Dental and Oral Health Considerations in Multiple Sclerosis

Danielle E. Currier

Gwendolyn S. Reeve

Marsha E. Rubin

Introduction

Dental clinicians are essential members of every patient’s health care team. They play an integral role in prevention, diagnosis, and treatment to ensure that oral health impacts the overall health of patients positively. Long-term challenges of multiple sclerosis (MS) have implications in the motor, sensory, and cognitive functions of these patients. The ability to maintain proper hygiene, control medication-induced changes in the oral environment, prevent infection, and preserve function can greatly affect the well-being of the patient beyond the context of their oral health.

An understanding of common symptoms associated with MS is essential. Temporomandibular disorders, parafunctional habits, facial palsies, and dysphagia are commonly seen among these patients. To a lesser but still significant extent, paroxysmal pain syndromes such as trigeminal neuralgia (TN) can affect individuals with MS.¹,²,³ These symptoms should be distinguished from symptoms of a dental origin, and in some instances, they can be the first sign of MS in the undiagnosed patient. When a dental source cannot be identified, the patient should be referred to a specialist for medical workup. The oral health care provider should help reduce
pain, diagnose infections early on, and educate the patient on individualized long-term dental care.

This chapter will discuss ways the oral health care provider should be involved with the treatment and management of patients with MS from the start of their care. It will review common oral symptoms related to the disease and medications to treat the disease, provide an overview of TN, review anesthetic considerations, discuss treatment considerations in patients on immunosuppressants/immunomodulators, corticosteroids, and bisphosphonates, and provide suggestions for treatment of patients in the more advanced stages of MS.

Oral Disease Prevention and Care of the MS Patient

Dental clinicians should be in communication with the patient’s other health care providers from the beginning of the patient’s care. A thorough medical history should be obtained from the patient or health care agent and confirmed with the MS specialist. It should include the clinically active or nonactive state and type of MS, a review of systems, a list of medications the patient is currently on as well as an understanding of the side effects, a record of past bisphosphonate use, and recent blood workups (which will be elaborated on in future sections).

Next, an oral hygiene and caries risk assessment should be performed. A thorough discussion on prevention, dietary counseling, and a review of patient goals and expectations should be had with the patient and family members. Some studies suggest that patients living with MS have a higher incidence of tooth loss, silent infection, and caries.²,⁴,⁵ Most dental disease is preventable, and therefore, this does not need to be the case. The biggest risk factors for dental disease are challenges in motor coordination for proper oral hygiene and difficulties with access to care. In one study, 48.5% of individuals with MS reported their health as poor, and of those, only 56% reported having seen their dentist in the last 6 months; of these, some reported difficulty in accessing the building (21%) and the waiting room (11%), while only a few (38%) reported suitable parking and less than half (48%) suitable toilet facilities.⁶ The optimal time to treat patients is when the disease is clinically inactive, when symptoms are minimal. Even as the disease progresses, there are no contraindications to treatment; however, modification to treatment modalities should be considered. Dental management should be adjusted over time to each person’s needs (see Tables 21.1 and 21.2). Suggestions for treatment of the patient with more advanced MS will be reviewed in the last section of this chapter.

TABLE 21.1 CONSIDERATIONS IN PREVENTION AND MANAGEMENT OF PATIENTS WITH MULTIPLE SCLEROSIS (MS)

Physical challenges in oral hygiene	▪ Customized toothbrush handles from dental acrylic or silicone impression putty to improve grip⁷,⁸ ▪ Use of electric toothbrush (Sonicare®, Oral B), power flosser (AirFloss®, Waterpik®) ▪ Recommend patient to sit down, rest arms on commode while brushing if fatigued ▪ Instruct family member or caretaker on assistance with hygiene when needed
Caries risk prevention	▪ Fluoride supplementation in the form of trays, 1.1% sodium fluoride (PreviDent®, Colgate) paste or gel ▪ Diet counseling including recommendations for reduction of acidic/sugary beverages and awareness of hidden sugars ▪ Use of products with xylitol substitutes (Spry®) ▪ Frequent recalls (q3-4 mo)
Xerostomia	▪ Sialagogues ▪ Muscarinic acetylcholine agonists (pilocarpine and cevimeline) ▪ Postmeal rinses with 8 oz water and ½ tsp baking soda ▪ Smoking cessation ▪ Saliva substitutes (Biotene Oral balance Moisturizing Gel®, Xylimelts®)
Hypersalivation/inability to control saliva	▪ Portable Yankauer suction at home in the more debilitated patient ▪ Botox injections at the parotid gland
Increase incidence of herpes simplex virus, candidiasis, angular cheilitis	▪ Common findings related to immunosuppression and xerostomia. Prescribe proper antiviral or antifungal medication for fungal or viral infections

