Barriers and Motivations to Provide Dental Care to Adult Patients with Movement Disorders.

Patients with movement disorders, like Parkinson's and Huntington's diseases, tend to have poor oral health. Although contributing factors have been proposed, the willingness and ability of dentists to treat this patient population are still unknown. Our objective is to understand the current barriers and motivations of dentists to treat this patient population as a path to improved care and quality of life. A total of 176 dentists in Texas were surveyed through a structured questionnaire which contained both closed and open-ended questions. Nearly 30% of participants reported having no barriers to treating these patients and 26.7% reported that no such patients have visited their practice. Barriers reported included lack of education on the topic (17.6%) and longer appointments than average (14.8%). A main motivation to treat these patients was more training and education on the subject (38.6%). Poor oral health in patients with movement disorders may not be due to barriers encountered by dentists, but rather encountered by patients, such as access to and use of dental treatment. General dentists are willing to provide care for adult patients with movement disorders and continuing education for these providers is preferred over referral to a specialist.

Oral Factors That Impact the Oral Microbiota in Parkinson's Disease.

Patients with Parkinson's disease (PD) are at increased risk of aspiration pneumonia, their primary cause of death. Their oral microbiota differs from healthy controls, exacerbating this risk. Our goal was to explore if poor oral health, poor oral hygiene, and dysphagia status affect the oral microbiota composition of these patients. In this cross-sectional case-control study, the oral microbiota from hard and soft tissues of patients with PD (n = 30) and age-, gender-, and education-matched healthy controls (n = 30) was compared using 16S rRNA gene sequencing for bacterial identification. Study participants completed dietary, oral hygiene, drooling, and dysphagia questionnaires, and an oral health screening. Significant differences in soft tissue beta-diversity (p < 0.005) were found, and a higher abundance of opportunistic oral pathogens was detected in patients with PD. Factors that significantly influenced soft tissue beta-diversity and microbiota composition include dysphagia, drooling (both p < 0.05), and salivary pH (p < 0.005). Thus, patients with PD show significant differences in their oral microbiota compared to the controls, which may be due, in part, to dysphagia, drooling, and salivary pH. Understanding factors that alter their oral microbiota could lead to the development of diagnostic and treatment strategies that improve the quality of life and survivability of these patients.

Impact of simulated patients on students' self-assessment of competency in practice of geriatric dentistry.

PURPOSE: The evaluation of the effectiveness of simulation training in dentistry has previously been focused primarily on psychomotor hand skills. This study explored the impact of simulated patient (SP) encounters in simulation on students' self-assessment of competency in their clinical and communication abilities with geriatric patients. METHODS: Students from 2 cohorts were recruited for this study. Cohort 1 (n = 30) participated in the standard curriculum with no simulation training and served as the control group. Cohort 2 (n = 34) participated in a SP experience, simulating the initial stages of a care visit for 2 nursing home patients. Students' perceptions of competency to perform these clinical and communication tasks were assessed. A group debriefing session was held 5 weeks post-simulation where Cohort 2 completed a student feedback form. RESULTS: A statistically significant change (P < 0.00001) was noted for both cohorts in their self-reported competence to perform clinical tasks following exposure to an independent clinical experience. In addition to this gain, individuals in Cohort 2 demonstrated improvements following simulation and expressed different responses of impact to questions related to treatment, pharmacology, and managing a complex medical history. CONCLUSIONS: This study suggests that simulation of patient interactions using SPs can strengthen students' self-assessment of competency in their abilities, leading to more genuine interactions with actual patients. These findings will help inform the design of future SP encounters as a component of an evolving humanistic curriculum.

Oral Health Assessment by Lay Personnel for Older Adults.

