Article published by the American Dental Association
Chronic Fatigue Syndrome (CFS), a long-term illness whose etiology remains elusive, effects more than one million people in the United States. A patient with CFS may have oral manifestations, such as TMJ disorders and Sjögren’s syndrome. In addition, commonly prescribed medications used in management of this syndrome may induce adverse reactions in the oral cavity.
The information provided here is intended as a resource for dentists to assist in the dental management of patients who have been diagnosed with CFS. If a patient reports symptoms consistent with CFS, the patient should be referred to his or her physician for appropriate diagnosis and treatment.
Awareness of CFS increased in the mid-1980s, when it was nicknamed the “yuppie flu”. It was subsequently mislabel as “chronic EBV” due to reports that the Epstein-Barr virus was a causative agent, but this etiology was quickly refuted. In March 1988, the CDC acknowledged the collection of symptoms known as Chronic Fatigue Syndrome, and developed the following definition:
1) Severe chronic fatigue of six months or longer duration with other known medical conditions excluded by clinical diagnosis; and 2) concurrently, four or more of the following symptoms: substantial impairment in short-term memory or concentration; sore throat; tender lymph nodes; muscle pain; multi-joint pain without swelling or redness; headaches of a new type, pattern or severity; unrefreshing sleep; and post-exertional malaise lasting more than 24 hours. The symptoms must have persisted or recurred during six or more consecutive months of illness and must not have predated the fatigue.1-3
The prevalent symptom of CFS is profound fatigue, especially fatigue that is not improved by rest or sleep. In addition to the symptoms listed in the CDC definition of CFS, 20–50 percent of patients with CFS can report atypical symptoms. These can include abdominal pain, jaw pain, dry eyes or mouth, alcohol intolerance, bloating, chest pain, chronic cough, diarrhea, dizziness, ear aches, irregular heartbeat, morning stiffness, nausea, night sweats, shortness of breath, skin sensations, tingling sensations, weight loss, depression, irritability, anxiety, and panic attacks (Table 1). If a patient reports symptoms consistent with CFS, the patient should be referred to his or her physician for appropriate diagnosis and treatment.
There are no physical signs or diagnostic laboratory tests that identify CFS. People who suffer the symptoms of CFS must be carefully evaluated by a physician because many treatable medical and psychiatric conditions are hard to distinguish from CFS. Common conditions that should be ruled out through a careful medical history and appropriate testing include mononucleosis, Lyme disease, thyroid conditions, diabetes, multiple sclerosis, various cancers, depression and bipolar disorder. Research conducted by the Centers for Disease Control and Prevention (CDC) indicates that less than 20 percent of CFS patients in this country have been diagnosed.
Chronic fatigue syndrome (CFS) affects more than one million people in the United States. There are tens of millions of people with similar fatiguing illnesses who do not fully meet the strict research definition of CFS.
Although there has been much speculation as to the causative agent of CFS, including transient traumatic conditions, stress, toxins, and latent viral infection, no definite cause or causes have been identified to date. Based on the current available research, there is no evidence indicating that CFS is a contagious disease. In most likelihood, CFS is a common endpoint resulting from multiple causes.
Treatment modalities for patients with CFS are aimed at relief of symptoms rather than curing the disease. Common pharmacologic therapies that may be prescribed by a physician include the administration of non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief, low-dose tricyclic antidepressants to improve sleep and relieve mild pain, and anxiolytic agents to treat anxiety (Table 2).3 In some cases, serotonin reuptake inhibitors prescribed to non-depressed patients have been found to be beneficial.3 Furthermore, evidence-based systematic reviews have illuminated the beneficial role of light exercise.4,5
The clinical course of CFS varies from patient to patient. For most patients, limited recovery to the point that one can return to work and undertake other activities occurs within the first five years. However, the syndrome can be cyclical in nature, with intermittent periods of fatigue. Some patients will experience a complete recovery, whereas others may never fully recover from the syndrome. There does not appear to be any notable correlation between recovery and symptoms, race, sex, age of onset, or other illness characteristic.
Oral manifestations of CFS can include Sjörgren’s syndrome, temporomandibular disorders, and fibromyalgia (myofascial pain). Furthermore, many of the medications prescribed to manage CFS can induce a variety of oral side effects, most commonly xerostomia (Table 2). Routine and elective dental treatment, including periodic examination and prophylaxis, are not contraindicated, but accommodations should be taken to care for the patient’s energy level.
This may include scheduling appointments for times when the patient is likely to feel well and limiting elective treatment plans to procedures that are manageable for the patient. Consultation with the patient’s physician may be indicated for extensive reconstruction procedures, oral surgery or periodontal surgery.
1. Nisenbaum R, Reyes M, Mawle AC, Reeves WC. Factor analysis of unexplained severe fatigue and interrelated symptoms: overlap with criteria for chronic fatigue syndrome. Am J Epidemiol 1998;148:72-7.
2. Fukuda K, Straus SE, Hickie I, et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med 1994;121(12): 953-59.
3. Centers for Disease Control and Prevention. Chronic Fatigue Syndrome. Accessed October 8, 2013.
4. Edmonds M, McGuire H, Price J. Exercise therapy for chronic fatigue syndrome. Cochrane Database Syst Rev 2004;3:CD003200.
5. Agency for Healthcare Research and Quality. Evidence Report Number 42, Defining and Managing Chronic Fatigue Syndrome (AHRQ Publication No. 01-E061). Accessed October 8, 2013.
6. Rx List: The Internet Drug Index. Accessed October 8, 2013.
7. Watson Pharmaceuticals. TRAMADOL HCl TABLETS 50 mg 100s: U.S. Prescribing information. 800.272.5525
8. Physicians’ Desk Reference. 58 ed. Montvale, NJ: Thomson PDR; 2004.