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Clinical Approach to Neurologic Disorders

Clinical Approach to Neurologic Disorders. Anatomic Pathophysiologic Phenomenologic. Symptomatic Protective Curative Surgical. Surgical Approaches. Ablative thalamotomy Pallidotomy Electrical stimulation (DBS) VIM thalamus, globus pallidus internus, sub-thalamic nucleus Transplant

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Clinical Approach to Neurologic Disorders

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  1. Clinical Approach to Neurologic Disorders Anatomic Pathophysiologic Phenomenologic Symptomatic Protective Curative Surgical

  2. Surgical Approaches • Ablative • thalamotomy • Pallidotomy • Electrical stimulation (DBS) • VIM thalamus, globus pallidus internus, sub-thalamic nucleus • Transplant • autologous adrenal, human fetal, xenotransplants, genetically engineered transplants

  3. Medtronic DBS system

  4. Disease Classification

  5. Physical Exam In neurology, asymmetric or focal findings are typically most important

  6. Physical Exam

  7. Physical Exam Motor exam Strength e.g. MRC 5/5 point scale Muscle mass Tone Reflexes deep tendon (can be elicited in the jaw) cutaneous (Babinski, abdominals) Rapid alternating movements speed, decrement rhythm Involuntary movements tremor myoclonus chorea athetosis tics dystonia ballismus dyskinesia Motor apraxias dressing, combing hair, brushing teeth

  8. Physical Exam Sensory exam Cranial divisions of V Other head and neck Angle of jaw Spinal levels Nerve or root Primary modalities Light touch Two point discrimination Pain Vibration Position sense Higher cortical modalities Graphesthesia Stereognosis

  9. Physical Exam Coördination Usually, but not always, tests for cerebellar dysfunction Targeted voluntary movements finger-to-nose heel-shin Rapid alternating movements fine hand, finger control Gait and posture Stride, stance truncal sway, arm swing Posture stooped, falling forward, backward Freezing in doors on or off medication at start of walking

  10. Disorders of muscle tone

  11. Disorders of muscle tone

  12. Basal ganglia disease

  13. Basal Ganglia • Subcortical forebrain structures connected to sensorimotor and limbic systems • Crucial part of the “control circuitry” that allows for the smooth execution of voluntary movement

  14. Basal Ganglia • Multiple cortico-basal ganglia-thalamo-cortical circuits • Help program and carry out motor plans • Scale the amplitude and effort of the execution of tasks with relation to requirements • Incorporate motivation and emotional drives

  15. GABA SP Dyn GABA SP Dyn GABA Enk GABA Enk - - - - Ventral Ventral thalamus thalamus Normal Parkinson’s disease Cerebral cortex Cerebral cortex Glu + Glu + Striatum Striatum D1 D1 D2 D2 Glu + Glu + - - + + DA DA SNc SNc GPe GPe GABA - GABA - GABA - GABA - STN STN GPi/SNr GPi/SNr Glu + Glu + GABA - GABA - Brainstem/spinal cord Brainstem/spinal cord

  16. GABA SP Dyn GABA SP Dyn GABA Enk GABA Enk - - - - Ventral Ventral thalamus thalamus Normal Huntington’s disease Cerebral cortex Cerebral cortex Glu + Glu + Striatum Striatum D1 D1 D2 D2 Glu + Glu + - - + + DA DA SNc SNc GPe GPe GABA - GABA - GABA - GABA - STN STN GPi/SNr GPi/SNr Glu + Glu + GABA - GABA - Brainstem/spinal cord Brainstem/spinal cord

  17. Basal ganglia disease

  18. Photo by James Parkinson from his paper "An Essay on the Shaking Palsy” 1817 Normal PD

  19. Basal ganglia disease

  20. Basal ganglia disease

  21. Neurologic Issues Relevant to Dentistry

  22. Bell’s palsy Initial presentation After 6 months

  23. Neurologic Issues Relevant to Dentistry • Disorders affecting the face, jaw, mouth and neck • Trigeminal neuralgia • Temporo-mandibular joint disorders • Other facial pains • Jaw tremors • Bruxism • Tardive dyskinesia • Meige’s syndrome • Other oro-buccal facial dystonias • Torticollis

  24. Other Neurologic Issues Relevant to Dentistry

  25. Malignant Hyperthermia

  26. Malignant Hyperthermia

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