#166 - Patricia Corby, D.D.S.: Importance of oral health, best hygiene practices, and the relationship between poor oral health and systemic disease

Hey everyone. Welcome to the Drive Podcast. I'm your host, Peter Attia. This podcast, my website and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, full stop, and we've assembled a great team of analysts to make this happen. If you enjoy this podcast, we've created a membership program that brings you far more in depth content. If you want to take your knowledge of this space to the next level, at the end of this episode I'll explain what those benefits are. Or if you want to learn more now, head over to peterattiamd.com subscribe Now without further delay, here's today's episode.

My guest this week is Patricia Corby. Pat is an Associate professor of Oral Medicine and Associate Dean of Translational Research at Penn Dental Medicine. Pat received her Doctor of Dental Surgery from Unencor University in Brazil and her Master's in Biomedical Informatics from the University of Pittsburgh School of Medicine. She completed her postdoctoral training in Molecular biology and microbiology genetics at Harvard. I wanted to have Pat on this podcast for some time because I've wanted to interview somebody on the broader theme of two things. One being oral health. What are the important things to be able to actually care for your mouth? Because as we think about longevity long term, there are a handful of things that I don't think get enough attention. So if you want to live to be 90 or 100, imagine a world where you do that with high quality teeth and without. It's sort of like imagining a world where you don't get cancer or heart disease or Alzheimer's disease, but you're too frail to get up and walk around. And I think the same sort of applies to your teeth. If your mouth is not in good health, I think your quality of life is quite compromised. And in the same vein, I wanted to understand to some extent if there was any relationship between poor oral health and and systemic diseases. It seems that there is an association, but I wanted to at least probe a little bit this idea of could there be a causal relationship? So in this episode we discuss all of these things and we conclude the discussion with what I think of as a very high yield list of best practices around oral care. I was surprised to learn that, for example, maybe fewer than 50% of people regularly floss, meaning floss daily. I was also very surprised to learn the importance of flossing. I always knew it was important. I don't think I realized how important it was. We also talked about certain things that are popular and trendy that may not actually be that beneficial. Talk about teeth whitening. We talk about the use of mouthwash. What type of floss is better, which type of toothbrush is better. All these things and more are discussed in this episode. So without further delay, please enjoy my conversation with Patricia Corby. Hey, Pat, thanks so much for sitting down with me today. I've been wanting to sit down with you for quite some time, and I know we've scheduled and rescheduled on several occasions, and between one thing or another, it took a while, but I am pretty confident it's going to be worth the wait. How are you?

I'm good, thank you. I'm very happy to be here. That's something that I have a lot of pleasure talking about. Oral health with mds. That's my life, is trying to do this connection. So I'm very excited to be here. It's going to be interesting. I don't know much about what to do, and I think I can bring something new about dentistry and oral health and things, which is so important.

Yeah, well, I think it is important, and that's certainly why I've wanted to talk about this for a while. And I've been trying to figure out who would be the right person to speak with. And you came very highly recommended because I think it's actually a very underappreciated part of health. I think it's easy to think of the mouth as this sort of thing. And we go to the dentist and hopefully we don't have cavities. And obviously we have a whole bunch of cosmetic concerns with the spacing of our teeth and the whiteness of our teeth, et cetera. But I'd like to sort of tie that all together. But I want to kind of start with a little bit of your background. So obviously you grew up in Brazil. I shouldn't say obviously, but I recognize your accent and I know your history a little bit. When did you leave Brazil?

So was a long time ago, over 20 years ago. So I had my dental degree in Brazil, and then I had my specialty in periodontics and implant dentistry, which is one of the fields that is more connected with systemic health. I always wanted that. And then I went. I came to us mostly for personal reasons and my passion for research, because that's what I do my whole life. And I never went back because I got fascinated by the opportunities and everything that I could have here that unfortunately, we don't have the resources in Brazil to do And I'm still doing research up to today, many years.

So this is a bit off topic, but tomorrow is a very sad anniversary. Do you remember where you were 27 years ago tomorrow?

No. Remind me.

Sunday, May 1, 1994, was the day Ayrton Senna died.

Oh, wow. I remember that day really clearly. Wow.

Yeah. Where were you that morning? Were you, like everybody watching the race on tv?

Yes, I was still there in Brazil.

Yeah. I have so many Brazilian friends, and we're just fortunate. So many people in our life are Brazilian. Our nanny is Brazilian. And I've never met a person from Brazil who was anything over about four or five years old on that day. It's etched in their minds forever.

Yeah, he is a big legend, and I think in a time that made Brazil so visible for the world and all those things. So everybody was always very proud of him.

Yeah, well, he's my personal hero. And so for you today, I wore one of my senna bracelets here. So let's start a little bit with tooth anatomy. Unfortunately, I have teeth that my wife refers to as atiya teeth, which she jokingly means. Like, I just have genetically horrible teeth. Like, I always seem to be at the dentist for something. Something's always going wrong. I'd like to think she's exaggerating a little bit, but there was a period in my life, unfortunately, of maybe 10 years when I didn't go to the dentist once. And I think I sort of ended up paying a bit of the price for that going on, which sounds like a stupid thing to say. Imagine somebody not going to the dentist for 10 years. But that's sort of what happened for largely much of my medical school and residency. I just never made the commitment to go. Still brushed my teeth and did all that stuff, but obviously wasn't getting regular checkups. And now that I find myself taking dental care so seriously, the first thing I realized is I had to understand the anatomy. I had to understand what they meant by pulp and dentin and all of these things. But I think it might make sense to give people a decent overview over the semantics of. Of the tooth at the individual level, and then sort of at the level of how all of the teeth fit into the mouth. Can we start with something like that?

Yeah, yeah, yeah, of course. I think. Which is strictly important. They all have a reason to be. So you have 32 teeth in your mouth. All of them, of course, they have very specific functions. So if you think about the anatomy of the tooth, you can feel. Think about one unique tooth Only which is the anatomy of. You have the root caries. If you think about between what you see in the oral cavity and what you don't see is like the crown and the roots, as you see in this figure. And then you have all the parts that surrounded the tooth, the supports, where this sits on top, which is the periodontum, which is another very complex system as well. And then if you think about this whole system together and you have multiplied that by 32, then you have this amount of very unique set of different. Think about individuals inside your mouth, and they all have very specific functions.

Can you pull that slide up again of the individual tooth? I have some questions about that, because the first thing that jumps out to me is that there's a vascular supply that is quite high in the tooth. If I didn't know better, I would assume that when I look in my mouth and I see that white crown, that everything inside it is a bone. In other words, I would assume the entire tooth is an avascular, amorphous thing that serves one purpose and one purpose alone, which is just to basically break down food. So why is it that this tooth is so much more complex than just having enamel? Why does it have this dentin and this pulp?

Yeah, it's a very complex structure, and it's for a reason. So the enamel is minerals, so it's a very hard surface. It's actually the hardest surface on the human body is the enamel. And then underneath the enamel, you have the cement and then the dentin, and then I have the pulp and the cement is everything part of the periodontum. But there's three layers of the tooth itself. The enamel protects the underneath layers. The second one that you see is just like cushion and has a lot of tubules as well. So it's hypersensitive. And then the heart of the tooth is actually the pulp. You see a lot of nerves, and they all connected to the body. That's why you have a lot of. Tooth pain is one of the most detrimental type of pains that we have, because you have all those nerves connecting everywhere, and then you have the bone as well. And the ligaments around the roots, they protect. It's that cushion that protects against the impact. And it gives you all that biological, symbiotic, so you can chew and you can function.

But why is it that we need a nervous connection to the tooth? Because I understand that if you had a dental implant, obviously you've given up the nerve and vascular supply to the tooth, correct?

Yes.

So we can still carry out the function of breakdown without that.

Or so the first signs when you have tooth loss, because you start with the decay and then the decay takes the pulp. The then you have to excise the pulp and you can still preserve the root. So the main thing, the way we want to think in dentistry is that you want to preserve health as much as you want, because you want to preserve function. So you don't want to extract teeth, because teeth, they have a very precise reason because they need to hold the space you need to chew. There's a lot of things that's part of the mouth. So you need to have the teeth. You can do a root canal or if you don't have any more the crown because you lost to the decay, you can take it out the crown, you can put some metals and then you can put an artificial crown. The moment that you lose, it's infected and you have to extract the whole tooth. Then you need to put the implants on. But not that implants is better. It will never be better than your natural function in your teeth because it's a metal and it has many other issues. And you still have periodontitis, which is infection of the implant. It doesn't mean that, oh, I'm going to take my teeth out and I would never going to get inflammation, periodontal disease. It's not true. You still have that.

