Multiple sclerosis: an update for oral health care providers

Evaluation of salivary nitric oxide levels and anxiety in multiple sclerosis patients, with and without Xerostomia: correlation with clinical variables

BACKGROUND

Xerostomia is a prevalent but often overlooked condition in multiple sclerosis (MS) patients, significantly impacting their quality of life and oral health. This cross-sectional observational study investigates the role of nitric oxide (NO) in the pathophysiology of multiple sclerosis (MS) and explores its association with xerostomia in MS patients. The primary objective was to compare salivary NO concentrations and stress levels between MS patients with and without xerostomia.

METHODS

MS patients diagnosed by neurologists and MRI were categorized into two groups: those with xerostomia and those without. Unstimulated whole saliva samples were collected using the spitting method, and salivary NO levels were quantified using an enzyme-linked immunosorbent assay (ELISA) kit based on the Griess reaction. Stress levels were assessed using the Beck Anxiety Inventory (BAI) questionnaire. The presence of xerostomia was evaluated through the Xerostomia Inventory (XI) and clinical examinations.

RESULTS

Salivary NO levels were significantly higher in MS patients without xerostomia (227.47 ng/mL) compared to those with xerostomia (102.37 ng/mL, p < 0.001). Stress levels were also notably higher in MS patients with xerostomia (17.23) versus those without (11.77, p = 0.03). A moderate negative correlation was observed between salivary NO levels and xerostomia (r = 0.44, p < 0.001), indicating that lower NO levels were associated with a higher likelihood of xerostomia. The correlation between stress levels and xerostomia was weaker but still significant (r = 0.28, p = 0.03). Multivariate binary logistic regression analysis identified salivary NO, stress levels, and age as significant predictors of xerostomia in MS patients. The logistic regression model achieved an 80% accuracy in predicting xerostomia based on salivary NO levels and stress.

CONCLUSION

This study highlights a significant negative correlation between salivary NO levels and xerostomia, suggesting that decreased salivary NO concentrations are associated with an increased risk of xerostomia in MS patients. Additionally, stress levels were positively correlated with xerostomia, indicating a potential link between higher stress and the likelihood of xerostomia in MS patients.

Multiple Sclerosis-A Demyelinating Disorder and Its Dental Considerations-A Literature Review with Own Case Report

Multiple sclerosis (MS) is a chronic, autoimmune condition that primarily affects the myelin sheath covering the neurons of the central nervous system, including those of the brain and spinal cord. Although the etiology is not completely understood, various factors, such as genetic infections and environmental background, play a role in the pathogenesis. Repeated active episodes of MS characterized with marked inflammation results in the scarring of particular nerve segments, and eventually results in functional impairment over a period of time. Based on the clinical course of the disease, four clinical types of MS have been identified, with the relapsing-remitting type being the commonest. MS is known to occur more commonly in females in the age group of 20-40 years. Dysarthria, fatigue, muscle spasm, and numbness are the common presenting symptoms of MS. Diagnosis is generally achieved with MRI brain scans, showing demyelination plaques and lumbar puncture. Treatment of MS's acute phase includes high doses of corticosteroids; whereas preventive treatment of MS includes the prescription of immunosuppressive therapy, including biologics. A large group of MS patients present with oral manifestations, including dysphagia, dysarthria, temporomandibular joint (TMJ) disturbances, facial palsy, and chronic periodontal diseases. Other typical oral manifestations seen in MS patients include trigeminal neuralgia, paresthesia, or orofacial pain. Dental treatment and following drug prescription needs to be tailored to each patient, as there is a possibility of drug interactions. This paper presents a comprehensive, updated review of MS, with emphasis on oral manifestations and dental considerations. Additionally, it presents a case of a 40-year-old female diagnosed with MS that was presented to a dental hospital. The report discusses the oral manifestations and dental management.

