Neuromuscular disorders affect the peripheral nervous system and cause progressive muscle weakness. While individually rare, as a group they are not uncommon. Some neuromuscular conditions can affect dental treatment for elderly patients who may have difficulty with oral hygiene. Myasthenia gravis is the most common neuromuscular disease, where antibodies prevent nerve impulse transmission to muscles causing weakness. Dental care requires awareness of medications and increased risk of secretions for patients with these disorders.

1. Neuromuscular
disorders and
dental
management
Ahmed Tareq
DDS.BDS.ORTHODONTIC FELLOW.
NBDE BOARD CERTIFIED

2. • Neuromuscular disorders include a wide-range of diseases affecting the
peripheral nervous system, which consists of all the motor and sensory
nerves that connect the brain and spinal cord to the rest of the body.
Progressive muscle weakness is the predominant condition of
these disorders.
• Number of relatively uncommon but significantly neuromuscular
conditions may affect dental treatment, particularly elderly patients.
• Inability to carry out proper oral hygiene may result in an increased
caries rate and greater incidence and severity of periodontal disease,
causing these patients to seek dental care for chronic and acute
disorders.

3. Types of neuromuscular disorders include:
• Amyotrophic lateral sclerosis (ALS), fatal type of motor neuron disease.
• Charcot-Marie-Tooth disease. inherited nerve problem.
• Multiple sclerosis.
• Muscular dystrophy.
• Myasthenia gravis.
• Myopathy. any disease that affects the muscles that control voluntary
movement.
• Myositis, including polymyositis and dermatomyositis. inflammatory
myopathies, can affect the internal organs, skin and multiple muscle groups of
patients.
• Peripheral neuropathy.
• Parkinsonism, Epilepsy, Bell’s pals , Cerebrovascular Disorders?????? are
they?

4. Parkinsonism
• Michael J. Fox

5. Parkinsonism
• Parkinson’s disease is a neurodegenerative brain disorder that
progresses slowly in most people. Symptoms can take years to develop,
and most people live for many years with the disease
• Parkinsonism is a general term that refers to a group of neurological
disorders that cause movement problems like those seen in Parkinson’s
disease such as tremors, slow movement and stiffness.
• The most common form of parkinsonism is Parkinson’s disease (paralysis
agitans) or shaking palsy, but parkinsonism is seen in a variety of
disorders such as postencephalitic parkinsonism, arteriosclerotic
parkinsonism, and post-traumatic parkinsonism following closed head
injury.

6. Etiopathogenesis
• In idiopathic parkinsonism, dopamine depletion due to degeneration of
the dopaminergic nigrostriatal system in the brainstem leads to an
imbalance of dopamine and acetylcholine, neurotransmitters that are
normally present in the corpus striatum.
• Symptoms like parkinsonism may also be induced by drugs that cause a
reduction of dopamine in the brain, the most common of the drugs being
phenothiazine derivatives.
• Although a definite etiology has not been established, the most likely
explanation is that the disease results from a combination of accelerated
aging, genetic predisposition, exposure to toxins, and an abnormality in
oxidative mechanisms

7. Clinical Manifestations
• Tremor, rigidity, bradykinesia, and postural instability.
• “pill-rolling” tremor
• “masklike” facial appearance
• Abnormalities in oral behavior, such as purposeless chewing, grinding,
and sucking movements

8. Oral manifestations & considerations
• ↑ Salivation & drooling, angular cheilitis
• Anticholinergic drugs -> xerostomia -> damage to teeth & PDL, difficulty
retaining dentures, mucosal ulcerations, denture sores, increased
chance of bacterial & fungal infections.
• Loss of facial expression, difficulty with mastication, & slow speech that
is soft & fading
• Tremors of the head, lips & tongue

9. Dental Management
• Periodontal recall every 4-6 mo
• Enameloplasty or mouth guard to prevent irritations to
tongue due to tardive dyskinesia
• Salivary substitutions & topical fluoride Rx in pts with
xerostomia
• Antibacterial rinses & antifungal ointments to limit
microbial Ds

