Posted at the Institutional Resources for Unique Collection and Academic Archives at Tokyo Dental College,

Available from http://ir.tdc.ac.jp/

TitleDental Treatment for a Patient with Parkinson’s

Disease and a Deep Brain Stimulation System

Author(s)

AlternativeKojima, Y; Nohara, K; Sakaguchi, Y

Journal Bulletin of Tokyo Dental College, (): -

URL http://hdl.handle.net/10130/4358

Right

Description

1

Bulletin of Tokyo Dental College:

Case report:

Title:

Dental Treatment for a Patient with Parkinson’s Disease and a Deep Brain Stimulation

System

Authors:

Yuki Kojima1), Mizuha Kojima2), Kaori Nohara3), and Yutaka Sakaguchi2)

1)Department of Physiology, Tokyo Dental College, 2-9-18 Misaki-cho, Chiyoda-ku, Tokyo

101-0061, Japan,

2) Sakaguchi Dental Clinic, 1-20-5 Kasuga, Chuo-ku, Chiba, 260-0033, Japan, and

3) Clinical Business Department, The Lion Foundation for Dental Health, 3-7,

Honjo 1-chome, Sumida-ku ,Tokyo 130-8644, Japan

Number of pages: 7 (without abstract, reference, and figure legends)

Number of figures: 3

Number of tables: 0

Short running head: Dental Treatment for DBS System

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Abstract

Parkinson's disease (PD) is a highly prevalent, long-term neurodegenerative disorder

that is sometimes treated via deep brain stimulation (DBS), which significantly reduces the need

for dopaminergic drug therapy and improves the patient’s quality of life. However, such patients

are cautioned that DBS may be interfered with by dental instruments such as a dental turbine or

ultrasonic scaler. We treated a 65-year-old woman with PD and an implanted DBS system for

upper right tooth pain. We diagnosed occlusal trauma and used occluding paper three times for

verification, as we milled the strong contact points of tooth 17. We then performed scaling with an

ultrasonic scaler. We encountered no problems in either procedure. There are no previous reports

about a dental instrument-DBS interaction. Despite the successful procedures in this case, we

suspect that the root canal length-measuring instrument, dental laser, and electrical scalpel could

potentially interact negatively with DBS implants.

Keywords:

Parkinson's Disease, Deep Brain Stimulation, Dental Treatment

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Introduction

Parkinson's disease (PD) is a long-term, neurodegenerative brain disorder characterized

mostly by motor dysfunctions; its prevalence also continues to increase as more people enter their

sixties and seventies. Early symptoms include shaking, rigidity, slowness of movement, and

difficulty walking, a constellation of symptoms described as "parkinsonism" that results from

dopaminergic cell death in the substantia nigra10, 9)

. The number of cases of PD in Japan is

estimated to be about 100,000. However, as the Japanese population ages, this number is

expected to rise dramatically. There is no cure for PD, but the symptoms can be mitigated with

levodopa or other pharmacological dopamine agonists3, 1)

. However, as the disease progresses,

pharmacotherapy becomes less effective and dopamine agonists are prescribed in increasing

amounts, despite the potentially severe side effects caused by long-duration, high levodopa

administration. In such cases, surgical implantation of microelectrodes for deep brain stimulation

(DBS) has been an effective second-line treatmen8, 12)

.

DBS is vulnerable to electromagnetic interference2, 7)

. Mobile phones and security gates produce

electromagnetic fields that can interfere with normal DBS function. DBS recipients are informed

that they should be cautious regarding dental treatment using a dental turbine (drill) or ultrasonic

scaler11)

, two of the most commonly used instruments in dental work. For both dentists and

patients alike, it is important to know whether typical dental treatment methods are safe for use in

patients with DBS systems, or whether special precautions must be taken in these cases.

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However, there are no reports clearly identifying if there is an interaction between dental

machinery and DBS systems. To this end, we present the case of a patient with PD and DBS

implants who underwent dental drilling and ultrasonic scaling.

Case presentation

Written informed consent was obtained from the patient for inclusion in this case report.

We treated a 65-year-old female patient whose main complaint was upper right tooth

pain on 11th March 2017. She developed symptoms of PD at age 49, and was treated

pharmacologically beginning at age 54. However, by age 62 she was taking the maximum

allowable amount of levodopa and had developed dyskinesia, a severe motoric side effect of

anti-PD drugs. At that time, she underwent successful surgery for implantation of a DBS system

(Activa®; Medtronic, MN, USA). DBS therapy significantly reduced her need for levodopa and

improved both her dyskinesia and her quality of life. Her Hoehn and Yahr Scale score indicated

stage 3 PD, and she had no eating disorder or dysphagia. She reported experiencing interference

with the DBS system two years ago, which was related to a nearby security gate. Because she

was instructed of the possibility that the DBS system might be interfered with by dental equipment,

she avoided such treatments despite having problems in her mouth. However, she reached the

point where she could not masticate properly because of her tooth pain, and consequently was

undereating. At this point, the pain had become unbearable, and she sought out dental care.

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During her visit, we noted that she had no other existing disease, nor did she have any

other whole-body abnormal findings. Our oral examination showed mild dental calculus adhesion,

and tooth separation in the anterior part (Fig. 1). The degree of oral cavity cleaning was good. An

examination of the mouth revealed no obvious caries and mild periodontitis with 2-3 mm

periodontal pockets. Of all the teeth, only tooth 17 was found to have percussion pain; furthermore,

the tooth had no cold or warm water pain, and no mobility. The patient’s history showed that 17

was treated with a prosthesis 20 years ago; however, she felt occlusion pain 6 months ago.

