Oral Health and Multiple Sclerosis

1. Oral Health and Multiple Sclerosis Eleonore D. Paunovich, DDS, MS, FASGD, DASCD eleonore.paunovich@va.gov Director, Clinical Oral Health Programs Geriatrics and Extended Care South Texas Veterans Health Care System Clinical Professor, Department of Comprehensive Dentistry University of Texas Health Science Center San Antonio, Texas VA MS Centers of Excellence Patient Conference Call – 1.800.767.1750, 43157# May 14, 2012

2. Learning Objectives • Describe the impact of Multiple Sclerosis on oral health • Identify ways to manage MS symptoms and side effects like movement difficulty, swallowing problems, facial pain, and dry mouth while taking care of your oral health • Discuss preventive strategies that can aid in good oral hygiene for MS patients

3. Oral Manifestations Multiple Sclerosis Oral/Facial pain • motor function • sensory function • cognitive function • medications Swallowing Difficulty Medication side effects Caries /Periodontal disease

4. Connection between multiple sclerosis and oral health? Muscle control failure • Difficulty maintaining oral health • Difficulty accessing care due to their symptoms

5. Multiple SclerosisOral Health Therapeutic Strategies • Transfer assistance from wheel chair to dental chair • Management of swallowing difficulty • Management of spastic/involuntary movements • Management of facial pain • Management of dry mouth and other oral side effects of medications

6. Oral Health Therapeutic Strategies Patient Seating • transfer boards • transfer belts • wheelchair lift

7. Multiple SclerosisSwallowing Problems • Extra effort chewing or swallowing • Eating very slowly • Packing foods into the cheeks • Drooling • Fluid leaking from the nose after swallowing • Increased congestion in the chest after eating ASPIRATION RISK ASPIRATION PNEUMONIA

8. Oral Health Therapeutic StrategiesSwallowing Problems • Daily oral hygiene care • caregiver assistance as needed • Check denture fit and stability • Routine professional dental visits • caries and periodontal disease • reduce risk of loosing more teeth • Dental visits • semi-supine to upright chair position- protect airway • Use of a rubber dam • limit water use • short-lasting local anesthesia

9. Oral Health Therapeutic StrategiesManagement of spastic/involuntary movement • extra-oral mouth props • secured, ratchet, HuFriedy molt prop • intra-oral mouth prop • rubber bite block, extended foam handle • physical, gentle hand-holding • stabilization of head

10. Multiple SclerosisOral/Facial Pain • Facial pain • Trigeminal Neuralgia • Facial Palsy • may be the first manifestation of MS • “electric shock” by touching cheek, tooth brushing or chewing • pain lasts for seconds, severe; returns several times/day • numbness of lower lip/chin, with or without pain • weakness/paralysis of facial muscles

11. Oral Health Therapeutic Strategies Management of Oral/Facial Pain • Medical management • carbamazepine, phenytoin, baclofen, gabapentin, clonazepam • Dental management • rule out dental etiology • occlusal orthotics, trigger point injections • Surgical management • peripheral nerve block/ablation, gasserian ganglion procedures, microvascular decompression, gamma knife • MD consult re: disease progression

12. Multiple SclerosisOral Side Effects of Meds • Dry mouth • Ulcers • Burning tongue/mouth • Altered taste • Cheilitis • Oral thrush • Steroids • ACTH • Interferons • Immunosuppressors

13. Oral Health Therapeutic StrategiesXerostomia Management Patient advice: • water misting • let ice melt in mouth • avoid mouth rinses with alcohol • humidify sleeping areas • restrict caffeine intake • reduce tobacco use • use lip balm, xylitol gum, sugar-free lemon drops

14. Oral Health Therapeutic StrategiesXerostomia Management • Taste • inability to taste • acids/sugars used to stimulate salivary flow • Texture • pastas • soups • liquid supplements (Ensure)

15. Xerostomia ManagementMaintain Oral Hygiene • Meticulous plaque control is mandatory • Caries likely anywhere plaque can accumulate • Reinforce instruction at frequently (q 3 mos) • Antibacterial rinses • Maximize fluoride strategies • Patient applied • rinse before bedtime • tablet • brush, swab • Professionally applied • fluoride varnish

16. Multiple Sclerosis Oral Manifestations Caries /Periodontal disease • Pain • Infection • Tooth loss • motor function • sensory function • cognitive function • medications

17. Oral Health Preventive Strategies Daily Self-Care • plaque removal • Brush twice daily – after breakfast, before bedtime • fluoride toothpaste • floss daily • brush tongue daily • eat a well balanced meal – limit sweets • replace toothbrush every 3-4 months • routine dental visits –report bleeding gums, jaw pain, sensitive teeth immediately