I think my question is more that if you have an implant and therefore you have a denervated tooth, it seems to still be able to carry out the function of breaking down food. I think the thing I'm trying to understand is you pointed out something that unfortunately most people listening to this can relate to, which is dental pain is some of the worst pain in the world. And it speaks to, I think that highly, highly innervated pulp that you showed. I'm trying to understand what the function is of having something so highly innervated. Like for example, our fingers are highly innervated because they serve such an important function. Our ability to have fine motor control with our fingers is why we have so much innervation here. So why is it that we have so much innervation in a surface beneath this enamel, which as you said, is the hardest surface in the body. What is the purpose that that innervation serves?

That's an interesting question. It's the viral part of the tooth that preserves blood flow and keeps the tooth alive. And it's connection, now that I'm thinking through, it's how you protect. So it's the connection with your immune response. If you have, let's say, if you have a caries infection.

Interesting.

So probably that's how your body might be able to respond and fight against infection, inflammation. So the moment you don't have there anymore. So it's just a damped piece of.

I see, I see. That's a good point.

That's what I think, now that we're talking.

So maybe it serves as such an early warning indicator, as a breach of a barrier, basically an important barrier. Okay, that's interesting. I just have to tell you, having been through so many miserable dental experiences, I've often cursed our evolutionary gods for giving us so much innervation in that tooth. So you've already started to talk a little bit about the pathology that can go wrong here. Before we do that, I want to get a little bit more an understanding of the function. Can you show me again that slide that has all of the teeth and maybe explain how different teeth serve a different purpose in the mouth?

So technically you have the incisors. So you have four of them on your jaw and each part of your jaw and the maxilla and the mandible. Then you have the canines, there are another four. So the incisors is mostly in your mouth. So you can cut your fruit in any animal. That's how you bite and how you separate pieces of fruit. And then you have the canine that is a very strong. That's the longer root that you have in your mouth that is to tear. So. So you can see animals when they are eating meat and all of that, that you tend to go to the side because it's a very strong anatomy that they have. And then you have four, we call premolars or bicuspids. So that's where you start to break down the element, the food that you eat, to tear them apart. And then the molars, they do the whole trip duration. That's where you have to chew. And I always talk about chews because the digestive process starts in the mouth. So it's very important that people chew their food in contact with the saliva and all the nutrients that we have. But it's a completely different subject talking about saliva, but it's mainly to chew your food to start the digestive product, so then you can get most of the nutrients out of your food.

Now, looking at the lower part of this figure, it seems that the different teeth have different numbers of roots. Is that correct?

Yes, that's correct. So incisors and laterals and premolars, they're one in front. They have single root Then if you go to premolars, they will have two. And the molars itself, they might have three or four, depending on how big the tooth is. So it's a much more complicated complex because they are much more strong and they have to get much more pressure to function. So they need to have much more sustainability so they can chew and triturate our food.

I see. So that actually probably explains another reason why these things are innervated, which is the harder they have to oppose other teeth. So the molars have the greatest opposition to another tooth. Then they need greater sensory input to understand the relative spacing and force. Would that be part of the difference as well?

As well, you think like in your mouth, it's like a bridge, has to be very well balanced. The occlusion needs to be perfect, because then you're going to hurt all your ligaments and cause inflammation in your mouth. So it's a very elaborated system. And if you think about the occlusion, they connect. They have to be very perfectly aligned. So if you start having issues like your teeth, they don't have a perfect occlusion, you start losing your vertical occlusion, then you have a lot of other issues like pain on your face and headaches. There are many other issues that can happen if you don't have a good function in your.

Okay. By the way, I learned the hard way that I have four roots in my molars, not three, because I've had two root canals, and the first one, they missed one of the roots. They only went after three roots. And I still had endless persistent pain. And I went to finally then see an endodontist who realized I had a very hidden fourth root. But we'll get to root canals later. My least favorite procedure in the world. So let's talk about what a healthy mouth looks like. You alluded to saliva. I assume that that plays a very important role in oral health. And I assume it does something beyond lubricating food. Does it play another role?

So the oral cavity is a very complex system. If you think that you have teeth, you have the gums, you have the gingitocravicular fluid, that. That it's open and allows the bacteria to go in and out. You have your tongue, which is a completely different texture structure. You have a throat, which is entrance to your body. So all this whole complex system, they need to live in a very organized way. And on top of that, you have the saliva. Saliva. Again, we could have a completely other podcast just about saliva, but in the context where we. They preserve Health. Because we know today that people with dry mouth, if you have. I treat patients with radiation, they're going through radiation oncology, we can talk about that later. But the moment you dry your mouth for any reason, systemic conditions, medication. Who causes dry mouth? There are many of them that causes or toxicities due cancer care, radiation, drug mouth. It's a completely ship or microbiome in your mouth because saliva protects. It's that biofood that is constant washing and flushing your mouth and maintaining a very homeostasis on the microbiome as well. It prevents DSP on the auto microbiome. So this whole complex needs to be balanced on every single aspect that we look. You need to have your. You need to brush, you need to have a lot of saliva and you need to eat well. So it's a combination of a lot of factors that makes people say to be in health when you look at oral health. But the primary is so simple. It's actually oral hygiene. If you brush your teeth, you're going to be technically, you preserve a little bit more of health than people who don't.

I want to go back to what you said about the dysbiosis and the microbiome of the mouth. So my recollection is that the mouth actually has a significant amount of anaerobic bacteria. Is that correct?

Well, they're both. You have aerobic, you have anaerobic, you have facultative bacteria that can play both roles because it's so strong they can change. But we have over 700 different bacteria that lives in a perfect symbiotic habitat in our. In a Kindle we call that. And they can live really well with the host without causing disease if you can maintain the state of health. Because in the past people think that what causes disease, oral disease, is this specific bacteria, but it's not true. We all have all those bacteria in your mouth. It's indigenous to you is not that it's from something external. You have that. It's a. Their normal habitat is your mouth. But for some reason you stop brushing or you start taking medication and your mouth becomes dry. You have a health condition that allows inflammation to be more prevalent in your mind. All those things might change the oral cavity environment. And that allows some benefits, bad bacteria to grow and supersede the good ones. And then that's what happens with this dysbiotic. So we talk about two things. Abundance, changes in abundance and diversity, which is allowing bad bacteria to flourish and suppress the good ones. That helps us preserving health. So that's mainly what's going on? Of course there are the complex things.

So in an ideal state, directionally, what amount of bacteria are aerobic, anaerobic and facultive? What's the approximate distribution? In a relatively healthy mouth, it's probably.

Half and a half between aerobic, anaerobic and another maybe 30 to 40% of them. They can play both roles. But those, let's say a clear example and we can talk about that in a completely different section. But like even children, when I did my studies with the twins and then we asked them to stop brushing for two weeks, all the periodontal pathogens, P gingival, chiding, cola for situ that we only see in adults with periodontal disease, in two weeks they became abundant in their mouth. So they were there. I couldn't see a baseline, the multiple, they stopped flossing, they became abundant. So they are there, but they will never cause disease unless you have a shift on the oral microbiome.

So let's talk about that study. So how old were these twins?

So we go back was a long time ago. That's when I first started my research because I was highly interested in dental caries. So there were between 12 and maybe 16 years old. I wanted to have adolescents because that's where they don't like to rush the floss. It's a very hard population to do that. So what we did, we. So when you do studies, I'm going to talk a little bit about the twins so you understand why we use the twins. So they are the perfect model to do clinical trials. That's my passion, is clinical trials. Because they share, especially on that age, the same households, the same, there is no confounders. You don't need to adjust for age. They're identical twins. You don't even need to adjust for gender because they share the same sex and they share 100% of the genes. So when you look at monozygotic and dizygotic twins, the monozygotic twins, they share 100% of their genes. Examples are perfect clones of each other, right?

And to your point, as adolescents, they're still in the same house. It would be different if you did this with 30 year old monozygotic twins because at least there might be some.