10. Dental Management
• Chair position- 45o to limit muscle rigidity & breathing
difficulties
• At the end of appt- chair should be slowly raised to prevent
orthostatic hypotension • Physical assistance may be required
• Appointments should be short & relaxing
• N2O sedation helps reduce stress & prevalence of tremors
• IV sedation/GA is a better alternative for pts with severe l/o
control over muscle movement
• Anticholinergics, rubber dam & saliva ejectors enhance
likelihood of successful dental procedures

11. What is the most common neuromuscular
disease?
• Myasthenia gravis is the most common disease of this category , an autoimmune disease where the immune system
produces antibodies that attach themselves to the neuromuscular junction and prevent transmission of the nerve
impulse to the muscle.
• Although individually rare, as a group neuromuscular diseases are not, being twice as high as multiple sclerosis
(80/100,000 in Europe) and similar to that seen with Parkinson's disease (100-300/100,000 worldwide)
• https://www.betterhealth.vic.gov.au/health/ConditionsAndTreatments/neuromuscular-disorders

12. • Myasthenia gravis is not inherited, and
it is not contagious. It generally
develops later in life when antibodies
in the body attack normal receptors
on muscle. This blocks a chemical
needed to stimulate muscle
contraction.
• A temporary form of myasthenia
gravis may develop in the fetus when a
woman with myasthenia gravis passes
the antibodies to the fetus. Generally,
it resolves in 2 to 3 months.
•

13. Symptoms of myasthenia gravis
Visual problems, including drooping eyelids (ptosis) and double vision (diplopia)
Muscle weakness and fatigue. It may vary rapidly in intensity over days or even hours and worsen
as muscles are used (early fatigue). For this reason, many symptoms are worse later in the day.
Facial muscle involvement causing a mask-like appearance. A smile may appear more like a snarl.
Trouble swallowing or pronouncing words
Weakness of the neck or limbs.

15. Myasthenia gravis diagnosed
PHYSICAL EXAM.
PATIENT RESPOND TO CERTAIN MEDICINES. ANTICHOLINESTERASE MEDICINE (EDROPHONIUM IS PRIMARILY USED AS A DIAGNOSTIC TOOL OWING TO ITS
SHORT HALF-LIFE)
BLOOD TESTS. THESE TESTS LOOK FOR ANTIBODIES THAT MAY BE PRESENT IN PEOPLE WITH MYASTHENIA GRAVIS.
GENETIC TESTS. THESE TESTS ARE DONE TO CHECK FOR CONDITIONS LIKE MYASTHENIA GRAVIS THAT MAY RUN IN FAMILIES.
NERVE CONDUCTION STUDIES. A TEST CALLED REPETITIVE NERVE STIMULATION MAY BE USED.
ELECTROMYOGRAM (EMG). THIS TEST MEASURES THE ELECTRICAL ACTIVITY OF A MUSCLE. AN EMG CAN DETECT ABNORMAL ELECTRICAL MUSCLE
ACTIVITY DUE TO DISEASES AND NEUROMUSCULAR CONDITIONS.
SINGLE-FIBER EMG. THIS IS A VERY SPECIAL EMG. IT RECORDS THE TRANSMISSION OF NERVE TO MUSCLE.

16. Treatment
• Medicine. Anticholinesterase medicines, steroids, or medicines that suppress the immune system’s response
(immunosuppressive) medicines may be used. Pyridostigmine is used for long-term maintenance
• Thymectomy. This is surgical removal of the thymus gland. The role of the thymus gland in myasthenia gravis is not
fully understood. , People who have their thymus removed tend to need less medicine. They also tend to have
fewer problems, such as needing a hospital stay, within 3 years after the surgery.
• Plasmapheresis. This procedure removes abnormal antibodies from the blood and replaces the blood with normal
antibodies from donated blood.
• Immunoglobulin. This is a blood product that helps decrease the immune system’s attack on the nervous system. It
is given intravenously (IV).
# Treatment will depend on the symptoms, age, and general health. It will also depend on how severe the condition is.

