Oral Health and Multiple Sclerosis Eleonore D. Paunovich,

Oral Health and Multiple Sclerosis Eleonore D. Paunovich, DDS, MS, FASGD, DASCD [email protected] 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 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 Oral Manifestations Multiple Sclerosis motor function sensory function cognitive function medications

Connection between multiple sclerosis and oral health? Muscle control failure Difficulty maintaining oral health Difficulty accessing care due to their symptoms Multiple Sclerosis Oral 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 Oral Health Therapeutic Strategies Patient Seating transfer boards transfer belts wheelchair lift Multiple Sclerosis Swallowing 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 Oral Health Therapeutic Strategies Swallowing 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 Oral Health Therapeutic Strategies Management 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 Multiple Sclerosis Oral/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 Oral Health Therapeutic Strategies Management of Oral/Facial Pain Medical management Dental management

rule out dental etiology occlusal orthotics, trigger point injections Surgical management carbamazepine, phenytoin, baclofen, gabapentin, clonazepam peripheral nerve block/ablation, gasserian ganglion procedures, microvascular decompression, gamma knife MD consult re: disease progression

Multiple Sclerosis Oral Side Effects of Meds Steroids ACTH Interferons Immunosuppressors

Dry mouth Ulcers Burning tongue/mouth Altered taste Cheilitis Oral thrush Oral Health Therapeutic Strategies Xerostomia Management Patient advice: 1) 2) 3) 4) 5) 6) 7) 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 Oral Health Therapeutic Strategies Xerostomia Management Taste inability to taste acids/sugars used to stimulate salivary flow Texture pastas soups liquid supplements

(Ensure) Xerostomia Management Maintain 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 Multiple Sclerosis

Oral Manifestations Caries /Periodontal disease motor function sensory function cognitive function medications Pain Infection Tooth loss 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 Oral Health Preventive Strategies Tooth 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 possibletoo tired at night, then in the morning is ok consider electric toothbrushes and flossing devices ask for help from family member or caregiver Oral Health Preventive Strategies Tooth 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 http://www.activeforever.com/p-1247-kinsman-weighted-toothbrush-and-razor-holder.aspx Hand tremors? Use a weighted Use weighted gloves

toothbrush http://www.fdmt.ca/catalogue/gantlourd-p-136.html?language=en Oral Health Preventive Strategies Flossing Floss types

Waxed and Unwaxed Dental Tape Yarn, gauze strip Tufted floss (Superfloss) Floss threaders Holders Rubber tips stimulator Interdental brush 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 Oral Health Preventive Strategies Tooth brushing Collis Curve Radius toothbrush Twin Brush Rotary Modified Plaque Vac Oral Health Preventive Strategies Flossing

Floss types Waxed and Unwaxed Dental Tape Yarn, gauze strip Tufted floss (Superfloss) Floss threaders Holders Rubber tips stimulator

Interdental brush 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 Multiple Sclerosis Oral Health Preventive Strategies Multiple Sclerosis Dental Management

Infection Pain Early comprehensive oral rehab Frequent professional visits Monitor caries/periodontal disease risk Monitor salivary function Educate care givers 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 Oral health care for patients with special needs http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1118393 / Dental care everyday: a caregivers guide http://www.nidcr.nih.gov/OralHealth/OralHealthInformation/Special Needs/SpecialCare.htm

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 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 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

Disposable Mouth Props and Surround Toothbrush http://www.specializedcare.com/shop/pc/viewCategories.asp?idCategory=5 Plaque Vac Oral Care System http://www.nidcr.nih.gov/OralHealth/Topics/DevelopmentalDisabilities/ WheelchairTransfer.htm http://www.trademarkmedical.com/docs/TM-Plak-Vac-System.pdf

Collis Curve Toothbrush http://colliscurve.com/ Priority levels regarding care and co-pay obligations Standard vs. Special and Limited benefits diminishing priority 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 Thank-you, for allowing me to share this time with you!

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