontal disease in patients with Parkinson's disease. Spec Care Dentist 2011;31:178-181..

Results of studies assessing oral health in patients with PD have been controversial 55. Müller, T; Palluch, R; Jackowski J. Caries and periodontal disease in patients with Parkinson's disease. Spec Care Dentist 2011;31:178-181.,77. Einarsdóttir, ER; Gunnsteinsdóttir, H; Hallsdóttir, MH; Sveinsson, S; Jónsdóttir, SR; Ólafsson VG et al.. Dental health of patients with Parkinson's disease in Iceland. Spec Care Dent 2009;29:123-127.,88. Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century-the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003;31 Suppl 1:3-23.,99. McGrath, C; Bedi R. The importance of oral health to older people's quality of life. Gerodontology 1999;16:59-63.. Surveys with larger number of participants showed that PD patients have more missing teeth, caries, dental biofilm 77. Einarsdóttir, ER; Gunnsteinsdóttir, H; Hallsdóttir, MH; Sveinsson, S; Jónsdóttir, SR; Ólafsson VG et al.. Dental health of patients with Parkinson's disease in Iceland. Spec Care Dent 2009;29:123-127. and poorer periodontal health 55. Müller, T; Palluch, R; Jackowski J. Caries and periodontal disease in patients with Parkinson's disease. Spec Care Dentist 2011;31:178-181.,88. Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century-the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003;31 Suppl 1:3-23. compared with individuals without the disease 77. Einarsdóttir, ER; Gunnsteinsdóttir, H; Hallsdóttir, MH; Sveinsson, S; Jónsdóttir, SR; Ólafsson VG et al.. Dental health of patients with Parkinson's disease in Iceland. Spec Care Dent 2009;29:123-127.. In contrast, Fukayo et al. 66. Fukayo, S; Nonaka, K; Shimizu, T; Yano E. Oral health of patients with Parkinson's disease: factors related to their better dental status. Tohoku J Exp Med 2003;201:171-179. found that PD patients had significantly more teeth and less caries than a control group of similar age 66. Fukayo, S; Nonaka, K; Shimizu, T; Yano E. Oral health of patients with Parkinson's disease: factors related to their better dental status. Tohoku J Exp Med 2003;201:171-179.. These controversial results underscore the need for further studies of oral health in PD patients.

Oral health means more than good teeth; it is a component of general health essential for well-being 88. Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century-the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003;31 Suppl 1:3-23.. Assessment of oral health, based solely on clinical diagnosis by dentists, often leads to an overestimation of the true need for treatment in elders 99. McGrath, C; Bedi R. The importance of oral health to older people's quality of life. Gerodontology 1999;16:59-63. because it does not evaluate self-perceptions about oral health. Self-perception of oral health is a multidimensional measurement that reflects individuals' subjective experience of their functional, social and psychological well-being 1010. Atchison, KA; Dolan TA. Development of the Geriatric Oral Health Assessment Index. J Dent Educ 1990;54:680-687., and often motivates seeking dental treatment 1111. da Silva, S; Castellanos Fernandes R. Self-perception of oral health status by the elderly. Rev Saude Publica 2001;35:349-355.. Subjective assessments 1212. Slade, GD; Spencer AJ. Development and evaluation of the Oral Health Impact Profile. Community Dent Health 1994;11:3-11.,1414. Bakke, M; Larsen SL; Lautrup, C; Karlsborg M. Orofacial function and oral health in patients with Parkinson's disease. Eur J Oral Sci 2011;119:27-32. were developed to enhance the clinicians' ability to assess self-perception of oral health and oral health-related quality of life in elders.

