Multiple Sclerosis Oral Health

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at dentalcare.com Continuing Education Course, August 1, 2014

Online Course:www.dentalcare.com/en-US/dental-education/continuing-education/ce444/ce444.aspx

Disclaimer:Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or

procedures into their practice. Only sound evidence-based dentistry should be used in patient therapy.

This course will provide an overview of Multiple Sclerosis (MS), offer ways to recognize oral symptoms

before an individual has been diagnosed, and present approaches for dental professionals to modify and

adapt the provision of oral health care to meet the needs of patients diagnosed with MS.

Conflict of Interest Disclosure Statement Dr. Simmer-Beck reports no conflicts of interest associated with this work.

ADA CERPThe Procter & Gamble Company is an ADA CERP Recognized Provider.

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying

quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses

or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

Concerns or complaints about a CE provider may be directed to the

provider or to ADA CERP at: http://www.ada.org/cerp

Approved PACE Program ProviderThe Procter & Gamble Company is designated as an Approved PACE Program Provider

by the Academy of General Dentistry. The formal continuing education programs of this

program provider are accepted by AGD for Fellowship, Mastership, and Membership

Maintenance Credit. Approval does not imply acceptance by a state or provincial board

of dentistry or AGD endorsement. The current term of approval extends from 8/1/2013 to

7/31/2017. Provider ID# 211886

Melanie Simmer-Beck, RDH, PhDContinuing Education Units: 2 hours

Providing Evidence-based Oral Health Care toIndividuals Diagnosed with Degenerative Disorders,

Part 1: Multiple Sclerosis
http://www.dentalcare.com/en-US/dental-education/continuing-education/ce444/ce444.aspxhttp://www.dentalcare.com/en-US/dental-education/continuing-education/ce444/ce444.aspx


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OverviewMultiple sclerosis (MS) is a chronic, unpredictable, and often disabling disease resulting from an immune

attack on the central nervous system. To facilitate patient-centered care for individuals diagnosed with MS,

dental professionals must be aware of disease variations, common symptoms, and treatments to modify the

course of disease and manage symptoms. The following course will provide an overview of the disease,

offer ways to recognize oral symptoms before an individual has been diagnosed, and present approaches

for dental professionals to modify and adapt the provision of oral health care to meet the needs of patients

diagnosed with MS.

Learning ObjectivesUpon completion of this course, the dental professional should be able to:

Describe multiple sclerosis.

Recognize the signs symptoms of multiple sclerosis and understand how they could affect the provision

of oral health care.

Delineate the four courses of disease progression.

Describe medications and treatments available to modify the course of disease and to manage

symptoms.

Understand appointment management modifications that dental providers should consider.

Apply disability etiquette when interacting with patients diagnosed with multiple sclerosis.

Identify resources to find the latest Multiple Sclerosis information, news, and support groups.

Course Contents What is Multiple Sclerosis (MS)? Etiology/causative Agents of MS

Clinical Signs and Symptoms of MS Signs and Symptoms of MS that May Affect the

Provision of Oral Health Care

Courses of Disease Medications to Modify the Course of Disease

Medications to Manage the Symptoms ofMultiple Sclerosis

Appointment Management Considerations Disability Etiquette Resources

Conclusion Course Test Preview

References About the Author

What is Multiple Sclerosis (MS)?Multiple Sclerosis (MS), one of the most common

neurological disorders among young adults, is achronic, inflammatory, immune-mediated disease

of the central nervous system for which there is

currently no cure. MS is a disease that resultsfrom individuals immune system attacking theircentral nervous system (brain, spinal cord, andoptic nerves). When the immune system attacks

the central nervous system, axons (nerve fibers)and myelin (fatty substance surrounding the nerve

fibers) are damaged. This results in the damaged

myelin forming scar tissue, commonly referred to

as demyelination. Demyelination episodes arecommonly referred to as relapses, exacerbations,

attacks, or flare-ups. Demyelination isunpredictable and can trigger new symptoms orworsen old ones.

As a consequence of demyelination, nerve

impulses, traveling through the central nervoussystem are distorted and interrupted causing a

variety of visible and non-visible symptoms. Thereduced efficiency of the nerve impulses producesmotor and sensory abnormalities which can lead

to fatigue, weakness, numbness, incoordination,imbalance, vision loss, bladder dysfunction, bowel

dysfunction, difficulty speaking, and cognitiveimpairment. Symptoms vary from individual to

individual and may resolve completely (remission)or remain and/or progress when scaring occurs(sclerosis).