17. Dental Implication
• Crisis rarely occurs suddenly and patients with crisis do not present for dental
treatment
• For routine dental care, awareness of immunosuppressive medications and the
potential for increased respiratory and oral secretions is mandatory
• May antibiotics may worsen MG e.g., imipenem, fluoroquinolones
• Ester local anesthetics may be toxic because they are hydrolyzed more slowly
• Patients are very sensitive to non depolarizing muscle relaxants.

18. Oral health considerations
• Patient may have difficulty with prolonged mouth opening and
swallowing.
• Aspiration risks can be high and can be reduced by adequate
suction, the use of rubber dam and avoiding bilateral mandibular
anesthetic block.
• The patient may be at risk for respiratory crisis due to
overmedication.
• Drugs that may affect the neuromuscular junction such as
narcotics, tranquilizers and barbiturates should be avoided.
• Certain antibiotics like tetracycline, streptomycin, sulphonamides
and clindamycin can affect neuromuscular activity and should be
avoided.

19. Case report
Heighpubs Journal of Dentistry
University St. Cyril and
Methodius, 2017

20. • Dental management of patients diagnosed with Myasthenia gravis (MG)
presents a challenge to the oral health care provider. Patil et al. in his
article review the etiology, pathogenesis, diagnosis, and clinical signs
and symptoms associated with MG, highlighting the role of the oral
health care provider in the process of diagnosis and management of the
oral and dental complications that might be associated with the disease,
while avoiding myasthenic crisis .

21. Guidelines for oral healthcare of patients with neuromuscular disease

22. Guidelines for oral healthcare of patients with neuromuscular disease

23. Article review
• ISSN: 2581-3218
IJDR 2019; 4(1): 13-19
© 2019, All rights reserved
www.dentistryscience.com

24. Multiple Sclerosis
• It is a relapsing remitting autoimmune
inflammatory demyelinating disease of the CNS.
• Multiple sclerosis (MS) is a long-lasting (chronic)
disease of the central nervous system. It is
thought to be an autoimmune disorder, a
condition in which the body attacks itself by
mistake. MS is an unpredictable disease that
affects people differently. Some people with MS
may have only mild symptoms. Others may lose
their ability to see clearly, write, speak, or walk
when communication between the brain and
other parts of the body becomes disrupted

25. Aetiology
M.S.
1. It can be caused secondary to trauma.
2. Though the exact cause of M.S. is unknown,
genetic susceptibility clearly exists.
3. It is mostly an autoimmune reaction in
which major histocompatibility complex (MHC)
on chromosome 6p21 has been identified.
4. Infection's agents like Epstein Barr virus and
human herpes virus 6 are also implicated in
the pathogenesis of M.S.

26. Clinical
features
• Age of onset of MS is typically between 20-45 years.
• It is more common among women than men (2:1 ratio).
• Clinical features of MS depend upon the area of the CNS
involved and frequently affected areas include optic chiasma,
brainstem, cerebellum and spinal cord.
• The sudden onset of optic neuritis without any other CNS signs
or symptoms could be the first symptom of MS.
• Diplopia, blurring, nystagmus is also commonly seen.
• Limb weakness is characteristic of MS and can be manifest as
loss of strength, fatigue or gait problems.
• Ataxia may affect the head and neck of MS patients and may
cause cerebellar dysarthria.
• These patients often show sensory impairment including
paraesthesia and hyperesthesia.
• These patients often show sensory impairment including
paraesthesia and hyperesthesia.

27. Diagnosis
M.S.
• MS lesions are called ‘plaques’ which are
characterised by perivenular cuffing with
inflammatory mononuclear cells, which are
seen in the white matter and periventricular
area of the CNS.
• These plaques are visible as hypertense and
hypotense areas on T2 and T1 weighted images
respectively, suggestive of chronic and active
lesion which is diagnostic of MS.
• Other advanced imaging techniques that are
being evaluated for diagnosis of MS are
diffusion sensor imaging, magnetization transfer
imaging, proton magnetic resonance
spectroscopy and functional MRI.