Previous studies in patients with PD assessed subjective data using a structured questionnaire 1313. Nakayama, Y; Washio, M; Mori M. Oral health conditions in patients with Parkinson's disease. J Epidemiol 2004;14:143-150. and Oral Health Impact Profile (OHIP) 99. McGrath, C; Bedi R. The importance of oral health to older people's quality of life. Gerodontology 1999;16:59-63.,1616. Reichmann H. Clinical criteria for the diagnosis of Parkinson's disease. Neurodegener Dis 2010;7:284-290.. The former 1313. Nakayama, Y; Washio, M; Mori M. Oral health conditions in patients with Parkinson's disease. J Epidemiol 2004;14:143-150. demonstrated that compared with the controls, PD patients complained more about their oral health due to chewing difficulties, denture discomfort and problems with oral health behavior. Subjective assessments using OHIP 1414. Bakke, M; Larsen SL; Lautrup, C; Karlsborg M. Orofacial function and oral health in patients with Parkinson's disease. Eur J Oral Sci 2011;119:27-32.,1515. Silva, PFC; Biasotto-Gonzalez, DA; Motta, LJ; Silva, SM; Ferrari, RAM; Fernandes KPS et al.. Impact in oral health and the prevalence of temporomandibular disorder in individuals with Parkinson's disease. J Phys Ther Sci 2015;27:887-891. also showed that PD patients reported more oral health-related problems than controls 1414. Bakke, M; Larsen SL; Lautrup, C; Karlsborg M. Orofacial function and oral health in patients with Parkinson's disease. Eur J Oral Sci 2011;119:27-32. and that the oral health impact in PD patients was greater on the "physical disability" and "psychological discomfort" subscales 1515. Silva, PFC; Biasotto-Gonzalez, DA; Motta, LJ; Silva, SM; Ferrari, RAM; Fernandes KPS et al.. Impact in oral health and the prevalence of temporomandibular disorder in individuals with Parkinson's disease. J Phys Ther Sci 2015;27:887-891.. However, studies evaluating self-perception of oral health in PD patients using the General Oral Health Assessment Index (GOHAI) have not been published yet.

Due to the controversial literature on oral health in PD subjects and their greater oral health complaints, additional studies in this area are required. Therefore, the present study aimed to evaluate the oral health of elders with PD both objectively and subjectively, using oral assessments and the GOHAI, respectively.

Material and Methods

Subjects

This cross-sectional study included 17 elders with PD (mean age 69.41±4.65 years; 8 women and 9 men), members of the Brazilian Parkinson's Association (Piracicaba, SP, Brazil) and 20 elders without PD (mean age 72.00±5.69; 10 women and 10 men), chosen among friends and relatives of the PD volunteers or from elders who sought prosthetic treatment at the dental clinic of the Piracicaba Dental School, Universidade Estadual de Campinas, Brazil. All PD subjects were diagnosed by a neuropsychiatrist using clinical diagnostic criteria 1616. Reichmann H. Clinical criteria for the diagnosis of Parkinson's disease. Neurodegener Dis 2010;7:284-290., were receiving daily levodopa treatment, and had a mean of 6.76±3.80 years since PD diagnosis. Elders with other neurodegenerative disorders or secondary Parkinsonism were excluded from the study. All participants gave written informed consent. The institutional Ethics Committee approved the study (protocol #097/2012). The study was also registered at the Brazilian Registry of Clinical Trials database (#RBR-3czhsf), which is linked to the International Clinical Trials Registration Platform (ICTRP/World Health Organization).

Sociodemographic characteristics including age, educational level and monthly income were collected. Characteristics of the prostheses were verified, including the type of maxillary and mandibular removable dental prosthesis and prosthesis age.

Objective Assessment

To assess oral health, all participants were subjected to clinical examination made using a probe, mouth mirror and flashlight. Each subject's teeth, hygiene and removable dental prosthesis conditions were evaluated as follows:

11. Alves, G; Forsaa, EB; Pedersen, KF; Dreetz, Gjerstad M; Larsen JP. Epidemiology of Parkinson's disease. J Neurol 2008;255:18-32. Number of remaining teeth: the number of teeth present in the mouth was recorded in the partially dentate volunteers.

22. Hoehn, MM; Yahr, MD. Parkinsonism: onset, progression and mortality. Neurology 1967;17:427-442. Decayed, missing and filled teeth (DMFT) index 1717. World Health Organization. Oral health surveys: basic methods. 4th ed. Geneva: World Health Organization; 1997.: the teeth were categorized as decayed if they were cavitated; missing if they were extracted or extraction was indicated; and filled if they presented amalgam, resin or prosthetic crowns. The sum of the decayed, missing and filled teeth was the DMFT index 1717. World Health Organization. Oral health surveys: basic methods. 4th ed. Geneva: World Health Organization; 1997..

33. Chaudhuri, KR; Odin, P; Antonini, A; Martinez-Martin P. Parkinson's disease: the non-motor issues. Parkinsonism Relat Disord 2011;170:717-723. Visual Plaque Index (VPI) 1818. Ainamo, J; Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J 1975;25:229-235.: an adaptation of the VPI was used to assess the oral hygiene. The occurrence of clearly visible plaque on the buccal and lingual surfaces of all remaining teeth was recorded as positive if it was visible beyond doubt by the researcher. The VPI was expressed as a percentage of the positive findings in the total number of examined surfaces.

