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Providing Evidence-based Oral Health Care to

Individuals Diagnosed with Degenerative Disorders,

Part 1: Multiple Sclerosis
Melanie Simmer-Beck, RDH, PhD
Continuing Education Units: 2 hours

Online Course:

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.


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Multiple 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 Objectives

Upon 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
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

myelin forming scar tissue, commonly referred to

as demyelination. Demyelination episodes are
commonly referred to as relapses, exacerbations,
attacks, or flare-ups. Demyelination is
unpredictable and can trigger new symptoms or
worsen old ones.

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 of
Multiple Sclerosis
Appointment Management Considerations
Disability Etiquette
Course Test Preview
About the Author

As a consequence of demyelination, nerve

impulses, traveling through the central nervous
system are distorted and interrupted causing a
variety of visible and non-visible symptoms. The
reduced efficiency of the nerve impulses produces
motor and sensory abnormalities which can lead
to fatigue, weakness, numbness, incoordination,
imbalance, vision loss, bladder dysfunction, bowel
dysfunction, difficulty speaking, and cognitive
impairment. Symptoms vary from individual to
individual and may resolve completely (remission)
or remain and/or progress when scaring occurs

What is Multiple Sclerosis (MS)?

Multiple Sclerosis (MS), one of the most common

neurological disorders among young adults, is a
chronic, inflammatory, immune-mediated disease
of the central nervous system for which there is
currently no cure. MS is a disease that results
from individuals immune system attacking their
central nervous system (brain, spinal cord, and
optic 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

MS affects approximately 400,000 individuals in

the U.S. and 2.5 million individuals worldwide.
Diagnosis generally occurs between the ages of
20 and 50; however, it can also occur in children.2
The average age of MS disease onset is 30
years; though, this can vary widely depending on
the type of MS and ones gender. MS is more
common in women than men with an estimated
female to male incidence ratio of 1.4 to 2.3.3

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Signs and Symptoms of MS that May

Affect the Provision of Oral Health Care

There is evidence suggesting the incidence of

MS in females is increasing.4,5 It has been well
documented the incidence and prevalence of MS
varies geographically.6,7 The frequency of disease
is higher in the northern United States, southern
Canada, Europe, New Zealand, and southeast
Australia. Caucasian populations of European
descent appear to be most at risk for developing
the disease. In the United States the prevalence
is 0.1%. Northern latitudes were once thought to
increase the risk of developing MS; however, that
notion has been dispelled in recent years.3,4,8

Cognition is comprised of high-level brain functions
such 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 diagnosed
with MS will develop problems with cognition;
however, only 5-10% develops severe cognitive
dysfunction that interferes with activities of daily
living. Cognition dysfunction that interferes with
activities of daily living could affect an individuals
ability to effectively perform oral self-care. It could
also affect dental providers ability to adequately
secure informed consent from patients. Cognition
dysfunction typically progresses slowly and is more
common as the course of disease progresses. It
rarely reverses itself. It is hypothesized disease
modifying drugs help stabilize cognitive changes.17

Etiology/causative Agents of MS

The etiology of MS is thought to be multifactorial;

the interaction of a genetically susceptible
individual with one or more environmental
factors. 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 smoking
has been shown to exacerbate symptoms of
MS. It has also been shown to increase risk of
disease progression transforming from RRMS to

Difficulty in swallowing (dysphagia), a less
common symptom of MS, can occur at any stage
of the disease process. It occurs most often when
the disease has advanced. Often individuals may
not be aware it is occurring. Dysphagia results
from liquids and foods being inhaled into the
trachea and presents itself as coughing or choking
while eating and drinking. It can ultimately result
in aspiration pneumonia or lung abscesses. It
also puts individuals at risk for malnutrition and

Clinical Signs and Symptoms of MS

MS is a complex disease with multiple signs and

symptoms; fatigue, difficulty with memory and
concentration, 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 experience
altered 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 severity
from relatively benign to completely disabling
depending 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 oral
health care. These symptoms will be discussed
in further detail. Dental professionals may be the
first providers to treat individuals with MS prior to
diagnosis; therefore, the providers awareness of
initial symptoms is critical.

