Introduction: Myasthenia gravis (MG) is an autoimmune neurological disorder characterized by defective transmission at the neuromuscular junction. This neuromuscular disease marked by repetitive intermittent skeletal muscle weakness and fatigue Clinical symptoms are manifested in varying degrees depending on the age of diagnosis and antibodies to acetylcholine receptors. Facial and oropharyngeal muscles are among the most affected by this disease, thus presenting a lot of difficulties when dental treatment is performed. Since the disease is known to specifically affect the masticatory, facial and oropharyngeal muscles, dental treatment proves very challenging for dentists and patients alike. In order to choose the optimal and less invasive treatment approach and avoid inherent complications, dentists must be acquainted with the clinical features of MG as well as the medications administered in MG patients.
Aim: The aim of the present study is to investigate and systematize the clinical presentations of MG in order to choose the most appropriate treatment approach and avoid complications. For this purpose, oral and maxillofacial clinicians must also be acquainted with the main groups of medications for this disease.
Materials and Methods: This research relied on Google Scholar and PubMed publications, published in the period 2000–2022.
Conclusion: Myasthenia gravis is a serious and rare chronic disease. In order to avoid complications, some of which life-threatening, it is of utmost importance to know its main symptoms as well as applicable medications in dental treatment.
Tamburini A, Tacconi F, Barlattani A, Mineo TC. An update on myasthenia gravis, challenging disease for the dental profession. J Oral Sci. 2015;57(3):161-8. doi: 10.2334/josnusd.57.161.
Rai B. Myasthenia gravis: challenge to dental profession. Internet J Acad Phys Assist. 2006;6(1):18-20.
Kiran U, Choudhury M, Sexena N, Kapoor P. Sevoflurane as a sole anaesthetic for thymectomy in Myasthenia gravis. Acta Anaesthesial Scand. 2000; 44(3):351-3. doi: 10.1034/j.1399-6576.2000.440324.x.
Palace J, Vincent A, Beeson D. Myasthenia gravis: diagnosis and management dilemmas. Curr Opin Neural. 2000;14(5):583-9. doi: 10.1097/00019052-200110000-00006.
Ciafoaloni E. Myasthenia gravis and congenital myasthenic syndromes. Continuum (Minneap Minn). 2019;25(6):1767-84. doi: 10.1212/CON.0000000000000800.
Parr JR, Andrew MJ, Finnis M, Beeson D, Vincent A, Jayawant S. How common is childhood myasthenia? The UK incidence and prevalence of autoimmune and congenital myasthenia. Arch Dis Child. 2014;99(6):539-42. doi: 10.1136/archdischild-2013-304788.
Popperud TH, Boldingh MI, Brunborg C, Faiz KW, Heldal AT, Maniaol AH, et al. Juvenile myasthenia gravis in Norway: A nationwide epidemiological study. Eur J Paediatr Neurol. 2017;21(2):312-7. doi: 10.1016/j.ejpn.2016.09.001.
Carr AS, Cardwell CR, McCarron PO, McConville J. A systematic review of population based epidemiological studies in Myasthenia Gravis. BMC Neurol. 2010;10:46. doi: 10.1186/1471-2377-10-46.
Robertson N. Enumerating neurology. Brain. 2000:123(Pt 4):663-4. doi: 10.1093/brain/123.4.663.
Verschuuren JJGM, Huijbers MG, Plomp JJ, Niks EH, Molenaar PC, Martinez-Martinez P, et al. Pathophysiology of myasthenia gravis with antibodies to the acetylcholine receptor, muscle-specific kinase and low-density lipoprotein receptor-related protein 4. Autoimm Rev 2013;12(9):918-23. doi: 10.1016/j.autrev.2013.03.001.
Hoch W, McConville J, Helms S, Newsom-Davis J, Melms A, Vincent A. Auto-antibodies to the receptor tyrosin kinase MuSK in patient with myasthenia gravis without acetylcholine receptor antibodies. Nat Med. 2001;7(3):365-8. doi: 10.1038/85520.
Leite MI, Jacob S, Viegas S, Cossins J, Clover L, Morgan BP, et al. IgG1 antibodies to acetylcholine receptors in 'seronegative' myasthenia gravis. Brain. 2008;131(Pt 7):1940-52. doi: 10.1093/brain/awn092.