Infections in MS Exacerbation of Symptoms

There is sufficient evidence that infection can add to the underlying abnormal immunological response of these patients, which can increase the risk of exacerbation of symptoms.⁹,¹⁰ No studies have been conducted on the association between dental infections and relapse specifically; however, the activation of the innate immune system by microbial products in MS patients has been proposed to be linked to the induction of MS relapse.¹¹ Systemic infection increases T-cell proliferation and proflammatory interleukins, leading to higher levels of inflammatory response.¹¹,¹² A number of bacterial and viral strains have been suggested to have a correlation on worsening some MS activity. Staphylococcus aureus enterotoxin A, for example, has been suggested to be one risk factor for exacerbations
through activation of disease modulating T-cells.¹³ Evidence has also demonstrated that upper respiratory infections have been linked to subsequent relapses.¹²,¹⁴

TABLE 21.2 CONSIDERATIONS IN TREATMENT AND IMPROVING ACCESS TO CARE OF PATIENTS WITH MULTIPLE SCLEROSIS (MS)

Provide wheelchair accessibility and staff assistance from the entrance to the operatories

Provide bathroom breaks before and during procedures for those with urinary incontinence

Provide sources of transportation assistance

Schedule morning visits as fatigue tends to be more pronounced in the afternoon

Consider shorter appointments for more symptomatic patients and more frequent recalls

Consider different levels of sedation for treatment depending on anxiety, neurological symptoms, or severity of the disease

Careful use of isolation methods and adequate evacuation as respiratory muscle and gag reflex impairment become more pronounced. Use a rubber dam for proper isolation if patient can adequately breathe through the nose. Use a bite block. Treat these patients in a semisitting position

Understand existing trigeminal neuralgia or facial anesthesia and avoid triggering episode

Consider dental implants for fixed prosthesis or to improve function of removable prosthesis

Use of resin-modified glass ionomers (RMGI) restorations and cements for biocompatibility and fluoride-releasing properties

Relapses are a distinctive characteristic of MS, and although they are usually followed by a period of clinical inactivity, residual side effects cause persistent functional impairment, impacting the quality of life of these individuals. Management and reduction of potential causes associated with MS relapses is important, as it may help to shorten and lessen the disability. Furthermore, patients on steroids or disease-modifying drugs may have a decreased ability to fight opportunistic infections or dental infections. Oral-facial infections should be identified and prevented early on. Patients with maxillary tooth and sinus pain or ear pain of nondental origin should be referred for evaluation if an upper respiratory infection is suspected. Antibiotics, antivirals, and/or antifungals should be judiciously prescribed as needed, and necessary treatment should be carried out early on. Patients with any suspicion of infection should be followed up with.

Multiple Sclerosis Treatment Medications and Oral Health

Although there is no cure for MS, the focus of treatment is to reduce the number of relapses and slow the disease process. The most common medications are steroids for treatment of acute attacks, disease-modifying therapies to suppress the activity of the disease, and symptomatic therapy for MS side effects, such as muscle relaxants, antidepressants, and anticholinergics. It is important to be aware of drug interactions when using medications in dentistry, and knowledge of the most common oral side effects of medications used to manage MS can positively impact the education and treatment planning of the patient.

Frequently seen side effects of MS medications that may be encountered include xerostomia, mucositis, ulcerative stomatitis, angular cheilitis, candida, dysgeusia, herpes simplex, and vomiting. See Table 21.3 for an overview.