28. Treatment
M.S.
1. Glucocorticoids can be used to manage both initial
attacks and acute
exacerbation of MS.
2. Intravenous methylprednisolone is administered at a
dose between 500-1000mg per day for 3-5 days
3. Disease modifying agents include injectable interferon
IFN- beta/a, IFN-beta/b, and glatiramer acetate.
4. Mitroxantrone (Novantrone) is a chemotherapeutic
agent administered intravenously that is effective in
reducing, neurologic disability.
5. Some other common agents used for management of
MS are anticonvulsants, benzodiazepines, tricyclic
antidepressants, smooth muscle relaxant, anticholinergic
agents and analgesics.

29. Oral health
consideration
M.S.
• MS patients can present with trigeminal neuralgia (TN) with
possible absence of trigger zones and continuous low intensity
pain which should be managed like typical TN.
• Patients may present with neuropathy of the maxillary(V2) and
mandibular branch (V3) of the trigeminal nerve which may
result in burning, tingling or reduced sensation.
• Neuropathy of the mental nerve can cause numbness of the
lower lip and chin.
• Facial weakness and paralysis may be seen in MS patient.
• Dysarthria may be seen as scanning speech in these patients.
• Elective dental treatment should be avoided in MS patients
during acute exacerbation.
• These patients may require dental treatment in operating
room under general anesthesia.
• Patient's relatives or nurse should be appraised about the
importance of daily home care of oral hygiene.

34. Article review
• Dent Clin N Am 64 (2020) 255–278
• https://doi.org/10.1016/j.cden.20
19.08.015 dental.theclinics.com
0011-8532/20/a 2019 Elsevier Inc.
All rights reserved.
• University of Pennsylvania School
of Dental Medicine, 2020

35. • https://pubmed.ncbi.nlm.nih.g
ov/30746009/

36. https://www.ncbi.nlm.nih.gov/p
mc/articles/PMC5683023/

37. Bell’s palsy
It is also called facial paralysis or seventh nerve
paralysis. Bell’s palsy, named after the Scottish
anatomist, Sir Charles Bell, is the most common acute
mononeuropathy, or disorder affecting a single nerve,
and is the most common diagnosis associated with facial
nerve weakness/paralysis.
The exact aetiology is not known but viral infection like
herpes simplex affecting the facial nerve causes
inflammation and hence paralysis of the nerve.
Other causes like trauma during dental extraction,
surgical procedures like parotidectomy, tumours of the
cranial base, parapharyngeal space and infratemporal
fossa can lead to seventh nerve palsy.

40. Clinical
features
• Bell’s palsy begins with slight pain around
one ear, followed by an abrupt paralysis of
the muscles on that side of the face.
• The eye on the affected side stays open,
corner of the mouth drops, and there is
drooling.
• As a result of masseter weakens, food is
retained in both the upper and lower buccal
and labial fold.
• The face becomes expressionless, and the
creases of the forehead are flattened.
• Due to impaired blinking, corneal ulcerations
from foreign bodies can occur.
• Involvement of the chorda tympani nerve
leads to loss of taste perception on the
anterior two-thirds of the tongue and
reduced salivary secretion.

41. Diagnosis
A thorough history taking, and physical examination helps in diagnosing
bell’s palsy and the extent of the weakness of the facial muscles.
Blood tests to detect viral or bacterial infection can diagnose the
aetiology for bell’s palsy.
MRI or CT scan can be advised to rule out any pathology in the brain.

42. Treatment
Spontaneous improvement is generally seen within 6
months in most cases.
Combination of acyclovir 400mg 5 times daily with
prednisolone (40-60mg daily) for a week is believed
to be more effective than steroid alone.
Supportive measures like protecting the eye with eye
patches, artificial tear substitutes should be given.
Injection of botulinum toxin has shown to be
effective in treating this disease.
Physiotherapy can be advised for the muscles of face.

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45. Thank you