Oral Health

     Oral health problems such as periodontal disease, dental caries, and tooth loss have been suggested to have associations with cardiovascular disease1,2. In a prospective study with nearly 500 MS patients, those with one or more cardiovascular risks showed more lesions and brain shrinkage 3.

    Oral Health ImageOral hygiene care – including daily or more frequent tooth brushing and flossing and regular dental visits for professional cleaning – has been shown reduce the risk of cardiovascular events such as heart attacks and strokes. This is in part because the mouth is full of gentle blood vessels with easy access to the general blood stream – which is why sublingual supplements are so powerful. Poor oral conditions trigger an immune reaction that makes for an inflamed mouth, therefore leading to system-wide inflammation, which is bad for the heart in prone individuals4 and for the nervous system in MS-affected people. Another possible connection is certain harmful oral bacteria like Porphyromonas gingivalis, which has been implicated not only in cardiovascular disease, but has been observed to possibly play a role in the pathogenesis of inflammatory neurological disorders such as MS, likely due to its excretion of lipopolysaccharide 5.

     Of note, good oral hygiene is especially important if oral tobacco products are used, as it is key to preventing the damaging inflammation associated with “snuff” and benefitting from the anti-inflammatory effects of certain tobacco plant components 6.

     The following are general recommendations for tooth and gum care (see your dental health professional for additional ones as needed):

  • Toothbrushing: Brush at least twice a day (ideally just after rising for the day and just before retiring for the night) for two minutes each time, taking care to be as thorough as possible, and including gums in your brushing.

  • Toothbrush: Medium softness is considered to provide the best balance between thorough care and prevention of erosion. Replace your toothbrush every three months or more often.

  • Tooth cleanser: Choose toothpastes or powders made from natural ingredients. The addition of fluoride is recommended by the National Multiple Sclerosis Society, but xylitol is considered to be an effective, less controversial (Reddy et al., 2021; Till and Green, 2021) alternative.

  • Between teeth: Clean between your teeth every day using floss, interdental brushes, floss picks, or water flossers.

  • Tongue: Use a tongue scraper or brush your tongue twice per day, ideally while brushing teeth.

  • General oral cleanser: Use a therapeutic mouthwash made from natural ingredients.

  • Dentist visits: At least twice per year for preventive care. See your dentist as soon as possible if you experience bleeding gums, tooth or jaw pain, or tooth sensitivity.

  • Fillings: White composite fillings are considered to be less toxic than mercury fillings, especially relevant in MS. Some are even BPA-free.

  • Nutrition: Avoid sugar-sweetened foods and beverages. Be sure to get plenty of calcium, magnesium, phosphorus, vitamins D and K2, and probiotics in your diet and/or through supplements.

  • Dry mouth care: Sip on water frequently to prevent creating an ideal environment for bacteria to flourish.

  • Mouth care when not eating or drinking by mouth: It is important to keep your mouth clean even if you are not eating. Continue to brush your teeth and tongue.

  • Other: Quit smoking or don’t start. An ideal alternative is chewing gum sweetened with xylitol.

Smoking Avoidance or Cessation

     Smoking has been associated with greater MS prevalence7 and disability8, and is considered to be a preventable contributor to MS progression9 and faster brain atrophy in MS 10, as well as worse prognosis 11.

In a study with nearly 500 MS patients, there were significantly more smokers (51.7% vs 36.5%, p = 0.001), with smoking associated with lower brain volume3. In a study involving nearly one million people aged 30-95, smoking was so strongly associated with cardiovascular risk that it even overshadowed oral health2. Given the link between cardiovascular risk and MS risk, there may be an additional reason to give up smoking or never start.

     The heat and combustion of cigarettes are considered to be the culprits in MS. They are lung irritants, which have direct neurotoxic effects in addition to contributing to proinflammatory and immune cascades that impact MS 11. The combination of heat and irritation is further supported by an association between waterpipe use and MS7, versus lack of risk with oral smokeless tobacco products9,11.

