Nap Your Way to Better Oral Health: IV Sedation Insights

Hi, everybody. I'm Dr. Sandhya Moldovan, periodontist and nutritionist. Welcome to the Holistic Dentistry Podcast, the show that gives you the tips and tools to detoxify your mouth for a healthier body as we explore together the root cause of disease. Remember, you're not healthy until your mouth is healthy, so take care of it in the most natural way.

Hi, everyone.

Welcome to today's show. I'm your host, Dr. Sandhya, and I'm very excited to talk today with Dr. Mark Torbener. Mark, welcome to the show.

Thank you for having me, Sanda.

Today's show is really going to be focused on IV sedation and dentistry. I think there's so many misconceptions. A lot of people are scared of the dentist, and then they're also scared of IV sedation. So I'm excited to talk to you today because I think you're going to help us shed some light on this topic. We've known each other now, Mark, for, I want to say, maybe around 20 years. Something like that. Something like that, exactly. And we worked on many cases in the office. Short cases from one to two hours, and long cases with Dr. Magami that are like eight hours. And a lot of people, I think, still don't know the benefit of having you as part of our team to be able to do our work better in what we do.

Have you been an anesthesiologist 38 years.

So in those 38 years, have you had, like, any, like, interesting happenings or, you know, would you consider IV sedation safe as an option in. In the dental office?

IV sedation, when done properly, is very safe in the dental office. As I tell most patients, their drive to the office. Their drive to the office is approximately a hundred thousand times more dangerous than the IV se. IV sedation doesn't make it less safe to be in the desk. Makes it safer because when you're having IV sedation, we're monitoring your heart rate, your blood pressure, your breathing. We check everything before we start, during and after to make sure everything is safe to proceed with the procedure or make adjustments or shorten the procedure or what have you. Once in a while, we have a patient who comes in whose blood pressure is too high to start and he didn't know it. So we can identify those patients and send them to their physician, get them controlled before we go ahead. So we make their life safer. Approximately 16% of adults do not know or have uncontrolled high blood pressure. 16%.

Wow, that's pretty high.

And oftentimes we pick this up in dental offices with screening because they don't go to their physician. We check and we defer them to the physician. They get a full physical, get a more controlled situation, then we can proceed safer, not only with dentistry, but with the rest of their lives.

Definitely. You know, and actually, we do check blood pressure, even whether or not you're there. It's very, very important as dentists and hygienists, numbing someone to check their blood pressure. And I think this is also something that I don't think it's being done regularly in a dental office.

Well, there's a number of things. There's blood pressure, there's heart rate, there's rhythm, there's blood sugar. There's the how the patient looks in terms of their pallor. See how they sweating, are they comfortable, are they short of breath? All things we should check before we proceed with dentistry. And many patients don't go regularly to their physicians. So they're coming to us before they've seen their physicians, which gives us a chance to divert them and improve their lives.

Now, is it possible that they have high blood pressure just because they. They're sitting in the dental chair? Would their blood pressure go up significantly or not?

Yes. There's approximately 80 million Americans who avoid the dentist at all costs because of severe anxiety. And the only time they go is when the pain becomes worse than the anxiety. And there's various reasons for that. There's needle phobia, there's the drill, there's claustrophobia, there's out of control, sitting the chair. Number of reasons. There's gagging and reasons they just don't go until they have to go. And there are other patients who are nervous about their procedure. I'm having sedation, I'm having dentistry. What are they going to do? And they're. And their blood pressure is high. However, a mild increase in blood pressure is expected. Let's say they're normally 130 over 70. They come in 150 over 75, that's fine. They come in 200 over 80. You can't proceed because you have to think, well, they're nervous now, they'll be nervous later, after the procedure, they may be uncomfortable, they may having pain, other issues. So we have to go ahead and first control the blood pressure before we proceed with treatment. So a mild increase, 10% or so, we would probably go ahead with the anxiety issue. But if it's too high, let's say a systolic blood pressure over 180 or a diastolic over 100. We probably have them go home, check with their physician, control the blood pressure and then resume treatment.

Yeah, super, super important. And you know, for those of you listening that have never checked your blood pressure and maybe have headaches or you know, you go bathroom frequently, check your blood pressure, it's easy, just go get a blood pressure cup from the pharmacy or you know, there's pharmacies that you can just, you know, check your blood pressure right there and then. So I, I, you know, for those of you that are not going to a physician, you haven't been to a, get a physical in a while, check your blood pressure and see where you're at. This is a great topic now when it comes to, you know, fear and dentistry. Right, that's people are afraid. You mentioned how many people? 80 million, I think you said that are not.