Environmental differences and the environment takes place and then a lot of, you know, epigenetics might change, even mutate genes. And then when you look at the dizygoric twins, they're 50, 50, they share 50% of their genes. It's the same as two brothers, siblings. So there's two ways that you can do studies with twins. You either get the twin set and then you do treatment A and B to see response to treatment because they're very similar or the way I like when you want to see traits and how a trait can modify by genetics or environmental factors, you get the same set of twin and you give the same drug, medication or treatment. Because then when you look before and after, if you see that the identical twins, they behave in the same way, you're going to say, well, genetics modulating that trait. But then if you look at both of them and say they're all over the place, they behave in the same way as the identical and the fraternal twins and say, well, here the environment is playing a big role because genetics are holding any. So when we do this flossing in twins, that's how we did this study. We didn't want to give separate treatments for the twins because they go into the same house. And I did very controlled. So for two weeks we asked the twins to come every day to the center. And I'd have dental hygienists and my clinical people trained and they do brushing and off flossing because they're two groups. So one group we wanted them just to brush. The other group we wanted them to brush and floss their teeth so the hygienist would floss and watch them doing. It was very supervised and controlled. And when they go home, I asked them to do at night at home. But if you think about that's a very hard Kubota to do because we have to bring the kids every single day with their parents to the center so we could actually watch them doing the intervention. So when we finished the study, what happens that we saw is that the children that did not floss, we saw elevated levels of gingival inflammation which was represented by gingival bleeding. We measured gingival bleeding and what was most striking was all those periodontal bacteria, they just came in abundance in their mouth.

Which ones in particular overexpressed? In the non flossing group, it's the.

Three big guys we call P. Gingivalis, tudentyhol A, actinomitans. They're very complicated names, but it's the top bacteria that causes periodontal disease and gingivitis we found in a very young population.

Are those all faculty of anaerobes or any of those?

Yeah, and anaerobic species, most of the bacteria. So caries and periodontal diseases are very similar in the way they behave and they risk factors, but they can be separated. That caries is most aerobic species because they live in the presence of the oxygen. So they are free on the oxygen because of the oral cavity. Most bacteria that cause periodontologies use, they are anaerobic. All the faculty that they can go up and they can hide again inside the gums. So they're anaerobic. That's why they love hiding in the periodontal pockets. It's the perfect reservoir for them to just grow and cause inflammation.

And just to be clear, the periodontal pocket is inside the tooth and the gingival pocket is between the gum and the tooth.

It's all the same thing. So the way periodontal disease manifests is that first it starts with inflammation around the gums. So the way the periodontal works is that it seals by the periodontal ligament attached. If you were in health, your periodontal ligament is very healthy. It's like a muscle. It's very tied to you. If you stop brushing, which is the primary cause that your gums get inflamed, you stop flossing or you relapse, you're going to immediately, if you floss, you're going to see some bleeding. That's the initial stage of periodontal disease, but it's highly modifiable. If you have only gingivitis, you can refer to health. So if you keep going and you continue with the traits of the disease, the ligament is going to get inflamed and they're going to be attached from the tooth. The bacteria is going to come in and then that whole process of inflammation, bacteria and deterioration of the ligaments. That's why you form the pocket. That cumulative, like harm to the periodontal culminates in bone loss. So the initial, the acute periodontic disease, you're going to see someone, is that they come to your office, you take radiographs, the gums are still somehow attached to the tooth, very inflamed. It bleeds a lot. You touch it bleeds. But if you go and look at the radiograph, you're going to see a big gap. The bone is all done, and then that's the pocket. It's when the bone goes down. And then if you put a probe, you're going to see 3 millimeters, 5 millimeters, 7 millimeters. It keeps going down.

Now, how does that relate to the carry? Because the carry typically occurs on the sort of top surface of the tooth. Typically. Correct. And everything you're describing is Often actually below the gum line.

Yes, well that's the next stage. So once the pocket gets influenced, the chronic periodontitis, what happens is that the animal atrophy of the gums. So the gums, they're going to recede and they're going to keep going down. So it's very typical that you look, if I look at someone, I know they have periodontal disease just by looking at their gums. Because you're going to see the teeth, they become bigger and then you're going to see the gap that can expose the root. So usually the roots of your teeth, they are not meant to be exposed because once they expose the bacteria can cause colonized. And you can have root caries as well. So you can have the corona caries, which is just on the crown of your tooth. But when the root get exposed due to periodontal disease, other forms of trauma, malocclusion and things like that, then you can get caries to take over the root of your teeth as well.

So in children, the sort of typical caries that we see are on the occlusive surface, correct?

Correct, mostly. But one of the most common caries we call early childhood caries, which is caused by baby bottle children that like not the breastfeeding but the bottle overnight and many times a day. So it's mostly on the anterior teeth. I don't know if you had a chance to see, but the carry develop very rapid because the milk accommodation plates in that area and it's extremely painful. It's actually one of the most common dental diseases, the most common disease worldwide due to that caries, everybody has dental caries.

Why did you say it doesn't happen with breast milk?

Because the breast milk we have studies showing that the cause is much less decay than formula because every formula has sugar.

So what is it about sugar? We all grew up knowing that sugar was the worst thing for your teeth. But what is it about sugar? Is it the fructose, is it the glucose, is it the combination of them that leads to a rapid overgrowth of the carry causing bacteria?

It's all of them. It's fructose, sucrose, lactose, more complex starch, they are even worse course all the drinks today, they have added sugar, you name it, everything has sugar. But the main mechanism is very simple actually is that the cryogenic bacteria, they love sugar, they metabolize the sugar, it's actually energy for them every time that they see it. So they have capability of attaching the tooth surface all this bacteria, so they get together and they stick to each other, and they have the ability to secrete that extra cellular matrix that is like a glue and we call biofilm, and that attach to the tube. So every time that you put sugar, they take that sugar, they metabolize that sugar as energy source, and they multiply and they grow with other food that we put on the outer cavity as well. But what happens that when they might metabolize sugar, they secrete acid, and that acid is the one who destroyed the enamel phytoplank. So that's the cycle.

So that suggests that they're metabolizing sugar anaerobically to produce lactate. If they're increasing the acidity of the environment, presumably hydrogen ion is coming out with lactate. They're doing this not in mitochondria, they're doing this outside of mitochondria. This is almost like the Warburg effect, where whether oxygen is present or not, they always choose anaerobic metabolism. Do we know if that's been looked at?

Probably, yes, but I don't remember.

And also, you say sugar, but I just want to be clear. Do these bacteria have a preference for glucose over fructose? Obviously, sucrose is both. It's an equal mix of them. But I want to get very specific on this point. Is fructose specifically more harmful? Because if that's true, then sucrose would be more damaging than, say, starch, which would just be pure glucose.

I think the glucose is the worst, especially when they do syrup, when they intensify with higher concentrations of sugar. But technically, all of them can be metabolized, Even the fructose from. They can metabolize that as well.

Do you have a sense of how our species survived before we brushed our teeth?

How they survived?

Yeah. I mean, when you think about it today, if after two weeks of twins not flossing their teeth, never mind not brushing, just two weeks of not flossing, you're able to induce significant periodontal disease, where you actually had gingival disease. That would induce bleeding in the gums. And now let's go back in time 300 years, which our species look the exact same as we do 300 years ago. It's not like we're talking neanderthals, but presumably 300 years ago, we didn't have toothbrushes and dental floss, did we? Do we know what oral care consisted of three or 400 years ago?

Well, we know that 400 years ago, we see from research that people have periodontal disease, they have dental Care. This is not new. But like, if I look at populations from developing countries, for example, I go to Africa and I do a lot of research there. They have like, some plants, they have like a stick that they use and they clean their teeth with that tree that they. Fine. So I'm assuming that people just use different devices to clean their teeth. Because if you think about removal of plaque is mechanical. The fragment you need to disrupt the biofilm. What we do with brushing, we're just trying to disrupt that matrix of the biofilm. But they form again. Research shows that you clean. You can have the mouth with zero plaque in two hours. You have them all formed again, they colonized back. But we're trying to do with the brushing is just disrupting that. We don't let that accumulate and be like overwhelming in the other cavity.

Yeah. I would assume that the food consumed somehow, even though obviously people hundreds of years ago still consumed glucose and fructose, maybe the form in which they consumed it was less concentrated and refined, which I suppose we know it was. And so they had less of an insult to the tooth. Every time I've had a bad dental pain, I've said to myself, how would I be functioning right now if this was hundreds of years ago and I didn't have modern medicine with lidocaine and a very good dentist who could take care of this? Again, I want to go back to this point earlier. It is the single most uncomfortable pain imaginable. It's horrible to have pulpitis or any of these things. You can't function.

And highly preventable.

Well, yes, yeah, we'll certainly get to that. But again, I'm just constantly amazed that our species would have had to presumably suffer quite a bit until we figured out this ability to clean these things. Because it's counterintuitive. I think now it seems obvious, but if you're sitting In a cave 10,000 years ago, I don't know that it would have been the most obvious thing that you need to remove this thin film bilayer on your teeth.

Yeah, but I think the diet, fibers, everything was very different back there. Today, with the modernization and the amount of sugar everywhere that you look, sometimes you can't even buy anything because everything has sugar. I think it's a big change on the culture and what we eat. How do things today? I think it's much worse.

