Myasthenia Gravis and Oral Health

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Myasthenia gravis can be a relatively uncommon disease through the band of autoimmune neuromuscular illnesses that was initially described a lot more than 400 years back. The very name of the disease comes from a combination of Greek and Latin words, which in Greek mus means muscle, sthenos means weakness, and gravis in Latin means seriously, so in English the name of this disease could be read as serious muscle weakness.

In myasthenia gravis, the body produces its own antibodies against the acetylcholine receptors on muscle cells (myocytes). These antibodies prevent the normal transmission of impulses between nerves and muscles, which prevents normal functioning of the muscles. Therefore, it quickly comes to muscle fatigue and feeling of exhaustion and weakness.

The causes of myasthenia gravis appearance are not yet fully realized, but scientists believe on viral infections, tension, individual predisposition to build up autoimmune illnesses and paraneoplastic development (tumor from the thymus gland).

The primary indicator of myasthenia gravis can be muscle mass fatigue which quickly becomes more pronounced during normal physical activity, and decreases after a period of rest. Therefore, these patients have the most muscle mass strength in the morning after a night’s rest, and at least at the end of the day. There are many other symptoms of myasthenia gravis, however the most typical are: the dropping from the eyelids, blurry eyesight with or without dual vision, nasal talk, nibbling and swallowing disorders, weak point within the arms and legs, difficulty inhaling and exhaling, etc. Spreading the condition on respiratory muscle tissues causes shortness of breathing, which in 15 to 20 percent of sufferers can result in a myasthenic turmoil, of which 4-8 percent of cases end fatally.

Symptoms of myasthenia gravis may occur at any period of life, and most often between 30 and 40 years of age for ladies and in the 60s and 70s in men. Among patients there are more women than men, and it is estimated that this ratio is usually 3: 2. Based on the Myasthenia Gravis Base of America in america the amount of people who have myasthenia gravis is certainly approximated at about 20 per 100,000 people. Nevertheless, it is regarded that the quantity is a lot higher because many situations stay unrecognized. Epidemiological data show that in the last 50 years the number of patients increases, but the number of deaths associated with myasthenia gravis is usually declining.

It often takes weeks to diagnose myasthenia gravis, and sometimes years after the 1st symptoms. Diverse and nonspecific symptomatology is possible reason for wanderings in the differential analysis, which may vary from psychiatric illnesses, pathological intracranial lesions, gastrointestinal complications, and during to motoneuron illnesses and myopathies. For that reason, patients tend to be subjected to needless diagnostic techniques and sometimes the incorrect remedies. Today, the medical diagnosis of myasthenia gravis pieces based on scientific presentation and app of particular pharmacological lab tests (eg. tensilon check), electrophysiological lab tests (eg. repetitive nerve stimulation), presence of antibodies (eg. muscle mass antibodies, antibodies to acetylcholine receptors, anti-MuSK antibodies), the thymus gland and thyroid gland examinations and computed tomography or magnetic resonance imaging exam. The level of antibodies to acetylcholine receptors in the serum is considered the gold standard in the analysis of myasthenia gravis, because they can be found in 80-85 percent of individuals with generalized form of the disease.

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Today myasthenia gravis is usually treated by acetylcholinesterase inhibitors, corticosteroids and thymectomy (surgical removal of the thymus gland). Prior to the app of acetylcholinesterase inhibitors in the treatment of myasthenia gravis, patients have usually died within a year of diagnosis, most often due to respiratory problems.

Oral manifestations of myasthenia gravis

The neuromuscular weakness in the head and neck region, caused by myasthenia gravis, can interfere with the normal functioning of the dental system, affect oral health and require a specific approach in the implementation of dental treatment.

Visible symptoms of myasthenia gravis in the oral cavity and pharynx can be found in 56 percent of patients, and in 19 percent of cases they are the only features that may be found in the first stages of the condition. Therefore, dental individuals must alert their dental professional at all practical and morphological adjustments in the top and neck area, and the dental professional is appreciated to spend on each patient, send him additional to neurologist and the correct neurological treatment.

Myasthenia gravis can result in changes for the tongue. The most frequent is definitely lipomatous atrophy where tongue turns into scarred, flabby and atrophic with feature triple longitudinal grooves (so-called myasthenic tongue). Furthermore, this flabby tongue because of altered muscle develop may become dysfunctional.

In people who have early stage of myasthenia gravis it could be noted specific manifestation of the facial skin that occurs due to fatigue of facial muscles. This is known as myasthenic face: sleepy, expressionless and apathetic. To the total expression contributes unilateral or bilateral ptosis (lowered eyelid). Also, due to the impairment of face muscles, laughing is partially or completely disabled, and such an attempt results in an expression that does not look like the usual smile and can be interpreted differently.

Lack of power in myasthenic muscles makes it difficult to close the mouth area, therefore lower jaw is frequently hanging using the mouth area remained open up. The chewing power is significantly decreased, which makes nibbling and grinding meals difficult. When, by the end from the masticatory routine, patient succeeds to make a morsel of meals prepared for swallowing, it’s routing towards the esophagus and swallowing can be quite difficult and slower. In cases like this we are discussing dysphagia. Issues with swallowing aren’t created exclusively by solid meals, fluids also hard to take so patients, rather than one large, consider several smaller sized sips. Dysphagia can be a major cause of mortality in myasthenia gravis, and swallowing problems may be one of the first symptoms that warn of presence of myasthenia gravis, which has a great diagnostic value.

gravis Long-term weakness of muscles that provide chewing and swallowing can lead to digestive problems, malnutrition, dehydration and hypokalemia. Hypokalemia can be especially dangerous because it further reduces muscle strength, which is particularly evident when myasthenic crisis occurs. Therefore, it is recommended that patients take the drug, which is cholinesterase inhibitor, one hour before each meal and to relax at least half an hour before eating. In addition, it’s important to eat gradually , nor car tire yourself out unnecessarily throughout meals. Because the body may be the many rested each day, it is desired that the main daily meal is usually consumed in the morning when the muscle tissue are stronger.