Maybe at least, at least 80 million. It's probably higher.

That is, that is outrageous. And there's a lot of people that avoid the dentist and they're getting all these chronic infections in their body that can be avoided. But a lot of people don't know there's such a service like yours for mobile anesthesiologists. So tell us a little bit about that, how you conduct your day to day business.

I'll go over a few things. There are a lot of indications for intravenous anesthesia. One of the obvious ones is anxiety, stress about procedure, needle phobia, gagging, claustrophobia, patients who for some reason they don't feel like they can get numb with local anesthetic. Those are normal indications where we use IV sedation. But there are other reasons. Patients who have, who have heart disease or high blood pressure, they're safer for monitoring, as we said, long procedures, extensive procedures where the IV sedation allows a smoother procedure and allows us provide medications for swelling and pain intraoperatively and ensure a smooth transition from the surgical procedure to going home. Because as you know, it's not just the procedure. We want them comfortable, we want them to go home and transition and be pain free, if at all possible, for the next three to five days where they're recovering from the surgery. So those are all reasons why we do IV sedation. When we do IV sedation, usually what happens is the office, such as your office, contacts me and I speak to the patient. I call them on the phone and go over their medical history thoroughly. Heart disease, high blood pressure, diabetes. And we also check about very serious issues such as cocaine and meth use, which are very Important use of cocaine or methamphetamines within 24 to 72 hours of dental treatment can result in sudden death. It's the local anesthetic with the epinephri, not the anesthesia that can kill them because of the epinephrine increases from coke and meth. Use marijuana use. Marijuana also is a problem with heart rate and blood pressure. We need to stop that for 24 to 72 hours. Also because people who use that chronically can have heart rate and blood pressure changes. An interesting fact. When people use marijuana, I think it's no big deal. The first hour after marijuana use, the average patient's increase of heart attack is five times over. A person not using marijuana, that's marijuana. Now, cocaine use. The first hour after cocaine use, the increase of heart attacks is 24 times hour after. So these are interesting facts that people need to know. People think that marijuana is an easy and simple thing, but it has a lot of dangers and risks. Because it used to be in the 70s, when I was a kid, before you were born, Sonda, that a typical marijuana stick had 1 to 3 milligrams of THC. Nowadays, those sticks can have 20, 25 milligrams. You can have synthetics that have up to 100 milligrams. What does that mean? That means there are more heart rhythm changes, more blood pressure changes, more psychosis, more instances of heart attacks and strokes. All how. Because of that. So the bottom line for dentists is we try to stop it in those patients for at least 72 hours so we have a more level blood pressure. And why these patients find other ways to be comfortable. This is the THC component. There is cbd, which is quite therapeutic for a number of reasons for pain and such an anxiety. But the THC has a lot of downsides. All this make you feel good?

Yeah. I'm glad you're bringing this marijuana subject up because a lot of people, I think, because now marijuana is legal in California, so they think, oh, you know what, for dental anxiety, why don't I just have some marijuana, take off the edge. And then, you know, when the IV sedation comes especially, you know, people are afraid of needles. They're like, they feel better, but they really. What you're saying is they really must report this.

Yes, they should be not doing it. And another one more caveat about marijuana use. If you're going to use it, please avoid smoking it. If you're going to use it at all. In small doses, 2, 3 milligrams, 4 milligrams smoking it has other issues. For example, smoking marijuana has three times the tar as cigarettes, causing more black lung. Smoking marijuana has five times carbon monoxide compared to cigarettes. What that means is your blood is carrying carbon monoxide instead of oxygen in the red blood cells. So when it's going to the heart, the liver, the kidneys, other organs, you're getting less oxygen. Also, the heat of marijuana is much higher than the heat of cigarettes, predisposing you to cancers of your lung, throat, et cetera. So the bottom line is smoking marijuana is something that people should avoid if at all possible. They must use thc, try to use in the gu. The problem with that is they don't get the immediate gratification whether when you smoke it, you feel the effects very quickly. When you have a gummy, it's 20 minutes, 30 minutes, 60 minutes. And the danger then is they take in one gummy, two gummies, four gummies, then they end up in the emergency room from a psychotic episode, from overdosing on marijuana.