So let's talk about the brushing. I once heard somebody say that the toothpaste is far less important than the toothbrush. In other words, you could almost brush your teeth without toothpaste but if you did a good enough job just using a wet brush to brush, you were getting most of the benefit. Is that true?

I tend to disagree. I think both are equal important. And I'll tell why. Because the toothpaste is the main source of fluoride. So the fluor protects your teeth and hardens the enamel and protects against cavities, especially in children. It's extremely important that children get exposed to fluoride if they have high risk of caries. There is other sources you can paint, you can have furnished. You have a bunch of approaches that you can preserve oral health in children just by brushing and fluoride. It's all about education. So. And the flossing is a combination. You have to clean in between your teeth, you have to clean the surface of the teeth and you need to put fluoride. And I'll tell you more now on my new clinical trial, I'm actually brushing the oral mucosa to decontaminate against bacteria. So I still think that is a another neglected surface of the autocad that you use. All the oral mucosa, the tongue. Most people don't brush the tongue. And there's a lot of bacteria that accumulates in the tongue. You need to clean every single surface. And just the brush itself is not going to do the job.

When you say brushing the tongue is the purpose to remove bacteria.

Yeah.

Okay. And what about the rest of the oral mucosa? Do you mean brushing the gums as well?

Technically, that's not standard of care. So the way research has done and proved that you can maintain optimal oral health just by brushing your teeth, by flossing really well and having good nutrition and all those things. Of course, there are phases in your life where like in this specific case of my population, they're undergoing radiation combination. They have a lot of ulcers in their mouth and they can't drink, they can't eat, or they cannot brush their teeth because it's so painful because of all the ulcers. And then there is a whole just the oz that occurs in the oral cavity on top of this has radiation and a bunch of things. So on that specific population, they need a more intense oral care program where we clean the periodontum, we clean the cheek, and we contaminating and brushing the oral mucosa. So it depends, it depends on the risks, it depends on the population that you're treating. It depends on their ability to brush. Every oral hygiene program, I think, needs to be personalized to the person, to the age to the risks that they have if they have dry mouth, if they have different diseases that affect the or cavity. So it's a holistic approach that not one regime would fit off.

Is the importance of flossing the mechanical removal of food particles between the teeth or is it the actual transient irritation of the gum that actually provides the benefit? Because you can imagine a thought experiment where a person subsided on an all liquid diet so there would never be food particles that are between the teeth, but where they might still benefit from flossing or more directly they might still experience a harm from not flossing. At least that's my hypothesis. Which would suggest that the benefit of flossing is not just the actual removal of the gross large particle, but it's the transient irritation that's created at the gum surface. Do you have a point of view on that?

There have been research on that. Some people on the opposite direction that might. If you floss, for example a mouth of someone who is immune compromised, you might see nurses and doctors saying don't floss.

Yeah, what about non immune compromised people?

I don't think there is any harm on flossy. It might give you more resistance to those constant exposure to bacteria, but mainly is to clean that anaerobic bacteria that it's really hiding in between your teeth. So that's the main function of flossing. And the brushing, if you think about brushing is also stimulates the gum. The gum is not different from any other muscle or in your body because it needs to be really strong going to patch around your teeth. So the brushing as well helps a lot with that dynamic constant. Because in massage all your gums, your periodontal and I believe that is a good benefit as well.

Is there a benefit or a rationale to flossing before brushing? Which for some reason is the way I've always done it. I don't know why.

Yes, I love that. Because that's usually how we recommend actually I ask them. You brush, you floss and you brush again if you want to be perfect. Because when you brush you remove all the biofilm of the bacteria and your surface. You have to cheat and you need to rinse your mouth well to just get everything out and then you floss. But imagine if you floss and then you throw in all that bacteria back in the auto cavity that might populate and recolonize again. So that's why I say you just brush your floss. We either rinse your mouth really well after that or you just quick brush again. That would Be the way if you want to be obsessed. And then you need to brush your tongue because bacteria, even the ones that you flossing and throw inside the mouth, they might just colonize the tongue as well. Some people have fissures on their tongue and then allows them to get in. When we do studies and I collect bacteria, for example, swabs from different parts of the mouth. Every study that we do, we collect that buccal, left buccal, right tongue, floor of mouth, throat. Every surface of your mouth you find different bacteria. So your tongue has a different colonization from your buckle, from the floor of mouth, from the throat. Throat we know colonized by bacteria and virus, the HPV virus. It's highly associated with oropharyngeal cancer. So all those variations, they do different things.

But you don't recommend also brushing the buccal surfaces or other surfaces if they're also a great source of bacteria.

I don't think I can recommend because it's not a standard of care. So everything that you recommend, recommend. For example, the trial that I'm doing right now, I'm implementing oral care that doesn't exist. So no one tells people, patients who are undergoing radiation treatment that they need to see a periodontist and do a periodontal treatment every week. That's how intense it is. They come, we do the whole debridement of the periodontal. We clean the olive corsa, we clean the teeth. That doesn't exist. And if you ask a dentist, they're going to say why I need to do that? And that type of procedure as well is not insured. So if you get a patient who is doing undergoing radiation treatment, they can get speech pathology, they go to see the oncologist, they go to see their nutrition. This is all part of the health care system. And this is all they can charge to the insurance or Medicaid, Medicare. Oral health is not part of that. And I want that to be part of a magically compromised patient. That same way that they need to see a nutrition, they need to see our health specialists because that's going to help them respond to the cancer treatment. They're not going to have the burden of infection, inflammation in their mouth. And of course they're going to perform better, they're going to eat better because if they have ulcers, they're not going to be able to eat. So there's a whole benefit around that. But there is no insurance would pay. And that is not a standard of care procedure. So I'm doing the research, I'M collecting all those biomarkers and I want to prove the benefit of that. And once I prove the benefit of that, because now I did a clinical trial, I might be able to push and get all the centers and other people to do it. And that might become a standard of care for this specific population.

Now, is there evidence that cancer patients, because of two things, their immune compromise through treatment, coupled with the increased susceptibility and the loss of immune barrier in the mouth, are actually at greater risk of systemic infections that arise from the mouth?

Yes, there's a lot of research on that and that's what I believe as well. And when they're going on top of everything that is going on with them, they have horrible dry mouth. Week two or three, some patients cannot produce saliva anymore because the radiation damage the salivary glands and that's changed. The whole oral microbiome allows opportunist organisms to prevail. So they have a lot of fungal infection because of the issues that they have with dry mouth. And that escalates a lot of local infection and inflammation in the oral cavity and affects them systemically. Because I don't have data from the trial that I'm doing right now, but the reason was I'm doing is that on my small pilot that I did to lead to this large trial that I'm doing now, I saw that main inflammatory markers. I look at saliva inflammatory markers and microbiome before they started the trial and three months after they completed the last dose of radiation. And then when I look at cytokines, I sampled several cytokines in saliva. Most of them, they're completely suppressed on the oral cavity. They're all cancer patients. But the group that I didn't do, the periodontal disease, they all had even increased on those. But the ones that I did this very comprehensive, they all gone suppressed on the negative. So it's clearly showing that there's something going on systemically on those patients that is just because I'm brushing your teeth. And the way my study started. That's why I always say that it makes me so happy when I'm discussing oral health when with MD like you, smart, that understands a lot about those things is that I started my life when I was at NYU and I used to work with all the radiation college and all the surgeons that they were doing surgeries on the patient. So they had diagnosed the cancer. And because I was doing research, I would go to the or collect the samples and take over of the patients throughout the whole research. Research when they're looking for oral cancers and all those things. And I started looking at those patients mouth. And I said, I can't believe that that is not a single doctor who is looking at their mouth. They have horrible oral hygiene. They got the cancer, they're depressed, they start radiation right after surgery, which they already can't brush their teeth because sometimes they lose half of their jaw, they take their tongue, so the higher their behavior mutated, so they stop brushing and they go into radiation. When they get into radiation, then comes rt. The radiation also changes the microbiome and they develop horrible ulcers in their mouth. And then they become immune compromised. And so it's a whole cascade of things that happen in those patients. And then I started one of them. I came to the oral surgery and I said, do you mind if I start cleaning your patient's mouth? And I said, why do you want to clean? And he said, well, I know he's going to go into radiation. Let me do a dental clean. I can't look at anymore the way it is. I said, pat, do it whatever you want to do it. So I start doing my cleaning. Periodontal disease. And after I treat it, and they were going through radiation, some of them, I'd say, well, I'm going to clean your mouth twice a week. Radiation usually sticks to eight weeks. So if I clean your mouth every two weeks, at least you're going to get a baseline middle radiation and end. And others will say, well, if he's not responding really well, I always just start training, say, what can I do to get a good oral health? Others I start every week. And then after I treated like 10 patients, I got a call in my office with the. He was a head. His name is Nicos Sanfilippo. He was the head of the head and neck crew and said, pat, I never had talked to him, but he was the referrals from our patients because you have the cancer, you have the surgery or not. And then radiation oncologist, like a referral. So you need to find a radiation oncologist that can see your patients. So he called me and said, pat, can you tell me what you're doing with my patients? And I was like scared because I knew that wasn't like a perfect standard of care. And then he said, well, I have maybe eight patients that you treated and they don't develop mucositis. And they're sitting on my waiting area and they're talking to each other. Well, I went to see Pat. Pat is doing that. Pat is doing that. And Then I said, can you tell me what you're doing? And I said, nick, you're going to laugh, but I'm brushing your teeth. Of course, it wasn't that brushing, but it's oral hygiene. And he was there and say, pat, can we do a pilot? I'm fascinated by that. Then we did. We saw 16 patients. That's the pilot that I submitted and we got the grant. But that was how everything started, was him calling and saying, what's going on now?