Oral Health Status and Multiple Sclerosis: Classic and Non-Classic Manifestations—Case Report

Background: Multiple sclerosis is an autoimmune disease of the central nervous system with neurological and motor symptoms that affect the orofacial region. The aim of this work is to present a patient that lacks the three classic orofacial manifestations but has other less common clinical alterations. Case presentation: A 49-year-old female patient diagnosed with long-term relapsing–remitting multiple sclerosis visited the dentist complaining of mild but persistent orofacial pain including the temporomandibular joint and pain not specific to any tooth. She presented mucosal irritation, xerostomia, halitosis, and localized gingivitis. There was excessive wear of the upper and lower incisal edges and the occlusal faces of the upper canines and loss of six teeth due to caries. After a clinical oral examination, the diagnosis was temporomandibular joint disorder, gingivitis, dental hypersensitivity, bruxism, hyposalivation, xerostomia, and halitosis. Conclusions: Patients with multiple sclerosis present classic orofacial manifestations. Although these were not observed in this patient, she had others, such as gingivitis, tooth hypersensitivity, and bruxism. In addition, despite few studies associating a higher prevalence of caries with these patients, the number of carious and missing teeth in this patient highlight the evidence that multiple sclerosis has had a significant impact on the patient’s dental status over the years.

Multiple sclerosis and its impact on dental care

Multiple sclerosis affects approximately 130,000 people in the UK. Due to the wide variation in the symptoms associated with this condition and their variable severity, the provision of dental care for affected patients must be determined by an individual's specific needs. This will often vary significantly over time. This paper reviews the aetiology, presentation and current management of multiple sclerosis, and explores the impact of these on oral health and the provision of dental care.

Orthodontics in patients with significant medical co-morbidities

A wide variety of patients with medical co-morbidities may present to general orthodontic practice. It is important for the treating clinician to have a general understanding of key medical conditions that may impact upon the treatment and management options. This clinical supplement provides a treatment-focused summative update for the orthodontist regarding significant medical co-morbidities, their general prevalence and an exploration of potential impacts upon orthodontic treatment. This review also discusses the significance of key medications and provides suggestions for the safe provision of orthodontic treatment.

Multiple Sclerosis: Impact on Oral Hygiene, Dysphagia, and Quality of Life

Multiple sclerosis (MS) is an autoimmune disease in which the immune system reacts by damaging the central nervous system, specifically myelin and oligodendrocytes. It is the most debilitating neurological disease among young adults, causing personal, familiar, social, and professional limitations. Multiple sclerosis can cause disturbances in the orofacial district, due to a demyelination process on the nerves of the head and neck district. The aim of this study was to evaluate the oral health status, dysphagia, and quality of life of patients affected by MS. For this study, 101 patients aged between 12 and 70 (47 males, 54 females) affected by MS were selected, and three questionnaires were handed out and anonymously filled in by them: An oral hygiene test, DYMUS (DYsphagia in MUltiple Sclerosis), and IOHIP-14 (Italian version Oral Health Impact Profile). Through the analysis of the questionnaires it was possible to observe pathological conditions, such as gingival inflammation, xerostomia, dysphagia, neuralgia, and dysarthria. Through the analysis it was possible to outline how the roles of a medical team, composed of a dentist, otolaryngologist, and dental hygienist, are fundamental in coping with other medical figures, during the whole development of the diseases, as well as to prevent possible complications.

Oral health and behaviours of people living with Multiple Sclerosis in Australia

OBJECTIVES

The literature describing the oral health of people with Multiple Sclerosis (MS) is scant and the findings equivocal. The aim of this study was to describe the oral health and oral self-care behaviours of people living with MS and compare it to the Australian population.

METHODS

Participants enrolled with the Australian MS Longitudinal Study (AMSLS) were invited to participate in the survey using an online or paper-based questionnaire. Data were collected on level of disability, oral health, oral self-care and factors influencing attendance for oral health care.

RESULTS

Completed questionnaires were received for 1523 respondents. Over one-fifth (n = 320; 22%) rated their oral health as fair or poor, and more than half (n = 840; 57%) reported toothache in the last 12 months. These proportions were higher than those for the general Australian adult population (oral health prevalence ratio (PR) = 1.25 [1.12, 1.40]; toothache PR = 3.63 [3.39, 3.88]), and this is despite comparable or better self-maintenance habits and dental attendance reported by respondents. People with MS reported high rates of mouth dryness (68.4%), teeth sensitivity (64.7%), change of taste (40.5%) and orofacial pain (39.0%); fewer than 10% experienced none of these. There was a lower prevalence of self-reported need for treatment (extraction or filling) than in the Australian adult population (15.8% vs 32.9%).