Higuchi O, Hamuro J, Motomura M, Yamanashi Y. Autoantibodies to low-density lipoprotein receptor-related protein 4 in myasthenia gravis. Ann Neuronal. 2011;69(2):418-22. doi: 10.1002/ana.22312.
Shiraishi H, Motomura M, Yoshimura T, Fukudome T, Fukuda T, Nakao Y, et al. Acetylcholine receptors loss and postsynaptic damage in MuSK antibody-positive myasthenia gravis. Ann Neurol. 2005;57(2):289-93. doi: 10.1002/ana.20341.
Le Panse R, Bismuth J, Cizeron-Clairac G, Weiss JM, Cufi P, Dartevelle P, et al. Thymic remodeling associated with hyperplasia in myasthenia gravis. Autoimmunity. 2010;43(5-6):401-12. doi: 10.3109/08916930903563491.
Leite MI, Ströbel P, Jones M, Micklem K, Moritz R, Gold R, et al. Fewer thymic changes in MuSK antibody-positive than in MuSK antibody-negative MG. Ann Neurol. 2005;57(3):444-8. doi: 10.1002/ana.20386.
Sasakura Y, Kumasaka S, Takashashi T, Shindo J. Myasthenia gravis associated with reduced masticatory function. Int J Oral Maxilllofac Surg. 2000;29(5):381-3.
Patil PM, Singh G, Patil SP. Dentistry and myasthenia gravis patient: a review of current state of the art. Oral Surg Oral Med Oral Pathоl Oral Radiol. 2012;114(1):e1-8. doi: 10.1016/j.tripleo.2011.08.023.
Yeeshu Arora, Yuebing Li. Overview of myasthenia gravis. Hosp Pract. 2013;41(4):40-50. doi: 10.3810/hp.2013.10.1079.
Grob D, Brunner N, Namba T, Pagala M. Lifetime course of myasthenia gravis. Muscle Nerve. 2008;37(2):141-9. doi: 10.1002/mus.20950.
Rajakulendran S, Viegas S, Spinalle J, Howard RS. Clinically biphasic myasthenia gravis with both AChR and MuSK antibodies. J Neurol. 2012;259(12):2736-9. doi: 10.1007/s00415-012-6661-9.
Engstrom JW. Myasthenia gravis: diagnostic mimics. Semin Neurol. 2004;24(2):141-7. doi: 10.1055/s-2004-830903.
Jamal BT, Herb K. Perioperative management of patient with myasthenia gravis: prevention, recognition and treatment. Oral Surg Oral Med Oral Pathol Oral Radoil Endod. 2009;107(5):612-5. doi: 10.1016/j.tripleo.2009.01.015.
Lewis RA. Myasthenia gravis: new therapeutic approaches based on pathophysiology. J Neuronal Sci. 2013;333(1-2):93-8. doi: 10.1016/j.jns.2013.06.018.
Gilhus NE, Verschuuren JJ. Myasthenia gravis: subgroup classification and therapeutic strategies. Lancet Neurol. 2015;14(10):1023–36. doi:10.1016/s1474-4422(15)00145-3.
Khan KA, Bennett JD. Undiagnosed Myasthenia gravis owning to a very unusual primary presentation. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;118(4):e101-4. doi: 10.1016/j.oooo.2014.02.027.
Gronseth GS, Baron RJ. Practice parameters thymectomy for autoimmune myasthenia gravis: Report of quality standard subcommittee of American Academy of Neurology. Neurology. 2000;55:7-15.
Yarom N, Barnea E, Nissan J, Gorsky M. Dental management of patients with myasthenia gravis: a literature review. Oral Surg Oral Med Oral pathol Oral Radiol Endod. 2005;100(2):158-63. doi: 10.1016/j.tripleo.2005.01.003.
Weijnen FG, van der Bitl, Kuks JBM, van der Glas HW, Oundernaarde I, Bosman F. Masticatory performance in patients with myasthenia gravis. Arch Oral Biol. 2002;47(5):393-8. doi: 10.1016/s0003-9969(02)00014-6.