Oral health is an often-undervalued contributor to overall health. The literature, however, underscores the myriad of systemic diseases influenced by oral health, including type II diabetes, heart disease, and atherosclerosis. Thus, assessments of oral health, called oral screenings, have a significant role in assessing risk of disease, managing disease, and even improving disease by oral care. Here we present a method to assess oral health quickly and consistently across time. The protocol is simple enough for non-oral health professionals such as students, family, and caregivers. Useful for any age of patient, the method is particularly key for older individuals who are often at risk of inflammation and chronic disease. Components of the method include existing oral health assessment scales and inventories, which are combined to produce a comprehensive assessment of oral health. Thus, oral characteristics assessed include intraoral and extraoral structures, soft and hard tissues, natural and artificial teeth, plaque, oral functions such as swallowing, and the impact this oral health status has on the patient's quality of life. Advantages of this method include its inclusion of measures and perceptions of both the observer and patient, and its ability to track changes in oral health over time. Results acquired are quantitative totals of questionnaire and oral screening items, which can be summed for an oral health status score. The scores of successive oral screenings can be used to track the progression of oral health across time and guide recommendations for both oral and overall health care.

Parkinson's Disease Oral Health Module: Interprofessional Coordination of Care.

Introduction: Patients with Parkinson's disease (PD) suffer progressive neurodegeneration and experience motor and nonmotor symptoms. Oropharyngeal dysfunctions are increasingly recognized as nonmotor PD symptoms that negatively impact a patient's quality of life. This module was primarily created to update dental health professionals and educate dental students on the oral health needs of patients with PD, with an emphasis on interprofessional collaboration and evidence-based dentistry. The module may also benefit other health professionals from different disciplines working with patients with PD. Methods: The module was developed to be delivered in one 55-minute large-group session followed by a short assessment and case study discussion. Associated materials include PowerPoint slides with transcript, a narrated video version of the PowerPoint lecture, a quiz, and the case study. Thirty-four first-year dental students were invited to watch the narrated presentation, complete a pre-/postsurvey, and take the quiz. Results: All participants agreed dental schools should provide education regarding oral health in patients with neurological disorders, as only 29% of them had previously taken a related class. After watching the presentation, students reported that most of the information was new content and that the difficulty level met their expectations. All students reported that the lecture increased their interest in interprofessional collaboration. In a quiz taken immediately after the presentation, the class average grade was 82.7, with 94% of the class passing the quiz with a grade of 70 or more. Discussion: Educating dental professionals regarding care of patients with PD must emphasize interprofessional collaborations among health care providers.

Incorporating oral health into interprofessional care teams for patients with Parkinson's disease.

Parkinson's disease (PD) is a progressive neurodegenerative disorder that primarily affects the motor system. However, non-motor symptoms such as cognitive, autonomic, sleep-related and sensory dysfunctions are often reported. A subgroup of non-motor symptoms, oropharyngeal problems, also affects these patients in ways that greatly deteriorate quality of life. Each patient may develop a different set of non-motor symptoms, making interprofessional collaboration among health care providers a must to treat patients with PD. In this review, we argue that dental health professionals must be included in this interprofessional health care team. Patients with PD are at a higher risk for developing oral health problems that can exacerbate or be exacerbated by other non-motor symptoms, such as mental health and dysphagia This accelerates decline in quality of life and even increases the risk of death by aspiration pneumonia. Dentists can create preventive oral health plans as soon as a diagnosis is made and promptly treat a patient's dental problems, preventing them from affecting other health areas. We describe major oral health concerns and how health professionals and dentists can participate and collaborate to improve the health of patients with PD.

Strategies to improve dental health in elderly patients with cognitive impairment: A systematic review.

BACKGROUND: Cognitive impairment is the gradual loss of one's ability to learn, remember, pay attention, and make decisions. Cognitively impaired elderly people are a challenging patient population for dental health care professionals and may be at higher risk of developing oral health diseases. The authors systematically reviewed interventions effective at improving dental health in patients with cognitive impairment and described research gaps remaining. TYPES OF STUDIES REVIEWED: In a comprehensive search of multiple databases, the authors identified 2,255 studies published in the English language from 1995 through March 2016. The authors included studies if the investigators evaluated oral health measures after an intervention in patients 65 years or older with cognitive impairment or dementia. Nine full-text articles met the criteria for inclusion. RESULTS: Only 1 study was a randomized control trial, whereas all others lacked appropriate controls. Investigators studied the effects of dental treatments, battery-powered devices for oral hygiene, and training of care staff members. Most interventions improved some aspect of the oral health of patients with dementia, and results were more pronounced when patients required assistance while performing oral hygiene tasks or had poor oral health at baseline. CONCLUSIONS AND PRACTICAL IMPLICATIONS: A basic care plan for patients with dementia should, at the minimum, match prevention strategies recommended for healthy elderly patients. Dental health care professionals should promote oral hygiene education for caregivers for elderly patients with cognitive impairment. There is a wide gap in knowledge regarding effective methods specifically to improve oral health in patients with dementia.