TABLE 21.3 MEDICATIONS COMMONLY USED TO MANAGE MULTIPLE SCLEROSIS (MS) AND POTENTIAL SIDE EFFECTS¹⁵,¹⁶

	Medications	Potential side effects
Disease-modifying therapies	Interferon beta-1a and beta-1b (Avonex®, Betaseron®, Rebif®) Glatiramer acetate (Copaxone®) Monoclonal antibody (Lemtrada®, Ocrevus®)	Immunosuppression (more so with the monoclonal antibodies which can cause lymphopenia), increased risk of infection (fungal, bacterial, or viral), fatigue, myalgia, headache, arthralgia, mucositis, glossitis, dysgeusia, xerostomia, salivary gland enlargement, elevated liver enzymes
Management of relapses	Corticosteroids (Solu-Medrol®, Deltasone®) Adrenocorticotropic hormone (H.P. Acthar Gel®)	Immunosuppression, increased risk of infection (fungal, bacterial, or viral), delayed wound healing, nausea, vomiting, GERD (gastroesophageal reflux disease), osteoporosis, risk of hepatotoxicity
Treatment of tremor, spasticity	Muscle relaxants (Lioresal®, Zanaflex®), Benzodiazepine (Valium®, Klonopin®)	Central nervous system (CNS) depression, hypotension, xerostomia
Treatment of depression, neuropathic pain	Tricyclic antidepressants, selective serotonin and norepinephrine reuptake inhibitors, anticonvulsants (Tegretol®, Dilantin®, Gabapentin)	Anticholinergic effects (i.e., xerostomia), CNS depression, cardiovascular effects, gingival hyperplasia
Treatment of frequent urination	Anticholinergics (Oxybutynin®), antimuscarinic	Xerostomia, dry eyes, CNS depression, constipation

Treatment of Xerostomia

One of the most common issues patients face as a consequence of the medications used to treat MS and depression, as discussed above, is dry mouth. Saliva is beneficial in protecting the dental cavity by diluting, clearing, and buffering acids and by supplying the necessary calcium and phosphorus needed for tooth demineralization. Depending on the extent of hyposalivation, saliva substitutes, gustatory or tactile stimulants, and pharmacologic sialagogues can promote salivation and lubrication of the oral cavity for these patients. The following are suggestions for treatment of xerostomia.

1. Frequent use of plain noncarbonated water.

2. Postmeal rinses with 8 oz. water and ½ tsp. baking soda to neutralize pH.

3. Salivary-stimulating lozenges such as topical pilocarpine lozenges and lozenges containing anhydrous crystalline maltose.¹⁷

4. Use of xylitol-containing chewing gum immediately after meal for 5 minutes. Xylitol is documented in protecting root caries and erosion, can stimulate salivary flow rates, and can cause mutation of Streptococcus mutans to a less acidic form.

5. Use of saliva substitute gels.

6. Treatment with pilocarpine or cevimeline in consultation with the physician. Get a baseline on the flow rates before initiating therapy; hyposalivation is when the stimulated flow rate is approximately below 0.7 mL/min and the unstimulated rate is <0.1 mL/min.¹⁸ Oral administration of pilocarpine HCl is typically 5 mg three to four times daily for 3 months, and cevimeline is prescribed at 30 mg three times daily for 3 month.¹⁹ Both of these medications are contraindicated in patients with uncontrolled asthma, COPD, or patients taking β-adrenergic blockers; the use of these medications should also be advised with caution in patients with cardiovascular disease. Pilocarpine is also contraindicated in patients with narrow-angle glaucoma and iritis.

Trigeminal Neuralgia in the Multiple Sclerosis

Trigeminal neuralgia (TN) is described as a recurrent unilateral brief electric shock-like pain with abrupt onset and termination, limited to distribution of one or more divisions of the trigeminal nerve often triggered by innocuous stimuli.²⁰ The incidence of TN in MS according to a meta-analysis of 28 articles including 7101 subjects published in 2013 is 3.8%. The symptoms of TN often precede the first MS symptoms.²¹,²² The mean age at diagnosis of TN was 45.4 years in a cohort of patients examined by Fallata et al.²²

Only gold members can continue reading. Log In or Register to continue