44. Schwarz, J; Heimhilger, E; Storch A. Increased periodontal pathology in Parkinson's disease. J Neurol 2006;253:608-611. Salivary flow rate: stimulated salivary flow rate was determined by having participants chew on a piece of parafilm with a 0.02″ thickness (Parafilm M(r); Bemis Company, Inc., Neenah, WI, USA) for 5 min, expectorating saliva at 30 s intervals into a pre-weighted dish. Salivary flow rate (g/min) was then calculated 1919. van der Bilt A. Assessment of mastication with implications for oral rehabilitation: A review. J Oral Rehabil 2011;38:754-780. by subtracting the initial weight from the final weight of the glass; and

55. Müller, T; Palluch, R; Jackowski J. Caries and periodontal disease in patients with Parkinson's disease. Spec Care Dentist 2011;31:178-181. Removable prostheses conditions: maxillary and mandibular complete dentures (CD) and/or removable partial dentures (RPD) were evaluated according to Vigild criteria 2020. Vigild M. Denture status and need for prosthodontic treatment among institutionalized elderly in Denmark. Community Dent Oral Epidemiol 1987;15:128-133.. Within the mouth, the maxillary and mandibular prostheses were evaluated for stability, retention, occlusion and vertical height; outside the mouth, they were evaluated for defects, such as wear and/or missing/fractured teeth, broken flanges and loss of pieces of the prosthesis base 2020. Vigild M. Denture status and need for prosthodontic treatment among institutionalized elderly in Denmark. Community Dent Oral Epidemiol 1987;15:128-133..

Subjective Assessment

Self-perception of oral health was evaluated using the validated GOHAI 1010. Atchison, KA; Dolan TA. Development of the Geriatric Oral Health Assessment Index. J Dent Educ 1990;54:680-687. Portuguese version 1111. da Silva, S; Castellanos Fernandes R. Self-perception of oral health status by the elderly. Rev Saude Publica 2001;35:349-355.. A single trained examiner administered the GOHAI, asking participants to respond the 12 items in reference to the last three months using a 3-point scoring scale (always, sometimes or never) 1111. da Silva, S; Castellanos Fernandes R. Self-perception of oral health status by the elderly. Rev Saude Publica 2001;35:349-355.. The final GOHAI score was calculated as previously described by Atchison and Dolan 1010. Atchison, KA; Dolan TA. Development of the Geriatric Oral Health Assessment Index. J Dent Educ 1990;54:680-687. and could range from 12 to 36. Scores of 34 to 36 were classified as high, scores of 31 to 33 as moderate and scores less than 30 as low 2121. Silva, DD; Sousa, MLR; Wada RS. Self-perception and oral health conditions in an elderly population. Cad Saude Publica 2005;21:1251-1259.. Higher GOHAI scores indicate more positive perceptions of oral health and lower GOHAI scores are associated with more self-reported oral health problems and poorer oral health conditions 1010. Atchison, KA; Dolan TA. Development of the Geriatric Oral Health Assessment Index. J Dent Educ 1990;54:680-687..

Statistical Analysis

Data were evaluated using SAS 9.3 (SAS Institute Inc., SAS Campus Drive, Cary, NC, USA). Exploratory analysis using the Shapiro-Wilk test showed that data were normally distributed. T-tests were used to analyze age, educational level, monthly income and prosthesis age, as well as the number of remaining teeth, DMFT, VPI, salivary flow rate, and subjective data from the GOHAI. Squared chi tests were used to analyze the type and condition of maxillary and mandibular removable dental prostheses. All statistical analyses were carried out at a 5% significance level.

Results

As shown in Table 1, sociodemographic and prosthesis characteristics of PD patients and controls were similar (p>0.05). Both groups had few remaining teeth, high DMFT, high VPI and normal salivary flow rate (>0.70 g/mL) (p>0.05) (Table 2). Still about DMFT, results showed no differences between groups for the decayed (p=0.876), missing (p=0.422) and filled teeth (p=0.284), with mean number of 0.24±0.75 decayed, 22.18±6.30 missing and 2.41±3.45 filled teeth for PD group; and 0.20±0.62 decayed, 25.40±4.52 missing and 1.25±2.77 filled teeth for controls. GOHAI scores showed a group difference: controls had moderate scores and PD patients had low scores, indicating more self-reported oral health issues in PD subjects (p=0.04) (Table 2). Group differences were also observed in the maxillary prostheses, which had greater defects in the control group (p<0.05), as shown in Table 3. The most common defects observed were worn artificial teeth and missing/fractured teeth.