Oh, my God. Yeah. So really limited to know the milligrams you're taking. That's kind of the message. And avoid it. You said, is it 48 hours?

24 if you're a heavy user, we like 72 hours. If you're a minor recreational user, 24 hours is, is suffic efficient.

Okay.

Cocaine use 24 hours. Methamphetamine use 72 hours.

Yeah. And you know, there's some people out there, I'm sure, that are thinking that it's not important for them to put this on the medical history in a dental office. They're thinking, I'm not going to tell them I use cocaine.

No, we have to know these things. We, we're not judging the patient. We just, we. By knowing the information, we can protect their safety and comfort. I tell my patients, hey, you sound healthy. If you're using coke or meth, please don't come. Otherwise, feel free to come and we'll take good care of you.

Yeah, I love it. Now, notice, like IV sedation compared with, let's say an oral sedative that somebody might take prescribed by a dentist. You know, there's an oral conscious sedation some people use, actually Halcyon or Xanax half an hour before dental procedure.

Oral sedatives provide some anxiety relief and some comfort in combination with nitrous oxide or by itself can be very useful for a lot of patients. It's a lot less costly. The major benefit is the lack of cost. The cost is far less the same Time, it's not as reliable. Neural sedative may work, may not work the way you want it to, may not provide the patient what they're expecting. Patient may overreact or underreact. You haven't got control. It's one pill. You see how you do. It's absorbed. Every patient's different. We do intravenous anesthesia. Besides going through the medical history, we check their blood pressure, heart rate, et cetera, and oxygen saturated before we start. And then we provide medication titrated to what is needed for the procedure. We're always successful. Whether it's a mild conscious sedation for some patients or someone who must be asleep the whole way because of their anxiety and stress and such that they can't do a sedation. We aim for light sedation where they're conscious when we can, as you know, Sanda. But oftentimes or sometimes patients need to be sleepier. So we monitor and adjust the level and we can get through the procedure reliably and comfortably as we watch heart rate, blood pressure, reaction to what you're doing.

Yeah, and I can relate to this because sometimes I use an oral sedative for a patient, especially when you're not available because you're a busy man. So we use an oral sedative, and the patient, let's say they've never had an oral sedative in their life. We don't know how they're going to react. And I can't promise them you're going to be asleep. That's the worst thing we could do. An oral sedative is just there to kind of take the edge off and have them be relaxed. So it's happened to us that we have some patients, I think it might be their genetic makeup, we actually give them, let's say, 0.5mg milligrams of Halcyon. And it's almost like they've taken nothing. So it's probably some kind of genetic metabolism of. So it's uncontrollable. We don't know exactly how precisely they're going to be asleep. So the only way to ensure that is with IV sedation.

Yeah, oral sedatives work well sometimes, but it's, as I said, it's variable and it saves money for the patient. And given that you're so patient and calm, you usually get through it, but it's not as easy for you or the patient. Sometimes it's perfect, sometimes not so perfect.

Yeah. And, you know, the thing is, I tell patients when they're stressed. I'm stressed because I pick up their stress when I'm working, you know, and I'm trying to calm them down. I have to focus on helping them be relaxed instead of focusing on my procedure. So one big advantage for me when you're there is that I could focus on what I'm doing. You know, I can really do very detailed work and it doesn't interfere, you know, with me having to be distracted by my patients, like being fidgety or, or anxious or not being able to breathe, having that claustrophobia episode. So yeah, highly recommend having somebody like you in the office with the people that really need it. So let's say we're having like a patient with heart disease. Would you recommend oral sedative for that or more IV sedation?