Emotional Disorders
Individuals diagnosed with MS routinely
experience mood disorders and affect disorders.
Figure 1 differentiates these two emotional
disorders. Typical mood disorders in MS include
major depressive disorder, anxiety disorders,
Mood Disorders: The study inner experience of
emotion that determines how someone feels in a
persistent, sustained way.
Affect Disorders: The changeable outward
expression of emotion and tend to fluctuate.
Figure 1. Emotional Disorders

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Table 1. Symptoms of Multiple Sclerosis.17

adjustment disorder, and bipolar disorder. Mood

disorders are a consequence of the interaction
of disease process, genetic predisposition,
and life events leading to a sense of loss and
grief. Mood disorders are more common in
individuals diagnosed with MS than in the general
population. For example, bipolar disorder occurs
in 13% of individuals diagnosed with MS and only
5% of the general population. Affect disorders
are a direct consequence of the MS disease
process. The most common of affect disorder
experienced by individuals diagnosed with MS is
periods 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 treat
emotional disorders; therefore, dental providers
need to thoroughly review the medications and
consider potential drug interactions prior to
prescribing additional medications, sedatives,
and local anesthetics. Dental providers need
to recognize that depressed patients may
lack interest in caring for themselves. This
could result in poor oral hygiene, malnutrition,
increased caries, and increased periodontal
disease. These effects may be compounded by

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Fatigue occurs in approximately 80% of individuals
diagnosed with MS. Fatigue can range from mild
to 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 condition
can be misinterpreted as depression and lack of
effort. Fatigue is thought to be the result of one or
more factors. Individuals may be sleep deprived
because of nocturnal muscle spasms or bladder
dysfunction. Individuals could also be drained
because they have to spend considerable effort
completing activities of daily living (e.g., dressing,
cooking, bathing, brushing teeth). Fatigue can also
occur as a result of depression. A unique form of
fatigue that occurs only in individuals diagnosed
with MS is called lassitude. This form of fatigue
occurs daily and may be present after a restful
nights sleep. It tends to be more severe than
typical fatigue. Lassitude is aggravated by heat
and humidity and can come on abruptly. This form
of fatigue will likely interfere with daily activities.17

important for dental providers because facial

muscle spasticity can lead to increased muscle
tone, muscle stiffness and spasm, decreased
coordination, discomfort, and pain.21 Spasm of the
bladder can create a feeling of urgency, causing
increased frequency of urination and the need for
appointment modifications.
Trigeminal Neuralgia
Trigeminal neuralgia, also known as tic
douloureux, is a condition that results from
irritating the trigeminal nerve. Trigeminal neuralgia
is an acute pain syndrome commonly known to be
an early presentation of MS. It is 20 times more
prevalent in individuals diagnosed with MS than
in 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 side
of 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, blowing
the nose, drinking hot or cold beverages, eating,
applying makeup, smiling or talking.25 The pain
routinely originates as a sensation of electrical
shocks 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

Pain Syndromes
Pain stemming from MS may present as
paresthesia (a sensation of tingling such as pins
and needles), dysesthesia (shock-like pain along
a nerve, burning, shooting electric-Lhermittes
Sign, throbbing), hyperesthesia (increased
sensitivity), facial twitching, itching, and/or
anesthesia (numbness, complete loss of sensation
of 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 oral
tissues which add to the complexity of oral health
care delivery. Anesthesia and paresthesia in upper
limbs and hands can interfere with oral self-care
and contribute to an increased risk for caries. It
is critical for dental professionals to be aware of
these different pain conditions so a differential
diagnosis can be made and appropriate care can
be rendered. In some instances, referrals may
be warranted. In addition, neuromuscular pain
may be secondary to a strain on the back for
other muscles from weakness, spasticity and poor

The pain of trigeminal neuralgia follows one of two

courses. Classic pain is intense and throbbing
with shock-like sensations. It is generally triggered
by a specific activity or touching an area of face
and there are definite periods of remission. In
contrast, atypical pain emerges as a constant,
dull, burning sensation that affects a large portion
of 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, Trigeminal
neuralgia is diagnosed more frequently in women
than men.25

Spasticity 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 during
the course of their disease.21 This symptom is

Trigeminal neuralgia usually begins unexpectedly;

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

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surgery. Most dental professionals do not believe

trigeminal neuralgia can be caused by dental
surgery. They believe initial symptoms, that were
already developing, were spontaneously triggered
by dental surgery. It is important for dental
professionals to perform a differential diagnosis
and not confuse trigeminal neuralgia with a dental
abscess. This could result in an unnecessary
root canal that brings no relief to the pain.25 The
Facial Pain Association advises MS should be
suspected and ruled out for anyone, under the
age of 40, who is diagnosed with trigeminal

patterns have been categorized into four courses

of disease.29-31 These are summarized in Table 2.