1

MS affects approximately 400,000 individuals in

the U.S. and 2.5 million individuals worldwide.

Diagnosis generally occurs between the ages of20 and 50; however, it can also occur in children.

2

The average age of MS disease onset is 30years; though, this can vary widely depending on

the type of MS and ones gender. MS is morecommon in women than men with an estimated

female to male incidence ratio of 1.4 to 2.3.3


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There is evidence suggesting the incidence ofMS in females is increasing.

4,5 It has been well

documented the incidence and prevalence of MSvaries geographically.

6,7 The frequency of disease

is higher in the northern United States, southernCanada, Europe, New Zealand, and southeastAustralia. Caucasian populations of European

descent appear to be most at risk for developingthe disease. In the United States the prevalence

is 0.1%. Northern latitudes were once thought toincrease the risk of developing MS; however, that

notion has been dispelled in recent years.3,4,8

Etiology/causative Agents of MSThe etiology of MS is thought to be multifactorial;the interaction of a genetically susceptible

individual with one or more environmentalfactors. The environmental factors include

exposure to Epstein-Barr virus, sun exposure,Vitamin D, and smoking.

1,9-13 It is important for

dental professionals to understand smokinghas been shown to exacerbate symptoms ofMS. It has also been shown to increase risk of

disease progression transforming from RRMS toPPMS.

14,15

Clinical Signs and Symptoms of MSMS is a complex disease with multiple signs and

symptoms; fatigue, difficulty with memory andconcentration, pain, spasticity, tingling/numbness

in the limbs, electric shock with head movements,muscle weakness, double vision, abnormal eye

movements, difficulty walking or inability to walk,loss of balance, tremors or paralysis in limbs,and trouble with bladder or bowels.

1-4,9 When the

brainstem is involved, individuals may experiencealtered sensations in the face such as trigeminal

neuralgia.2 Initial signs and symptoms of MS

are fluctuating, transient, and frequently appear

during young adulthood. They range in severityfrom relatively benign to completely disablingdepending upon the region of the CNS affected

and the degree of disruption that has occurred.1,16

Table 1 summarizes the most common symptoms

of MS.17 Eight of the symptoms, designated

with a *, significantly affect the provision of oralhealth care. These symptoms will be discussedin further detail. Dental professionals may be thefirst providers to treat individuals with MS prior to

diagnosis; therefore, the providers awareness ofinitial symptoms is critical.

Signs and Symptoms of MS that MayAffect the Provision of Oral Health Care

Cognition

Cognition is comprised of high-level brain functionssuch 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 diagnosedwith MS will develop problems with cognition;however, only 5-10% develops severe cognitive

dysfunction that interferes with activities of dailyliving. Cognition dysfunction that interferes with

activities of daily living could affect an individualsability to effectively perform oral self-care. It could

also affect dental providers ability to adequatelysecure informed consent from patients. Cognition

dysfunction typically progresses slowly and is morecommon as the course of disease progresses. Itrarely reverses itself. It is hypothesized disease

modifying drugs help stabilize cognitive changes.17

Dysphagia

Difficulty in swallowing (dysphagia), a lesscommon symptom of MS, can occur at any stage

of the disease process. It occurs most often whenthe disease has advanced. Often individuals may

not be aware it is occurring. Dysphagia resultsfrom liquids and foods being inhaled into the

trachea and presents itself as coughing or chokingwhile eating and drinking. It can ultimately resultin aspiration pneumonia or lung abscesses. It

also puts individuals at risk for malnutrition anddehydration.

17

Emotional Disorders

Individuals diagnosed with MS routinelyexperience mood disorders and affect disorders.Figure 1 differentiates these two emotional

disorders. Typical mood disorders in MS includemajor depressive disorder, anxiety disorders,

Mood Disorders: The study inner experience ofemotion that determines how someone feels in apersistent, sustained way.

Affect Disorders: The changeable outwardexpression of emotion and tend to fluctuate.