Discussion

This cross-sectional study on oral health of elders with PD revealed similar numbers of remaining teeth, DMFT and VPI between the PD and control subjects. Interestingly, PD elders had more negative self-perceptions about their oral health, despite having fewer defects in the maxillary prostheses than the controls.

PD and control subjects had similar age, educational level, monthly income and prosthesis characteristics. Both groups had few remaining teeth; no group difference was observed. This result may be influenced by the sample characteristics, which included edentulous and partially edentulous elders in both groups. Previous studies also found similar numbers of teeth between PD subjects and controls 1414. Bakke, M; Larsen SL; Lautrup, C; Karlsborg M. Orofacial function and oral health in patients with Parkinson's disease. Eur J Oral Sci 2011;119:27-32. and those authors reported that problems such as missing teeth become more marked only in advanced PD stages. In contrast, Nakayama et al. 1313. Nakayama, Y; Washio, M; Mori M. Oral health conditions in patients with Parkinson's disease. J Epidemiol 2004;14:143-150. and Hanaoka and Kashihara 2222. Hanaoka, A; Kashihara K. Increased frequencies of caries, periodontal disease and tooth loss in patients with Parkinson's disease. J Clin Neurosci 2009;16:1279-1282. found few teeth in PD patients than in controls and reported that caries and periodontal disease are frequent complications in this population. Since greater severity of PD predisposes individuals to a poorer state of oral health 55. Müller, T; Palluch, R; Jackowski J. Caries and periodontal disease in patients with Parkinson's disease. Spec Care Dentist 2011;31:178-181., these contrasting results may be due to inclusion of patients with different degrees of PD severity 1313. Nakayama, Y; Washio, M; Mori M. Oral health conditions in patients with Parkinson's disease. J Epidemiol 2004;14:143-150.,2222. Hanaoka, A; Kashihara K. Increased frequencies of caries, periodontal disease and tooth loss in patients with Parkinson's disease. J Clin Neurosci 2009;16:1279-1282., which was not recorded in the present study

As regards DMFT, no difference was observed between groups in the total DMFT, as well as in their components (decayed, missing and filled teeth), demonstrating the same need for caries treatment in PD and control participants. Previous studies also found similar DMFT values for PD and control subjects 2323. Kennedy, MA; Rosen, S; Paulson, GW; Jolly, DE; Beck FM. Relationship of oral microflora with oral health status in Parkinson's disease. Spec Care Dentist 1994;14:164-168.. In contradiction, some authors 66. Fukayo, S; Nonaka, K; Shimizu, T; Yano E. Oral health of patients with Parkinson's disease: factors related to their better dental status. Tohoku J Exp Med 2003;201:171-179.,77. Einarsdóttir, ER; Gunnsteinsdóttir, H; Hallsdóttir, MH; Sveinsson, S; Jónsdóttir, SR; Ólafsson VG et al.. Dental health of patients with Parkinson's disease in Iceland. Spec Care Dent 2009;29:123-127. found different total DMFT values in the PD group than in controls. Fukayo et al. 66. Fukayo, S; Nonaka, K; Shimizu, T; Yano E. Oral health of patients with Parkinson's disease: factors related to their better dental status. Tohoku J Exp Med 2003;201:171-179. verified lower DMFT in PD patients, because they maintained a better routine of oral hygiene than the control ones. Petersen et al. 77. Einarsdóttir, ER; Gunnsteinsdóttir, H; Hallsdóttir, MH; Sveinsson, S; Jónsdóttir, SR; Ólafsson VG et al.. Dental health of patients with Parkinson's disease in Iceland. Spec Care Dent 2009;29:123-127. found higher DMFT in PD subjects, probably due to the greater number of missing teeth in their PD subjects, which may explain the difference in results.