Traumatic Brain Injury Alters Methionine Metabolism: Implications for Pathophysiology.

Methionine is an essential proteinogenic amino acid that is obtained from the diet. In addition to its requirement for protein biosynthesis, methionine is metabolized to generate metabolites that play key roles in a number of cellular functions. Metabolism of methionine via the transmethylation pathway generates S-adenosylmethionine (SAM) that serves as the principal methyl (-CH3) donor for DNA and histone methyltransferases (MTs) to regulate epigenetic changes in gene expression. SAM is also required for methylation of other cellular proteins that serve various functions and phosphatidylcholine synthesis that participate in cellular signaling. Under conditions of oxidative stress, homocysteine (which is derived from SAM) enters the transsulfuration pathway to generate glutathione, an important cytoprotective molecule against oxidative damage. As both experimental and clinical studies have shown that traumatic brain injury (TBI) alters DNA and histone methylation and causes oxidative stress, we examined if TBI alters the plasma levels of methionine and its metabolites in human patients. Blood samples were collected from healthy volunteers (HV; n = 20) and patients with mild TBI (mTBI; GCS > 12; n = 20) or severe TBI (sTBI; GCS < 8; n = 20) within the first 24 h of injury. The levels of methionine and its metabolites in the plasma samples were analyzed by either liquid chromatography-mass spectrometry or gas chromatography-mass spectrometry (LC-MS or GC-MS). sTBI decreased the levels of methionine, SAM, betaine and 2-methylglycine as compared to HV, indicating a decrease in metabolism through the transmethylation cycle. In addition, precursors for the generation of glutathione, cysteine and glycine were also found to be decreased as were intermediate metabolites of the gamma-glutamyl cycle (gamma-glutamyl amino acids and 5-oxoproline). mTBI also decreased the levels of methionine, α-ketobutyrate, 2 hydroxybutyrate and glycine, albeit to lesser degrees than detected in the sTBI group. Taken together, these results suggest that decreased levels of methionine and its metabolic products are likely to alter cellular function in multiple organs at a systems level.

Oculomotor executive function abnormalities with increased tic severity in Tourette syndrome.

BACKGROUND: Reports conflict as to whether Tourette syndrome (TS) confers deficits in executive function. This study's aim was to evaluate executive function in youths with TS using oculomotor tasks while controlling for confounds of tic severity, age, medication, and severity of comorbid disorders. METHOD: Four saccade tasks requiring the executive functions of response generation, response inhibition, and working memory (prosaccade, antisaccade, 0-back, and 1-back) were administered. Twenty youths with TS and low tic severity (TS-low), nineteen with TS and moderate tic severity (TS-moderate), and 29 typically developing control subjects (Controls) completed the oculomotor tasks. RESULTS: There were small differences across groups in the prosaccade task. Controlling for any small sensorimotor differences, TS-moderate subjects had significantly higher error rates than Controls and TS-low subjects in the 0-back and 1-back tasks. In the 1-back task, these patients also took longer to respond than Controls or TS-low subjects. CONCLUSIONS: In a highly controlled design, the findings demonstrate for the first time that increased tic severity in TS is associated with impaired response inhibition and impaired working memory and that these executive function deficits cannot be accounted for by differences in age, medication or comorbid symptom severity.

Human mild traumatic brain injury decreases circulating branched-chain amino acids and their metabolite levels.