Figure 1.Emotional Disorders


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adjustment disorder, and bipolar disorder. Mood

disorders are a consequence of the interactionof disease process, genetic predisposition,and life events leading to a sense of loss and

grief. Mood disorders are more common inindividuals diagnosed with MS than in the general

population. For example, bipolar disorder occurs

in 13% of individuals diagnosed with MS and only5% of the general population. Affect disordersare a direct consequence of the MS diseaseprocess. The most common of affect disorder

experienced by individuals diagnosed with MS isperiods 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 treatemotional disorders; therefore, dental providers

need to thoroughly review the medications andconsider potential drug interactions prior to

prescribing additional medications, sedatives,

and local anesthetics. Dental providers needto recognize that depressed patients maylack interest in caring for themselves. Thiscould result in poor oral hygiene, malnutrition,

increased caries, and increased periodontaldisease. These effects may be compounded by

xerostomia.18

Table 1. Symptoms of Multiple Sclerosis.17


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Fatigue

Fatigue occurs in approximately 80% of individuals

diagnosed with MS. Fatigue can range from mildto 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 conditioncan be misinterpreted as depression and lack of

effort. Fatigue is thought to be the result of one ormore factors. Individuals may be sleep deprived

because of nocturnal muscle spasms or bladderdysfunction. Individuals could also be drained

because they have to spend considerable effortcompleting activities of daily living (e.g., dressing,cooking, bathing, brushing teeth). Fatigue can also

occur as a result of depression. A unique form offatigue that occurs only in individuals diagnosed

with MS is called lassitude. This form of fatigueoccurs daily and may be present after a restful

nights sleep. It tends to be more severe thantypical fatigue. Lassitude is aggravated by heat

and humidity and can come on abruptly. This formof fatigue will likely interfere with daily activities.

17

Pain Syndromes

Pain stemming from MS may present as

paresthesia (a sensation of tingling such as pinsand needles), dysesthesia (shock-like pain alonga nerve, burning, shooting electric-Lhermittes

Sign, throbbing), hyperesthesia (increasedsensitivity), facial twitching, itching, and/or

anesthesia (numbness, complete loss of sensationof 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 oraltissues which add to the complexity of oral health

care delivery. Anesthesia and paresthesia in upperlimbs and hands can interfere with oral self-care

and contribute to an increased risk for caries. Itis critical for dental professionals to be aware of

these different pain conditions so a differentialdiagnosis can be made and appropriate care canbe rendered. In some instances, referrals may

be warranted. In addition, neuromuscular painmay be secondary to a strain on the back for

other muscles from weakness, spasticity and poor

posture.

SpasticitySpasticity 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 duringthe course of their disease.

21 This symptom is

important for dental providers because facialmuscle spasticity can lead to increased muscle

tone, muscle stiffness and spasm, decreasedcoordination, discomfort, and pain.

21 Spasm of the

bladder can create a feeling of urgency, causingincreased frequency of urination and the need forappointment modifications.

Trigeminal Neuralgia

Trigeminal neuralgia, also known as ticdouloureux, is a condition that results from

irritating the trigeminal nerve. Trigeminal neuralgiais an acute pain syndrome commonly known to bean early presentation of MS. It is 20 times more

prevalent in individuals diagnosed with MS thanin 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 sideof 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, blowingthe nose, drinking hot or cold beverages, eating,applying makeup, smiling or talking.

25 The pain

routinely originates as a sensation of electricalshocks 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 throbbingwith shock-like sensations. It is generally triggered

by a specific activity or touching an area of faceand there are definite periods of remission. In

contrast, atypical pain emerges as a constant,dull, burning sensation that affects a large portionof 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, Trigeminalneuralgia is diagnosed more frequently in womenthan men.

25

Trigeminal neuralgia usually begins unexpectedly;

however, individuals have reported the painoccurring after trauma to the face or dental


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patterns have been categorized into four coursesof disease.

29-31 These are summarized in Table 2.

Medications to Modify the Course ofDiseaseThe underlying etiology of MS has been widelydisputed within the research community. Some

researchers consider MS an autoimmune,inflammatory disease.

32 Others, however believe

MS is a chronic metabolic disorder or that itis a neurodegenerative disease by which the

bodys autoimmune response is reacting toneurodegenerative debris.

33,34 Regardless of the

how researchers view the etiology of the disease,

they all agree it is linked to autoimmune activity.This involvement has driven the treatment options

available today.

Since 1993 the U.S. Food and Drug Administration(FDA) has approved ten disease modifying

surgery. Most dental professionals do not believetrigeminal neuralgia can be caused by dental

surgery. They believe initial symptoms, that werealready developing, were spontaneously triggered

by dental surgery. It is important for dentalprofessionals to perform a differential diagnosisand not confuse trigeminal neuralgia with a dental

abscess. This could result in an unnecessaryroot canal that brings no relief to the pain.