In the present study, VPI values were similar between groups and all participants were considered to have high VPI, which represents poor oral hygiene. Fukayo et al. 66. Fukayo, S; Nonaka, K; Shimizu, T; Yano E. Oral health of patients with Parkinson's disease: factors related to their better dental status. Tohoku J Exp Med 2003;201:171-179. observed more frequent tooth brushing and better oral health in PD outpatients with mild symptoms than in controls. However, they also reported that when some of the caries-associated environments were particularly poor in both PD and control patients, the oral health status between them did not differ 66. Fukayo, S; Nonaka, K; Shimizu, T; Yano E. Oral health of patients with Parkinson's disease: factors related to their better dental status. Tohoku J Exp Med 2003;201:171-179., which agrees with the present results. On the other hand, Bakke et al. 1414. Bakke, M; Larsen SL; Lautrup, C; Karlsborg M. Orofacial function and oral health in patients with Parkinson's disease. Eur J Oral Sci 2011;119:27-32. reported that dental plaque, food debris and periodontal health are probably more marked in patients with advanced PD, and Müller et al. 55. Müller, T; Palluch, R; Jackowski J. Caries and periodontal disease in patients with Parkinson's disease. Spec Care Dentist 2011;31:178-181. reported that younger and hospitalized PD patients had poorer plaque index compared to controls. Those authors 55. Müller, T; Palluch, R; Jackowski J. Caries and periodontal disease in patients with Parkinson's disease. Spec Care Dentist 2011;31:178-181. did not consider motor fluctuations during evaluations, which may influence their results and support explaining the study's contrasting data.

In addition to the fact that PD subjects were able to perform their own oral hygiene in the current study, the salivary flow rate could also help to explain the similarity of VPI values between groups. Salivary flow rate plays an important role in the buffering capacity of the saliva 2323. Kennedy, MA; Rosen, S; Paulson, GW; Jolly, DE; Beck FM. Relationship of oral microflora with oral health status in Parkinson's disease. Spec Care Dentist 1994;14:164-168., which is essential to maintain oral health due to its protective functions, including flushing plaque and bacteria from mucosal and dental surfaces in the mouth 55. Müller, T; Palluch, R; Jackowski J. Caries and periodontal disease in patients with Parkinson's disease. Spec Care Dentist 2011;31:178-181.. Although PD participants in the current study were receiving levodopa, which may reduce salivary secretion 66. Fukayo, S; Nonaka, K; Shimizu, T; Yano E. Oral health of patients with Parkinson's disease: factors related to their better dental status. Tohoku J Exp Med 2003;201:171-179., no difference in salivary flow rate was observed between the PD and control elders. Thus, similar levels of salivary protective functions in PD and control elders could have influenced the VPI observed in both groups in the current study.

Removable prosthesis conditions showed group differences only in defects of the maxillary prostheses, which were greater in the controls. These defects were mainly due to wear of artificial teeth and missing/fractured teeth. Although no previous studies have evaluated prosthesis conditions in PD patients, Bakke et al. 1414. Bakke, M; Larsen SL; Lautrup, C; Karlsborg M. Orofacial function and oral health in patients with Parkinson's disease. Eur J Oral Sci 2011;119:27-32. reported impaired masticatory performance in PD patients. Thus, the authors of this study hypothesize that the higher frequency of artificial tooth wear and consequently the greater defects of the maxillary prostheses observed in controls of the current study, which was due to their better masticatory ability and greater wear of artificial teeth as consequence.

The GOHAI index showed that PD participants had a more negative self-perception of their oral health than controls, indicating more self-reported oral health issues. This finding supports previous reports 99. McGrath, C; Bedi R. The importance of oral health to older people's quality of life. Gerodontology 1999;16:59-63.,1515. Silva, PFC; Biasotto-Gonzalez, DA; Motta, LJ; Silva, SM; Ferrari, RAM; Fernandes KPS et al.. Impact in oral health and the prevalence of temporomandibular disorder in individuals with Parkinson's disease. J Phys Ther Sci 2015;27:887-891., despite the use of different methodologies for this subjective evaluation. Since the PD and control participants in this study had the same need for dental treatment, as observed in the DMFT results, the PD symptoms may contribute for the GOHAI results. PD tremors and rigidity can affect the orofacial musculature, and they may also induce orofacial pain, cracked teeth dental attrition 2424. Dirks, SJ; Paunovich, ED; Terezhalmy, GT; Chiodo LK. The patient with Parkinson's disease. Quintessence Int 2003 May;34:379-393. and could probably create difficulties in controlling and retaining dentures 2525. Friedlander, AH; Mahler, M; Norman, KM; Ettinger RL. Parkinson disease: systemic and orofacial manifestations, medical and dental management. J Am Dent Assoc 2009;140:658-669.. Thus, the motor symptoms of PD may explain the more negative self-perceptions of oral health in these patients.