How in depth was the oral care you delivered to these patients? Is it the type of thing that they could do for themselves if taught? Or did it have to be done while they're sitting in a dental chair and by someone who was highly trained?

It's a combination, actually. On the current trial, I'm trying both approaches. If I can just give a baseline cleaning, because if someone has a lot of plaque for a long period of time and you haven't brushed for six months, for example, the plaque becomes harder and becomes tough. No one can remove that unless we have a very specific ultrasound that vibrates, an instrumentation, and it's very hard.

That's what we do every six months when we go and get our dental cleaning.

Yeah, they either scrape your teeth with very sharp instruments or they use the electronic one blood to disrupt and they get plugged. So at a minimum, you have to do once in a dental office. But in my trial, I'm doing both because I don't know which one is better. Nobody ever did before. So one group, I'm doing mechanical debridement as a periodontist. It's the same, even I go sub gingival. I'm trying to flush every toxins that I have sitting on the oral mucosa inside their gums, on the gums, on the tongue. I brush and floss. There is not a single surface on the oracle that we don't clean.

How long does that take?

Takes one hour on the chair. The other group, we give them. Dental hygienists come every week to reinforce the importance of brushing, flossing, and she flosses the patient's mouth, tell them how to proper do that. So it's just to blind the study. They both come to the clinic. They didn't have to come because it's just a brush, but we want to blind. So both groups come to the chair and the hygienist does a light cleaning, flossing only and brushing. Or she does this holistic, comprehensive approach that I put together, which is something that is striking, going on right now, my patients in either group, they're not developing the disease.

Just to make sure I understand how many of these patients are patients with head and neck cancer where they're either directly receiving radiation to the mouth or this area, which is resulting in the deterioration of the environment, versus patients with other cancers whose chemotherapies are rendering them susceptible due to the mouth sores that are pretty, pretty common with chemotherapy coupled with the anticholinergics that can dry the mouth out.

On my population, because I wanted to do a more controlled clinical trial, they all head and neck cancer scheduled to undergo radiation. Head and neck cancer can be different areas of the head and neck, but I have a very strict inclusion criteria that at a minimum 50 grades of radiation needs to be there. Leave it to the oral cavity due to the cancer because I know that in this particular condition, 90% of them will develop mucositis.

And this is male and female.

Male, female. And we have RT only. And we have combined treatment. RT plus chemo. 100% get mucocytes. There's not a single patient, if you have a combined program regime like that, it's very aggressive. They all. And then on top of that they get immune compromised.

But these are mostly squamous cell, not lymphomas. And head and neck lymphomas. Correct. This is mostly squamous cell, yeah. And how many of these patients are HPV positive?

Probably 90% of them oropharyngeal oral cancer. It's very low incidence, which is known by research as only the oropharyngeal cancer that has been linked to the hpv. Most of them are HPV positive.

This is an interesting epidemic that's getting very little attention. And I don't know why, but I think these HPV driven squamous cell carcinomas of the oropharyngeal region really frighten me because we don't have really adequate ways to screen for them. The way we can screen for HPV cancers of the pelvis in women, unless people are doing very advanced imaging like MRIs, they're often caught quite late. What do you think accounts for the rise in incidence we're seeing of this cancer? I mean, it's obvious that it's the hpv, but is it just sexual transmission? Like, why are we seeing it is sexual transmission?

So we wearing condoms? It's oral sex. We know today that is sexual transmission. Of course, combined with poor oral health, they might cause disease or not, because we know there are like several periodontal bacteria. They have a Very symbiotic relationship. They allow virus to grow, like the PG and G values. There's several studies that show that they can allow other virus to grow. Immune system deficiency as well. We know that every time that your immune system is not strong allows virus and bacteria, fungal infection to grow. So. But it is. It's just, you know, you need to modify habits so you can prevent.

I want to go deeper into this, but before we do, I want to actually go back to some of the more mundane stuff, the blocking and tackling of dentistry and talk about caries again and what the stages of caries look like when the tooth can be preserved. So when you're just replacing a little bit of enamel and then what that next layer of damage looks like, that ultimately leads to a root canal, presumably once the pulp is irreversibly damaged. And then ultimately when even that can't be reserved and a crown is no longer sufficient and you have to replace the whole tooth. Can you. I know you have some nice figures on that. Can we kind of go through those different stages of dental care? Because I think it is important to see these images. It certainly helps me understand what's going on.

Give me one second. Can you see the image?

Perfect.

So, technically, the first initial stage of dental decay is the one that breaks through the enamel. They are very incipient decays. They haven't got to the second layer of the tooth. And those are the ones. Some of them even, like if we call white spot lesion, you start the decalcification, they can be reversed. If you have a child, you can have a very intense fluoride varnish application, it would reverse. So most of those very significant lesions we shouldn't be touching or treating.

And to be clear, is this the type of thing where the dentist will use a little probe and say, it's a little bit soft there, but I think it's okay. Or it's a shadow on the tooth.

Yeah, there are, like, some controversy on that. In the past, they would have that very pointy probe and they would poke and do inspection. Today, most people, they would clean and they look with air. Because you don't want to break the enamel more yet. Because if the enamel is already with loss of minerals, you don't want to be poking. So you need to be very careful when it's a very superficial case. Caries like that, because you might want to restore in a different way.

But this is not painful. The enamel caries have come nowhere near the pulp, so no one feels anything. There's no Cold insensitivity or heat insensitivity, very, very minimal.

Most people, they just don't even know it's there. And then when it gets close, the more it gets close to the pulp because it has so many nerves, the more painful it's going to be. The dention now is very soft, so it's more like a sponge that it's there with very rich inside. So the moment it hits the dention, it's painful. So that's when you're going to start feeling like you get something cold and say something stiffened my tooth. Hot is more signs of inflammation. If you feel the hot surfaces, things that you put in your mouth, or when it gets infected and the bacteria can come to that hole and start colonizing, then it starts the inflammation and is that pulsation that you feel and the pain now doesn't stop before you.

Get to full blown pain. When you're just dealing with temperature insensitivity. Is there anything that can be gleaned clinically between the cold versus the hot insensitivity versus both?

I'm not an endodontist expert, but most tests that they do to look for inflammation and infection. When you have more of that hot sensation that is painful, you know that you most likely might need to do the root canal because it's highly infected, inflamed, the cold, it's a little bit better because it's not in more advanced stage. And then when you go, if the decay progresses, that's when you see on this other two figures is that it hits the pulp. The moment it hits the pulp. There is no way you can not do the root canal because now everything's already infected. And most root canals are done when the pulp it's still alive. They just excise the pulp and clean and disinfect. So it's not from a dead tissue that has been there for a long time because it's hard to keep up with the pain.

But just to be clear, the dentin carry can be fixed without a root canal?

Yes. If it is not as close to the pulp that it got to the point that it's infected and it broke through, you can resort.

So this is my own personal misery. Both root canals I've had were from what I now believe were dentin caries. The first one was actually a dentist that wanted to change an old filling that I had from when I was a child. So I had an old mercury filling from when I was a kid. And fast forward 20 years, he said, you know, your insurance will cover the changing of this to a white filling. We should just change this out. Keep in mind, for 20 years, I had no complaint of this filling. Filling whatsoever. And the moment he changed that mercury filling over to a white one, in the process of mucking around, that tooth started really hurting. And over the next couple of weeks, the pain got worse and worse and worse. And ultimately, I needed a root canal on that tooth. So needless to say, I was very unhappy about that. Let sleeping dogs lie. The next one I had was the same thing, was another filling that the dentist thought, in this case, hey, I think there's another little carry next to it. It should be an easy fix. And it actually was on a wisdom tooth. But my mouth seems to be big enough that I'm able to tolerate having all my wisdom teeth. So he said, look, we can do a root canal on a. Or, sorry, this was before we needed the root canal. This was just, hey, we'll just fix the carry there. But same thing. It ended up hurting and hurting and hurting. So they ended up doing the root can canal. I still have that tooth with a. They didn't even put a crown on that one, actually, which is amazing on a wisdom tooth, not to have a crown, I assume.

