Swallowing and Dental Challenges

By Michelle Ciucci, Ph.D., S.L.P. and Jane Busch, D.D.S.

Did you know that Parkinson’s disease (PD) can lead to difficulties swallowing and maintaining dental health? These challenges are common in PD, and can interfere with important parts of life, such as the ability to eat well.

Most people with PD who have swallowing problems are not aware of them. The good news is that being aware is the first step to taking charge. Here we outline the effects of PD on swallowing and dental health and provide tips for staying safe, eating well and establishing a routine for dental care.

Parkinson’s and Swallowing

Because swallowing involves a very complex sequence of movements, it is no surprise that PD — a movement disorder — affects swallowing. For example, the slowness of movement that often comes with PD may affect chewing, biting, the ability to work the tongue and the ability to get food or liquid down in one bite.

What are other signs of a problem? A person with PD may lose food or liquid out of the mouth, may swallow in small bites or sips or may have difficulty with certain textures. He or she may stop eating foods that are difficult to swallow, may cough or have a wet or hoarse voice while eating and drinking.

The term for swallowing difficulty is dysphagia. It affects the mechanics of swallowing and quality of life. Many people become frustrated or embarrassed and isolate themselves from social activities such as dining with friends or family.

More importantly, dysphagia can lead to malnutrition, dehydration and aspiration (when food or liquid “goes down the wrong pipe”). Aspiration, which can sometimes be “silent,” meaning a person does not cough or choke, can lead to aspiration pneumonia — the leading cause of death in PD. Thus, it is important to ensure that people with PD can swallow effectively and eat safely.

What Can Be Done?

The first step to addressing swallowing issues is to speak to a neurologist about getting an evaluation performed by a speech-language pathologist (SLP). This professional will take a medical history and interview the person with PD about eating and swallowing.

This is typically followed by either a video x-ray or an endoscopic examination, which allow the medical specialist to observe the swallowing process as an individual sips liquid and eats food, as these substances flow from the mouth, down the throat and esophagus, to the stomach. With these tests, it is possible to see where exactly the trouble is occurring, and to recommend therapies.

Follow the recommendations of the swallowing specialist, which may include the following:

Exercise and Swallow Hard. Just as exercise can ease other PD-related movement difficulties, it can also help with swallowing. One technique is the Lee Silverman Voice Technique® (LSVT®), familiar to many people with PD as a therapy to help people improve speech. It helps a person to exaggerate speaking and swallowing. In addition, working with an SLP on an individualized program can help the person to swallow hard and move food from the mouth down the throat.

Expiratory Muscle Strength Training. This therapy strengthens respiratory muscles, improves cough and swallowing and reduces aspiration.

Change the Food. Modifying liquids and solids can help. For people who find that liquids get into the airway, liquid may need to be thickened or avoided completely. Swallowing difficulties can also be eased by taking bigger or smaller bites or sips — or by pureeing the solid foods. The best first step is to obtain an evaluation, so the SLP can recommend how to modify food and liquid.

Parkinson’s and Dental Care

Regular visits to the dentist are important for all of us. For a person who has PD, dental care is even more critical because PD can impact the health of the mouth, teeth and jaw and make dental care challenging.

Rigidity or tremor may make it difficult to brush one’s teeth. Symptoms such as fatigue, anxiety and tremor can make it difficult to commute to appointments, sit still in the dentist’s chair or open the mouth wide.

Common PD symptoms and side effects such as rigidity, tremor and dyskinesias can cause discomfort in the joint that connects the lower jaw to the skull. They can also be a cause of cracked teeth, tooth wear, changes in the fit and wear of dentures and tooth grinding. Too much saliva can lead to a fungal infection at the corners of the mouth, which is easily treated. By contrast, too little saliva or dry mouth increases the risk of cavities. Sucking on sugar-free hard candy or using artificial saliva substitutes can help. It may also help to avoid alcohol, tobacco and spicy and acidic foods.

What Can Be Done? Tips for Visits to the Dentist

A few tips can significantly improve dental visits. Call first to make the office aware of you or your loved one’s PD symptoms. This will help the dentist and the staff to provide better treatment.

The dentist should have a sense of overall health of a person with PD, and someone on staff should record vital signs upon arrival. It is important to tell the dentist if the person with PD is taking MAO-B inhibitors (rasagiline and selegiline), as these may interact with anesthetics.

Lastly, because dental visits may become more troublesome as PD progresses, consider scheduling the replacement of old fillings, crowns and bridges, and ill-fitting dentures, during the early stages of PD. For other tips see box above.

What Can Be Done? Tips for Home

Regular brushing, flossing and rinsing with an over-the-counter fluoride rinse help prevent cavities and gum disease, but PD movement symptoms can interfere with one’s ability to maintain oral hygiene. People with PD should try using a toothbrush with a large-handled grip and soft bristles. A small brush head reaches the corners better. To make the toothbrush easier to grasp, it may help to place the handle inside a bike handlebar grip or tennis ball or to use an electric toothbrush.

Aim to brush after every meal for two minutes, and also brush the tongue. It’s best to brush one-handed, using the stronger side of the body. If it’s not possible to brush after a meal, simply rinsing the mouth with water will help.

Flossing is important, but may mean getting help from a care partner. For fluoride rinses, if swishing and spitting are difficult, the dentist may recommend a brush or sponge applicator. Antimicrobial mouth rinses also can be applied with a brush. If you have dentures, remove after each meal, brush and rinse them. At night, brush or clean them in a solution.

Conclusion

Parkinson’s can affect a person’s ability to swallow, and maintain dental and oral health.The good news is you, or a loved one with PD, can address these difficulties, while making meals enjoyable.

Michelle R. Ciucci, Ph.D., S.L.P., of the University of Wisconsin, and Jane Busch, D.D.S., a person living with Parkinson’s, first presented this topic as a PD ExpertBriefing, now available online at www. pdf.org/parkinsononline.