Lotia S, Randal C, Dawson LJ, Longman LP. Dental management of the myasthenic patient. Dent Update. 2004;31(4):237-42. doi: 10.12968/denu.2004.31.4.237.
Kamalakidis S, Papaemmanouil G, Anastassiadou V. Exploring factors influencing complete denture management of patient with myasthenia gravis. Balk J Dent Med. 2020;24(2):113-7.
AlHelal A, Jekki R, Richardson PM, Kattadiyil MT. Application of digital technology in the prosthodontic management of a patient with myasthenia gravis: A clinical report. J Prosthet Dent. 2016;115(5):531-6. doi: 10.1016/j.prosdent.2015.11.014.
Cook RJ, McParland H, Escudier M. An unusual primary presentation of myasthenia gravis. Br J Oral Maxillofac Surg. 2008;46(6):494-6. doi: 10.1016/j.bjoms.2007.12.009.
Phoenix RD, Engelmeier RL. Lingualized occlusion revisited. J Prosthet Dent. 2010;104(5):342-6. doi: 10.1016/S0022-3913(10)60153-9.
Abel M, Eisenkraft JB. Anesthetic implications of myasthenia gravis. Mt Sinai J Med. 2002;69(1-2):31-7.
Gritti P, Scarzi M, Carrara B, Lanterna LA, Spinelli L, Khotcholava M, еt al. А standardized protocol for the perioperative management of myasthenia gravis patient. Experience with 110 patients. Acta Anaesthesiol Scand. 2012;56(1):66-75. doi: 10.1111/j.1399-6576.2011.02564.x.
Singh P, Idowu O, Malik I, Nates JL. acute respiratory failure incidence by magnesium replacement in a 62-old woman with myasthenia gravis. Tex Hear Inst J. 2015;42(5):495-7. doi: 10.14503/THIJ-14-4584.
Harnett MT, Chen W, Smith SM. Calcium-sensing receptor: a high-affinity presynaptic target for aminoglycoside-induced weakness. Neuropharmacology. 2009;57(5-6):502-5. doi: 10.1016/j.neuropharm.2009.07.031.
Sheikh S, Alvi U, Soliven B, Rezania K. Drugs that induce or cause deterioration of myasthenia gravis: an update. J Clin Med. 2021;10(7):1537. doi:10.3390/jcm10071537.
Jones SC, Sorbello A, Boucher RM. Fluorquinolone-associated myasthenia gravis exacerbation: evaluation of postmarketing reports from the US FDA adverse event reporting system and a literature review. Drug Saf. 2011;34(10):839-47. doi: 10.2165/11593110-000000000-00000.
Wang SH, Xie YC, Jiang B, Zhang JY, Qu Y, Zhao Y, et al. [Fluoroquinolone associated myasthenia gravis exacerbation: clinical analysis of 9 cases]. Zhonghua Yi Xue Za Zhi. 2013 May 7;93(17):1283-6.
Vacchiano V, Solli P, Bartolomei I, Lai G, Liguori R, Salvi F. Exacerbation of myasthenia gravis after amoxicillin therapy: A case series. Neurol. Sci. 2020;41(8):2255-7. doi: 10.1007/s10072-020-04387-5.
Prabhu SS, Khan SA, Doudnikoff AL, Reebye UN. Anesthetic consideration for a patient with myastheniq gravis undergoing deep sedation in an outpatient oral surgery setting. J Dent Anesth Pain Med 2019;19(1):67-72. doi: 10.17245/jdapm.2019.19.1.67.
Keesey JC. Clinical evaluation and management of myasthenia gravis. Muscle Nerve 2004;29(4):484-505. doi: 10.1002/mus.20030.
Wendell LC, Levine JM. Myasthenic crisis. Neurohospitalist. 2011;1(1):16-22. doi: 10.1177/1941875210382918.
Alshekhlee A, Miles JD, Katirji B, Preston DC, Kaminski HJ. Incidence and mortality rates of myasthenia gravis and myasthenic crisis in US hospitals. Neurology. 2009;72(18):1548-54. doi: 10.1212/WNL.0b013e3181a41211.