So.

You said something very interesting that's counterintuitive, I suppose, which is, most times you do a root canal, the pulp is actually alive, but you still have to remove it all. I mean, once they anesthetize you, they kill all that pulp. So the process is remarkably crude. They're using these little fine. I don't know what you want to call them. They're almost like knee needles, but they're a bit bigger and they're sort of serrated. I remember wanting to play with these things after I had my root canal. But it's like these little. You wind these little serrated, jagged tools into the end of the root. It's basically a very mechanical procedure.

It is. But today they're very sophisticated. They do all microscopically. I think in the past, they had a lot of the issues from 100 years ago is because we're not sophisticated enough. So they would put those fine things and they would break through the roots because they couldn't see well. And they caused immediately, like, the inflammation, the reaction, because you're just perforating everything. But today, if you look today, how they treat periodontal disease, it's a microscopic surgery. So they just put the tooth under the microscope. They. A completely aseptic environment because they put those rubber bands and to isolate to not Let the bacteria from the oracavia to get inside, and they do the whole excision of the probe. They disinfect everything and they fill in with special materials to just fill the hole. It becomes like just a cast, the tooth, because there is no more vitality on that tooth, but yet preserves function, which is extremely important. That's why you shouldn't be extracting all the teeth unless you really need it. Because even the implants is better than your. Even without having a root canal is not better than your natural.

Yeah, I mean, I think that's probably one takeaway here, which is. And I want to talk about the concerns that people have around root canals, because it seems to be one of these very complicated, controversial topics in some small circles. But if you're going to have a root canal, it seems to me that you have to have this done under a microscope by an endodontist. I just think the days of freewheeling root canals, where a dentist is looking through his or her regular glasses and ramming these things through, just doesn't make any sense. And I know that both of my root canals were done initially in that way. Ultimately, both of them needed to be corrected by endodont, who did it with microscopes in a much more aseptic fashion. Ultimately, one of them ended up developing an abscess many years later. That tooth needed to be extracted. Which, by the way, after that tooth was extracted, I was relieved of so much pain that I decided in a temporary moment of insanity, I wanted to, in that moment, have all of my teeth extracted and replaced by implants so I could never deal with this again. Of course, that's a. Idiot.

No.

Yeah, yeah, yeah, no. So let's talk about the controversy around root canals, Notwithstanding the discomfort of them and things like that. Basically the controversies are root canals are a dangerous procedure and they lead to kind of fill in the blank. And fill in the blank is. I've heard everything, right? I've heard people say, oh, root canals cause cancer, they cause Alzheimer's disease, they cause sore toes, you name it. What is the state of evidence about the safety of root canals, or frankly, the state of evidence that root canals are indeed potentially hazardous?

It's hard to say in a nice way, but I think it's a total nonsense. It's been. For. It's 100 years ago that all those focal theories that they said that would exist, there is zero evidence. There is no research. There is nothing that can prove that this is true. If you think about. I was even the other day talking to One of my faculty, because I said I'm not a endodontist. So I've done. But it was a long time ago. But I was asking him, what do you think about this? And he said the same thing. To bet that there's no common sense on what's going on is that focal point of infection. But what he said is that if you think about the most root canals, the way they start is through the crown and the same bacteria that colonizer tooth goes inside the pulp and then comes and goes inside the root. And that's the infection that we are saying that it's causing all those infections. But this is all in your body already. And if that's the case, every time that you have a dental care, you need to extract the tooth because it's all the same route of infection. So when I think about all those things and talking to him and said this makes no sense, there's no way we can explain that. And again, I still think if it is well done. Of course there are a lot of root canals out there that people don't know what they're doing. They don't clean well, they leave things behind or they perforate. And we see with how many radiographs we take and we see a focal infection on the root, but that's because it's malpractice or someone or not even they couldn't see well to do a proper way. But in today, most root canals, if you walk in the clinic today, they all under a microscope and I can guarantee is really well done the process. And people don't have issues after that if it is well done.

Yeah. I mean, I guess the question is, even in the cases of root canals which were not done ideally, such as mine, beyond the local complication, which is the need for subsequent root canals, ultimately the need for even an extraction, does that pose a systemic risk even when it's done poorly?

I don't believe so. Most have localized. There are a few surgeries that they do and they open through the gum and they clean that area and you see that improve with this root canal, for example. Another paper who's saying that people with root canal have breast cancer, for example, but then they look at a hundred of women that didn't have root canal and also had breast cancer.

Yeah, these epidemiologic sort of, I call them bottom of the birdcage papers. Cause that's about what they're good for. They're the papers that say, well, if you look at the number of women who have had a root canal on the same side that they get breast cancer. It demonstrates the relationship. But these papers always fail to look at the numerator, which is all the women who develop breast cancer who did not have root canals. Yeah. So it's true. True and unrelated. And it's unfortunate because I think what bothers me the most about this type of pseudoscience is when a woman gets breast cancer, it's already upsetting enough. I think the last thing she needs to be told is this is because you had a root canal five years ago. That's probably the biggest issue I take with this sort of nonsensical science. And unfortunately, it tends to aggregate from the same group of people who tend to have other beliefs that are very unsubstantiated, such as vaccines causing autism and things like that. So. So there tends to be kind of a core group of beliefs like that. So let's go back a bit to the kind of broader theme of these systemic diseases. When you think about major chronic diseases, is it safe to say that the greatest causal relationship we have between poor oral health and poor systemic health would be with cardiovascular disease? Or do you think there are. First of all, how strong do you think that relationship is causally and how does it compare to others?

There is a lot of research showing association. We don't know what comes first. So they show the relationship that's proven with periodontal disease and diabetes, periodontal disease in low birth weight, periodontal disease and heart. There is a hypothesis, of course, it's all based on the insult of the bacteria causing inflammation and systemic health. We know that and other things. Alzheimer's, for example, amyloid in the brain. And a few studies that we did showed markers as well, periodontal disease and markers of Alzheimer's. So they're all associations. But the only way you can can say causality is if you do a clinical trial. You need to treat those patients and see changes on those markers. And then you say, see, I changed their behavior. They're brushing their teeth now. Look how better they became. So you need to do those things. We have a group of people that I work with from NYU, since I was at NYU. Moni de Leon is his name. And Dr. Kamer, she's been for over 10 years trying to make the point. She has all those things. She saw, for example, children that have motor skills or. I think she. Her study was in. I just blinked here now the name of the disease. But we found in children that they had amyloid beta amyloid B in their Brains accumulation. And we know this population has very poor oral health. They have periodontitis and six years old, it's down syndrome. So the first study that she looked, it was down syndrome. So we know because they have motor skills, they have cognition issues, it's very hard to brush and to have maintain a good oral hygiene.

So that's interesting. So because we know that children with down syndrome are very susceptible to Alzheimer's disease and cardiovascular disease. In fact, people with down syndrome usually do not live live a normal lifespan and they usually succumb to these chronic conditions much sooner, as early as in their 40s or 50s. So you're saying that. Well, again, it's hard to know if the increase that she sees in amyloid is an independent process that's being driven by the chromosomal abnormalities that are found in down syndrome versus related to the poor oral care, which could be true, true and unrelated. It could be that they have poor oral care because they don't have the life skills developed to provide oral care. So an interesting experiment would be a longitudinal study of two groups of peers with down syndrome. One that are provided intensive support for oral care and one that are sort of standard of care. But again, those are very difficult studies to do because they're very time consuming.

Well, they, they are, but it's all about prevention. How about if you intensify, very intense preventive approach so you don't let that child be with caries and periodontal disease and pain and inflammation and all of that. It's not only that disease, it's any people with disability. So like we just opened at Penn right now, because the gene's visionary, he's really focused on prevention. He opens a center for people with disabilities. So any person who has any motor skills or have any disease that impacts cognition, we're going to create this program that we can do a lot of research. How is the best way of cleaning toothpaste toothbrushes? What can we intensify in the scope of population which through caregivers, it's a whole educational process because it's not them. You need to educate people who are taking care of those individuals to do optimal oral hygiene. It's simple as that. Can we just brush, brush, brush, fluoride intensify? Because you can prevent. All those things are highly preventable. But I was looking for say, what are we going to measure? There is no outcome assessment that you can use for this specific population because they're so neglected.

