Providing Evidence-based Oral Health Care to Individuals Diagnosed with Degenerative Disorders, Part 1: Multiple Sclerosis
Signs and Symptoms of MS that May Affect the Provision of Oral Health Care

Cognition

Cognition is comprised of high-level brain functions such as the ability to learn and retain information (memory); accurately sensing the environment (information processing); critical thinking, organizing, and prioritizing (executive functions); maintaining focus (attention and concentration); language comprehension (verbal fluency). Approximately 50% of individuals diagnosed with MS will develop problems with cognition; however, only 5-10% develops severe cognitive dysfunction that interferes with activities of daily living. Cognition dysfunction that interferes with activities of daily living could affect an individual’s ability to effectively perform oral self-care. It could also affect dental providers’ ability to adequately secure informed consent from patients. Cognition dysfunction typically progresses slowly and is more common as the course of disease progresses. It rarely reverses itself. It is hypothesized disease modifying drugs help stabilize cognitive changes.¹⁷

Dysphagia

Difficulty in swallowing (dysphagia), a less common symptom of MS, can occur at any stage of the disease process. It occurs most often when the disease has advanced. Often individuals may not be aware it is occurring. Dysphagia results from liquids and foods being inhaled into the trachea and presents itself as coughing or choking while eating and drinking. It can ultimately result in aspiration pneumonia or lung abscesses. It also puts individuals at risk for malnutrition and dehydration.¹⁷

Emotional Disorders

Individuals diagnosed with MS routinely experience mood disorders and affect disorders. Figure 1 differentiates these two emotional disorders. Typical mood disorders in MS include major depressive disorder, anxiety disorders, adjustment disorder, and bipolar disorder. Mood disorders are a consequence of the interaction of disease process, genetic predisposition, and life events leading to a sense of loss and grief. Mood disorders are more common in individuals diagnosed with MS than in the general population. For example, bipolar disorder occurs in 13% of individuals diagnosed with MS and only 5% of the general population. Affect disorders are a direct consequence of the MS disease process. The most common of affect disorder experienced by individuals diagnosed with MS is periods of sudden uncontrolled crying or laughing called Pseudobulbar Affect (PBA). Symptoms can occur for no apparent reason. Euphoria, apathy, and emotional liability also occur.¹⁸ Patients may be taking medications to treat emotional disorders; therefore, dental providers need to thoroughly review the medications and consider potential drug interactions prior to prescribing additional medications, sedatives, and local anesthetics. Dental providers need to recognize that depressed patients may lack interest in caring for themselves. This could result in poor oral hygiene, malnutrition, increased caries, and increased periodontal disease. These effects may be compounded by xerostomia.¹⁸

Fatigue

Fatigue occurs in approximately 80% of individuals diagnosed with MS. Fatigue can range from mild to severe and can affect work and activities of daily living such as brushing teeth.¹⁷ Fatigue may be so severe that it is disabling. This condition can be misinterpreted as depression and lack of effort. Fatigue is thought to be the result of one or more factors. Individuals may be sleep deprived because of nocturnal muscle spasms or bladder dysfunction. Individuals could also be drained because they have to spend considerable effort completing activities of daily living (e.g., dressing, cooking, bathing, brushing teeth). Fatigue can also occur as a result of depression. A unique form of fatigue that occurs only in individuals diagnosed with MS is called “lassitude.” This form of fatigue occurs daily and may be present after a restful night’s sleep. It tends to be more severe than typical fatigue. Lassitude is aggravated by heat and humidity and can come on abruptly. This form of fatigue will likely interfere with daily activities.¹⁷

Pain Syndromes

Pain stemming from MS may present as paresthesia (a sensation of tingling such as pins and needles), dysesthesia (shock-like pain along a nerve, burning, shooting electric-Lhermitte’s Sign, throbbing), hyperesthesia (increased sensitivity), facial twitching, itching, and/or anesthesia (numbness, complete loss of sensation of touch, pain, and temperature).¹⁹ Chronic pain is experienced by 64% of patients with MS.²⁰ These types of pain often affect the facial and/or oral tissues which add to the complexity of oral health care delivery. Anesthesia and paresthesia in upper limbs and hands can interfere with oral self-care and contribute to an increased risk for caries. It is critical for dental professionals to be aware of these different pain conditions so a differential diagnosis can be made and appropriate care can be rendered. In some instances, referrals may be warranted. In addition, neuromuscular pain may be secondary to a strain on the back for other muscles from weakness, spasticity and poor posture.

Spasticity

Spasticity occurs when opposing muscles involuntarily contract and relax at the same time.²¹ It is estimated 90% of individuals diagnosed with MS will experience some form of spasticity during the course of their disease.²¹ This symptom is important for dental providers because facial muscle spasticity can lead to increased muscle tone, muscle stiffness and spasm, decreased coordination, discomfort, and pain.²¹ Spasm of the bladder can create a feeling of urgency, causing increased frequency of urination and the need for appointment modifications.

Trigeminal Neuralgia

Trigeminal neuralgia, also known as tic douloureux, is a condition that results from irritating the trigeminal nerve. Trigeminal neuralgia is an acute pain syndrome commonly known to be an early presentation of MS. It is 20 times more prevalent in individuals diagnosed with MS than in the general population.^16,22-24 According to the American Association of Neurological Surgeons, MS is usually the cause of trigeminal neuralgia in young adults.²⁵

Trigeminal neuralgia presents as excruciating, stabbing or shock-like burning pain along the side of the face. The pain is so agonizing it has been referred to as “the suicide disease.”²⁶ Trigeminal neuralgia pain can be easily triggered by lightly touching the skin, shaving, brushing teeth, blowing the nose, drinking hot or cold beverages, eating, applying makeup, smiling or talking.²⁵ The pain routinely originates as a sensation of electrical shocks or zings and within 20 seconds the pain concludes with an excruciating stabbing pain. The pain has been known to leave patients with uncontrollable facial twitching.²⁵

The pain of trigeminal neuralgia follows one of two courses. “Classic” pain is intense and throbbing with shock-like sensations. It is generally triggered by a specific activity or touching an area of face and there are definite periods of remission. In contrast, “atypical” pain emerges as a constant, dull, burning sensation that affects a large portion of the face. In most circumstances, there are no periods of remission.²⁵ The “atypical” course is more common in patients diagnosed with MS.²⁷ Patients are usually under the age of 40 and the pain may occur bilaterally and unstimulated.²⁸ Similar to being diagnosed with MS, Trigeminal neuralgia is diagnosed more frequently in women than men.²⁵

Trigeminal neuralgia usually begins unexpectedly; however, individuals have reported the pain occurring after trauma to the face or dental surgery. Most dental professionals do not believe trigeminal neuralgia can be caused by dental surgery. They believe initial symptoms, that were already developing, were spontaneously triggered by dental surgery. It is important for dental professionals to perform a differential diagnosis and not confuse trigeminal neuralgia with a dental abscess. This could result in an unnecessary root canal that brings no relief to the pain.²⁵ The Facial Pain Association advises MS should be suspected and ruled out for anyone, under the age of 40, who is diagnosed with trigeminal neuralgia.²⁷