The pathophysiology of traumatic brain injury (TBI) is complex and not well understood. Because pathophysiology has ramifications for injury progression and outcome, we sought to identify metabolic cascades that are altered after acute human mild and severe TBI. Because catabolism of branched-chain amino acids (BCAAs; i.e., valine, isoleucine, and leucine) leads to glucose and energy metabolism, and neurotransmitter synthesis and availability, we investigated BCAA metabolites in plasma samples collected within 24 h of injury from mild TBI (Glasgow Coma Scale [GCS] score >12), severe TBI (GCS ≤8), orthopedic injury, and healthy volunteers. We report decreased levels of all three BCAAs in patients with mild TBI relative to healthy volunteers, while these BCAAs levels in patients with severe TBI were further reduced compared with all groups. Orthopedic patients exhibited reductions in BCAA comparable to those in patients with mild TBI. The decrease in patients with mild and severe TBI persisted for derivatives of BCAA catabolic intermediates. Only plasma levels of methylglutarylcarnitine, a derivative of a leucine metabolite, were increased in patients with severe TBI compared with all other groups. Notably, logistic regression combination of three BCAA metabolites whose levels were changed by 24 h post-injury provided prognostic value (area under the curve=0.92) in identifying patients with severe TBI in whom elevated intracranial pressure (≥25 mm Hg) developed. These changes suggest alteration of BCAA metabolism after TBI may contribute to decreased energy production and neurotransmitter synthesis and may contribute to TBI pathophysiology. Supplementation of BCAAs and/or their metabolites may reduce TBI pathology and improve outcome.

Biomarkers for the diagnosis and prognosis of mild traumatic brain injury/concussion.

Mild traumatic brain injury (mTBI) results from a transfer of mechanical energy into the brain from traumatic events such as rapid acceleration/deceleration, a direct impact to the head, or an explosive blast. Transfer of energy into the brain can cause structural, physiological, and/or functional changes in the brain that may yield neurological, cognitive, and behavioral symptoms that can be long-lasting. Because mTBI can cause these symptoms in the absence of positive neuroimaging findings, its diagnosis can be subjective and often is based on self-reported neurological symptoms. Further, proper diagnosis can be influenced by the motivation to conceal or embellish signs and/or an inability of the patient to notice subtle dysfunctions or alterations of consciousness. Therefore, appropriate diagnosis of mTBI would benefit from objective indicators of injury. Concussion and mTBI are often used interchangeably, with concussion being primarily used in sport medicine, whereas mTBI is used in reference to traumatic injury. This review provides a critical assessment of the status of current biomarkers for the diagnosis of human mTBI. We review the status of biomarkers that have been tested in TBI patients with injuries classified as mild, and introduce a new concept for the discovery of biomarkers (termed symptophenotypes) to predict common and unique symptoms of concussion. Finally, we discuss the need for biomarker/biomarker signatures that can detect mTBI in the context of polytrauma, and to assess the consequences of repeated injury on the development of secondary injury syndrome, prolongation of post-concussion symptoms, and chronic traumatic encephalopathy.

Human traumatic brain injury alters circulating L-arginine and its metabolite levels: possible link to cerebral blood flow, extracellular matrix remodeling, and energy status.

Altered cerebral blood flow, cell-matrix interactions, and energy metabolism are secondary pathologies contributing to outcome after traumatic brain injury (TBI). Because L-arginine serves as the precursor for metabolites that are critical to these processes, we measured their plasma levels using LC-MS/GC-MS. Samples were collected from healthy volunteers (n=20), and patients with mild TBI (n=18), severe TBI (n=20), or orthopedic injury without a TBI (n=15), within the first 24 hours of injury. Severe TBI levels of L-arginine, citrulline, ornithine, and hydroxyproline were significantly reduced compared to the other groups. In contrast, the levels of plasma creatine were significantly increased in severe TBI patients compared to healthy volunteers and orthopedic injury subjects. Of interest, the levels of creatine were found to be higher in severe TBI patients (GCS score ≤8) whose intracranial pressure (ICP) remained below 25 mm Hg throughout the 5-day monitoring period, compared to TBI patients (GCS score ≤8) who subsequently developed elevated ICP (≥25 mm Hg). The changes in L-arginine and its metabolite levels were not detected in subjects with mild TBI. The altered levels of arginine and its metabolites may contribute to secondary pathologies following severe TBI, and plasma levels of creatine may have prognostic value in identifying patients at risk for ICP elevation.