But going back to your earlier point, just to make sure I Understood. Did you say that if you took two groups of people and one group received excellent oral care and the other group did not, and this is not in cancer patients, let's just say patients who are not immune compromised and whose oral mucosa is not compromised. So if this hasn't been done, consider it a thought experiment. One group receives best in class oral care, which I want to come back and define. The other group receives horrible oral care or mediocre at best. Would you expect to see a difference in inflammatory markers including cytokines and inflammatory cells, macrophage monocyte derived LE lineage cells across those two groups? Because if that's true, that alone could explain the increase in systemic disease. In other words, that could be a causal factor. It's undeniably well established the relationship between inflammation and cardiovascular disease. You could take two people that have virtually an identical profile of lipoproteins. But in one group, the high amount of inflammatory inflammation will lead to a greater burden of disease than in the other. Inflammation plays an important role in cancer and certainly inflammation plays an important role in Alzheimer's disease. So that to me seems that's the Occam's razor approach here, which is poor oral health leads to poor or substandard amounts of inflammatory environment. And that's the driver of these diseases? That would be my guess.

Yeah. It's very simple. But think about when did you ever go to a doctor? You are MD that the doctors ask you, how's your mouth? Do you have periodontal disease? How do you brush your teeth? Think about when.

Sure. It's not at all part of the doctor's toolkit ever.

So look, what's going on with COVID Covid is an infectious disease. What is the transmission of COVID saliva as the mouth. Now there are papers coming up because the AC2 receptors, which is the COVID bind to enter the body. They are highly expressed in the oral cavity. Look at the literature. They're in the tongue, floor of mouth, gingival clavicle of food. They're everywhere in your mouth. So a patient gets cold. The two things that I'm like, very like surprised and saying why people are not doing anything. So people get Covid. They go to the hospital. The first thing that they do, they put them a mask. They never brush their teeth. They don't look if they have periodontal disease, how is the quality of the oral cavity? They put on the subpoena position because they need to free up the lungs. And that patient spend a month, some people more Than that in a very critical condition. They think this is going to lead to pulmonary infection. Of course, if someone has periodontal disease and already have a lot of bacteria and pockets, all the periodontal pocket is a perfect reservoir for the virus to thrive. And even like the new. I don't know if you saw. There is a publication that just came out only hypothesis because nobody ever tested that it might be. If you look at the characteristics of COVID the way manifests the upper respiratory tract in terms of secretion, how congested you have is very minimal. You might have a stuffed nose, but from the mouth goes directly to the lungs. So there is a huge connection there. No one is doing anything to tell people can you brush your teeth, do a mouthwash, clean your mouth? If you have Covid, you have to have excellent in the hospitals, give the nurses. You have to ask this patient to brush. No one is doing that. Look at the committee. So of course now science is going back because our new president they have. They're very. They fostering all those prevention maps and everything. Look at the committee that we have that has been put in to support Covid. Is that any one of them is an oral expert. I'm guessing not oral epidemiologist, an oral periodontist. Is there anyone there, if there are anyone there that understands a little bit about the mouth. If you connect the mouth with the body, I can guarantee that you can prevent. Look what's going on in Brazil, China. It's just ridiculous because there is no prevention. The only prevention is the mask, which we could do something better.

Some argued that last year we saw a great increase in the rise of dental caries. Some suggested it had to do with mask wearing. To me it seems the most obvious explanation would be simply that people sought less dental care last year. Do you have a point of view on. First of all, is it true that dental caries went up last year?

So what happened that we're still dealing with that is that when Covid hit dentists was considered not essential. So they shut down everything that wasn't essential. Which healthcare and places that you can buy food and things like that. So dentist was left behind. So dental clinics. I know because I had to suspend my clinical trial for three or four months. I came back immediately the moment they allowed me to open the clinic. But dental clinics, they were closed, completely closed for about almost a year. And on top of that they suspended and every single type of procedure that produces a result because they thought that was a way of infecting people. So people Couldn't go to the dentist. You saw horrible things on the Internet. We had left our emergency clinic open only and we saw really detrimental things because people couldn't get access to care. So combined with, of course, putting masks and if you want wearing a mask at work a whole day, you forget to brush because you can't drink too much, because you need to hide, because you have to drink water or eat. So everything is detrimental. You might breathe more through your mouth because the mask people don't know how to breathe well through the mask. So it dries your mouth. You have dry mouth because you're breathing. So this combination of hygiene, you have dry mouth, you have a mask. So it's not the mask that is causing anything, but it's just a cumulative effect of everything that is going on.

Yeah, that makes a ton of sense. You mentioned thrush earlier. Right. So oral candida. And you mentioned it in the obvious context of people who are immune compromised. But from time to time, I've seen people with a totally normal immune system develop oral thrush. Now, I will say there's usually something going on like they're usually on an inhaled steroid for asthma or something like that. So maybe that's partially explaining it. But do you have any other explanations for how a person with a normal immune system could develop oral candida or thrush?

It's highly associated with candida infection and it can be through. I think the primary reason is lack of saliva because your mouth is dry. So that's why MDs, they should look at their patients and how much medication they have and ask the question, do you have dry mouth? They might have other complications that you don't even know why. But primarily I would think it's poor oral hygiene, because if you have periodontal disease and or oral hygiene, you're going to allow those opportunistic species to grow. And medication, they don't have a specific cause, but mainly, I would say medication and poor oral health would allow viruses to grow.

You mean fungus?

Fungal? Yeah, I've said virus, because virus and fungal, they work really well together. Like people with hiv, they have fun episodes, constant of fungal infection in their mouth.

So there are lots of reasons why people could have dry mouth. Certainly one of the most popular classes of drugs that would do it are anticholinergics. It's also interesting, by the way, that there's some strong associations between anticholinergics and Alzheimer's disease. It hasn't been demonstrated whether that's causal, but if indeed anticholinergics which lead to a very dry mouth would increase the, or rather decrease the resistance of the bacteria in the mouth to the systemic system. And that could play a role. So it becomes very interesting. But for an individual who has dry mouth, is there a downside in using sugarless chewing gum or lozenges or sort of having something in the mouth to induce saliva? Is there a downside to that? Is that considered one of the effective methods? Methods that someone can use to keep their mouth lubricated?

Yeah, I don't see any wrong doing that. But never use anything that is sugar content. There are a lot of sugar substitutes that you can do because you can stimulate the salivary glands and you constantly moving your tongue and your mouth. And I always say hydration, it's extremely important as well. If you don't like to drink, just get a sip water all day long. You're always washing the oral cavity, the gastrointestinal tract. Because it's all one system. It starts in the mouth and go to the bacteria. They are all together. So always hydration and drinking water. I think it's very important for oral health as well.

Now, have you looked into xylitol specifically? I've seen some literature to suggest that xylitol may actually not only not be harmful because I think there are lots of things out there that are not harmful. Aspartame or any other things that might be thrown into gum that are sugar substitutes. But that xylitol specifically could be beneficial. And so I've always kind of. My practice has been to have some xylitol based chewing gum that if I'm out and I eat, I can chew it for a while. To serve to two purposes. One is get saliva there, but two also kind of clean the food out of teeth. Do you recommend anything like that? Because a person can't brush their teeth four times a day. Presumably at some point it becomes counterproductive.

Yeah, that's the one that I like the most. I actually did some research a long time ago where we are looking for mothers to child transmission of dental caries. We know that as mutants can be highly transmissible from mother to child for different things. Like the mom who proved the food and put in the child's mouth. It's proven that you can transmit this tract mutants to the child. They've done some research about kissing in the mouth. They didn't find a huge correlation. But they know that proving and tasting the food, which is you should take a look at nannies and people who are watching children. But I really like xylitol. And we found that we prevented the transmission because we gave the xylitol to the moms during the gestation time. We asked them to chill on xylitol just to prevent that vertical transmission of the mutants that strep mutant. And it prevents decay too because the bacteria does not metabolize that.

That's great. So I'll plug my favorite brand of it. I use one called Pure P U R E. You can buy it on Amazon. And I like the pure gum and the pure mints. So Pat teeth appearance is something that obviously people have a lot of concern about. I mean we've spent everything that we've talked about to date has really been about the function of the tooth, the health of the tooth, et cetera. But generally the two things people notice about somebody's teeth when they smile is how straight are they and how white are they. So let's talk a little bit about the latter. This is the color of a person's tooth genetically determined somehow.