The GOHAI usually requires a larger sample size than the current study, which could be considered a limitation. However, standardizing by age, educational level and monthly income improved the study's confidence levels. Another potential limitation is that oral health parameters deteriorate as PD progresses 55. Müller, T; Palluch, R; Jackowski J. Caries and periodontal disease in patients with Parkinson's disease. Spec Care Dentist 2011;31:178-181. and PD patients in the current study were not stratified by disease severity 22. Hoehn, MM; Yahr, MD. Parkinsonism: onset, progression and mortality. Neurology 1967;17:427-442.. However, the PD volunteers had a mean of 6.76 years since PD diagnosis and all of them were able to attend clinical care sessions and perform their own oral hygiene. This suggests that the PD subjects in the present study were not in the advanced PD stage.

In conclusion, the present study showed that elderly individuals with PD have similar oral health as elderly individuals without the disease. Although all elders showed few remaining teeth, high DMFT and high VPI, those with PD had more negative self-perceptions of their oral health.

Acknowledgements

This study was supported by the National Counsel of Technological and Scientific Development (CNPq) and São Paulo Research Foundation (FAPESP), Brazil.

References

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    Alves, G; Forsaa, EB; Pedersen, KF; Dreetz, Gjerstad M; Larsen JP. Epidemiology of Parkinson's disease. J Neurol 2008;255:18-32.
  • 2
    Hoehn, MM; Yahr, MD. Parkinsonism: onset, progression and mortality. Neurology 1967;17:427-442.
  • 3
    Chaudhuri, KR; Odin, P; Antonini, A; Martinez-Martin P. Parkinson's disease: the non-motor issues. Parkinsonism Relat Disord 2011;170:717-723.
  • 4
    Schwarz, J; Heimhilger, E; Storch A. Increased periodontal pathology in Parkinson's disease. J Neurol 2006;253:608-611.
  • 5
    Müller, T; Palluch, R; Jackowski J. Caries and periodontal disease in patients with Parkinson's disease. Spec Care Dentist 2011;31:178-181.
  • 6
    Fukayo, S; Nonaka, K; Shimizu, T; Yano E. Oral health of patients with Parkinson's disease: factors related to their better dental status. Tohoku J Exp Med 2003;201:171-179.
  • 7
    Einarsdóttir, ER; Gunnsteinsdóttir, H; Hallsdóttir, MH; Sveinsson, S; Jónsdóttir, SR; Ólafsson VG et al.. Dental health of patients with Parkinson's disease in Iceland. Spec Care Dent 2009;29:123-127.
  • 8
    Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century-the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003;31 Suppl 1:3-23.
  • 9
    McGrath, C; Bedi R. The importance of oral health to older people's quality of life. Gerodontology 1999;16:59-63.
  • 10
    Atchison, KA; Dolan TA. Development of the Geriatric Oral Health Assessment Index. J Dent Educ 1990;54:680-687.
  • 11
    da Silva, S; Castellanos Fernandes R. Self-perception of oral health status by the elderly. Rev Saude Publica 2001;35:349-355.
  • 12
    Slade, GD; Spencer AJ. Development and evaluation of the Oral Health Impact Profile. Community Dent Health 1994;11:3-11.
  • 13
    Nakayama, Y; Washio, M; Mori M. Oral health conditions in patients with Parkinson's disease. J Epidemiol 2004;14:143-150.
  • 14
    Bakke, M; Larsen SL; Lautrup, C; Karlsborg M. Orofacial function and oral health in patients with Parkinson's disease. Eur J Oral Sci 2011;119:27-32.
  • 15
    Silva, PFC; Biasotto-Gonzalez, DA; Motta, LJ; Silva, SM; Ferrari, RAM; Fernandes KPS et al.. Impact in oral health and the prevalence of temporomandibular disorder in individuals with Parkinson's disease. J Phys Ther Sci 2015;27:887-891.
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    Reichmann H. Clinical criteria for the diagnosis of Parkinson's disease. Neurodegener Dis 2010;7:284-290.
  • 17
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Publication Dates

  • Publication in this collection
    May-Jun 2016

History

  • Received
    14 Jan 2016
  • Accepted
    29 Apr 2016
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