Klair JS, Rochalini YM, Meena NK. Myasthenia gravis masquerading as dysphagia: Unveiled by magnesium infusion. BMJ Case Rep. 2014;2014:bcr2014204163. doi: 10.1136/bcr-2014-204163.
Gummy RR, Kukulka NA, Deroche CB, Gvindarajan R. Factors associated with acute exacerbations of myasthenia gravis. Muscle Nerve. 2019;60(6):693-9. doi: 10.1002/mus.26689.
Varan O, Kucuk H, Tufan A. Myasthenia gravis due to hydroxylchloroquine. Reumatismo. 2015;67(3):125. doi: 10.4081/reumatismo.2015.849.
Van den Bersselaar LR, Snoeck MMJ, Gubbels M, Riazi S, Kamsteegeg EJ, Jungbluth H, et al. Anaesthesia and neuromuscular disorders: What a neurologist needs to know. Pract. Neurol. 2020;21. doi: 10.1016/j.nmd.2021.11.005
Nguyen QT, Yang J, Miledi R. Effects of atypical antipsychotics on vertebrate neuromuscular transmission. Neuropharmacology. 2002;42(5):670-6.
She S, Yingjun Z, Zhang B, Zheng Y. Worsening of myasthenia gravis after administration of antipsychotics for treatment of schizophrenia. J Clin Psychopharmacol. 2017;37(5):620-2. doi: 10.1097/JCP.0000000000000741.
Timmermans G, Depierreux F, Wang F, Hansen I, Maquet P. Cosmetic injection of botulinum toxin unmasking subclinical myasthenia gravis: a case report and literature review. Case Rep Neurol. 2019;11(2):244-51. doi: 10.1159/000502350.
Watts J, Brew B, Tisch S. Myasthenia gravis exacerbation with low dose ocular botulinum toxin for epiphoria. J Clin Neurosci. 2015;22(12):1979-81. doi: 10.1016/j.jocn.2015.05.032.
Dionisiotis J, Zoukos Y, Thomaides T. Development of myasthenia gravis in two patients
with multiple sclerosis following interferon beta treatment. J Neurol Neurosurg Psychiatry. 2004;75(7):1079. doi: 10.1136/jnnp.2003.028233.
Li Y, XiaoB, Xiao L, Zhang N, Yang H. Myasthenia gravis accompanied by premature ovarian failure and aggravation by estrogen. Intern Med. 2010;49(6):611-13. doi: 10.2169/internalmedicine.49.2737.
Yoo YJ, Han SB, Yang HK, Hwang JM. Case report: Ocular myasthenia gravis associated with in vitro fertilization procedures. Optom Vis Sci. 2018;95(5):475-8. doi: 10.1097/OPX.0000000000001217.
Mehndiratta MM, Pandey S, Kuntzer T. Acetylcholinesterase inhibitor treatment for myasthenia gravis. Cochrane Datebase Syst Rev. 2014(10):CD006986. doi:10.1002/1465858.CD006986.pub3
Drachman DB, Adams RN, Hu R, Jones RJ, Brodsky RA. Rebooting the immune system with high-dose cyclophosphamide for treatment of refractory myasthenia gravis. Ann N Y Acad Sci. 2008;1132:305-14. doi: 10.1196/annals.1405.033.
Dental Practitioners’ Formulary/British National Formulary; 2002-2004.
Patil S, Rao RS, Majumdar B, Anil S. Clinical appearance of oral Candida infection and therapeutic strategies. Front Microbiology. 2015;6:1391. doi:10.3389/fmicb.2015.01391.
Rüping MJ, Vehreschild JJ, Cornely OA. Patients at high risk of invasive infection: when and how to treat. Drugs. 2008;68(14):1941-62. doi: 10.2165/00003495-200868140-00002.
Azzam R, Shaikh AG, Serra A, Katirji B. Exacerbation of myasthenia gravis with voriconazole. Muscle Nerve. 2013;47(6):928–30. doi:10.1002/mus.23751.
Akcam FZ, Bacanak BN, Turk O, Yilmaz GR, Pekbay B, Yirmibes EOB, et al. A rare side effect due to voriconazole: myasthenia gravis. Eur J Clin Pharmacol. 2022;78(8):1357-9. doi: 10.1007/s00228-022-03349-4.
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