Not brushing teeth at night may increase the risk of cardiovascular disease

In this study, we investigated cardiovascular events and life outcomes associated with toothbrushing time. Although we encounter many middle-aged and elderly patients who do not brush their teeth at night in clinical practice, current research results show that there is a certain proportion of individuals in each age group who do not brush their teeth at night. This may be due to the influence of parents' habits. Some people have been taught since childhood to brush their teeth after getting up (before breakfast), regardless of whether they brush their teeth at night. Brushing habits may also be related to lifestyle and regional differences. Participants who only brushed their teeth in the morning and those who did not brush at all also showed a tendency not to brush after lunch, indicating a lack of interest in dental hygiene. Therefore, we did not create a separate group for those who did not brush their teeth after lunch because this group was almost identical to those who did not brush their teeth at night in this study.

Because this study was limited to hospitalized patients, their poor physical condition may have hindered the maintenance of oral health and affected their prognosis. Additionally, as this was a retrospective study, there may be selection bias. Because only inpatients from one hospital were included, the techniques and treatment strategies of the attending physicians may differ from those of other hospitals. Since our hospital is a university hospital, there are many difficult cases and the types of treatment are also biased. Although heart disease is often considered a disease of the elderly, many of our patients had severe congenital heart disease, and some had artificial assist hearts or died while awaiting heart transplantation. In other words, not all young patients in our hospital are healthy. Therefore, we included patients aged 20 years and older. Multicenter studies are needed to generalize the results of this study. In addition, the median observation period of 1,583 patients was 441 days, during which 176 deaths, 226 cardiovascular events, and 762 hospitalizations occurred. The short cohort period is also a limitation of this study.

However, research results clearly show that simply brushing your teeth after getting up in the morning is not enough. Brushing your teeth at night is beneficial to maintaining health.These implications are consistent with the theory that reduced salivary flow during nighttime sleep results in increased bacterial load in the oral cavity.16,17.

Although the complete mechanism is not yet clear, the following mechanisms have been proposed: (1) tooth loss due to periodontal disease or dental caries caused by increased oral bacteria, impairing chewing efficiency and health; (2) disruption of intestinal bacterial balance by oral bacteria can impair healthy18,19; (3) Cardiovascular events are caused by bacteremia caused by periodontal disease.

There were no significant differences in cardiovascular events, hospitalization events, or life outcomes between the groups based on the number of teeth, caries, or periodontal disease. The lower the number of teeth, the lower the chewing intensity. Tanaka et al.20 Including a low number of remaining teeth is a factor in oral frailty, which increases frailty, sarcopenia and mortality, but they said there were no significant differences in health deterioration based on tooth count alone. Retention of teeth with advanced periodontal disease carries the risk of endocarditis. In our department, we encourage patients with cardiovascular disease to aggressively undergo extraction of teeth with endodontic or periodontal problems and a poor prognosis. In fact, Lockhart et al.number 17 The report stated that bacteremia after brushing is related to poor oral hygiene and bleeding gums after brushing.

In this study, it was unclear whether participants brushed their teeth correctly because they were not judged on objective indicators of oral hygiene, such as plaque index. Additionally, data on aids such as flossing and interdental brushes and brushing time were not included because they would complicate the analysis and do not provide a direct assessment of whether patients were brushing adequately, even if they spent more time doing so Or use auxiliary tools. Therefore, plaque scores should also be assessed. We did not include this in the analysis because only a subset of samples were examined for plaque scores. Furthermore, many patients in the MN group had gingival pockets >8 mm. A periodontal pocket of 8 mm was chosen as the cutoff value because periodontal pockets >8 mm are an indication for tooth extraction as they are a source of infection for severe periodontal disease. However, it is unclear whether participants brushed their teeth more voluntarily because they had pre-existing periodontal disease, or whether their teeth were preserved despite having advanced periodontal disease because they were enthusiastic about brushing. Patients with pocket depth exceeding 8 mm had advanced periodontal disease and may have been affected by cardiovascular disease even though they belonged to the MN group, which is a limitation of this study. However, although this study was not included in Kaplan-Meier analysis, after excluding patients with pocket depths exceeding 8 mm, there was almost no difference in the presence or absence of cardiac events and life prognosis.

Although our findings are limited to cardiovascular disease and cannot be applied to healthy individuals, they suggest that brushing your teeth at night is important. To prevent cardiovascular disease, it is necessary to brush your teeth before breakfast, but the most important thing is to brush your teeth before going to bed at night. Traditional oral hygiene practices followed in Japan may not be suitable for good general health. Therefore, it is necessary to improve the general public's awareness of tooth brushing time.

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