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FACT SHEET: Multiple Sclerosis (also known as “MS” and “multiple cerebrospinal sclerosis”)

Date of Publication: May 19, 2015
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Is the initiation of non-invasive dental hygiene procedures* contra-indicated?

  • No.

Is medical consult advised?  

  • No, assuming patient/client is already under medical care for multiple sclerosis, which is well controlled.
  • Yes, if undiagnosed or poorly controlled multiple sclerosis is suspected.

Is the initiation of invasive dental hygiene procedures contra-indicated?**

  • Possibly, but not typically. See below.

Is medical consult advised? 

  • Possibly (depends on severity and level of control of the disease, particularly if there is an active episode). The dental hygienist should direct an undiagnosed patient/client with clinical findings suggestive of MS to an appropriate healthcare provider for a definitive diagnosis (typically a primary care physician, who in turn can refer to a neurologist).1 

Is medical clearance required? 

  • Possibly (e.g., if there is an active episode and/or there are manifestations that may affect safety of procedures). Medical clearance may be required if patient/client is being treated with medications associated with immunosuppression +/- increased risk of infection (e.g., oral or intravenous corticosteroids [such as prednisone or methylprednisolone for acute exacerbations] and/or disease-modifying, immunomodulatory drugs [such as natalizumab, ocrelizumab, alemtuzumab, interferon, glatiramer, mitoxantrone, ofatumumab, teriflunomide, dimethyl fumarate, monomethyl fumarate, fingolimod, siponimod, ozanimod, ponesimod, and cladribine]).

Is antibiotic prophylaxis required?  

  • No, not typically (although extended use of corticosteroids and/or immunosuppressants may warrant consideration of antibiotic prophylaxis).

Is postponing treatment advised?

  • Possibly, but not typically (depends on severity and level of control of the disease, including whether there are signs/symptoms of an active episode or exacerbation of MS, as well as whether there is a need for medical clearance for patients/clients on medications associated with immunosuppression). Elective professional oral care should be scheduled during periods of remission as applicable and to the extent reasonably possible. Patients/clients experiencing a relapse should have their routine dental hygiene care postponed in most circumstances.

Oral management implications

  • The patient/client with multiple sclerosis should be evaluated to determine the severity and level of control of the disease, as well as the types of medications being used. 
  • Patients/clients with stable disease and little motor spasticity or weakness can receive routine dental hygiene care. Persons with more advanced MS may require assistance in transferring to and from the dental chair, and wheel chair accessibility may be necessary. Positioning adjustments may need to be made if patients/clients have myofascial and/or neck pain. Patients/clients taking muscle relaxants (e.g., baclofen and benzodiazepines) are at increased risk of dizziness, hypotension, and ataxia, and the supine chair position may need to be avoided.
  • If the patient/client’s eyes are sensitive to the dental light, darkened protective glasses can be worn during treatment. Assistance may be required for patients/clients with vision problems as they enter or leave the clinic.
  • Severe fatigue is common, particularly after an ordinary day’s activities. Therefore, the patient/client with MS should usually be booked for short appointments in the morning. Mouth props can be used to minimize strain on masticatory muscles. As well, a comfortable, quiet, relaxed environment may reduce patient/client stress.
  • Because the patient/client with MS may be sensitive to heat, the clinic room temperature should be kept cool. As well, washroom breaks may be needed if the patient/client has bladder or bowel incontinence. 
  • Patients/clients with MS often take anti-inflammatory medications, corticosteroids, immunomodulators, and other medications which can impact oral care (see above and below).
  • Oral hygiene in patients/clients with MS can be limited due to neurological deficits, such as motor deficits, cognitive dysfunction, visual disorders, and pain. Some patients/clients may report good oral self-care and hygiene, which are not borne out upon objective evaluation.
  • Oral self-care instructions should include adaptations for ambulation problems, muscle weakness, tremors, and vision disturbances. Power or modified manual toothbrushes may be easier for the patient/client to use, and sitting to brush and floss is less tiring than standing. Saliva substitutes and other measures are indicated for xerostomia2.
  • Various infections may stimulate relapses of MS symptoms. Thus, the prevention of oral infections via frequent dental hygiene appointments may prevent disease exacerbation.  
  • As MS progresses, the patient/client loses muscular coordination, and oral hygiene care becomes increasingly difficult. Involvement of the tongue and facial muscles interferes with self-cleansing mechanisms in the oral cavity.
  • Severe upper extremity intention tremor and/or muscle weakness/spasticity, as well as sensory changes in the hands (i.e., numbness, tingling, or pain), make simple self-care tasks, including oral hygiene activities, difficult or impossible. Hand tremors can be managed by wearing a weighted glove while brushing teeth.   
  • There is no substantive evidence that mercury from dental amalgam causes MS or that removing dental amalgam improves the course of MS.3