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The weakness of palatal and pharynx muscle tissue, which are essential for phonation and articulation, can result in disorders of talk. Normally, this is referred to as a sinus speech or talk through the nasal area. Within the advanced stage of the condition, due to the talk disorder and weak point of the face muscles, it could be very hard for sufferers to verbal and non-verbal communicate.

Dental care

Dental care of sufferers with myasthenia gravis, in the first stages of the condition, can be executed with no need for any particular modifications in the look and execution of interventions. Nevertheless, in advanced levels of the disease, treatment can be complex and has its own characteristics. That includes disease acknowledgement and effective action in myasthenic problems, avoiding adverse drug relationships, monitoring the effect of treatment of myasthenia gravis on oral health and the implementation of necessary modifications to dental treatment. To reduce the risk of problems in situations of advanced disease, it really is desirable which the dental practitioner consults with your physician or neurologist who goodies the individual.

For dental care of sufferers with myasthenia gravis, dental practitioners need to timetable more short-term early morning visits, which enable using patient’s morning mouth muscle strength and prevent accumulated daily murder. If longer treatments are planned, it is desired that the patient, in discussion with the physician and the dental professional, one hour and a half prior to the operation take acetylcholinesterase inhibitors to achieve their maximum effect during the implementation of dental care. In appointment with the individual, dentist must find probably the most comfy position for the individual in the oral chair, and when necessary in the ask for of the individual to improve it through the procedure.

Emotional tension due to fear of dental procedures can cause myasthenic crisis. Therefore, it is advisable that dentist explains to the patient workflow of dental treatment and the procedure and ensures it’s painless (to apply local anesthesia). Quality relationship between patient and doctor and their mutual trust helps the patient to avoid emotional stress. Where this isn’t possible to accomplish, dentist should make an effort to apply additional different methods or sedation.

Among the result of taking medicine for the treating myasthenia gravis could be improved salivation. This, coupled with swallowing complications, may cause problems in the execution of dental procedures because there is a risk of inhalation of the content of the oral cavity. Therefore, a quick and efficient removal of oral content should be enabled with dental suction and, if possible, applied protective rubber dam.

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When making mobile dentures for such patients, dentist should be especially careful. Holding and usage of cellular dentures (specifically complete dentures) needs great neuromuscular coordination inside the oral system which is difficult to accomplish in individuals with myasthenia gravis who’ve weakened muscle develop and reduced neuromuscular coordination. All of this can additional complicate the process of chewing and swallowing. For that reason, whenever possible, rather than the traditional complete denture producing finish dentures or implants is preferred.

Extensive mouth surgical procedure interventions in sufferers with myasthenia gravis may just end up being performed when sufferers are in a well balanced phase.

The usage of drugs in teeth sufferers with myasthenia gravis

In these sufferers the ester local anesthetics, such as for example procaine, ought to be prevented. The ester local anesthetics are progressively hydrolyzed by plasma cholinesterase and therefore are less effective in patients who are treated with anticholinesterase. Surface ester local anesthetics, such as benzocaine, and the amide local anesthetics, such as lidocaine and mepivacaine may apply. In order to reduce the dose of anesthetic, intraligamental or intrapulpal anesthesia techniques are recommended.

Dentists should be careful when prescribing antibiotics to patients with myasthenia gravis because some antibiotics such as tetracycline, polymyxin, aminoglycosides, azithromycin and erythromycin have relaxing effect on the muscle tissue, which can become a problem in sufferers with myasthenia gravis. Antibiotics predicated on penicillin in process haven’t any neuromuscular activity, but still, regarding antibiotic prescriptions, it is advisable to consult a doctor or neurologist who goodies sufferers of myasthenia gravis.

In preoperative preparing of these sufferers for dental care, premedication with benzodiazepines and comparable drugs ought to be prevented because sufferers with myasthenia gravis are delicate to respiratory depressants. Premedication with nitric oxide is known as safe.

Preventive mouth hygiene procedures

Sufferers with myasthenia gravis should frequently and properly maintain their dental hygiene. Tooth and oral cavity should be washed at least twice each day (in the morning and in the evening after the last meal). Due to the quick muscle fatigue, the use of electric toothbrush is recommended. If there is no major obstacle because of the pharynx muscle tissues function, a mouthwash can be recommended to lessen dental care plaque.

With prevention of caries and oral cavity diseases, the need for dental appointments and the implementation of more complex dental procedures which are not constantly suitable for individuals experiencing myasthenia gravis, are decreased. But, despite the fact that you can find no problems with the orofacial system, the dentist should still be visited every 3-6 months.


A special attention should be given to dental treatment of patients with myasthenia gravis. In stable patients with controlled disease special precautions are usually not necessary. But with patients in the advanced stages of the disease, the execution of the task and the use of required medicines ought to be modified. With regular and appropriate personal oral cleanliness along with regular oral checkups it’s possible, regardless of the disease, to truly have a healthful mouth for a long period.

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