18. Oral Health Preventive StrategiesTooth Brushing and Flossing Tips • Weak/poor grip? • look for tooth brushes with handles • check with your dentist for help with modifying toothbrush. • floss at night if possible…too tired at night, then in the morning is ok • consider electric toothbrushes and flossing devices • ask for help from family member or caregiver

19. Oral Health Preventive StrategiesTooth Brushing and Flossing Tips • Tired or weak? • Sit to brush and floss • Start out by brushing with water only, after thorough brushing, then use toothpaste • Hand tremors? • Use a weighted toothbrush • Use weighted gloves http://www.activeforever.com/p-1247-kinsman-weighted-toothbrush-and-razor-holder.aspx http://www.fdmt.ca/catalogue/gantlourd-p-136.html?language=en

20. Oral Health Preventive StrategiesFlossing • Floss types • Waxed and Unwaxed • Dental Tape • Yarn, gauze strip • Tufted floss (Superfloss) • Floss threaders • Holders • Rubber tips stimulator • Interdental brush

21. What can caregivers do for MS patients? • Motivate and encourage independency • Regularly give oral hygiene • Bring for regular check-ups --- build a relationship with a dentist • http://www.nidcr.nih.gov/OralHealth/OralHealthInformation/SpecialNeeds/SpecialCare.htm

22. Oral Health Preventive Strategies Tooth brushing Collis Curve Radius toothbrush Twin Brush Rotary Modified Plaque Vac Ultrasonic

23. Oral Health Preventive StrategiesFlossing • Floss types • Waxed and Unwaxed • Dental Tape • Yarn, gauze strip • Tufted floss (Superfloss) • Floss threaders • Holders • Rubber tips stimulator • Interdental brush

24. Oral Health Preventive Strategies Denture Care • remove full or partial dentures daily • clean the vestibule • pull open the cheek to increase visibility. • use a moist cloth, finger, cotton swab, or a large sponge-tipped swab (Toothette) • sweep from the back of the vestibule forward to remove large particles of debris • brush and clean dentures daily • remove dentures from mouth before bedtime and place in denture soaking cleansing solution

25. Multiple SclerosisOral Health Preventive Strategies

26. Multiple SclerosisDental Management • Early comprehensive oral rehab • Frequent professional visits • Monitor caries/periodontal disease risk • Monitor salivary function • Educate care givers Prevent Infection Pain

27. For more information….. Disclaimer: Dr. Paunovich has no relevant financial interest or other relationship with: (1) the manufacturer(s) of any commercial product(s) and/or (2) the provider(s) of commercial services discussed in this educational activity as well as any commercial supporters of the activity. • Special Care in Oral Health, National Institute of Dental and Craniofacial Research • http://www.nidcr.nih.gov/OralHealth/OralHealthInformation/SpecialNeeds/SpecialCare.htm • Oral health care for patients with special needs • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1118393/ • Dental care everyday: a caregiver’s guide • http://www.nidcr.nih.gov/OralHealth/Topics/DevelopmentalDisabilities/DentalCareEveryDay.htm • Dental health: the basic facts – National Multiple Sclerosis Society • http://www.nationalmssociety.org/download.aspx?id=73

28. For more information….. • Fischer DJ et al. Multiple sclerosis: an update for oral health care providers. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2009; 108(3):316-27 • Multiple Sclerosis – Oral Care for Persons with Disabilities http://www.dental.ufl.edu/faculty/pburtner/disabilities/english/phmscle.htm • American Dental Association: www.ada.org/public/ • Academy of General Dentistry: www.agd.org/consumer • National Foundation of Dentistry for the handicapped: www.nfdh.org • Special Care Dentistry: www.scdonline.org

29. For more information….. Disclaimer: Dr. Paunovich has no relevant financial interest or other relationship with: (1) the manufacturer(s) of any commercial product(s) and/or (2) the provider(s) of commercial services discussed in this educational activity as well as any commercial supporters of the activity. • Wheelchair Transfer Guide • http://www.nidcr.nih.gov/OralHealth/Topics/DevelopmentalDisabilities/WheelchairTransfer.htm • Disposable Mouth Props and Surround Toothbrush • http://www.specializedcare.com/shop/pc/viewCategories.asp?idCategory=5 • Plaque Vac Oral Care System • http://www.trademarkmedical.com/docs/TM-Plak-Vac-System.pdf • Collis Curve Toothbrush • http://colliscurve.com/

30. diminishing priority Priority levels regarding care and co-pay obligations • “Standard” vs. “Special and Limited” benefits • Dental is “limited” to • 2 yr post-discharge • 70+% service-connected • Service-related oral/dental trauma • Former Prisoners of War • Emergency care • Participants in VA Vocational Rehab programs • Inpatients (includes LTC) “as resources allow” • Medically adjunct“as resources allow”

31. Thank-you, for allowing me to share this time with you!