CONCLUSIONS

People with MS have a greater oral health burden, demonstrated by their poorer self-reported oral health than the Australian adult population. Furthermore, they experience high rates of toothache, mouth dryness, teeth sensitivity, change of taste and orofacial pain. These findings are contrary to their self-reported good oral self-care and dental attendance habits and suggest some of the oral health impacts are due to MS rather than dental behaviours.

Managing the oral side-effects of medications used to treat multiple sclerosis

BACKGROUND

Many medications used to manage multiple sclerosis (MS) affect oral health. This review aimed to identify the oral side-effects of the current drugs recommended in Australia to treat MS and make dental practitioners aware of the range of symptoms.

METHODS

The Australian Therapeutic Guidelines and the Australian Medicines Handbook were searched for medications used to treat MS. For each medication, the generic name, class, route of administration, dosage and drug company reported side-effects were extracted from the online Monthly Index of Medical Specialties (MIMs) database. Meyler's Side-effect of Drugs Encyclopaedia was used to identify any additional oral adverse reactions to medications used to treat MS.

RESULTS

Fourteen drugs were identified for the treatment of MS progression and 13 drugs for the treatment of MS symptoms. For these medications, 18 oral side-effects were documented: xerostomia was the most common, followed by dysgeusia, dysphagia, mouth ulceration and sinusitis. Anticholinergic drugs caused xerostomia while immunosuppressants resulted in more infection-related side-effects.

CONCLUSIONS

Dental practitioners should be aware of the range of symptoms likely to be reported by this population. Clinicians are encouraged to continue providing dental care for their patients who develop MS and refer complex cases to specialists.

How do Australians living with MS experience oral health and accessing dental care? A focus group study

OBJECTIVES

The symptoms of multiple sclerosis (MS) can affect oral care and access to dental services, but there is limited literature describing the oral health and perceived oral healthcare needs of people with MS. This study aimed to explore the oral health experiences, oral health behaviours and barriers to accessing dental care perceived by people living with MS in Australia.

METHODS

Six focus groups were held across two metropolitan areas (Brisbane, Queensland and Melbourne, Victoria) and one regional area (Toowoomba, Queensland). Focus group data were analysed using thematic analysis.

RESULTS

Living with MS was a highly individual experience due to the range of symptoms that may be experienced. In addition to having different symptom experiences to others with MS, individual symptoms also differed on a daily basis as the disease relapsed and remitted. The physical expressions of MS directly and indirectly affected the oral health of participants. Additionally, oral health was affected by the side effects of medications and orofacial pain symptoms. Depending on the symptoms experienced by the individual, personal oral hygiene was affected and professional dental appointments were difficult. Participants also experienced structural barriers to accessing professional dental care including difficulty accessing transport to-and-from dental appointments, space limitations in the dental surgery and financial barriers to care.

DISCUSSION

Dental care was perceived to be inflexible and was not tailored to individual experiences of MS, which contributed to perceptions of poor quality and appropriateness of care. It is important for dental professionals to offer tailored and individualized dental care when treating people with MS. Our findings suggest that there needs to be greater interprofessional communication and referral to manage atypical dental pain symptoms. Oral health education for people with MS should include altered strategies to performing daily oral hygiene, the management of xerostomia and advice regarding low cariogenic diets suitable for dysphagia. Additionally, policy and strategies to improve the oral health of people with MS should focus on enhancing access through transport, reducing the cost of dental services to the individual and providing domiciliary oral health care.

Orofacial evaluation in patients with multiple sclerosis using Nordic Orofacial Test-Screening

OBJECTIVES

The aim of this study is to investigate whether patients with multiple sclerosis (MS) have more orofacial dysfunctions than the general population, using the Nordic Orofacial Test-Screening (NOT-S).

MATERIALS AND METHODS

The NOT-S instrument was applied in 34 patients with MS, who went to the MS Reference Center, Universidade Metropolitana de Santos and 34 healthy patients, matched for gender and age. NOT-S results were compared between patients with MS and control subjects. Disability and disease duration were assessed among the patients, in order to establish whether these parameters might affect the results from NOT-S.

