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Diastema, multiple sclerosis, orthodontic treatment, spacing

Multiple sclerosis (MS) is a chronic, inflammatory autoimmune neurological disease that affects the central nervous system (CNS). Its cause is unknown; however, several factors may play a role in its etiology. It affects myelinated axons in the CNS, destroying the myelin and damaging axons to varying degrees.[1] MS has been classified into different types: relapsing remitting; secondary progressive; primary progressive; and progressive relapsing. Fortunately, 85–90% of patients have the least aggressive type, relapsing-remitting MS (RRMS), which is characterized by relapses and remissions that can last months to years without the development of new symptoms. RRMS can progress to secondary-progressive MS within a 19-year period, with a steady increase in disability. However, 10–15% of cases are primary-progressive MS, involving a steady increase in disability and no remission.[2] The rarest type is progressive-relapsing MS, in which patients experience a constant increase in disability that includes exacerbations without any symptom-free remissions.[2] In addition to fatigue, pain, speech, or swallowing issues, many systemic, visual, cognitive, and emotional symptoms arise.[3] MS may cause various symptoms that can negatively affect the patient's ability to clean their teeth, or use intermaxillary elastics and removable appliances during orthodontic treatment.[4] These symptoms include muscle weakness, abnormal muscle spasms, difficulties with mobility, and coordination and balance issues.[4] Moreover, all MS symptoms can be exacerbated by increase in body temperature (Uhthoff's phenomenon). More than 400,000 individuals in the United States, and approximately 2.3 million globally have MS.[2,5] Although the Arabian Gulf region is situated in a low-risk zone for MS[6] and Saudi Arabia has low MS prevalence (25 per 100,000),[7] some studies have reported indications of increasing MS incidence in Saudi Arabia.[6] Clinical diagnosis of MS must be supported by evidence from other tests, such as neurological examinations, magnetic resonance imaging (MRI), evoked potential tests, and, possibly, a spinal fluid test.[8] MRI is an important diagnostic tool in MS, and is used to track disease progression over time and determine treatment effectiveness. Areas of damaged myelin and injured tissue (lesions) caused by MS can be visualized as white ovoid plaques on MRI.[3] Treatment of MS includes at least three types of therapy aimed at reducing the biological activity of the disease, treating the symptoms of specific clinical complaints, and repairing neural damage.[3] MS diagnosis and treatment can be highly impacted by orthodontic treatment. Different metals used during orthodontic treatment can negatively affect MRI accuracy.[9,10] Additionally, some medications used to treat MS, such as interferons and nonsteroidal antiinflammatory drugs (NSAIDs), can negatively affect orthodontic treatment by slowing tooth movement.[11,12] Prompted, in part, by the lack of studies regarding orthodontic treatment of patients with MS, the present article highlights some of the difficulties the orthodontist may encounter during the treatment of an MS patient and how to overcome them. Multiple sclerosis (MS) is a chronic, autoimmune inflammatory disorder of the central nervous system (CNS) that affects myelinated axons, destroying the myelin and damaging axons to varying degrees. The course of MS is highly varied and unpredictable. Metals used during orthodontic treatment can negatively affect imaging techniques used to diagnose and monitor the progression of MS, while medications used to treat MS can negatively affect orthodontic tooth movement. The present case report highlights some of the challenges encountered during orthodontic treatment of a patient with MS and how to overcome them. The patient was a 20-year-old woman with complaints of diastema and spacing in the upper arch. Although closing the spaces was challenging due to some of the MS medications, she was treated successfully, without complications, within 20 months using closing loops.
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