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Oral Health and Multiple Sclerosis Oral Health and Multiple Sclerosis Eleonore D. Paunovich, DDS, MS, FASGD, DASCD Director,

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Presentation on theme: "Oral Health and Multiple Sclerosis Oral Health and Multiple Sclerosis Eleonore D. Paunovich, DDS, MS, FASGD, DASCD Director,"— Presentation transcript:

1 Oral Health and Multiple Sclerosis Oral Health and Multiple Sclerosis Eleonore D. Paunovich, DDS, MS, FASGD, DASCD 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 – , 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  motor function  sensory function  cognitive function  medications

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

5 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

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

7 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

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

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

10 Multiple Sclerosis Oral/Facial Pain Facial pain Facial pain Trigeminal Neuralgia Trigeminal Neuralgia Facial Palsy 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 Medical management carbamazepine, phenytoin, baclofen, gabapentin, clonazepam carbamazepine, phenytoin, baclofen, gabapentin, clonazepam Dental management Dental management rule out dental etiology rule out dental etiology occlusal orthotics, trigger point injections occlusal orthotics, trigger point injections Surgical management Surgical management peripheral nerve block/ablation, gasserian ganglion procedures, microvascular decompression, gamma knife peripheral nerve block/ablation, gasserian ganglion procedures, microvascular decompression, gamma knife MD consult re: disease progression MD consult re: disease progression

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

13 Patient advice: 1)water misting 2)let ice melt in mouth 3)avoid mouth rinses with alcohol 4)humidify sleeping areas 5)restrict caffeine intake 6)reduce tobacco use 7)use lip balm, xylitol gum, sugar-free lemon drops Oral Health Therapeutic Strategies Xerostomia Management

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

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

16 Caries /Periodontal disease Multiple Sclerosis Oral Manifestations  motor function  sensory function  cognitive function  medications  Pain  Infection  Tooth loss

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

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

19 Tired or weak? Tired or weak? Sit to brush and floss Sit to brush and floss Start out by brushing with water only, after thorough brushing, then use toothpaste Start out by brushing with water only, after thorough brushing, then use toothpaste Hand tremors? Hand tremors? Use a weighted toothbrush Use a weighted toothbrush Use weighted gloves Use weighted gloves Oral Health Preventive Strategies Tooth Brushing and Flossing Tips

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

21 What can caregivers do for MS patients? Motivate and encourage independency Motivate and encourage independency Regularly give oral hygiene Regularly give oral hygiene Bring for regular check-ups --- build a relationship with a dentist Bring for regular check-ups --- build a relationship with a dentist

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

23 Oral Health Preventive Strategies Flossing Floss types Floss types Waxed and Unwaxed Waxed and Unwaxed Dental Tape Dental Tape Yarn, gauze strip Yarn, gauze strip Tufted floss (Superfloss) Tufted floss (Superfloss) Floss threaders Floss threaders Holders Holders Rubber tips stimulator Rubber tips stimulator Interdental brush 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 soluti on

25 Multiple Sclerosis Oral Health Preventive Strategies

26 4 Early comprehensive oral rehab 4 Frequent professional visits 4 Monitor caries/periodontal disease risk 4 Monitor salivary function 4 Educate care givers Infection Pain Multiple Sclerosis Dental Management

27 For more information….. Special Care in Oral Health, National Institute of Dental and Craniofacial Research Special Care in Oral Health, National Institute of Dental and Craniofacial Research alNeeds/SpecialCare.htm alNeeds/SpecialCare.htm alNeeds/SpecialCare.htm alNeeds/SpecialCare.htm Oral health care for patients with special needs Oral health care for patients with special needs / / / / Dental care everyday: a caregiver’s guide Dental care everyday: a caregiver’s guide ities/DentalCareEveryDay.htm ities/DentalCareEveryDay.htm ities/DentalCareEveryDay.htm ities/DentalCareEveryDay.htm Dental health: the basic facts – National Multiple Sclerosis Society Dental health: the basic facts – National Multiple Sclerosis Society 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. 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.

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): 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): Multiple Sclerosis – Oral Care for Persons with Disabilities phmscle.htm Multiple Sclerosis – Oral Care for Persons with Disabilities phmscle.htm phmscle.htm phmscle.htm American Dental Association: American Dental Association: Academy of General Dentistry: Academy of General Dentistry: National Foundation of Dentistry for the handicapped: National Foundation of Dentistry for the handicapped: Special Care Dentistry: Special Care Dentistry:

29 For more information….. Wheelchair Transfer Guide Wheelchair Transfer Guide chairTransfer.htm chairTransfer.htm chairTransfer.htm chairTransfer.htm Disposable Mouth Props and Surround Toothbrush Disposable Mouth Props and Surround Toothbrush Plaque Vac Oral Care System Plaque Vac Oral Care System Collis Curve Toothbrush Collis Curve Toothbrush 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. 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.

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

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


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