People with multiple sclerosis are at increased risk of periodontitis or gum disease, which may be linked to worse MS outcomes. The newsletter discusses what can be done about it.
Very interesting read. In my case I find it difficult to say what worsened or improved what, as I was initially diagnosed with aggressive RR ms and was suffering from periodontitis. As I have started treating both: Tysabri for the MS and soon enough extraction of several teeth, a course of dental deep cleaning and eventually I stopped smoking. I feel great but as mentioned I find it hard to pinpoint which factor alongside the Tysabri was most beneficial, I bet on quitting with smoking :-)
I saw an excellent periodontist several years ago. She did a very deep clean under local anaesthetic and gave me a stringent daily dental hygiene protocol:
* Use a good electric toothbrush eg Oral B after every meal, not just morning and night. Ordinary toothbrushes inadequate.
* Use Corsodyl gum toothpaste. Ordinary toothpaste not as effective.
* Then use an electric dental flosser. Panasonic very good (Amazon approx £36.) Fill the reservoir with warm water mixed with Curasept mouthwash. Water alone won't work so well. Use after every brushing.
* Use Curasept gel along line between teeth and gums as and when needed.
* Referral to periodontist was from a private dentist. Expensive but worth it.
Hi Judy, that’s a super plan. My only (ha! Only?) complaint with Oral B toothbrush was their brushes weren’t soft enough. So I use the brush every other night. Are you tape flossing along with the water? (I had Water Pic, but was instructed to also floss.) I really hate flossing. 🌷
I also hate flossing but it's probably best to floss as well.as irrigate. I found the Panasonic better than the Waterpik. If you don't do all these things every day you soon suffer the consequences. Gum disease is just waiting to come back with a vengeance. Gum disease also linked to heart disease.
Yes, and it’s difficult with the top teeth. I’ve been so frustrated with having awful sinus infections and having to let them worsen to the point where they’re bleeding and causing fevers before treatment is begun. That causes tooth sensitivity also.🌷
I would love to hear more about the sinusitis angle. Getting COVID didn't "activate" my MS at all, but any time I spend time in my parents' dusty basement and don't VERY actively manage my sinuses (masking, antihistamines, decongestants), the subsequent several days are terrible with aches, fatigue and brain fog. I thought I was crazy!
Note also the relationship between EBV and periodontal disease/gingivitis. Whether it’s causative, or just the result of an immune system overwhelmed by keeping EBV in check which allows proliferation od oral disease, antivirals completely resolve my oral issues including gingivitis and mouth ulcers. Since the oropharyngeal cavity hosts HSV and EBV (and allows for lytic reactivation) this could be a measurable outcome in antiviral trials and also encourage preventative care in the MS population.
This is an excellent subject overall, including recovery time from infections. Both periodontal disease and sinus infection can begin as low grade occurrences, one feels lousy, then the infection escalates quickly. MS reacts, one gets sicker and then recovery can take weeks. PCPs often don’t realize that time is of the essence in getting the infection cleared. I have a bone to pick in the holistic treatment arena that, for whatever reason, dental issues (our teeth/mouth) aren’t considered part of our bodies. (And I believe post menopausal women lose their teeth earlier also which is why I don’t understand the estrogen fights). It’s also difficult to maintain maximum dental health depending on an individual’s dexterity. I hate flossing; it’s tiring, but I do it. I considered a water flosser, but my dentist daughter advised the handle is quite heavy because it holds the water, so I stuck with automatic brush, flossing (grr) and sinus irrigation. The situation that drives me bonkers is getting one infection after another, as I have lately, and never quite recovering equilibrium. Now, I am frighteningly out of condition. It’s only my opinion, but I believe chronic sinus disease and dental disease are interrelated and rarely treated as such. Those top teeth are often right up in the sinuses. A good Monday to all! Thank you, Prof G.🌷
Thank you for bringing this up I was experience silmar stuff. I have started treatments etc and it seem to be working .
Like yourcase study.
I hope you don't pointing out.
The immune system attacks bacteria as the plaque spreads below the gum line into the pockets. This leads to an immune reaction, which involves the release of toxins and inflammation. Yes I agree how it effects our MS..
I also increased my vit and calcium tabs and few others . It helps.