25 The

Facial Pain Association advises MS should besuspected and ruled out for anyone, under the

age of 40, who is diagnosed with trigeminalneuralgia.

27

Courses of DiseaseThe course of MS and symptoms are dependent

upon the type of MS and where the lesions,within the central nervous system, are located.

Disease patterns can vary from a benign illnessto a progressive, debilitating disease. Disease

Table 2. Multiple Sclerosis Disease Characterizations.


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the symptoms of MS, it is not uncommonfor individuals to subscribe Eastern medical

philosophy. Roughly 75% of patients diagnosedwith MS employ complementary and alternativemedicinal (CAM) therapies for palliative

treatment.39 There are numerous alternative

therapies; relaxation techniques, hyperbaric

oxygen therapies, acupuncture, cold baths,bowel, parasite and/or liver cleansings, amalgam

and/or root canal removal and chelation therapy,special diet, cannabis, and vitamin, antioxidant

and mineral supplementation.39,40 At the presenttime CAMS are not typically approved by theFDA, their safety is unknown, and the evidence

to support the benefits and risks of CAMs isinconclusive.

40,41

Cannabis (universally known as marijuana), isone of the only CAMs approved, in certain forms,

by the FDA.41 There is strong evidence to support

the use of oral cannabis extract to effectively

manage pain and spasticity in patients with MS.41

Cannabis use may increase stress responses to

local anesthesia, therefore, dental professionalsmust consider the possibility of marijuana usewhen addressing pain management options for

patients diagnosed with MS and vital signs shouldbe taken prior to administering local anesthesia.

42

Cannabis can also cause xerostomia, fiery redgingivitis, white gingival patches, papilloma, and

candidiasis.19

Removal of amalgam fillings followed by

chelation therapy is an invasive CAM thatdental providers need to be aware of. Chelation

therapy is controversial and dangerous due to

the risk of potential kidney damage. For years,amalgam fillings (containing mercury) have beenconsidered hazardous and alleged to causecentral nervous system disorders. It is not

unusual for patients to believe amalgams are thecause of MS and request for them to be removed

in conjunction with chelation therapy. There isno published scientific research that supports the

medications for the treatment of RRMS. Thesemedications have been shown to reduce the

number of relapses/exacerbations, decrease thenumber of new lesions formed, and conceivably

slow the progression of disease. Table 3 outlinesdosing, warnings, and common side effects ofthe disease modifying therapies approved by

the FDA. Nine of the therapies are consideredfirst line therapies. Five of the first line therapies

are dispensed by injection, three are dispensedorally, and one is dispensed by IV. Tysabri

(natalizumab), the therapy dispensed by IV, isgenerally reserved for people who see no resultsfrom or cannot tolerate other types of treatments.

This is a monoclonal antibody was approvedfor marketing by the FDA in 2004; however, in

2005 the manufacturer voluntarily suspendedmarketing of the therapy after several reports of

significant adverse events. In 2006 the therapywas again approved by the FDA under strict

treatment guidelines. Novantrone(mitoxantrone)is the only therapy not considered a first line.This immunosuppressant therapy is approved

for individuals with progressing forms of RRMS(those whose RRMS is progressing in despite of

treatment with a first-line medication), SPMS, andPRMS.

35,36 Due to potential cardiac events and

leukemia Novantroneis rarely administrated to

people with MS.

Medications to Manage the Symptomsof Multiple SclerosisAt the present time, there is no cure for MS.However, in addition to having effective strategiesto modify the course of disease, medications

are also available to treat exacerbations,manage symptoms, improve function and safety,

and provide emotional support. Collectively,these therapies can enhance the quality of life

for people living with MS. Table 4 providesan exhaustive list of medications commonlyprescribed to manage MS symptoms and adverse

effects relevant to dental providers. There arenumerous adverse effects that could impact the

provision of oral health care.19,38

Some of the

most common adverse effects are xerostomia,taste perversion, and caution with localanesthetic.

Conventional therapies are typically onlypartially effective and as illustrated in Table 4,

they have many side effects. Therefore, inaddition to utilizing western medicine to manage

Chelation therapyis an investigational therapyplacing man-made water soluble, amino acidcalled EDTA, into the blood through a vein. TheEDTA binds to metallic ions such as mercury andis excreted. To date, it is only approved to treatlead poisoning.