Well, when they have heart disease, first of all, we're going to check with their physician for the stability of heart disease. Now the physician's job is to provide information as to the how well their heart disease is controlled. Are they experiencing chest pains, are they not, are they short of breath? These all tell us what we can and can't do. If they're controlled, an oral sedative is perfectly fine. If they're uncontrolled, they shouldn't have any dentistry until their situation is stabilized. Unless it's an acute infection or pain. We have patients, as you know, Sondha, with acute infections and very bad pain, where we must go in and take care of that pain as safely as we can. And we do that with sedation, pain control, limit the epinephrine, maximize the pain control with the local anesthetic, and then we get them to the physician to stabilize them. But in an ideal world, we have them see their physician if they're not controlled, get everything is as best we can control in terms of heart rate, blood pressure, ability to tolerate dentistry and then move forward. And then we may do a small area at a time. We might not do a whole mouth. We'll do as much as we can and divide it in visits to make sure the patient is safe and comfortable, not only during, but afterwards. Because when they get home, we have to provide a pain free existence for them as well. Otherwise if they get home and their blood pressure, if they're, if they're in pain, their blood pressure didn't go, their heart rates go up, which is going to endanger the safety as well. All things we take into account in advance. And that all comes in the preoperative visit, which is really important to let the patient know everything that's going to happen, how they're going to sit in the chair, what monitors, what the treatment is, what they'll feel when they wake up, what kind of pain they will or will not experience. We try to avoid all pain if at all possible. We try our best, but I tell most of my patients they're going to be sore for five days, even though most are not, because I prefer them to anticipate more discomfort as opposed to being surprised. Patients who are surprised become more anxious, more difficult to handle, and for their own safety.

Yeah. Now, can you walk us through, let's say a patient's wondering, oh, my God, I'm really afraid of the dentist. I want to go in. Hopefully they want to come to see us at Beverly Hills Dental Health and Wellness. So you can help them. But can you walk us through what a patient can expect during a visit that includes IV sedation from the arrival to kind of the completion of the treatment?

Sure. So there are basic rules in terms of making sure you continue all your regular medications. The only exception is sometimes we may stop a blood thinner for a short time and not always. All other medications are continued up until the appointment. There's no food, milk, or cream for seven hours before. Water is okay up until three hours before. When they come into the office, we do a routine exam. We place heart monitor, oxygen monitor, blood pressure monitor, and check all the baseline values. For our very nervous patients who are really needle phobic, we can put some cream on their arm to numb the skin where the IV goes in advance. We do that. They almost will not feel that at all. Most patients are okay with the iv, but some are not. And we put the cream on. Once the IV is in, we slowly titrate to the level with medications to get them to a comfortable level. Once they're at the.

How quickly does that happen? Like that comfort level? It's like 10 minutes or like less than 10?

Less than 10 minutes. Are they well? They'll start feeling better within 30 seconds. Once the minute we. We immediately we see the patients are anxious, we give them a sedative right away to get them calmer so they'll feel. Once the IV is in, in less than a minute, they'll feel much better about being there. After that, we then titrate to the level so they're at the right level to administer the local anesthetics, which I usually get. Once I localize the area, I'm sure it's numb. Dr. Moldovan comes in and does the surgery. We maintain the patient at a level Consistent with their comfort, safety and ability to cooperate throughout. And I'm in the room breath for breath, and Dr. Moldovan is terrific, always communicating. So we know each other, what to expect and what we need to keep the patient safe throughout the procedure.

Yeah, and one thing I like about your anesthesia, Mark, is that you keep the patients light. You give just enough medication, you never overdo the medication to where they wake up, like groggy or nausea. I've never ever had an experience like that with any of the patients that, that you're sedating.

Well, we're grateful if we have. We avoid that. We go. The basic rule is we give as little as possible the patient comfort and safe. There are some patients, as you know, which we have to put them to sleep and we do, and we keep them just below, conscious of threatening and wake them at the end. Now, when they wake up, they're usually recovered, within, recovered, ready to leave the. Usually in less than 30 minutes. And they wake up pain free. We do this intentionally. We give long acting local anesthetic, as you know, so that when they wake up, there's no acute discomfort. And when we give the medications, we like to use the oral ones, such as Advil and Tylenol, where possible, we maintain them afterwards. And all patients have both our cell phone numbers and they have the instructions to keep themselves pain free. There's any issue, they call me and I usually respond in less than five minutes, as you know, Sonda, when you call me. And we make sure that they're comfortable not only during, but after procedure. And we have, we have a pretty good formula for pain control. We can talk about that too, if you like.

Definitely. That's part two, everyone. So stay tuned for part two with Dr. Torbiner when we talk about pain control. Now, I know that, you know, when I was a resident, I was trained to do some IV sedation. I choose not to because I cannot focus on my surgery. I just, you know, and you're so much better trained than I am in that. So I, from 20 years ago, I decided, okay, I'm not going to get an IV sedation license, but what specialized training and certificate does somebody need, you know, to do IV sedation in a dental office?