RESULTS

There was no significant difference in orofacial function between patients with MS and control subjects. There was no statistically significant correlation between disability and NOT-S or between disease duration and NOT-S. However, the correlation between disease duration and the degree of disability was statistically significant, thus suggesting that the results are in accordance with what would be expected regarding MS.

CONCLUSIONS

These results indicate that there was no correlation between orofacial dysfunction and MS, although there were some differences in the affected domains.

CLINICAL RELEVANCE

This study points out the orofacial dysfunctions which health professionals should be aware in this population.

Neurologic Diseases in Special Care Patients

Neurologic diseases can have a major impact on functional capacity. Patients with neurologic disease require individualized management considerations depending on the extent of impairment and impact on functional capacity. This article reviews 4 of the more common and significant neurologic diseases (Alzheimer disease, cerebrovascular accident/stroke, multiple sclerosis, and Parkinson disease) that are likely to present to a dental office and provides suggestions on the dental management of patients with these conditions.

Expanded Disability Status Scale-Based Disability and Dental-Periodontal Conditions in Patients with Multiple Sclerosis

OBJECTIVE

The aim of this study was to evaluate the association between different disability states in patients with multiple sclerosis (MS) as determined by the expanded disability status scale (EDSS) and dental-periodontal measures.

SUBJECTS AND METHODS

Eighty patients with MS (64 females and 16 males) were included in this study. Data on MS types, attack frequency, disease duration, EDSS scores and orofacial complaints prior to an MS attack were obtained from medical records. The plaque index (PI), probing depth (PD), clinical attachment level (CAL), gingival index (GI), decayed-missing-filled teeth (DMFT) index and number of present teeth were measured during one dental examination for each subject. The MS patients were divided into the following 2 groups based on their EDSS scores: low physical disability (L-DS) and high physical disability (H-DS). Differences in dental parameters between groups of low and high disability were investigated. p < 0.05 was considered statistically significant.

RESULTS

The mean age of the participants was 38.06 ± 10.11 years. Age and disease duration were higher in the H-DS MS group than in the L-DS MS group (p < 0.05). The PI, PD and GI were higher and the number of filled teeth was lower in the H-DS MS group than in the L-DS MS group (p < 0.05). The EDSS scores of the H-DS MS group presented a significant correlation with the number of decayed teeth (r = -0.548, p = 0.005). Orofacial complaints prior to an MS attack were reported by 18 (22.5%) patients.

CONCLUSION

Oral measurements revealed various differences between groups of low and high disability in MS patients. In addition, some maxillofacial-oral complaints prior to an MS attack were observed.

Orthognathic Surgery in a Patient with Multiple Sclerosis

AIM

The aim of this paper was to report a case of orthognathic surgery successfully done in a patient with multiple sclerosis.

BACKGROUND

Multiple sclerosis (MS) is a chronic, progressive inflammatory disorder of the central nervous system affecting young adults, characterized by lymphocytic infiltration of the brain and spinal cord leading to demyelination and focal axonal damage. Clinically, MS patients present with reversible neurological dysfunction in the early stages, which progresses to irreversible neurological disability and deficit. Oral manifestations of MS include facial numbness or pain, neuralgias, facial paralysis, dysarthria and dysphagia. While dental treatment is not contraindicated in MS patients, it is, however, limited to preventive and supportive dental care.

CASE DESCRIPTION

A 23-year-old Saudi male patient with a diagnosis of MS since 2008 reported to the oral and maxillo-facial surgery (OMFS) department for correction of dentofacial deformity. The patient was under follow-up with the neurology department and was being treated with interferon beta-1a. Following consent from the neurologist and the patient, a Lefort 1 segmental osteotomy was done under general anesthesia. The patient was stable throughout the surgical procedure and during the postoperative period. The patient was discharged upon complete surgical recovery and no acute exacerbations of MS were reported during the perioperative period.

CONCLUSION

Based on our observations, orthognathic and maxillofacial surgical procedures can be safely carried out in patients with MS, provided a strict perioperative prophylactic regimen for stress reduction and prevention of acute attacks of MS is adhered to.

CLINICAL SIGNIFICANCE

Due to the stressful nature of dental treatment and oral and maxillofacial surgical procedures, acute exacerbations of MS are very much likely. Hence, it is imperative that dental and oral surgical practitioners are aware of the manifestations of MS and are able to manage such patients with suitable treatment modifications.