Oral manifestations

  • Disease-related orofacial manifestations affect up to 90% of persons with MS. These include dysfunction of the tongue, facial muscles, and temporomandibular joint (the latter including pain, difficulty opening the mouth, and TMJ sounds); numbness of the orofacial structures (including lip and chin); dysarthria (in MS, characterized by slow irregular speech with unusual separation of syllables of words — termed scanning speech); dysphagia (i.e., chewing and swallowing difficulties); and facial pain. Some studies also report bruxism, dental hypersensitivity, and xerostomia.
  • The orofacial region may be the site of initial signs/symptoms of MS, including those of relapses. In relapses, attacks usually last for at least 24 hours with an average of 3 times per year. Common presentations include mild dysarthria, Lhermitte sign (transient electric shock sensation down the spine with neck flexion), intermittent unilateral facial numbness or pain, and facial palsy or spasm.4
  • During an acute attack of MS, the patient/client may experience facial paresthesia, and muscles of facial expression can undulate in a wavelike motion termed myokymia (which feels like a “bag of worms” on palpation).
  • Trigeminal neuralgia5 (TN, also known as tic douloureux) is much more likely to occur among persons with MS than in the general population, and it is often one of the first manifestations of disease. Unlike conventional trigeminal neuralgia, tic douloureux caused by MS can be bilateral. The orofacial pain — which may resemble pain of dental origin — is paroxysmal, throbbing, and “electric shock-like”. It can be provoked by touching the cheek, tooth brushing, or mastication. Although the pain lasts for only a few seconds, it is usually severe and can recur several times during the day. 
  • Glossopharyngeal neuralgia6 (GN) is another typical expression of neuropathic pain in MS. In GN, patients/clients report unilateral, abrupt, severe pain in the throat or ear that lasts seconds to minutes. The pain is often provoked by swallowing, talking, yawning, coughing, and eating spicy foods. The stabbing pain of GN may remit and relapse similar to TN.
  • Other orofacial manifestations include trigeminal neuropathy7 (TNO), hemifacial spasms, facial paralysis, and Charcot triad8.
  • Prevalence of periodontal disease is high, but studies are contradictory regarding the prevalence of caries.
  • Medications used to manage MS and its complications may cause side effects such as xerostomia (e.g., anticholinergics for bladder control or tricyclic antidepressants for depression, and antispasmodics/muscle relaxants); gingival hyperplasia (e.g., phenytoin for pain management of trigeminal neuralgia); gingivitis; angular cheilitis; and dysgeusia (altered taste). Ulcerative stomatitis and salivary gland enlargement may result from treatment with glatiramer acetate injection, and mitoxantrone infusion may cause mucositis and stomatitis.
  • Oral candidiasis may result from xerostomia, difficulty in keeping the mouth clean, and corticosteroids used to treat relapses.
  • Patients/clients on long-term immunosuppressant treatment have an elevated risk of oral squamous cell carcinoma and lymphoma.

Related signs and symptoms

  • MS is the most common progressive and disabling neurologic condition affecting young adults. It is typically diagnosed in persons aged 15 to 40 years. MS predominantly affects persons of northern European background (with women being affected two to four times more commonly than men), and it is more common in the cold and temperate climates of higher latitudes, including Canada.9 More than 90,000  Canadians have multiple sclerosis. No cures exist.10
  • MS is a central nervous system (CNS) disorder in which there is ongoing destruction — autoimmune-mediated (with or without possible triggering infectious agent) — of the myelin sheath of nerve axons. This demyelination leads to neurologic signs and symptoms that accrue over time. The white matter of the cerebral hemispheres, brainstem, cerebellum, and spinal cord are vulnerable; the peripheral nervous system is not affected.
  • The natural progression of MS is unpredictable. Clinically isolated syndrome refers to a single (perhaps initial) episode of neurological signs/symptoms suggestive of MS. In most persons, the disease is initially relapsing-remitting (RRMS — “on again, off again”), with transition to a slow and relentless chronic progression (secondary progressive, or SPMS) within 10 to 20 years of diagnosis in 20% to 40% of RRMS cases. However, in some persons MS maintains a relapsing-remitting course indefinitely, and in others the course is relatively benign, with the patient/client having only one or a few mild exacerbations and no or minimal functional disability. By contrast, about 15% of people with MS have primary-progressive MS (PPMS)11, characterized by a slow accumulation of disability, without, or with relatively few, discrete exacerbations. 
  • Infection, surgery, and trauma are associated with a worsening of MS. Fever, significant physical exertion, hot weather, a hot bath or shower, and sunlight exposure may cause a transient, reversible worsening of symptoms. 
  • Motor signs/symptoms are common, including muscular weakness and spasticity; ataxia (lack of voluntary coordination of muscle movements); scanning/halting quality of speech; and upper extremity intention tremor. 50% of persons with MS need help to walk within 15 years of disease onset; continued muscle atrophy can lead to wheelchair use or bed restriction with consequent increased risk for pneumonia. 
  • Sensory signs/symptoms include numbness, tingling, impairment of temperature sensation, impairment of proprioception (i.e., abnormal sense of one’s own position, posture, and equilibrium), and chronic pain.
  • Occipital neuralgia, somewhat analogous to trigeminal and glossopharyngeal neuralgias, is a paroxysmal pain syndrome that affects the occiput (i.e., back of the head).
  • Dysfunction of the bladder (e.g., overactive bladder, urinary incontinence, urinary retention, and bladder infection), bowel (e.g., constipation and fecal incontinence), and sexual dysfunction (e.g., erectile dysfunction and pain) can result from nerve conduction disturbance.   
  • Visual disturbances (e.g., impaired visual acuity and colour vision, visual field defects, double vision, and pain in or behind the eye) are common. Photophobia may also occur. Optic neuritis (i.e., inflammation of the optic nerve) involving temporary blindness is sometimes the first presenting sign/symptom.
  • Depression and emotional instability often accompany MS, and there may also be cognitive impairment.
  • Some medications used to treat MS are immunosuppressants, and these place patients/clients at increased risk for opportunistic and community-acquired infections and for the development of cancers (e.g., lymphoma with biologic response modifier drugs, and leukemia with mitoxantrone). Anemia (low red blood cell count), neutropenia (low white blood cell count) and thrombocytopenia (low platelet count) can also result from use of immunomodulators.
  • Most persons who have MS can expect a normal or near-normal lifespan, which is due to improvements in symptom management and disease-modifying therapies.