Once again I be happy to receive any help with mine .
I found this also interesting
Factors that increase the risk include:
Inadequate oral hygiene: This includes not brushing and flossing regularly.
Smoking: This increases the risk of gum problems and undermines the efficacy of treatment. Around 90% of cases that are hard to treat are in smokers.
Genetic factors: Some people are more likely to develop gum disease, for example, because of the way their immune system reacts.
Age: Periodontitis can happen at any age but usually starts after the age of 35 years. The risk of consequences, such as tooth loss, increases with age.
Some health conditions: Type 2 diabetes increases the risk of periodontitis if a person is unable to manage their blood glucose levels.
Diet: A high intake of processed carbohydrates, including added sugars, increases the risk. In contrast, fruits and vegetables contain antioxidants, which can help protect the gums, according to research.
Stress: Stress can affect the immune system and increase the chance of inflammation.
Weakened immune system: Health conditions and medication that affect the immune system can increase the risk of gum disease.
Medications: Drugs that reduce salivaTrusted Source can increase the chance of gum disease.
Hormonal changes: A person is more at risk during pregnancy and when using oral birth control.
Physical irregularities: Examples include crooked teeth, damaged fillings, and dental bridges that no longer fit correctly.
The NHS refused me access to healthcare for decades, so I was too ill to see a dentist, and I don't know if I ever had periodontitis. But not as far as I'm aware. (Though I suspect I had many undiagnosed/treated UTI's; the other conditions I need to research). I just had root canal under Special Care dentistry, so I don't think I have gum disease now, they'd have noticed. I'd recommend Special Care Dentistry, for anyone who fits their criteria and can get a referral; they're more understanding and accommodating of one's other conditions, and can make home visits if one's too ill to get there.
I have been flossing almost daily since my early 20s, so for 30 years now. I have also used an electric toothbrush for years and keep up with routine dental visits. Also, not a smoker. After reading this, I am wondering if it is a major reason for doing so well so far. I was diagnosed 9 years ago with RRMS and had >10 brain lesions and several spinal cord lesions. Symptoms at diagnosis were fairly minimal. I have since been reclassified as PPMS but it has been 9 years since original diagnosis. My walking has gotten worse but still able to work full time as a nurse so long as I wear an AFO. I know there are other factors leading to what I feel is fairly slow progression, such as being on Ocrevus since 2016, being active, eating halfway healthy, etc. But now I am thinking good oral hygiene has also played a big role. Thanks for this info. It is always nice to be able to give newly diagnosed pwMS advice on something they can do to help themselves!
To check my understanding: is this saying that pwMS are at higher risk of periodontitis as a result of their MS (and/or likely immunosuppressant medication), or that periodontitis can make symptoms worse? Or both? I’m asking to understand my level of risk - basically am I more at risk even if I do all the right things regarding oral hygiene, professional cleaning etc?
It is association and not necessary causal. We don't know if the periodontitis starts before MS or MS leads to periodontitis. To sort this out we would need to do longitudinal studies and other research. All I am saying if you have MS and co-morbid periodontitis you need to get it treated as it may be making your MS worse.
This is interesting to read and I have found my teeth/guns have declined significantly since I was diagnosed with RRMS in 2016. I take Cinnarazine 3 times per day for ongoing dizziness/nausea and wonder if this could have contributed to the steep decline in my dental health. I’m also on a low dose of steroid for colitis, bone medication for osteopenia and Tecfidera so I guess this is probably not a great combination for my teeth. Despite brushing as advised and using interdental brushes my teeth always end up stained and the gums worsen at each 3 month clean. Is there anything else I can do to try and reverse this as I’ve lost 4 teeth since diagnosis : (
Cinnarazine has anticholinergic effects and reduces saliva production, which has a major impact on the oral flora and hence health. Can you stop ? If not, you may want to use artificial saliva or chew sugar-free gum to stimulate saliva flow. The steroids may also be contributing to the problem. Not sure about dimethyl fumarate (Tecfidera). There is no mention of gum disease in the summary of product characteristics. However, is there is some basic science suggesting DMF may affect osteoclast function and hence could affect bone remodelling; this could potentially affect your teeth, but unlikely as it has not emerged as a major problem despite extensive use. After saying all this my money would be on cinnarazine being the culprit.
