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22 November 2021

Multiple sclerosis: impact on oral health and useful advice on the management of affected patients

Lara Figini

Multiple sclerosis (MS) is an acquired, chronic disease, an immune-mediated inflammatory condition of the central nervous system (CNS) that can affect the brain, brainstem and spinal cord. It is a condition in which autoantibodies attack proteins in the myelin sheath surrounding neurons, leading to the formation of scars and plaques that interfere with neuronal function. As a result, the transmission of nerve impulses can become slowed, distorted or completely blocked. Unfortunately, the cause of MS is not yet fully understood; genetics, environmental factors and lifestyle factors appear to be implicated in its etiology.

Four main types of MS:

- relapsing-remitting MS (RRMS),

- primary progressive MS (PPMS),

- Secondary progressive MS (SPMS) e

- Benign MS.

Benign MS is characterized by mild bouts of symptoms separated by long periods with no symptoms, but the other types of MS are often progressive with gradually increasing disability. Since there is no single diagnostic test or pathognomonic symptom of MS, it can sometimes take a long time to diagnose.

The most common primary symptoms of this condition are:

• Visual disturbances

• Neuropathy

• Motor weakness - which can lead to reduced mobility

• Balance problems - which can cause movement and mobility problems

• Fatigue.

MS symptoms are known to be affected by a number of mediators and moderators such as core body temperature, stress, concomitant illnesses, infections, pressure sores, and general health and well-being. Advanced MS is characterized by paralysis of the limbs, decreased muscle tone, bladder problems, and impaired cognitive function, which can affect memory, motivation, intuition and personality.

Orofacial features may include speech, swallowing and hearing disorders, decreased muscle tone, facial paralysis, and trigeminal neuralgia.

Materials and Methods
In a recent article, published on British Dental Journal, September 2021, the authors examined the characteristics and etiology of multiple sclerosis with particular attention to the impact this disease can have on oral health and dental care provision, and they developed advice to guide the dentist in the management of MS patients, especially in the most severe phases.

Impact of MS on oral health and dental management:

Difficulties in performing proper home oral hygiene and accessing a dental facility have the potential to increase the risk of MS patients developing periodontal disease and dental caries. Although limited, literature studies have shown poorer gum health and higher rates of dental caries within this population group. Common manifestations of MS such as motor disturbances, spasticity, trigeminal neuralgia, facial pain and fatigue can impair the patient's ability to maintain proper oral hygiene, while concomitant facial paralysis and drug-related xerostomia can hinder the removal of food from the cavity oral. The varying severity and range of symptoms associated with MS and their tendency to fluctuate, often over short periods of time, require the dental team to modify the management of MS patients according to their individual needs.

The optimal time to provide dental care to patients is during periods of remission, when neurological symptoms may be minimal. In cases where MS is classified as progressive, there are no contraindications to dental treatment other than those related to the medical management of MS. Information on the accessibility of the dental clinic and the availability of transport services for the patient should be provided early on when arranging appointments. Shorter appointments and the use of a support to hold the mouth open can compensate for symptoms of fatigue and / or muscle spasm. Placing the patient in a semi-reclining position, use of the rubber dam, and high-volume aspiration may mitigate the risk of pulmonary aspiration secondary to dysphagia. Sedation or general anesthesia may be considered for individuals with muscle spasms and / or high levels of dental anxiety.

Dentists should be aware of the range of side effects associated with medications given to manage MS: oral side effects include xerostomia, altered taste, and opportunistic infections such as candidiasis, angular cheilitis, and herpes simplex virus reactivation. Biologics can cause systemic side effects such as thrombocytopenia and neutropenia, which increase the risk of bleeding and infection, respectively. The need for a complete blood count and indication for antibiotic prophylaxis prior to invasive dental treatment should be considered.

As manual dexterity decreases, patients can benefit from the use of an electric toothbrush and tailored aids, such as modifications to the toothbrush handle (with manual shaping for easier handling).

Salivary substitutes may be justified for those suffering from xerostomia as a result of their medications.

Individuals with MS can be treated safely and effectively in ordinary dental facilities; however, referrals to community dental services or secondary care centers may be required for those who need:

- Lifters to facilitate the transfer from the wheelchair to the dentist's chair

- Treatment in a reclining wheelchair

- Home care when personal mobility is severely impaired

- Treatment under intravenous sedation or general anesthesia.

It is important to recognize that not all people with MS have all of the symptoms described in this article and that the severity of these symptoms varies from individual to individual and over time. Connecting with competent healthcare professionals and adopting a patient-centered approach is essential to ensure safe and effective dental care for people with MS.

Clinical implications
In the mid-1980s, there was concern that mercury in amalgam restorations could precipitate MS symptoms. There is no evidence base to support these claims and elective replacement of amalgam restorations with non-mercury-containing materials is not justified.

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