Figure 2.Chelation Therapy


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Table 3. Summary of FDA-approved disease modifying agents.19,35


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Table 4. Medications used for MS-related symptom management.19,38


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from RRMS to PPMS and to exacerbatesymptoms. Tobacco cessation is critical for

this population. Cool and stress free environments may aid in

reduction of exacerbated symptoms. Frequent and shortened morning appointments

may be better for patients with MS.47

Wheelchair accessibility may be required inorder to treat patients with more progressive

disease symptoms. Consider providing oralhealth services to patients directly in their

wheelchair if a patient cannot transfer from

their wheelchair into the dental chair. Patients may require frequent bathroom

breaks due to incontinence. Using anoperatory near a restroom can make frequent

breaks easier on the patient. Plan short appointments for patients who

experience trigeminal neuralgia or facialdiscomfort. The shooting pain and discomfort

benefits of this therapy for individuals with MS.The ADA, FDI World Dental Federation, and FDA

consider amalgam to be safe.43-45

The NationalMultiple Sclerosis Society categorizes the removal

of dental amalgam as ineffective and chelationtherapy as ineffective and dangerous.

46

Appointment ManagementConsiderations Elective dental treatments should be postponed

during exacerbations or flare ups of MS

symptoms.47

Individuals diagnosed with MS are at elevatedrisk for caries due to xerostomia, fatigue,dexterity limitations, and muscle dysfunction ofthe oral cavity.

Oral self-care instructions should be based onthe patients functional ability and values.

Cigarette smoking has been shown to increaserisk of disease progression transforming

Table 4. Continued.


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should offer assistance and be respectful of the

individuals response. When communicating withan individual in a wheelchair make eye contactby stepping back or sitting in a chair to have the

conversation. Do not lean on the individualswheelchair. Individuals with disabilities will

sometime utilize a service dog. Providers shouldnot interact or pet the service dog unless they areinvited to do so.

ResourcesMS is a complex disease with differingpresentations and patient needs. Organizations

are available to provide information about thedisease, identify support groups, offer financialresources, outline the latest research, and provide

suggestions to promote activities of daily livingand independence. The below list provides a

starting point for dental professionals to identifyorganizations that provide support to individuals

diagnosed with MS. Many of these organizationshave regional and local components that canprovide more individualized support.

Organizations that Support Multiple Sclerosis:

ADA National Network

http://adata.org/ Canine Companion for Independence

http://www.cci.org/site/c.cdKGIRNqEmG/b.4011119/

Multiple Sclerosis Association of America

http://www.mymsaa.org/

Multiple Sclerosis Foundation

http://www.msfocus.org/

brought on by dental procedures can become

too arduous for patients. Always note extra-oral findings of facial nerve

pain in a patients dental record. Refer patient

to a physician immediately if patients reportfacial pain that cannot be explained. Dental

professionals are at an advantage to detectearly MS symptoms.

Disability EtiquetteProper disability etiquette is continually evolving

as we learn more about providing care to, andinteracting with, individuals diagnosed with a

disability. The number one factor healthcareproviders need to be conscious of is the individualalways comes before the disability. This is called

People First Language. For example, you areproviding care to an individual diagnosed with

MS. You are not providing care to your MSpatient. Individuals do not want to be defined by

their disability. Keep in mind, the right languageshould avoid prejudices, assumptions, andstereotypes. Providers should focus on using

language that is respectful and courteous. Table5 provides phrases dental professionals should try

to avoid and suggestions for making the statement

in a non-discriminatory, respectful way.48

Proper disability etiquette should also avoidmaking assumptions. Figure 3 provides a list

of assumptions commonly made that should beaverted. Providers should not assume a person

diagnosed with a disability needs help. They

Table 5. People First Language.

People living with disabilities are courageous.

Peoples lives are ruined by disease or disability.

Disability (MS) dominates a persons life.

Disease or disability was caused by something the person did or did not do.

People with disabilities arent as smart (capable, interesting, diverse) as other people.

People with disabilities are sick.

Figure 3.Commonly Made Assumptions that Should be Averted.