Thank you so much for coming back to me, hugely appreciated and I will look at the artificial salvia. Having looked online there are lots to choose from- is there a particular ingredient within I need to look for please? It’s also complicated by the fact I have acute intermittent porphyria so some medications/ preparations can be contraindicated.
I used to only go to the dentist when visiting my mother in NZ. She would always book me in to have a checkup with my childhood dentist while I was there! Then the pandemic came and I couldn't travel there for three years - and my dentist retired. Fortunately for me I found an NHS dentist close to home that could take me. I've been very impressed with my experience there so far. They know I have MS and always ask after my health. I know from doing a public health-related MSc that dental health is linked to other health impacts, so I'm glad they take it seriously. I was a bit worried about my gums for a while but my dentist said I was probably brushing my teeth a bit too hard. I've eased off and on my last visit she said very nice things about the state of my teeth!
I have used an electric toothbrush from a very young age. I have also always brushed with fluoride toothpaste. I have a healthy diet and have never smoked. I think all these things have helped. I used to get a lot of mouth ulcers but found that if I used a toothpaste that doesn't contain SLS I don't get them now unless very stressed or run down. Unfortunately most toothpastes contain SLS! I used Sensodyne until recently, when I switched to Life Supplies (refillable toothpaste pump - I don't like using non-recyclable packaging!).
I had inflamed gums for a long time and a battle with tartar, my dentist told me the issue was aggravated by my dry mouth caused by medications. Since eliminating all sugar and carbohydrates from my diet my gums are healthy and tartar minimal. At my last check up my dentist told me whatever you are doing keep doing it.
I suffer with periodontal disease. So bad that my teeth were so loose I had to have some removed and have a denture made. I have been given a gum shield however, I did tell my dentist I do not grind my teeth.
As always, thank you Prof G for excellent article. I don't have gum issues, but I find other points in your article very helpful. As you said, infections (any kind) make MS worse, and boy did pneumonia worsen my MS... I feel small relief when reading that you had patients whose MS never got better after severe Covid - finally an explanation why I have been getting worse since April 2022
I'm very fortunate that when my dentist found out I have MS, she suggested getting a cleaning every 3 months because of this very thing. My disability approved a cleaning every 4 months, so I am very grateful for that! So far I don't have gum disease but I am starting to get some receding gums, and my dental hygienist is keeping her eye on that.
On a different topic, can you point me to any information on Latent TB and MS? It was discovered I have that while doing the work up pre-Kesimpta initiating. I have been on Tysabri since 2017 but my last MRI showed active lesions, so my neuro wants to change to Kesimpta. I have no idea what is about to happen going forward now, but I sure as hell don't want Tysabri rebound, well obviously lol The last TB test I had was in 2016, and it was negative, so I'm a little suspect of this result.
Latent TB is quite common. However, anti-CD20 is not a major risk factor for TB as it targets B-cells and not T-cells and innate immunity that is essential for immunity against TB. Our TB service don't think screening for TB before starting an anti-CD20 therapy is necessary. We do it because we often do the screening prior to patients selecting which class of therapy they are on. Once we identify latent TB they infectious disease consultants invariably treat to try and clear the bacterium and hence prevent active TB from developing.
Thank you so very much for answering and for the link. I feel so much better now with your one paragraph answer and the link you provided. I really do appreciate your kindness and education. Every post I've read and comments from other readers, has been invaluable. This is why I became a member!
Thanks, this is really interesting. Looking into the nutraceutical list on the attachment, I find it confusing where some of the items are things I have been advised not to take for fear of OVER-stimulating the immune system eg ginkgo? And echinacea actually has a not on the box NOT to be taken by people with ms? Thanks for your comments.
I don't mention any actual nutraceutical in the infographic as the evidence base for them is too poor to make definitive recommendations. The only one I routinely recommend is vitamin D for bone health and a large number of supplements if you are vegan.
