49 year old married female with multiple sclerosis. She is very open to discuss her disease and the impact it has on her life. She practises yoga and relaxation therapy. A friend of hers mentioned that MS was caused by mercury toxicity from dental amalgam fillings. Her chief complaints were sensitivity to hot, cold in her upper left lower right quadrant, bleeding gums, possible amalgam removal and dry mouth. Client used to see her dentist regularly for dental check ups but stopped all of a sudden. Her last dental visit was at a Dental Hygiene College 3 years ago. In 1976 She reported to have trigeminal neuralgia that lasted about 2 months, and previous use of cigarettes and marijuana from (1974 to 1988). She also reported to have problems with urine leakage. She sees her physician and neurologist bi-annually. Her vital signs were within normal limits, she was hospitalized two times due to acute MS episodes one in 1978 and the other in 1992. She reported taking medication to prevent the progression of MS, and gets injected every other day with Betaseron 5mg and Copaxone 20mg; diazepam 1mg twice daily; ibuprofen 800mg three times a day and baclofen 10 mg four times a day. Dry mouth is a frequent side effect of these medications. Client is disabled she must use a walker to walk. Fatigue has affected her oral hygiene before bedtime so she often brushes only in the morning. This client lacks manual dexterity and coordination due to the numbness and pain in her hands. Her diets consist of fried foods and lots of soda.
Clinical Assessment Data
On the first appointment the following things were completed. Extra and intraoral, periodontal hard tissue examination, a full mouth serious, intraoral photographs were taken and homecare practices were observed and discussed. Significant findings included the following.
Extraoral: Unilateral swelling on the right side of the face; bilateral firm masseter muscles; TMJ crepitation; occasional pain upon opening mouth in the morning and nocturnal bruxing.
Intraoral: Linea Alba bilateral 6mm on both sides; small tori on the palate and decreased salivary flow. Moderate subgingival calculus with grayish extrinsic stains.
Periodontal: Generalized 2-6 mm probing depth and localized 5mm readings on the posterior interproximal areas; furcations located on 16,14,47,46. Bleeding upon probing on all posterior teeth.
Hard Tissue: Generalized slight attrition. Multi surface restorations on most posterior teeth.
Plaque Control Record: Plaque-free score 75%; Radiographs: Generalized bone loss 10 to 30% horizontal bone loss; localized slight vertical bone loss in posterior; visible calculus spicules; suspected caries on #15 under restoration.
Nutrition: Meal pattern consist of breakfast, snack, lunch, snack, dinner, snack. Calorie intake is inadequate. Food Groups consumed daily are mainly Meat and alternatives. Fat intake high. Body weight above healthy. Activity level low.
Social: Regardless of having MS client feels her overall health is good. The client has no insurance, so that’s why she has been avoiding dental care but she is ready to make a lifestyle change. She has a support system to aid her with transportation
Dental hygiene treatment care plan
1. Take vital signs at each appointment to ensure that V/S are WNL
2. Update medical history for any possible contraindication to treatment.
3. Review her medication intake to determine any side effect that might compromise the treatment.
4. Book the patient at morning appointments since morning appointments tempt to be less stressful to patients with neurological problems.
5. Ensure a quite and relaxant environment for the patient during the appointment.
6. Allow multiple brakes during the appointment to help relaxing her facial muscles and allow necessary frequent urination.
7. Minimize fatigue by complying with the patient daily regime and comfort during treatment (positioning the chair in the most comfortable position for the patient).
8. Monitor oral conditions that are associated with client at every appointment and make referral if necessary, (to determine any intra extra oral changes that might compromise treatment or patient health).
9. Use clorhexidine prior to treatment to reduce bacterial flora within the oral cavity.
10. Debridement of calculus and plaque by ultrasonic (One quadrant at the time) to reduce the scaling time. 1-2 appointments.
11. Debridement by hand scaling ( one quadrant at the time) to make sure that all the calculus and dental plaque left after using ultrasonic is removed. 1-2 appointments
12. Selective polishing to selectively remove intristic stain. (Whiter teeth are associated with beauty and a healthier lifestyle)
13. Use fluoride rinse Neutral sodium 2% to help re mineralize clients teeth.
14. Take an impression on lower anteriors to fabricate a mouthguard that will prevent further attrition on the lower anteriors due to buxism.
15. Referral to DDS for restoration due to clients request to replace old amalgam fillings with white restoration material
16. Diet counseling to increase salivary flow. ( during intra oral examination xerostomia was evident possibly from medication side effects)
17. Consider Local anesthetic ( Lidocaine 2% in case Topical anesthetic 2% is not enough in making client comfortable during the appointment.
1. Prescribe antisensitivity toothpaste to eliminate sensitivity to hot and cold.
2. Suggest increasing of H2o consumption to increase salivary flow in the oral cavity.
3. Client will be educated in the relationship that MS has on her oral cavity to increase her cognitive knowledge towards OSC (for example bruxism, subluxation, crepitation, xerostomia).
4. Discuss the relation between MS patients and the high risk of caries activity.
5. Demonstrate floss and brushing aids to the client. ( proxy brush, floss aid, modified brush handles.) to improve patients OSC skills.
6. Use disclosing agent to show to the client the problematic areas that are missed during at home oral self care. This will increase the awareness of the client to the present oral situation.
7. Suggest powered toothbrush to increase the brushing time due to clients compromised plaque removal skills.
8. Suggest different modifications to the OSC aids that client will feel comfortable with, to increase comfort in grasping oral aid handles
9. suggest water pick to allow a certain degree of independence in cleaning interproximal areas from plaque.
10. Suggest different physical activities ( like yoga) to improve the dexterity that will help client with self oral care.
Multiple Sclerosis and Dental Hygienist
Treating patients with MS provides dental hygienists with many opportunities to learn. The multiple links between oral conditions and MS symptoms enable dental hygienists to fulfill their roles as primary holistic health care providers. MS is the most prevalent demyelinating disease of the CNS, and the third leading cause of neurological disability in the United States. For patients presenting with MS, the dental hygienist can contribute by promoting both physical and oral comfort. Appointments that accommodate special physical needs and treatment plans that offer meaningful health promotion and disease prevention plans are ways to foster MS patient compliance. Current knowledge about MS symptoms, etiology, physical limitations, treatments, and CAM will aid the dental hygienist in providing optimal care.