Medications to Modify the Course of


The underlying etiology of MS has been widely

disputed within the research community. Some
researchers consider MS an autoimmune,
inflammatory disease.32 Others, however believe
MS is a chronic metabolic disorder or that it
is a neurodegenerative disease by which the
bodys autoimmune response is reacting to
neurodegenerative 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.

Courses of Disease

The 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 illness
to a progressive, debilitating disease. Disease

Since 1993 the U.S. Food and Drug Administration

(FDA) has approved ten disease modifying

Table 2. Multiple Sclerosis Disease Characterizations.

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medications for the treatment of RRMS. These

medications have been shown to reduce the
number of relapses/exacerbations, decrease the
number of new lesions formed, and conceivably
slow the progression of disease. Table 3 outlines
dosing, warnings, and common side effects of
the disease modifying therapies approved by
the FDA. Nine of the therapies are considered
first line therapies. Five of the first line therapies
are dispensed by injection, three are dispensed
orally, and one is dispensed by IV. Tysabri
(natalizumab), the therapy dispensed by IV, is
generally reserved for people who see no results
from or cannot tolerate other types of treatments.
This is a monoclonal antibody was approved
for marketing by the FDA in 2004; however, in
2005 the manufacturer voluntarily suspended
marketing of the therapy after several reports of
significant adverse events. In 2006 the therapy
was 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, and
PRMS.35,36 Due to potential cardiac events and
leukemia Novantrone is rarely administrated to
people with MS.

Chelation therapy is an investigational therapy

placing man-made water soluble, amino acid
called EDTA, into the blood through a vein. The
EDTA binds to metallic ions such as mercury and
is excreted. To date, it is only approved to treat
lead poisoning.
Figure 2. Chelation Therapy

the symptoms of MS, it is not uncommon

for individuals to subscribe Eastern medical
philosophy. Roughly 75% of patients diagnosed
with MS employ complementary and alternative
medicinal (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 present
time CAMS are not typically approved by the
FDA, their safety is unknown, and the evidence
to support the benefits and risks of CAMs is
Cannabis (universally known as marijuana), is
one 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 professionals
must consider the possibility of marijuana use
when addressing pain management options for
patients diagnosed with MS and vital signs should
be taken prior to administering local anesthesia.42
Cannabis can also cause xerostomia, fiery red
gingivitis, white gingival patches, papilloma, and

Medications to Manage the Symptoms

of Multiple Sclerosis

At the present time, there is no cure for MS.

However, in addition to having effective strategies
to 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 provides
an exhaustive list of medications commonly
prescribed to manage MS symptoms and adverse
effects relevant to dental providers. There are
numerous 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 local

Removal of amalgam fillings followed by

chelation therapy is an invasive CAM that
dental 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 been
considered hazardous and alleged to cause
central nervous system disorders. It is not
unusual for patients to believe amalgams are the
cause of MS and request for them to be removed
in conjunction with chelation therapy. There is
no published scientific research that supports the

Conventional therapies are typically only

partially effective and as illustrated in Table4,
they have many side effects. Therefore, in
addition to utilizing western medicine to manage

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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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Table 4. Continued.

benefits of this therapy for individuals with MS.

The ADA, FDI World Dental Federation, and FDA
consider amalgam to be safe.43-45 The National
Multiple Sclerosis Society categorizes the removal
of dental amalgam as ineffective and chelation
therapy as ineffective and dangerous.46

Appointment Management

Elective dental treatments should be postponed

during exacerbations or flare ups of MS
Individuals diagnosed with MS are at elevated
risk for caries due to xerostomia, fatigue,
dexterity limitations, and muscle dysfunction of
the oral cavity.
Oral self-care instructions should be based on
the patients functional ability and values.
Cigarette smoking has been shown to increase
risk of disease progression transforming

from RRMS to PPMS and to exacerbate

symptoms. 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 in
order to treat patients with more progressive
disease symptoms. Consider providing oral
health 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 an
operatory near a restroom can make frequent
breaks easier on the patient.
Plan short appointments for patients who
experience trigeminal neuralgia or facial
discomfort. The shooting pain and discomfort


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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.