Reflexive and volitional saccades: biomarkers of Huntington disease severity and progression.

BACKGROUND: Huntington disease (HD) is a genetic, neurodegenerative disorder characterized by chorea, behavioral co-morbidities, cognitive deficits, and eye movement abnormalities. We sought to evaluate whether reflexive and voluntary orienting prove useful as biomarkers of disease severity in HD. METHODS: Eleven HD subjects were evaluated with the motor subscale of the Unified Huntington Disease Rating Scale (UHDRS) and the Montreal Cognitive Assessment. Using an infrared eye tracker, we also measured latency and error rates of horizontal and vertical saccades using prosaccade and antisaccade eye movement tasks. We calculated simple and age-controlled correlations between eye movement and clinical parameters. RESULTS: Prosaccade latency correlated with total chorea score. HD patients with greater clinical severity were significantly slower in the prosaccade task. Antisaccade error rate also correlated with UHDRS motor score and total chorea score. HD patients with greater clinical severity as measured by either measure made significantly more errors in the antisaccade task. All these correlations remained significant even when age was taken into account. CONCLUSIONS: The results of the present age-controlled study show for the first time that both reflexive and voluntary eye motor control in HD patients decrease with increase in disease severity suggesting declines in both motor and cognitive function. Thus, relatively simple eye movement parameters (latency and error rate) obtained from simple tasks (prosaccade and antisaccade) may serve as quantitative biomarkers of sub-cortical and cortical disease severity in HD and could aid in predicting onset, distinguishing subtypes, or evaluating disease progression and novel therapies.

Novel n-back spatial working memory task using eye movement response.

We created a novel eye movement version of the n-back task to measure spatial working memory (WM). Rather than one continuous trial, discrete trials were presented in order to develop a simpler WM task. In Experiment 1, we varied the visibility of the final stimulus to maximize the difference in performance between 0-back and 1-back tasks (WM effect). In Experiment 2, we administered the optimized task to children. In Experiment 3, we further simplified the task. Both adults and children easily completed our task, displaying significant WM effects. Further, similar WM effects were obtained in our original and simplified n-back spatial WM tasks, demonstrating flexibility. Because WM deficits are often an early feature of disease and a marker of disease progression, our saccadic measure of spatial WM may be particularly useful in hard-to-test populations, such as patients and children, and may have application in brain-imaging studies that require discrete trials.

Vividness of mental imagery: individual variability can be measured objectively.

When asked to imagine a visual scene, such as an ant crawling on a checkered table cloth toward a jar of jelly, individuals subjectively report different vividness in their mental visualization. We show that reported vividness can be correlated with two objective measures: the early visual cortex activity relative to the whole brain activity measured by functional magnetic resonance imaging (fMRI) and the performance on a novel psychophysical task. These results show that individual differences in the vividness of mental imagery are quantifiable even in the absence of subjective report.

Dissociating sensory and motor components of inhibition of return.

Two explanations for inhibition of return (IOR) have been proposed. The first is that IOR reflects inhibition of attentional processing at previously cued locations, resulting in altered sensory analysis. The second is that IOR reflects the inhibition of responses directed towards those previously cued locations. We used a variant of a double-saccade paradigm to dissociate these two proposed effects of IOR and attempted to reveal both effects within the context of a single experimental task. Subjects viewed a series of exogenous cues and then made a localization response to subsequent targets with either a target-directed saccade or a pointing response. Results were similar for both response modes. An important finding was that the pattern of IOR depended critically on how subjects reacted to the exogenous cues. Subjects either oriented to the cued locations (via saccades or pointing) prior to responding to the target (Respond), or passively viewed the cues before responding (Ignore). In the Respond condition, IOR was observed at the most recently cued position. Although this could be consistent with an altered sensory interpretation, it would also be consistent with a spatiotopic representation. In the Ignore condition, the sole inhibited location was not the most recently cued position, but the first cued position. This finding is surprising and in conflict with previous work with multiple exogenous cues. The data are discussed in relation to a number of prominent issues in the area of IOR and suggest important new constraints and boundary conditions.