Those are good questions. Well, I went through a, I went through a medical program in anesthesia, the same as all physicians. And at that time, the anesthesia programs were two years. And I worked with physicians and I did everything they did, open heart craniotomies, trauma. It was, it was very, it was a lot of experience. And exciting work. And we had a lot of patients there. We learned a lot from most dentists now who are not trained anesthesiologists go through courses. I don't know how many hours is they learn IV conscious sedation where they're taught to have a very limited view of what they do. They're supposed to go through, let's say 20 or 40 or 60 hours. And they do mild sedation where the patient must be conscious at all times. They're not allowed to put the patient to sleep and if they do, they're violating their license. Now those are obviously have limitations because you can only keep the patient awake. And if sometimes that make them deeper, they can't do it because their patient must be responsive at all times. They go through training and they have a permit issued by the state board. I'm an examiner for the state board. I often examine these people to make sure that they're up to, that they're ready to proceed and protect their patients.

Yeah.

Now they're doing the procedure and the sedation at the same time. And I'm sure they do an outstanding job. I know that you prefer to focus on the surgery and let me focus on the patient as interact which allows you to do that. But dentists have been doing it throughout California. Oral surgeons, for example, are trained very well to do sedation and oral surgery. Although I worked with an oral surgeon yesterday. We were working on a patient who was medically compromised and he preferred isolate the patient. In fact, after the procedure was over, I had an extra hour. He said, can you stay? I have another patient who's a heavy marijuana user. Can you just do it for me since you're here? We're friends, so of course I did it. And he was a heavy marijuana user and we were able to maintain manage it by using some different medications. And you slept through it and got through the four wisdom teeth in about 20 minutes.

Wow. Incredible. Now, most of the sedations you do are what we call conscious sedation.

Right.

Do you ever have to do a general anesthesia?

Yeah, of course. We have patients where they're completely unconscious and throughout, but they're just below consciousness. We always like to have an exit route. So even when my patients are asleep, I know that I can turn off the medications, most of which are short acting, have them awake and in less than five minutes. So let's say I don't like their blood pressure or I don't like something I can say. Sandra, we're going to lighten up the patient, wake him up and of course you would say yes or I go to a lighter level. But we always like an exit rep. But most we do a conscious or semi conscious sedation that works very well for the great majority of patients.

Now you've had so much extensive experience, you know, in anesthesiology, so what has been the most rewarding aspect for you?

Well, I think that would be the children. I teach little children and we, they have to be asleep. Little 2 year olds. There's no reasoning with a 2 year old. God bless them when they're in the dental chair, they're either asleep or they're going to try to bite the poor dentist's fingers. So we have to put them to sleep and the look on the parents face when they're finished is the most rewarding.

Wow. Yeah, that's like an invaluable service you offer for sure. I want to talk also about some common misconceptions about like IV sedation. Like for example, it's dangerous, you know, there's a risk of dying.

Okay. There is of course a risk with any procedure with local anesthetic, but the risk is less if we're there. If I'm there, I've checked their blood pressure, I've checked their heart rate, I've checked their medical history. We're not going to, we're going to watch it throughout procedure, make sure it's safe and comfortable throughout. We make it less, less likely to have a heart attack and a stroke. We make sure we guide the cardiologists and the physicians what we want to do. So their safe and comfortable throughout the procedure. The risk of dying with a separate anesthesiologist is a almost zero. In the state of California there's only been, I believe there have been two mishaps in the last 20 years unfortunately two of them that I know of in last California. And that's over millions of administrations by us millions now.

And some people, I've had some patients that oh, you know, it's too much toxicity with IV sedation. My body can't handle it.

Medications are generally gone within 48 hours. There's no residual effect from anesthesia after 48 hours. The half lives, the medication, which is the time where half measure is, is very short. We tend to sort of, we don't have long effects in the last 38 years. I can't remember a patient that said they felt drowsy two days after. Some feel drowsy the next day. Most just go with their normal activities the next day. We don't want them to exercise too much. That's a part of the pain control continuum. When they were having surgery, I don't want them exercising for five days. I want them using ice the day of the procedure, ice the next morning for an hour, and warm salt water rinses, Advil and Tylenol and relaxing. But they can walk around and do everything normally. The next day. Usually they feel almost normal about four hours after they the procedure is over.