References and sources of more detailed information


Date: October 16, 2014
Revised: April 8, 2020; August 18, 2024


FOOTNOTES

1 Diagnosis of MS involves history, clinical examination, analysis of cerebrospinal fluid, evoked potential studies, and magnetic resonance imaging.
2 Some newer bladder muscle relaxant medications (e.g., mirabegron, which is a beta adrenergic agonist and not an anticholinergic) do not cause, or are less likely to cause, xerostomia in patients/clients requiring treatment for overactive bladder.
3 Having said this, the U.S. Food and Drug Administration (FDA) issued an official Statement in 2020 that stated “certain groups may be at greater risk for potential harmful health effects of mercury vapor released from the device. As a result, the agency is recommending certain high-risk groups avoid getting dental amalgam whenever possible and appropriate.” Persons with pre-existing neurological diseases such as MS, Parkinson disease, and Alzheimer disease were listed as being in a high-risk group. However, the FDA also advised against removing or replacing mercury-containing amalgam fillings if they are in good condition, unless deemed medically necessary. This was “because removing intact amalgam fillings can cause a temporary increase in exposure to mercury vapor and the potential loss of healthy tooth structure, potentially resulting in more risks than benefits.” FDA Statement, September 24, 2020
By contrast, the Canadian Dental Association Position on Dental Amalgam of 2021 states, “Current scientific evidence supports the use of dental amalgam as an effective and safe restorative filling material that provides a long-lasting solution for a broad range of clinical situations.” The CDA concurs, however, with the FDA regarding “unnecessary and ill-advised” replacement of “functional and serviceable dental amalgam fillings.” [CDA Board of Directors, Position Revision, February 2021]
4 Visual disturbances are also common during relapses.
5 The trigeminal (cranial 5) nerve innervates the anterior part of the head, and it divides into maxillary, mandibular, and ophthalmic branches.
6 The pain manifestations of glossopharyngeal neuralgia occur in the sensory distribution fields of the glossopharyngeal (cranial 9) or vagus (cranial 10) nerves (i.e., the base of the tongue, the tonsillar fossa, the ear, and/or beneath the angle of the jaw).
7 Trigeminal neuropathy refers to dysfunction of sensory or motor functions involving cranial nerve 5. TNO commonly manifests with sensory symptoms such as constant numbness in the region innervated by the trigeminal nerve, and it is sometimes associated with other constant paresthesias or pain. (The constant pain of TNO distinguishes the condition from trigeminal neuralgia, which is characterized by episodic pain.) Motor symptoms are less frequent, and they may present with masticatory weakness.
8 Charcot triad is a neurologic triad of: scanning or staccato speech; nystagmus (involuntary eye movement); and intention tremor (a tremor that occurs during directed and purposeful motor movement — such as coordinated movement of speech muscles and limbs — and which worsens before reaching target).
9 The causes of MS, its relapses, and progression are not fully understood, but genetics combined with other factors (e.g., vitamin D deficiency, certain viral infections, and smoking) may be implicated.
10 While various immunomodulatory, anti-inflammatory, antispasmodic, etc., medications are the mainstays of treatment, plasmapheresis (i.e., plasma exchange, to minimize damage from an ongoing MS attack) and deep brain stimulation (to reduce serious tremors) may be options for some persons.
11 PPMS includes the older category of progressive-relapsing MS (PRMS), in which about 5% of patients/clients with MS experience exacerbations with or without recovery and steadily worsening disease from the beginning.


* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.