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CDHO Advisory: Multiple Sclerosis

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CDHO ADVISORY

SCOPE

RECOMMENDATIONS

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

CONTRAINDICATIONS

COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY

ADVISORY TITLE

Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with multiple sclerosis.

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory Multiple Sclerosis, 2020-04-08

INTERVENTIONS AND PRACTICES CONSIDERED

Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).

SCOPE

DISEASE/CONDITION(S)/PROCEDURE(S)

Multiple sclerosis

INTENDED USERS

Advanced practice nurses
Dental assistants
Dental hygienists
Dentists
Denturists
Dieticians
Health professional students
Nurses
Patients/clients
Pharmacists
Physicians
Public health departments
Regulatory bodies

ADVISORY OBJECTIVE(S)

To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have multiple sclerosis, chiefly as follows.

  1. Understanding the medical condition.
  2. Sourcing medications information.
  3. Taking the medical and medications history.
  4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.
  5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.
  6. Deciding when and when not to proceed with the Procedures proposed.
  7. Dealing with adverse events arising during the Procedures.
  8. Keeping records.
  9. Advising the patient/client.

TARGET POPULATION

Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged 80 and over
Male
Female
Parents, guardians, and family caregivers of children, young persons and adults with multiple sclerosis.

MAJOR OUTCOMES CONSIDERED

For persons who have multiple sclerosis: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.

RECOMMENDATIONS

UNDERSTANDING THE MEDICAL CONDITION

Terminology used in this Advisory

Resources consulted

Multiple sclerosis (MS) is

  1. a nervous system disease affecting myelin that sheathes the nerve fibres in the brain and spinal cord.
  2. classified by type and sub-type, as follows
    1. clinically isolated syndrome (CIS), which
      1. is the earliest form of MS
      2. refers to a single episode of neurological signs/symptoms suggestive of MS
    2. relapsing remitting multiple sclerosis (RRMS), which 
      1. is characterized by unpredictable episodes
        1. during which
          1. new symptoms appear
          2. existing symptoms worsen
        2. which last from two days to several months
        3. which are followed by remissions of variable duration, during which recovery to the pre-episode level of function
          1. is complete or nearly so
          2. persists for a clear period
      2. accounts for about 85 percent of diagnoses
      3. includes “benign multiple sclerosis”, which
        1. is marked by post-relapse remission that is almost complete
        2. exhibits no or minimal disability 10 to 15 years after onset
        3. creates symptoms mainly with vision and or touch
        4. accounts for 10 to 15 percent of diagnoses, though some estimates are lower
    3. primary-progressive multiple sclerosis (PPMS), which
      1. accounts for about 15 percent of multiple sclerosis diagnoses
      2. manifests as almost continuous worsening from the outset without clear relapses or remissions
      3. generally is diagnosed in persons after age 40
      4. tends to affect men and women equally
      5. includes formerly separately categorized “progressive relapsing multiple sclerosis” (PRMS), which is
        1. characterized by progressive worsening of the condition from the outset
        2. accounts for about 5 percent of total MS diagnoses
    4. secondary-progressive multiple sclerosis (SPMS), which
      1. becomes progressive after an initial relapsing-remitting phase
      2. progresses with or without relapses
      3. usually recovers incompletely when attacks do occur
      4. creates disability that accumulates over time 
      5. develops within 10 years in about 50 percent of persons diagnosed with relapsing remitting multiple sclerosis. 

Other terminology used in this Advisory includes the following.

  1. Myelin, an insulating layer that 
    1. surrounds nerves, including those in the brain and spinal cord, in the form of a sheath 
    2. is composed of protein and fatty substances
    3. facilitates transmission of neurochemical messages through the nerve cells
    4. when damaged, impairs the transmission of the neurochemical messages, as happens in multiple sclerosis.
  2. Paresthesia, an abnormal sensation, typically tingling or pricking, caused chiefly by pressure on or damage to peripheral nerves.
  3. Spasticity, sustained stiffness caused by 
    1. increased muscle tone
    2. muscle spasms.
  4. Tremor, unintentional, involuntary and seemingly rhythmic muscle movement involving to-and-fro movements of one or more parts of the body.