Very interesting read. In my case I find it difficult to say what worsened or improved what, as I was initially diagnosed with aggressive RR ms and was suffering from periodontitis. As I have started treating both: Tysabri for the MS and soon enough extraction of several teeth, a course of dental deep cleaning and eventually I stopped smoking. I feel great but as mentioned I find it hard to pinpoint which factor alongside the Tysabri was most beneficial, I bet on quitting with smoking :-)
I saw an excellent periodontist several years ago. She did a very deep clean under local anaesthetic and gave me a stringent daily dental hygiene protocol:
* Use a good electric toothbrush eg Oral B after every meal, not just morning and night. Ordinary toothbrushes inadequate.
* Use Corsodyl gum toothpaste. Ordinary toothpaste not as effective.
* Then use an electric dental flosser. Panasonic very good (Amazon approx £36.) Fill the reservoir with warm water mixed with Curasept mouthwash. Water alone won't work so well. Use after every brushing.
* Use Curasept gel along line between teeth and gums as and when needed.
* Referral to periodontist was from a private dentist. Expensive but worth it.
Hi Judy, that’s a super plan. My only (ha! Only?) complaint with Oral B toothbrush was their brushes weren’t soft enough. So I use the brush every other night. Are you tape flossing along with the water? (I had Water Pic, but was instructed to also floss.) I really hate flossing. 🌷
I also hate flossing but it's probably best to floss as well.as irrigate. I found the Panasonic better than the Waterpik. If you don't do all these things every day you soon suffer the consequences. Gum disease is just waiting to come back with a vengeance. Gum disease also linked to heart disease.
Yes, and it’s difficult with the top teeth. I’ve been so frustrated with having awful sinus infections and having to let them worsen to the point where they’re bleeding and causing fevers before treatment is begun. That causes tooth sensitivity also.🌷
I would love to hear more about the sinusitis angle. Getting COVID didn't "activate" my MS at all, but any time I spend time in my parents' dusty basement and don't VERY actively manage my sinuses (masking, antihistamines, decongestants), the subsequent several days are terrible with aches, fatigue and brain fog. I thought I was crazy!
Tiny, you aren’t crazy. Dust can be awful because of the dust mites. I always know when the house is getting too dusty. 🌷
Note also the relationship between EBV and periodontal disease/gingivitis. Whether it’s causative, or just the result of an immune system overwhelmed by keeping EBV in check which allows proliferation od oral disease, antivirals completely resolve my oral issues including gingivitis and mouth ulcers. Since the oropharyngeal cavity hosts HSV and EBV (and allows for lytic reactivation) this could be a measurable outcome in antiviral trials and also encourage preventative care in the MS population.
https://cordis.europa.eu/article/id/442277-the-important-role-that-the-epstein-barr-virus-plays-in-periodontitis#:~:text=Severe%20infection%2Ddriven%20gum%20disease,the%20herpes%20family%20of%20viruses
This is an excellent subject overall, including recovery time from infections. Both periodontal disease and sinus infection can begin as low grade occurrences, one feels lousy, then the infection escalates quickly. MS reacts, one gets sicker and then recovery can take weeks. PCPs often don’t realize that time is of the essence in getting the infection cleared. I have a bone to pick in the holistic treatment arena that, for whatever reason, dental issues (our teeth/mouth) aren’t considered part of our bodies. (And I believe post menopausal women lose their teeth earlier also which is why I don’t understand the estrogen fights). It’s also difficult to maintain maximum dental health depending on an individual’s dexterity. I hate flossing; it’s tiring, but I do it. I considered a water flosser, but my dentist daughter advised the handle is quite heavy because it holds the water, so I stuck with automatic brush, flossing (grr) and sinus irrigation. The situation that drives me bonkers is getting one infection after another, as I have lately, and never quite recovering equilibrium. Now, I am frighteningly out of condition. It’s only my opinion, but I believe chronic sinus disease and dental disease are interrelated and rarely treated as such. Those top teeth are often right up in the sinuses. A good Monday to all! Thank you, Prof G.🌷
Thank you for bringing this up I was experience silmar stuff. I have started treatments etc and it seem to be working .
Like yourcase study.
I hope you don't pointing out.
The immune system attacks bacteria as the plaque spreads below the gum line into the pockets. This leads to an immune reaction, which involves the release of toxins and inflammation. Yes I agree how it effects our MS..
I also increased my vit and calcium tabs and few others . It helps.
Once again I be happy to receive any help with mine .