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 report
facial pain that cannot be explained. Dental
professionals are at an advantage to detect
early MS symptoms.

should offer assistance and be respectful of the

individuals response. When communicating with
an individual in a wheelchair make eye contact
by stepping back or sitting in a chair to have the
conversation. Do not lean on the individuals
wheelchair. Individuals with disabilities will
sometime utilize a service dog. Providers should
not interact or pet the service dog unless they are
invited to do so.

Disability Etiquette


Proper disability etiquette is continually evolving

as we learn more about providing care to, and
interacting with, individuals diagnosed with a
disability. The number one factor healthcare
providers need to be conscious of is the individual
always comes before the disability. This is called
People First Language. For example, you are
providing care to an individual diagnosed with
MS. You are not providing care to your MS
patient. Individuals do not want to be defined by
their disability. Keep in mind, the right language
should avoid prejudices, assumptions, and
stereotypes. Providers should focus on using
language that is respectful and courteous. Table
5 provides phrases dental professionals should try
to avoid and suggestions for making the statement
in a non-discriminatory, respectful way.48

MS is a complex disease with differing

presentations and patient needs. Organizations
are available to provide information about the
disease, identify support groups, offer financial
resources, outline the latest research, and provide
suggestions to promote activities of daily living
and independence. The below list provides a
starting point for dental professionals to identify
organizations that provide support to individuals
diagnosed with MS. Many of these organizations
have regional and local components that can
provide more individualized support.
Organizations that Support Multiple Sclerosis:
ADA National Network

Canine Companion for Independence

Proper disability etiquette should also avoid

making assumptions. Figure 3 provides a list
of assumptions commonly made that should be
averted. Providers should not assume a person
diagnosed with a disability needs help. They

Multiple Sclerosis Association of America

Multiple Sclerosis Foundation


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National Multiple Sclerosis Society

be aware of the initial signs and symptoms of the

disease. Individuals diagnosed with MS often
experience oral side effects from medications
they are taking to modify the course or disease
and/or manage symptoms. Providing patientcentered oral health care to individuals diagnosed
with MS can be a rewarding experience for dental
professionals when they understand the disease
variations, know how to make appropriate
appointment modifications, and appreciate how to
properly interact in a non-discriminatory manner
with patients diagnosed with MS.

National Service Animal Registry

Paws with a Cause

The Consortium of Multiple Sclerosis Centers


Dental 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 Preview

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

Multiple sclerosis is an _______________.


Which of the following is NOT a typical motor or sensory abnormality that individuals
diagnosed with MS may experience?


infectious disease of the central nervous system

immune-mediated disease of the central nervous system
infectious disease of the circulatory system
immune-mediated disease of the circulatory system

a. Hearing loss
b. Numbness
c. Fatigue
d. Bladder dysfunction


What is the painful sensation that occurs when the trigeminal nerve is aggravated?


Approximately ______% of individuals diagnosed with MS will develop problems with


a. Spasticity
b. Dysphagia
c. Trigeminal neuralgia

a. 10
b. 30
c. 50
d. 80


Lassitude is a form of fatigue that occurs daily and may even be present after a restful
nights sleep.
a. True
b. False


Pain along a nerve presenting as shock-like, burning, throbbing and shooting electric
sensations is called _______________.
a. hyperesthesia
b. anesthesia
c. paresthesia
d. dysesthesia


When an individual is diagnosed with trigeminal neuralgia under the age of 40 dental
professionals should always suspect MS.
a. True
b. False


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.


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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. Avonex
b. 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 MS
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

a. completed immediately
b. postponed
c. No modifications are necessary.

15. Which of the following phrases is discriminatory?




is wheelchair bound.
was diagnosed with MS in January.
requires accessible parking.
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 project
director of Miles of Smiles, a school-based oral health program. In 2013, SimmerBeck was selected to serve as an ambassador for the American Dental Associations
Dental Quality Alliance. Her publications and research interests include measuring
dental 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.


Crest + Oral-B at Continuing Education Course, August 1, 2014