We then inspected the teeth using a portable X-ray imaging system (Dexco ADX4000W®,

Dexcowin, Pasadena, CA, USA) (Fig. 2); the X-ray findings were also negative for caries and

severe periodontitis. However, we observed a slight expansion of the periodontal ligament space.

We checked for occlusion and found that tooth 17 had high occlusal points. Therefore,

we diagnosed occlusal trauma as the cause of her tooth pain.

Clinical Procedures and Outcomes

We consulted her lead neurosurgeon and the manufacturer of her DBS system about

using a dental turbine and ultrasonic scaler. They advised us to check the operation of her DBS

system via her on/off switch during her dental treatment (Fig. 3). We determined that the system

was functioning normally when the patient became dyskinetic 15 minutes after we turned it off.

This particular DBS system utilised a stimulating electrode in the subthalamic nucleus. We

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consulted with her lead neurosurgeon and the manufacturer of her DBS system regarding

potential risks of the different imaging modalities, and were told that it did not interfere with X-ray

and CT imaging, but could not be used for MRI. After an explanation of how to perform an X-ray

inspection safe for both the patient and equipment, we inspected the teeth using a portable X-ray

imaging system.

All treatments were performed in the patient’s home. We milled (Viva Mate G5®; NSK,

Tokyo, Japan) the high occlusal points of tooth 17 after checking them with occluding paper. The

milling procedure was divided into 3 sessions. Within 15 minutes following each session, we

checked the operation of the DBS system with the patient’s switch and confirmed that her pain

was improving. We milled only the points of high occlusion, and then did scaling via an ultrasonic

scaler for the full jaw (Portable Unit N3®; Yoshida, Tokyo, Japan); the power of ultrasonic scaler

was frequency; 29 kHz and amplitude; 100 µm. We didn’t use hand scaler because we couldn’t

take fixed point from her dyskinetic movements.

To increase the likelihood that there would be no interference between equipment, we

maintained the following separation distances between components: about 6 cm to the extension

cord; about 25 cm to the patient programmer; and about 15 cm to the electrodes. We restricted

treatment time to no more than 20 minutes because her parkinsonian symptoms began to

re-appear when the DBS system was shut off for longer than that limit.

The patient’s tooth pain responded completely to the milling. The patient immediately

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started eating more, and was able to chew even the crunchiest food without pain. During both

procedures, the DBS system functioned normally. Her tooth pain did not recur and her clinical

course was good; additionally, her anxiety regarding dental treatment was eliminated, and she

began having regular dental checkups.

Discussion

Without an explicit declaration, the internal nature of the DBS equipment makes

it difficult to judge whether or not the patient has had such a procedure. If this patient had not

stated that she had received DBS implants, we might have assumed that the patient had only mild

PD. It is important for dentists to know the treatment status of patients with PD, especially in the

case of DBS treatment, because involuntary, jerky (dyskinetic) movements of the tongue or face

will intensify if the DBS system is off or not working correctly.

Some reports indicate that abnormalities in the DBS system develop with

electrocardiogram and electrical scalpel use6, 5)

. In the field of dental treatment, instruments that

are likely to interact negatively are the root canal length-measuring instrument, dental laser, and

electrical scalpel. These instruments all create a strong electromagnetic field in or very near to the

patient’s body. For cases in which these instruments are needed, dentists should consult the

patient’s primary doctor (or neurologist) to ensure that there will be no adverse interactions, thus

ensuring the patient’s safety as well. DBS has found use in not only PD, but a number of other

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neurological diseases as well4)

. Therefore, individual differences may need to be accounted for.

To the best of our knowledge, there are no reports detailing the relationship between

dental instruments and DBS systems. Although awareness of DBS is still low, the delicate nature

of its physical parts and the fine-tuning necessary for its stimulation protocol to work correctly

indicate that there is a need for much greater awareness regarding the device by other healthcare

workers. Furthermore, there is a distinct need for published reports regarding the medical

practices and equipment that could pose problems for patients using DBS systems. In this case,

we could communicate with the patient throughout treatment. However, the difficulty of voluntary

movement in PD frequently interferes with speech, preventing a number of patients from

communicating effectively. In such cases, the dentist must take care to check the DBS system

him- or herself, and ensure it is turned back on if it was stopped. Additionally, the dentists will need

to frequently check on the patient’s general condition during treatment, and take care to limit

treatment time to prevent parkinsonian symptoms from becoming severe.

Acknowledgements

There is no conflict of interest.

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Reference

1) Barbeau A (1969) L-dopa therapy in Parkinson’s disease: a critical review of nine years’

experience. Can Med Assoc J 101:59–68.

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thalamic stimulation in Parkinson’s disease, essential tremor and extra-pyramidal

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11) Medtronic (2014) Activa. Patient’s manual. Tokyo, Japan.

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Reprint requests to:

Dr. Yuki Kojima

Department of Physiology,

Tokyo Dental College,

Tokyo 101-0061, Japan

E-mail: yukikojima@tdc.ac.jp

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Figure legends

Fig. 1. Photograph of the mouth at the time of oral examination

There was no swelling or redness of the patient’s gingiva observed. The examination did show

tooth separation in the anterior part.

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Fig. 2. Radiographic findings

No abnormal findings were found in the teeth and alveolar bone in X-ray images. However, we

observed a slight expansion of the periodontal ligament space.

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Fig. 3. The patient’s switch for the implanted deep brain stimulation (DBS) system

This on/off switch can be used to check the operation of the DBS system, allowing the patient to

self-manage at all times.