I found this also interesting
Factors that increase the risk include:
Inadequate oral hygiene: This includes not brushing and flossing regularly.
Smoking: This increases the risk of gum problems and undermines the efficacy of treatment. Around 90% of cases that are hard to treat are in smokers.
Genetic factors: Some people are more likely to develop gum disease, for example, because of the way their immune system reacts.
Age: Periodontitis can happen at any age but usually starts after the age of 35 years. The risk of consequences, such as tooth loss, increases with age.
Some health conditions: Type 2 diabetes increases the risk of periodontitis if a person is unable to manage their blood glucose levels.
Diet: A high intake of processed carbohydrates, including added sugars, increases the risk. In contrast, fruits and vegetables contain antioxidants, which can help protect the gums, according to research.
Stress: Stress can affect the immune system and increase the chance of inflammation.
Weakened immune system: Health conditions and medication that affect the immune system can increase the risk of gum disease.
Medications: Drugs that reduce salivaTrusted Source can increase the chance of gum disease.
Hormonal changes: A person is more at risk during pregnancy and when using oral birth control.
Physical irregularities: Examples include crooked teeth, damaged fillings, and dental bridges that no longer fit correctly.
The NHS refused me access to healthcare for decades, so I was too ill to see a dentist, and I don't know if I ever had periodontitis. But not as far as I'm aware. (Though I suspect I had many undiagnosed/treated UTI's; the other conditions I need to research). I just had root canal under Special Care dentistry, so I don't think I have gum disease now, they'd have noticed. I'd recommend Special Care Dentistry, for anyone who fits their criteria and can get a referral; they're more understanding and accommodating of one's other conditions, and can make home visits if one's too ill to get there.
I have been flossing almost daily since my early 20s, so for 30 years now. I have also used an electric toothbrush for years and keep up with routine dental visits. Also, not a smoker. After reading this, I am wondering if it is a major reason for doing so well so far. I was diagnosed 9 years ago with RRMS and had >10 brain lesions and several spinal cord lesions. Symptoms at diagnosis were fairly minimal. I have since been reclassified as PPMS but it has been 9 years since original diagnosis. My walking has gotten worse but still able to work full time as a nurse so long as I wear an AFO. I know there are other factors leading to what I feel is fairly slow progression, such as being on Ocrevus since 2016, being active, eating halfway healthy, etc. But now I am thinking good oral hygiene has also played a big role. Thanks for this info. It is always nice to be able to give newly diagnosed pwMS advice on something they can do to help themselves!
To check my understanding: is this saying that pwMS are at higher risk of periodontitis as a result of their MS (and/or likely immunosuppressant medication), or that periodontitis can make symptoms worse? Or both? I’m asking to understand my level of risk - basically am I more at risk even if I do all the right things regarding oral hygiene, professional cleaning etc?
It is association and not necessary causal. We don't know if the periodontitis starts before MS or MS leads to periodontitis. To sort this out we would need to do longitudinal studies and other research. All I am saying if you have MS and co-morbid periodontitis you need to get it treated as it may be making your MS worse.
This is interesting to read and I have found my teeth/guns have declined significantly since I was diagnosed with RRMS in 2016. I take Cinnarazine 3 times per day for ongoing dizziness/nausea and wonder if this could have contributed to the steep decline in my dental health. I’m also on a low dose of steroid for colitis, bone medication for osteopenia and Tecfidera so I guess this is probably not a great combination for my teeth. Despite brushing as advised and using interdental brushes my teeth always end up stained and the gums worsen at each 3 month clean. Is there anything else I can do to try and reverse this as I’ve lost 4 teeth since diagnosis : (
Cinnarazine has anticholinergic effects and reduces saliva production, which has a major impact on the oral flora and hence health. Can you stop ? If not, you may want to use artificial saliva or chew sugar-free gum to stimulate saliva flow. The steroids may also be contributing to the problem. Not sure about dimethyl fumarate (Tecfidera). There is no mention of gum disease in the summary of product characteristics. However, is there is some basic science suggesting DMF may affect osteoclast function and hence could affect bone remodelling; this could potentially affect your teeth, but unlikely as it has not emerged as a major problem despite extensive use. After saying all this my money would be on cinnarazine being the culprit.