Overview of multiple sclerosis

Resources consulted 

Multiple sclerosis

  1. in development, is characterized by
    1. a diagnosis that is
      1. either made soon after onset
      2. or that is persistently elusive, leading to years of uncertainty dogged by inconsistent symptoms that inexplicably come and go 
    2. unpredictability of severity, progression and symptomatology at the time of diagnosis 
    3. affects only mildly most persons with the condition though, in the worst manifestations, it may variously prevent 
      1. writing
      2. speaking
      3. walking
    4. lesions, plaques, in the protective myelin sheath of the brain and spinal cord that
      1. cause inflammation and often patchy destruction of myelin
      2. disrupt communications between the brain and other parts of the body by impeding the flow of neurochemical messages in the nerve fibres
      3. produce effects that depend on the part or parts of the brain and spinal cord involved
      4. sometimes permanently damage the nerve fibres.
  2. occurs as types that
    1. present most commonly with the relapsing-remitting form, which may in time develop into the secondary-progressive form
    2. may exist in one or other of the forms 
      1. primary progressive 
      2. clinically isolated syndrome
    3. in Canada appear
      1. at any age, though are commonly diagnosed in the age range 15 to 40 years
      2. as new diagnoses at the rate of 1,000 cases per year and, at any one time, affect a total estimated population of about 80,000 Canadians
      3. three times more often in women that in men
      4. most commonly in persons with a northern European heritage.
  3. is of unknown cause and without clear risk factors, though it
    1. is believed to be an autoimmune disease (CDHO Advisory) in which malfunction of the body’s immune system causes the attacks on myelin, but the cause of the inflammation is unclear, though it may singly or jointly be
      1. triggered by a virus
      2. associated with a genetic defect
    2. may be the subject of predisposition caused by genetic factors, though it is not a directly inherited condition.
  4. creates signs and symptoms that
    1. vary 
      1. in type, location and severity
      2. considerably from person to person
      3. from time to time in the same person
    2. occur episodically, with remissions
      1. in which symptoms are reduced or absent
      2. which separate episodes
    3. reflect or contribute to disability that may be mild, moderate or severe
    4. develop variously in body systems, including
      1. bowel and bladder, causing
        1. constipation
        2. stool leakage
        3. urination problems
          1. difficulty in starting urination
          2. frequency of need to urinate
          3. strong urge to urinate
          4. incontinence
      2. brain and mental function, causing  
        1. decreased attention span, poor judgment, and memory loss, which are
          1. experienced by about half of persons with the condition
          2. usually mild and thus frequently overlooked
        2. short-term memory problems
        3. difficulty reasoning and solving problems
        4. depression, which is common
        5. dementia, a set of symptoms and signs associated with damage to particular parts of the brain (CDHO Advisory)  
        6. extreme fatigue, which is very common
      3. ear and hearing, causing  
        1. dizziness and balance problems
        2. hearing loss, which is infrequent
      4. eyes, which 
        1. may be the site of the earliest symptoms, variously
          1. blurred or double vision
          2. red-green colour distortion 
          3. blindness in one eye
        2. may also present
          1. discomfort
          2. uncontrollable, rapid eye movements
      5. muscle and movement, causing  
        1. muscle weakness and related symptoms of muscles, including
          1. stiffness
          2. spasms
          3. weakness in one or more arms or legs
          4. problems with 
            1. coordination and making small movements
            2. moving arms or legs
            3. walking
        2. difficulty with coordination and balance that 
          1. is experienced by most persons with the condition
          2. may be sufficiently severe to 
            1. impair walking or standing
            2. cause partial or complete paralysis
            3. cause loss of balance
      6. nervous system, causing  
        1. facial pain
        2. painful muscle spasms
        3. paresthesia, experienced by most persons with the condition
        4. numbness or abnormal sensation in any area
        5. tremor in one or both arms or one of both legs
      7. oral cavity, causing  
        1. speech impediments, such as
          1. slurred speech
          2. difficult-to-understand speech
        2. trouble chewing and swallowing.
  5. is clinically investigated by
    1. MRI, which
      1. provides the best imaging technology for detecting the presence of plaques
      2. differentiates old lesions from those that are new or active
      3. cannot be the sole basis for diagnosis because it does not sufficiently differentiate the condition from changes associated with aging or lesions caused by other conditions 
    2. visual evoked potential tests
      1. to analyze the nervous system’s electrical response to the stimulation of specific sensory pathways 
      2. to provide evidence of damage to myelin that results in slowing of nerve conduction along the pathways tested
      3. are considered most useful for confirming the diagnosis.
  6. is treated with2
    1. medications
    2. rehabilitation, such as 
      1. physiotherapy
      2. occupational therapy
      3. speech/language/swallowing therapy
      4. cognitive therapy (e.g., with neuropsychologist)
      5. mental health therapy (e.g., psychiatric/psychologic treatment for depression)
      6. social work
      7. vocational rehabilitation 
    3. lifestyle adjustments, such as 
      1. balanced diet
      2. adequate rest
      3. regular exercise.
  7. is not caused or worsened by dental amalgam (mercury-metal alloy fillings), and therefore is not a reason to have such fillings removed
  8. offers for prevention
    1. no known means 
    2. though episodes may be triggered by avoidable stimuli such as 
      1. fever
      2. hot baths
      3. stress
      4. sun exposure.
  9. offers a prognosis
    1. that, expressed as outcome, is difficult to predict for individuals, though 
      1. most persons with the condition continue with minimal disability for 20 or more years and are variously able to 
        1. walk 
        2. work
      2. typically have the best outlook if they 
        1. are female
        2. were aged under 30 years when the condition began 
        3. experience episodes infrequently 
        4. have the relapsing-remitting type
        5. have imaging studies indicative of limited disease
    2. that, expressed as life expectancy, results in little or no shortening of life span even though the condition is chronic and incurable.
  10. involves social considerations
    1. because persons with a support system are often able to remain in their home
    2. that invoke support organizations 
      1. in Canada, which include
      2. in the US, include

