Orofacial Pain and Oral Medicine
Featuring Dr. Joel Epstein, Professor and Medical Director of Oral Oncology, City of Hope National Cancer Centre and Cedars-Sinai Health System
Multiple sclerosis (MS) often touches the dental office before it reaches the neurologist. In a recent podcast conversation with Jane Wrinch, Dr. Joel Epstein—a board-certified oral medicine specialist with active appointments at City of Hope and Cedars-Sinai—described how oral presentations have, in several of his cases, led directly to a previously undiagnosed MS diagnosis. For dental clinicians, the implications are immediate.
Diagnosis Before Intervention
Dr. Epstein’s overarching principle is straightforward: confirmed clinical diagnosis must precede any reversible dental treatment. MS can produce sensory changes, neuropathy, and trigeminal-neuralgia-like facial pain that mimics dental pathology. A patient presenting with vague, electric, or burning pain along a trigeminal distribution may end up with an unnecessary root canal or extraction when the underlying driver is a demyelinating lesion in the central nervous system. “Reversible dental treatment should be provided only upon a confirmed clinical diagnosis,” he emphasized. When the dental etiology is uncertain, the right next step is a workup, not a handpiece.
Visit Logistics and Tolerance
For patients with known MS, routine care still applies—with modifications. Fatigue and limited jaw-opening tolerance often call for shorter appointments and the judicious use of mouth props. Wheelchair access and safe transfer techniques may be needed. Reduced hand strength affects home hygiene as much as the chairside experience; electric toothbrushes with larger handles, sonic brushes, and water irrigators with antimicrobial additives can compensate for diminished dexterity. None of this is exotic—it is standard prevention applied thoughtfully to a patient whose physical capacity may fluctuate.
The Amalgam Question
Dr. Epstein addressed the persistent media narrative linking amalgam removal to MS directly: the studies have been done, and there is no evidence supporting the relationship. Sound restorations should not be removed on the basis of an unproven connection—doing so causes additional tooth damage and increases patient cost with no demonstrated benefit.
Managing Oral Side Effects of MS Therapy
Several MS therapies—including methotrexate and certain targeted biologics—can produce mucositis or mouth sores, often inflammatory and autoimmune in character. First-line topical management uses anti-inflammatory agents, with compounded steroid rinses preferred when lesions are widespread. For pain control, Dr. Epstein highlighted compounded doxepin suspension, a tricyclic with topical anesthetic and analgesic effect that is well-studied in cancer-related mucositis and useful even when mucosal pain is present without visible lesions. Topical gabapentin suspensions are another option for superficial neuropathic pain. The principle: manage the local problem locally whenever possible, so systemic MS therapy can continue at its optimal dose.
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Dry Mouth and the Case for Stimulating Natural Saliva
Dry mouth is a common complication of MS and its therapies, and it drives much of the downstream risk: caries, candidiasis, taste change, and mucosal pain. Dr. Epstein’s preferred approach is to measure resting and stimulated saliva first, then attempt to stimulate the patient’s own production rather than reach immediately for substitutes. Natural saliva contains antimicrobial and wound-repair molecules that artificial replacements cannot replicate. When pharmacologic stimulation is indicated, cevimeline (U.S.) generally offers a smoother profile than pilocarpine, and in Canada, the non-prescription anethole trithione (Sialor) provides an additional mechanism that can be combined with cholinergic agents in refractory cases. For very dry mouths, high-strength sodium or stannous fluoride applied via custom trays remains the gold standard for caries prevention—though once-weekly maintenance is often appropriate, since daily use can over-harden enamel.
The Oral Microbiome: An Emerging Frontier
Dr. Epstein flagged the oral microbiome as a rapidly developing area with direct implications for MS patients. Salivary changes and mucosal disruption shift the microbial community, opening the door to opportunistic colonization. Antifungals clear candida but do not change the environment that allowed the overgrowth, which is why recurrence is common. The emerging strategy is to address the environment itself—replenishing the oral flora with non-cariogenic, non-periodontal organisms so that pathogenic species cannot regain a foothold. The evidence base is still early, but the conceptual model is sound and increasingly relevant.
Practical Takeaways
The message is consistent: diagnose before you treat, modify visit logistics around the patient’s tolerance, prevent aggressively, and manage local problems locally before reaching for systemic interventions. MS adds complexity to dental care, but it does not change the fundamental discipline of careful diagnosis and evidence-based management. The dental office is sometimes the first place an MS-related symptom surfaces, which makes the dental team’s clinical judgment part of the broader diagnostic chain.
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