     Smoking cessation has been tightly linked to reduced MS disability progression12. While there are various methods, nicotine replacement therapy may be particularly advantageous in MS, as it has demonstrated anti-inflammatory effects that appear to often overcome its pro-inflammatory effects6. In a 15-year study of over 9000 individuals with MS, smokeless oral tobacco use was associated with slower disease progression9, consistent with previous research suggesting benefits of the tobacco plant for addressing neurodegenerative conditions13. It should be noted that if oral tobacco products are used, good oral hygiene is key to preventing damaging inflammation 6.


References

1. Herrera D, Sanz M, Shapira L, et al. Periodontal diseases and cardiovascular diseases, diabetes, and respiratory diseases: Summary of the consensus report by the European Federation of Periodontology and WONCA Europe. Eur J Gen Pract. Dec 2024;30(1):2320120. doi:10.1080/13814788.2024.2320120

2. Batty GD, Jung KJ, Mok Y, et al. Oral health and later coronary heart disease: Cohort study of one million people. Eur J Prev Cardiol. Apr 2018;25(6):598-605. doi:10.1177/2047487318759112

3. Kappus N, Weinstock-Guttman B, Hagemeier J, et al. Cardiovascular risk factors are associated with increased lesion burden and brain atrophy in multiple sclerosis. J Neurol Neurosurg Psychiatry. Feb 2016;87(2):181-7. doi:10.1136/jnnp-2014-310051

4. Church LA, Robins L, Xu F, et al. Oral health education strategies for patients living with cardiovascular disease within hospital settings: a scoping review. Front Public Health. 2024;12:1389853. doi:10.3389/fpubh.2024.1389853

5. Shapira L, Ayalon S, Brenner T. Effects of Porphyromonas gingivalis on the central nervous system: activation of glial cells and exacerbation of experimental autoimmune encephalomyelitis. J Periodontol. May 2002;73(5):511-6. doi:10.1902/jop.2002.73.5.511

6. Zhang W, Lin H, Zou M, et al. Nicotine in Inflammatory Diseases: Anti-Inflammatory and Pro-Inflammatory Effects. Front Immunol. 2022;13:826889. doi:10.3389/fimmu.2022.826889

7. Bazmi E, Behnoush AH, Talebian MT, Afrooghe A, Sahraian MA. Waterpipe Tobacco Smoking and Multiple Sclerosis: A Systematic Review and Meta-Analysis. Neuroepidemiology. Jul 25 2024:1-11. doi:10.1159/000540087

8. Polick CS, Dennis P, Calhoun PS, Braley TJ, Lee E, Wilson S. Investigating disparities in smoking cessation treatment for veterans with multiple sclerosis: A national analysis. Brain Behav. May 2024;14(5):e3513. doi:10.1002/brb3.3513

9. Wu J, Olsson T, Hillert J, Alfredsson L, Hedstrom AK. Influence of oral tobacco versus smoking on multiple sclerosis disease activity and progression. J Neurol Neurosurg Psychiatry. Aug 2023;94(8):589-596. doi:10.1136/jnnp-2022-330848

10. Gouider R, Souissi A, Mrabet S, et al. Environmental factors related to multiple sclerosis progression. J Neurol Sci. Sep 15 2024;464:123161. doi:10.1016/j.jns.2024.123161

11. Rosso M, Chitnis T. Association Between Cigarette Smoking and Multiple Sclerosis: A Review. JAMA Neurol. Feb 1 2020;77(2):245-253. doi:10.1001/jamaneurol.2019.4271

12. Tanasescu R, Constantinescu CS, Tench CR, Manouchehrinia A. Smoking Cessation and the Reduction of Disability Progression in Multiple Sclerosis: A Cohort Study. Nicotine Tob Res. Apr 2 2018;20(5):589-595. doi:10.1093/ntr/ntx084

13. Zhang W, Pan X, Fu J, et al. Phytochemicals derived from Nicotiana tabacum L. plant contribute to pharmaceutical development. Front Pharmacol. 2024;15:1372456. doi:10.3389/fphar.2024.1372456

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