Multimedia and images

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with multiple sclerosis but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice.

For multiple sclerosis, comorbid conditions, complications and associated conditions are as follows.

Resources consulted 

  1. Psychiatric and psychological comorbid conditions, complications and associated conditions include 
    1. depression, anxiety, psychosis, and behavioural problems, which 
      1. may complicate diagnosis and treatment
      2. may result in under-recognition and sub-optimal treatment of multiple sclerosis 
      3. require consideration of multiple causes, including 
        1. the multiple sclerosis itself
        2. primary psychiatric disorders
        3. dementia, a set of symptoms associated with changes in particular parts of the brain (CDHO Advisory)  
        4. side effects of treatment of both the mental condition and the multiple sclerosis
        5. other psychological factors
      4. may benefit from psychotherapy and social support as adjunctive treatment
      5. result in symptoms such as headache that are more likely to be associated with a comorbid condition than with the multiple sclerosis
      6. may delay diagnosis or complicate disability assessment because of
        1. behaviour-related factors such as smoking and obesity 
        2. depression, which should be considered specifically as a possible factor in
          1. self-assessments of quality of life
          2. attitudes to treatment and self-care.
  2. Physical comorbid conditions, complications and associated conditions include
    1. diminishing ability for self-care
    2. medication side effects 
    3. osteoporosis (CDHO Advisory)  
    4. pressure sores
    5. reliance on indwelling urinary catheters
    6. swallowing problems
    7. urinary tract infections.
  3. Limited evidence suggests that autoimmune diseases tend to co-occur, though the topic is a complex one and the subject of intense research; one study suggested an unexpected inverse relation between multiple sclerosis and rheumatoid arthritis.

Oral health considerations

Resources consulted

Dental hygienists should take account of the factors of multiple sclerosis that are relevant to oral health and oral healthcare, as follows.

  1. Symptoms 
    1. of some relevance to the Procedures include
      1. physiological fatigue, which may be exacerbated by the stress of a prolonged treatment session in a warm environment
      2. the presence or absence of a sense of wellbeing and good quality of life, supported by attention to oral self-care, assisted or otherwise
    2. that may interfere with the patient/client’s efforts to brush and floss, include
      1. facial pain 
      2. fatigue
      3. paresthesia with or without pain in the hands 
      4. spasticity
      5. tremor
      6. weakness.
  2. Strategies and assistive devices include
    1. help from a family or other caregiver with brushing and flossing
    2. attention to dry mouth caused by some medications
    3. toothbrushes with modified handles 
    4. electric toothbrushes and flossing devices
    5. combating fatigue by 
      1. sitting to brush and floss if standing is tiring
      2. flossing in bed or, after a period of rest
    6. a weighted glove while brushing to manage tremors.
  3. Oral healthcare visits should be organized with the intention of
    1. reduction of the challenges of fatigue, poor balance, spasticity, and transportation by
      1. alerting the patient/client to office building accessibility procedures
      2. ensuring that the patient/client’s special needs are known to office staff before the appointment
      3. considering the availability of a dental chair that is sufficiently accessible 
      4. advising on extra rest for the patient/client prior to and after the appointment
      5. scheduling appointments for a time of day when the patient/client normally feels most rested
    2. facilitation of access to dental treatment services and assistance with daily oral healthcare by
      1. exploring the availability of special services or funding for oral healthcare for persons with special needs, and their caregivers
      2. ensuring that appropriate oral health assessments are performed and reported to the community care services access coordinator for patients/clients resident in the community or in long-term care facilities.