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be aware of the initial signs and symptoms of thedisease. Individuals diagnosed with MS often

experience oral side effects from medicationsthey are taking to modify the course or disease

and/or manage symptoms. Providing patient-centered oral health care to individuals diagnosedwith MS can be a rewarding experience for dental

professionals when they understand the diseasevariations, know how to make appropriate

appointment modifications, and appreciate how toproperly interact in a non-discriminatory manner

with patients diagnosed with MS.

National Multiple Sclerosis Societyhttp://www.nationalmssociety.org/

National Service Animal Registryhttp://www.nsarco.com/

Paws with a Causehttps://www.pawswithacause.org/i-want-a-dog/service-dogs

The Consortium of Multiple Sclerosis Centers

http://www.mscare.org/

ConclusionDental professionals may be the first provider

to treat individuals with MS prior to diagnosis;therefore, it is critical for dental professionals to


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Course Test PreviewTo receive Continuing Education credit for this course, you must complete the online test. Please go to:

www.dentalcare.com/en-US/dental-education/continuing-education/ce444/ce444-test.aspx

1. Multiple sclerosis is an _______________.

a. infectious disease of the central nervous system

b. immune-mediated disease of the central nervous system

c. infectious disease of the circulatory systemd. immune-mediated disease of the circulatory system

2. Which of the following is NOT a typical motor or sensory abnormality that individualsdiagnosed with MS may experience?

a. Hearing loss

b. Numbness

c. Fatigue

d. Bladder dysfunction

3. What is the painful sensation that occurs when the trigeminal nerve is aggravated?a. Spasticity

b. Dysphagia

c. Trigeminal neuralgia

4. Approximately ______% of individuals diagnosed with MS will develop problems withcognition.

a. 10

b. 30

c. 50

d. 80

5. Lassitude is a form of fatigue that occurs daily and may even be present after a restful

nights sleep.

a. True

b. False

6. Pain along a nerve presenting as shock-like, burning, throbbing and shooting electric

sensations is called _______________.a. hyperesthesia

b. anesthesia

c. paresthesia

d. dysesthesia

7. When an individual is diagnosed with trigeminal neuralgia under the age of 40 dental

professionals should always suspect MS.a. True

b. False

8. Trigeminal neuralgia pain can be triggered by _______________.

a. shaving

b. lightly touching the skin

c. blowing the nose

d. drinking warm beverages

e. All of the above.
http://www.dentalcare.com/en-US/dental-education/continuing-education/ce444/ce444-test.aspxhttp://www.dentalcare.com/en-US/dental-education/continuing-education/ce444/ce444-test.aspx


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9. The most common form of MS is _______________.

a. Relapsing Remitting

b. Primary Progressive

c. Secondary Progressive

d. Progressive/Relapsing

10. Which of the following disease modifying agents is dosed orally?

a. Avonexb. Betaseron

c. Aubagio

d. Copaxone

11. Possible side effects of FDA approved first line disease modifying therapies include_____________.

a. xerostomia

b. flu-like symptoms

c. ulcerative stomatitis

d. injection site reactions

e. All of the above.

12. Which of the following is NOT a common adverse effect of medications used to manage MSsymptoms?

a. Xerostomia

b. Caution with local anesthesia

c. Flu-like symptoms

d. Taste perversion

13. The National Multiple Sclerosis Society supports the removal of amalgam fillings followed

by chelation therapy to reverse the effects of MS.a. True

b. False

14. Dental treatment should be _______________ during exacerbations or flare ups of MS

symptoms.a. completed immediately

b. postponed

c. No modifications are necessary.

15. Which of the following phrases is discriminatory?a. Mr. Smith is wheelchair bound.

b. Mr. Smith was diagnosed with MS in January.

c. Mr. Smith requires accessible parking.

d. Mr. Smith has a disability.


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About the Author

Melanie Simmer-Beck, RDH, PhD

Melanie Simmer-Beck, is an associate professor in the Division of Dental Hygiene at

the University of Missouri-Kansas City School of Dentistry. She is also the projectdirector of Miles of Smiles, a school-based oral health program. In 2013, Simmer-Beck was selected to serve as an ambassador for the American Dental Associations

Dental Quality Alliance. Her publications and research interests include measuringdental quality improvement, program evaluation, place-based care, special patient

care, service learning, advanced instrumentation, and ergonomics. Simmer-Beck is

also a member of Dimensions of Dental Hygienes Peer Review Panel.

Email: [email protected]

Documents

Multiple Sclerosis Oral Health