Thank you so much for coming back to me, hugely appreciated and I will look at the artificial salvia. Having looked online there are lots to choose from- is there a particular ingredient within I need to look for please? It’s also complicated by the fact I have acute intermittent porphyria so some medications/ preparations can be contraindicated.
I used to only go to the dentist when visiting my mother in NZ. She would always book me in to have a checkup with my childhood dentist while I was there! Then the pandemic came and I couldn't travel there for three years - and my dentist retired. Fortunately for me I found an NHS dentist close to home that could take me. I've been very impressed with my experience there so far. They know I have MS and always ask after my health. I know from doing a public health-related MSc that dental health is linked to other health impacts, so I'm glad they take it seriously. I was a bit worried about my gums for a while but my dentist said I was probably brushing my teeth a bit too hard. I've eased off and on my last visit she said very nice things about the state of my teeth!
I have used an electric toothbrush from a very young age. I have also always brushed with fluoride toothpaste. I have a healthy diet and have never smoked. I think all these things have helped. I used to get a lot of mouth ulcers but found that if I used a toothpaste that doesn't contain SLS I don't get them now unless very stressed or run down. Unfortunately most toothpastes contain SLS! I used Sensodyne until recently, when I switched to Life Supplies (refillable toothpaste pump - I don't like using non-recyclable packaging!).
I had inflamed gums for a long time and a battle with tartar, my dentist told me the issue was aggravated by my dry mouth caused by medications. Since eliminating all sugar and carbohydrates from my diet my gums are healthy and tartar minimal. At my last check up my dentist told me whatever you are doing keep doing it.
That was extremely interesting to read.
I suffer with periodontal disease. So bad that my teeth were so loose I had to have some removed and have a denture made. I have been given a gum shield however, I did tell my dentist I do not grind my teeth.
As always, thank you Prof G for excellent article. I don't have gum issues, but I find other points in your article very helpful. As you said, infections (any kind) make MS worse, and boy did pneumonia worsen my MS... I feel small relief when reading that you had patients whose MS never got better after severe Covid - finally an explanation why I have been getting worse since April 2022
I'm very fortunate that when my dentist found out I have MS, she suggested getting a cleaning every 3 months because of this very thing. My disability approved a cleaning every 4 months, so I am very grateful for that! So far I don't have gum disease but I am starting to get some receding gums, and my dental hygienist is keeping her eye on that.
On a different topic, can you point me to any information on Latent TB and MS? It was discovered I have that while doing the work up pre-Kesimpta initiating. I have been on Tysabri since 2017 but my last MRI showed active lesions, so my neuro wants to change to Kesimpta. I have no idea what is about to happen going forward now, but I sure as hell don't want Tysabri rebound, well obviously lol The last TB test I had was in 2016, and it was negative, so I'm a little suspect of this result.
Wishing everyone a good week!
Re: latent TB
https://gavingiovannoni.substack.com/p/the-rationale-for-derisking-dmts
Latent TB is quite common. However, anti-CD20 is not a major risk factor for TB as it targets B-cells and not T-cells and innate immunity that is essential for immunity against TB. Our TB service don't think screening for TB before starting an anti-CD20 therapy is necessary. We do it because we often do the screening prior to patients selecting which class of therapy they are on. Once we identify latent TB they infectious disease consultants invariably treat to try and clear the bacterium and hence prevent active TB from developing.
Thank you so very much for answering and for the link. I feel so much better now with your one paragraph answer and the link you provided. I really do appreciate your kindness and education. Every post I've read and comments from other readers, has been invaluable. This is why I became a member!
Thanks, this is really interesting. Looking into the nutraceutical list on the attachment, I find it confusing where some of the items are things I have been advised not to take for fear of OVER-stimulating the immune system eg ginkgo? And echinacea actually has a not on the box NOT to be taken by people with ms? Thanks for your comments.
Which attachment are you referring to?
Sorry! The holistic management of MS infographic
I don't mention any actual nutraceutical in the infographic as the evidence base for them is too poor to make definitive recommendations. The only one I routinely recommend is vitamin D for bone health and a large number of supplements if you are vegan.
Please see:
https://gavingiovannoni.substack.com/p/nutraceuticals-what-is-the-state#details
Thank you, I’ll have a read through 😊