MEDICATIONS SUMMARY

Sourcing medications information

  1. Adverse effect database
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications.
  4. Information on herbals and supplements 
  5. Complementary and alternative medicine

Types of medications

Resources consulted

Medications

  1. Disease-modifying, immunomodulatory medications, which
    1. impact the underlying disease
      1. are classed as immunomodulators
      2. generally target some part of the inflammatory process 
      3. generally aim at preventing the inflammation that causes relapses 
    2. include Health Canada approved, Food and Drug Administration (USA) approved, and off-label use medications that reduce the frequency and severity of multiple sclerosis relapses; some may slow the progression of disease or disability
  2. Steroids
    1. help to decrease the severity and duration of relapses by suppressing the areas of acute inflammation in the spinal cord and brain 
    2. do not affect the long-term course of the condition
    3. have various side effects if taken for lengthy periods
    4. are used for short periods to relieve symptoms of relapse and to speed healing
    5. include
  3. Medications for symptomatic treatment of 
    1. bladder problems (bladder muscle overactivity)
    2. fatigue
    3. neuropathic pain and paresthesias
    4. spasticity
    5. vision problems, treated  by oral steroids (e.g., prednisone) preceded by a short course of

Side effects of medications

See the links above to the specific medications.

THE MEDICAL AND MEDICATIONS HISTORY

The dental hygienist in taking the medical  and medications history-taking should 

  1. focus on screening the patient/client prior to treatment decision relative to
    1. key symptoms
    2. medications considerations
    3. contraindications
    4. complications
    5. comorbidities
    6. associated conditions.
  2. explore the need for advice from the primary or specialized care provider(s).
  3. inquire about
    1. pointers in the history of significance to the provision of oral healthcare and oral self-care, such as
      1. fatigue
      2. poor balance
      3. spasticity
      4. tremor
      5. weakness
      6. vision problems.
    2. symptoms indicative of psychiatric and psychological comorbid conditions, dementia, complications and associated conditions.
    3. the patient/client’s understanding and acceptance of the need for oral healthcare.
    4. medications considerations, including over-the-counter medications, herbals and supplements.
    5. problems with previous dental/dental hygiene care.
    6. problems with infections generally and specifically associated with dental/dental hygiene care.
    7. the patient/client’s current state of health.
    8. how the patient/client’s current symptoms relate to
      1. oral health
      2. health generally
      3. recent changes in the patient/client’s condition.

IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE

Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

The dental hygienist should

  1. record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number
  2. obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider
  3. use a consent/medical consultation form, and be prepared to securely send the form to the provider
  4. include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.

UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS

Infection Control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

  1. the CDHO’s Infection Prevention and Control Guidelines (2022)
  2. relevant occupational health and safety legislative requirements
  3. relevant public health legislative requirements
  4. best practices or other protocols specific to the medical condition of the patient/client.

DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED

  1. There is no contraindication to the Procedures  for most patients/clients. Exceptions include: active MS episode (exacerbation/relapse) and/or manifestations that may affect safety of procedures; and significant immunosuppression resulting from medications used to treat acute exacerbations (i.e., steroids) or used to modify disease course (i.e., immunomodulatory drugs). 
  2. With a healthy patient/client whose symptoms are under control and whose treatment is proceeding normally, the dental hygienist should implement the Procedures, though these may be postponed pending medical advice, which is likely to be required if the patient/client has
    1. symptoms or signs of an active episode or exacerbation of multiple sclerosis
    2. a history of comorbidity, complication or an associated condition of multiple sclerosis
    3. not recently or ever sought and received medical advice relative to oral healthcare procedures
    4. recently changed significant medications, under medical advice or otherwise
    5. recently experienced changes in his/her medical condition such as medication or other side effects of treatment
    6. is deeply concerned about any aspect of his or her medical condition.

DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES

Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.

First-aid provisions and responses as required for current certification in first aid.

RECORD KEEPING

Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2) for a patient/client with a history of multiple sclerosis, the dental hygienist should specifically record

  1. a summary of the medical and medications history
  2. any advice received from the physician/primary care provider relative to the patient/client’s condition
  3. the decision made by the dental hygienist, with reasons
  4. compliance with the precautions required
  5. all Procedure(s) used
  6. any advice given to the patient/client.

ADVISING THE PATIENT/CLIENT

The dental hygienists should 

  1. urge the patient/client to alert any healthcare professional who proposes any intervention or test to 
    1. his or her history of multiple sclerosi
    2. the medications he or she is taking.
  2. should discuss, as appropriate 
    1. the importance of 
      1. checking the mouth regularly for new signs or symptoms
      2. reporting to the appropriate healthcare provider any changes in the mouth
    2. the need for regular oral health examinations and preventive oral healthcare 
    3. oral self-care including information about 
      1. choice of toothpaste
      2. tooth-brushing techniques and related devices
      3. dental flossing
      4. mouth rinses
      5. management of a dry mouth 
    4. the importance of an appropriate diet in the maintenance of oral health
    5. for persons at an advanced stage of a condition or debilitation
      1. regimens for oral hygiene as a component of supportive care and palliative care
      2. the role of the family caregiver, with emphasis on maintaining an infection-free environment through hand-washing and, if appropriate, wearing gloves
      3. scheduling and duration of appointments to minimize stress and fatigue
    6. comfort level while reclining, and stress and anxiety related to the Procedures
    7. medication side effects such as dry mouth, and recommend treatment
    8. mouth ulcers and other conditions of the mouth relating to multiple sclerosis, comorbidities, complications or associated conditions, medications or diet
    9. pain management.

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

  1. Promoting health through oral hygiene for persons who have multiple sclerosis.
  2. Reducing the adverse effects, such as stress and exacerbation of fatigue, by
    1. generally increasing the comfort level of persons in the course of dental hygiene interventions 
    2. using appropriate techniques of communication
    3. providing advice on scheduling and duration of appointments.
  3. Reducing the risk that oral health needs are unmet.

POTENTIAL HARMS

  1. Causing  injury from falls in the dental office through failure to recognize the patient/client’s problems with balance.
  2. Performing the Procedures at an inappropriate time, such as 
    1. when the patient/client’s physiological fatigue may be exacerbated by the stress of a prolonged treatment session in a warm environment
    2. in the presence of comorbidities, complications and associated conditions for which prior medical advice is required (such as medication-induced immunosuppression)
    3. in the presence of acute oral infection without prior medical advice.
  3. Disturbing the normal dietary and medications routine of a person with multiple sclerosis.
  4. Inappropriate management of pain or medication.

CONTRAINDICATIONS

CONTRAINDICATIONS IN REGULATIONS

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III

ORIGINALLY DEVELOPED

2009-10-27

DATE OF LAST REVIEW

2011-07-01; 2020-04-08

ADVISORY DEVELOPER(S)

College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists

SOURCE(S) OF FUNDING

College of Dental Hygienists of Ontario

ADVISORY COMITTEE

College of Dental Hygienists of Ontario, Practice Advisors

COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY

Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow
MD, MHSc, MBA, DTM&H, CHE, CCFP, DABPM, LFACHE, FCFP, FACPM, FRCPC

Lisa Taylor
RDH, BA, MEd

Kyle Fraser
RDH, BComm, BEd, MEd

ACKNOWLEDGEMENTS

The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande
Final layout and proofreading

© 2009, 2011, 2020 College of Dental Hygienists of Ontario

FOOTNOTES

1 Persons includes young persons and children.
2 At the time of this update (April 2020), endovascular surgical intervention (“liberation procedure” or venoplasty) has not been proven to be effective for the management of MS. In fact, the preponderance of research findings to date suggest that what is termed chronic cerebrospinal venous insufficiency (CCSVI) is not associated with MS, and venoplasty is ineffective for the treatment of MS.