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"When did you last see your dentist?" - the oral health of people with multiple sclerosis

Wendy Baird, Department of Epidemiology and Public Health, University of Leicester

Way Ahead 2004;8(1):6-7

Oral health is defined as a standard of health of the oral and related tissues, which enables an individual to eat, speak, and socialise without active disease, discomfort or embarrassment and which contributes to general well-being. 1 Poor oral health can result in a negative response from others and lead to poorer social functioning in general regardless of health status.2

People with multiple sclerosis (MS) are not more susceptible to dental decay than the general population. However, they do have special needs in relation to dental care3 because they often face difficulties in maintaining oral health and accessing care due to their symptoms. 4, 5 It is these difficulties that place them at greater risk of developing oral health problems. 6 Their symptoms may also impact on their ability to endure even simple dental treatment. The nature of a condition such as MS will mean that problems maintaining oral health may only be present during a relapse or become a problem as the severity of symptoms increase. It is particularly important for people with MS to avoid dental infection and trauma in view of the possible trigger to relapse this may represent. 7, 8

Many patients with MS are taking long-term medication such as steroids and diuretics to control their symptoms, which can have a significant impact on their oral health by causing a dry mouth. Having a dry mouth can make eating, talking and wearing dentures more difficult. People with a dry mouth are also more at risk of tooth decay, infection and gum disease. The frequent intake of sugar through drinks and mints to relieve the symptoms of a dry mouth also increases the risk of dental decay.

Their need for oral health care often goes unmet and as a consequence they are at risk of unavoidable dental pain. Dental care for people with MS has been poorly co-ordinated which is probably related to the fact that both those who care for them and the wider NHS has failed to perceive their dental needs as being important.

Recent studies in Leicestershire9 highlighted the fact that oral health was very important to the overall quality of life of people with MS (Box 1). The main barrier was a lack of information on services available and a lack of awareness of the impact that having MS might have on their oral health. It is this lack of awareness that has resulted in the oral health of people with MS being overlooked by health professionals with the belief that it is someone else's responsibility. The significance of this is greatest when the individual is dependent on someone else to make decisions about their health.

Health professionals receive little training on the importance of oral health,10 therefore, they feel unqualified either to carry out oral health care or to train auxiliary staff to do it. However, it has been shown that with adequate training of caregivers, significant improvements can be achieved in the oral health of institutionalised elderly people.11

Box 1. Quotes from people with MS who took part in focus group discussions about the importance of oral health and barriers to attending the dentist.

Importance of oral health

  • "Well it's important to everybody really isn't it"
  • "It's like everything else, if you get an infection in your mouth it's going to have an effect on your MS and your general health"
  • "I don't feel clean, the first thing I do when I get out of bed is brush my teeth"
  • "Brushing your teeth is as good as a wash"
  • "When I was in hospital (with a relapse) they never asked if I needed any help brushing my teeth"
  • "The hospital provided me with the thick handled knives and forks when my hands went, nothing was said about toothbrushes"
  • "We have to take such a lot of medication we should be assured of getting some information about whether this medication will affect our teeth, not everybody with MS has got plastic teeth"
  • "I think they (the government) should make people more aware that they should see the dentist"

Barriers to attending the dentist

  • "We are left to find our way ourselves in the dark"
  • "I find out more from the day centre than I do from anyone else"
  • "If everyone knew about MS it wouldn't be a problem"
  • "It wouldn't just be access to the building it would be getting there"
  • "If I wanted an X-ray that would cause a problem as the x-ray room is upstairs"
  • "Dentists are frightened of treating people with disabilities"

With the emphasis on providing integrated health and social services it is important that oral health is considered an essential part of any framework for providing care for people with MS (Box 2). Routine health assessments should also include an oral health assessment. This will help identify people who are having difficulty maintaining their oral health and those who are not receiving routine care. An oral health care plan should also be developed for each individual patient.

People with MS are particularly vulnerable and frequently suffer unnecessary pain and extractions because they are not made aware of the potential impact MS can have on their oral health. Oral health is rarely included in assessments of health status or when planning pathways of care because it is commonly believed that people with MS pay little importance to having good oral health. It is believed that something as simple as their oral health cannot feature high on their priorities when they suffer such a range of debilitating conditions. The fact that people with MS have never been previously consulted confirms that what the patient regards as important can be very different from what the professional regards as important. Targeted information on prevention alone would help improve oral health of people with MS.

Box 2. What would help improve the oral health of people with MS?

  • Provide information on locally available dental services
  • Increase awareness on the impact MS may have on oral health
  • Understand the impact of side effects of medication on oral health
  • Suggest adaptations to toothbrushes for people with manual dexterity problems
  • Use an electric toothbrush if suffering from weak limbs or fatigue
  • Train caregivers to provide oral health care if required
  • Refer to dental team for advice on oral hygiene, use of mouthwashes, training on caring for someone else's oral health and the use of saliva substitutes
  • Include oral health in any routine health assessment or on admission to hospital/ care homes
  • Incorporate a member of the dental team onto the group responsible for planning an integrated system of care to ensure routine dental care is provided
  • re that oral health care is performed as part of the personal care package delivered by caregivers

References

  1. Department of Health. An oral health strategy for England. London: HMSO;1994.
  2. Gift HC,.Redford M. Oral health and the quality of life. Clinic Geriatr Med 1992;8(3):673-83.
  3. Fiske J, Griffiths J, Thompson S. Multiple sclerosis and oral care. Dent Update 2002;29(6):273-83.
  4. Cnossen MW. Considerations in the dental treatment of patients with multiple sclerosis. J Oral Med 1982;37(2):62-4.
  5. Griffiths JE,Trimlett HJ. Dental status and barriers to care for adults with multiple sclerosis. Int Dental J 1996;46:445.
  6. McGrother CW, Dugmore C, Phillips MJ et al. Multiple sclerosis, dental caries and fillings: a case-control study. Br Dent J 1999;187(5):261-4.
  7. Rapp NS, Gilroy J, Lerner AM. Role of bacterial infection in exacerbation of multiple sclerosis. Am J Phys Med Rehab 1995;74(6):415-8.
  8. Bamford CR, Sibley WA, Thies C et al. Trauma as an etiologic and aggravating factor in multiple sclerosis. Neurology 1981;31(10):1229-34.
  9. Baird WO. Dental attendance pattern of people with MS. MSc Leicester 2003.
  10. Adams R. Qualified nurses lack adequate knowledge related to oral health, resulting in inadequate oral care of patients on medical wards. J Adv Nurs 1996;24(3):552-60.
  11. Frenkel HF, Harvey I, Newcombe RG. Improving oral health in institutionalised elderly people by educating caregivers: a randomised controlled trial. Community Dent Oral Epidemiol 2001;29(4):289-97