Yeah, actually remember we. I had this one patient, he helped us out with him. David, he had not gone to the dentist in about 15 years. Really well to do guy. You know, he owned a company of 50 people, but just fear kept him out of the dentist. He couldn't even sit in the chair when I first met him. Just for a regular exam. We have this datum. In the beginning, even for his deeper cleaning, we had to do a more deeper cleaning detoxification because of the tartar that had built up. And fast forward this. I want to say this was maybe five years ago and today, I mean, he comes in regularly for his dental cleanings. He no longer needs IV sedation for cleaning, which you shouldn't. But we really turned him around in terms of him being comfortable in a dental office, which is pretty amazing. And I think if it wasn't for IV sedation, he would never have stepped foot or do anything in the beginning.

Yeah, I'm not an expert, but I know this. These patients are avoiding dentistry for years and years having toxic buildup under their gums, bone loss, teeth loss, infection. And there's obviously some cardiac considerations now that are believed when you have toxicity in the mouth. All these things are being avoided for years because of anxiety and stress. That shouldn't be done. Patients should go to the dentist probably every three to six months or whatever you think you should see their physician every year. And we have to make it so that the patients know that they can be safe, comfortable and pain free throughout treatment. And that's what we try to offer them.

Yeah. I do have to bring up one medication that people are on a lot today because you and I had this conversation about ozempic. Yes, the GLP1 agonist drug. So what? I read a recent article, I brought it up to your attention. Of course you already knew about it. So what, what are the risks there when it comes to Ozempic? Because people think it's just like, you know, the best weight loss medication ever.

Well, first of all, I don't recommend weight loss medications. I recommend the basic things that you do do. Exercise, diet and sleep are the best ways to be better. Not using Ozempic, but in terms of anesthesia, we need to stop it for eight days because the risk of regurg and aspiration because of the medication, and that's the big risk. So if I have a patient who has Ozempic, we try to stop it for eight days and I still will keep them conscious throughout. So if they still throw up, there's no chance of it going into their airway and causing serious sequelae when people.

Are awake, do they, Is that, what, one of the side effects of the medication, it causes people to throw up?

No, when they're asleep, unconscious. As you know, son, we don't have a lot of throw ups in our patients. Thank God. I can't remember the last one. But when they're unconscious with general acidity, with Ozempic, they can have passive stuff coming from their stomach up into their airway and into their lungs if the airway is not protected. So the easy way to avoid is, number one, stop the medicine for eight days. And number two, even if they do, we won't go to a level where if they should bring something up, it'll get into the lungs, they would cough it up. In other words, their airway reflexes remain intact. So just like they would when they were awake. Oh, they got something in my throat, I just cough it up. There's no chance of a aspiration and the consequences thereof.

Very good.

But I would, I would strongly avoid getting off the latest drug and exercising, eating right and sleeping more. Those are the ways to. For a better life, as most physicians would say.

Yeah, absolutely. We're 100% in agreement on that one. And we have such better methods today. Like, you know, the breath test. We actually, it's on one of our previous podcast episodes when we talk about breath test analysis and cardiometabolic analysis. That could be a very precise way for somebody to start losing weight. So make sure you stop ozempic 8 days before. Very good. Any, any final thoughts that you want to share with us regarding IV sedation before we move on to the pain control?

No, we're just grateful that we're able to bring a lot more patients into the fold, provide a higher quality of care for patients and allowing dentistry to move forward. I mean, dentistry is one of the most aggressive fields and seek, seeking new ways to improve. And by using IV sedation we've helped, helped, we've assisted you in the new things, all the new things you're doing to make patients safer, more comfortable and have more aesthetically pleasing appearances through their teeth.

Absolutely. Especially for those long appointments. I highly actually recommend people if you have an eight hour dentist appointment, it's the best way to actually have IV sedation, even lightly to be able to make the procedure comfortable. Excellent. Well, Dr. Torbiter and everyone else stay tuned for part two. Talking about the best pain control, the most effective pain control after surgery or dental procedures. Thank you so much for joining me this week. Please make sure you check out the show notes for any links mentioned in the show. If you like today's show, please invite your friends to listen as well. That would mean a lot to me. Do you have a question, question you'd like me to answer? Message me on Instagram @Dr. Sanda. This is Dr. Sanda. And remember, your mouth is the gateway to your health. So take care of it in the most natural and best way possible.