Yes, we can see that different races, they might have more white, but it's relative as well because let's say for this person with a darker skin, the teeth are going to come much more whiter. So it's almost blend with someone who has a very white skin. Most of the changes on tooth color can either be done by some genetic factors. There are people who might have a lot of very yellow and that will never change since they're born. Or sometimes they're like in few countries they have fluor in the water. So excess of fluoride might have some stains on your teeth, but mostly the color of the teeth. It's highly environmental determined because we talk about my study with the twins where when we gave the same product for the two twins, they behave completely different. So even they were identical 100% of the genes. If the kid who had like drink a lot of tea, coffee and things, they had much more stain their teeth. And of course the whitening wasn't as efficient of another one who had less. So the environment takes place and it's highly. We can modify just with those whitening products, brushing and things like that.

Yeah, I have found that for me, the two worst actors by far in terms of darkening my teeth are black tea and red wine. We're going to talk about whitening in a second because I want to ask you about it. I don't whiten my teeth due to sheer laziness. So my approach has been to just try to minimize how dark these get by Always rinsing my mouth out with water or chewing gum or something like that after I consume those things. So is whitening a safe procedure? Is it something that harms the tooth in an effort to produce this aesthetic? Does it bleach the enamel away or do something that's dangerous?

Yeah, it's bleach. And it's of course in excess, which most people do because they want to always have the teeth white. It's detrimental because somehow it has loss of minerals. Because of this, the product is very strong. Also, if you're allowed to touch the gums, it's very aggressive because you're bleaching and it cannot be for prolonged time. So what I tell people is that if you want to do at home, because it's less expensive, ideally you should do at the dentist. If you care about your teeth, do at the dentist. They're going to protect your gum. They're not going to apply the product. If you have periodontal disease, if you have root caries and all those things, they would know exactly what is the population who can have that. But people just go and buy out of the counter and they don't know what they're doing. Sometimes they place that and they watch tv, they spend hours or every time they have a party, oh, I want my cheat white. They put again and then becomes that constant demeritization. Of course you're going to susceptibility, you're going to harm your gums and things like that. So if you want to do talk to your dentist, ask them, am I a candidate for that? And do at the dentist, do at the correct timeline, look at the prescription, don't do cheap or products that are not FDA approved. So all those considerations, if you do the right way, it's okay. It's just when they go outside to do things that they shouldn't.

But it still seems that prevention is worth a lot here. If you minimize the things that really discolor your teeth, it would at least reduce the need to do those other things. I alluded to it earlier that one of my most miserable dental, not one of my hands down, my most miserable dental experience of my life went as mercury filling placed when I was, whatever. Ten, 30 years later someone comes along and says, you really ought to have that removed because your insurance company will now cover the replacement of these. And you can have something white instead of something silver. And that damaged the dentin and or pulp enough that I needed a root canal, that root canal. And eventually that's the one where they missed the Root I had to go back and back and back and back and ultimately led to an injury that required the tooth. Coming up. Okay, let's go back to the jugular question. Should we remove mercury fillings if they're highly functioning?

There is no decay under. There are several statements and research that has been done and that the minimum they're afraid about the mercury that gets in the. It's proven that there is no harm with that. So if it's working fine, if you eat function and it doesn't affect the appearance, the aesthetics of the tooth, just leave it there. I don't think you should.

You also talked about fluoride earlier. This might sound like a naive question, but does all toothpaste have fluoride in it?

No. You have to look for. And not all of them have the correct amount. You want like 1000 ppm to 1500 ppm of fluor. So that's very important. And the ADA, the American Dental association, if you go to their website, they have all the toothpaste that they endorsed. Not for political reasons or anything, because we've done research and we know they work. They have the correct amount of fluoride that prevents decay. So you just need to get from a good source. And it's extremely important to have fluoride in any toothpaste, usually children, before one year. They recommend not to put it because they swallow all the time. But as long as they have the first tooth in their mouth, you can start putting very small amounts and start to brush. The child gets used to. But other than that, everybody should use fluoride.

And is there fluoride at all in any small amount in drinking water?

It depends. I know that US is very particular with fluoride. In many regions, people don't like to have. Most countries, the drinking water is fluorated. But there are additional sources of fluoride. That pediatrician. They can give you like drops that you. Even when you're breastfeeding, you can just put drops on the child or varnish, which I think is extremely preventive for children. It's so simple. It's like a varnish that you paint in their teeth every six months. And guess what we learned about decay because it's just protecting more and more.

So I do that myself. Also. I have discovered that I have one area in my mouth where my gum has receded just a little bit. And as opposed to putting a filling there, I just use every three to six months a little bit of what you said, like sort of a fluoride varnish. And it reduces any sensitivity. And my goal is obviously just to prevent any decay there.

Yeah, the fluoride varnish. If someone is highly susceptible to decay, it's a prescription based. You have to ask your dentist. One of the ones that we have in the market is prevident I give to my cancer patients. But they are highly concentrated fluoride and we recommend that they use once every night for people who are high risk of caries, which is people undergoing radiation. And then you do a regular oral hygiene with the regular fluoride toothpaste. You floss and everything. And then you put that toothpaste on a toothbrush and then you brush and you don't rinse with water. You want the product to treat the cavities and everything overnight. So that's very efficient as well. And mainly. And it's a very fun story if you ask my son because I have two kids and none of them have never had decay.

How old are they today?

They are 30, 34, but they never had decay. But if you think France is which my youngest. Because I would tell the stories about microbial that they're going to eat your teeth. If you have food, they're going to eat the food and they're going to just go down and make holes in your teeth. So I would tell them those stories overnight. And how many times that kid in the middle of the night because he would fall asleep and I'll put him like three years old in the bed. And I would watch the middle of the night rush the bathroom and brush their teeth. Because you're afraid. I always told them because the most important time of the day is actually night brush. And never give your child baby bottles and things overnight because when you're sleeping you have a suppressed saliva production and that's the perfect environment for the bacteria to grow. That's why child have baby bottle decay. Because when they're sleeping and they put the bottle in their mouth, the milk concentrates all on the anterior teeth and they get severe decay. So brushing before you go to bed and you floss, you'd like a hood that you have in. The optimal oral hygiene is really high and you're going to prevent. It's a very important brushing time.

What are the implications of children having caries in their baby teeth? I mean, for example, I assume we would never do a root canal in a child. You just yank the tooth out because you know that the adult tooth is coming right behind it. Do people put fillings into children's teeth?

It's highly complicated to Treat those kids first because you traumatize them, you cannot do local anesthesia. They will never come back to the dentist if you try to do that in a regular way, because they don't understand. They're very, very young. It's 1, 2, 3 years old that those type of decay appears. So they do in the hospital, under sedation, the teeth that they can treat, they treat. They would extract the ones they're causing a lot of pain. Some of them just treat the pulp, put some medication there and wait until the tooth exfoliates just to preserve function because otherwise they're not going to be able to chew. So every case they need to approach that is another type of fluoride as well. It's a highly concentrated that they put with a marrow together. But the teeth becomes black. That's another resource that they have because they cannot open, put a hole and restorations because the child would never allow us to do so.

Excessive fluoride darkens teeth.

Just this specific, specific time it's mixed with a metal that the moment it gets in contact with this soft dentine, it hardens and becomes that very hard layer.

Okay, so it doesn't affect their adult teeth. It's just a temporary barrier until the tooth falls out.

Yeah. Arrests the decay in a very nice way. But we need to tell the mom and say, I know it's going to take the pain away, it's going to arrest the decay. But the teeth is going to become black. So it's a trait because we know that a couple years later the tooth is going to exfoliate. It's not going to be black forever. So it's an approach that we can do for this age of children.

There's an entire cottage industry of products out there like oil for pulling through the teeth and tongue scraping things. Are you aware of any research that supports the use of such devices? You've obviously talked about brushing the tongue, but any research that suggests scraping the tongue is efficacious or. I don't even understand what oil pulling is, although I've seen the oils and I don't think I fully understand what the claim is about why oil pulling is beneficial.

Honestly, I've seen. I have no idea. There is no clinical oil or research evidence that shows that it's good or bad. I've seen a few studies on the tongue scraping, which is similar with whatever the brush is doing. But I really like much better the brush because I asked the patients to put a little bit of toothpaste because toothpaste is also antibacterial and then you just brush. It doesn't harm the cells or anything. You just brush the surface. If I had to choose between this toothbrush, brushing, the tongue, the tongue scraping, I would say just brush. It's simple and easy.

Okay. Is there a difference between the types of dental flosses out there? So the two most common that I see, actually, let's say three. One is like kind of the ribbon, you know, it's like a very soft, almost looks like a Gore Tex like, ribbon. The other is like a ribbon rope, a miniature rope. And then the third one would be like kind of a miniature rope that's coated in wax. Are they all basically the same and you just pick the one that is the most comfortable to you, or do you have a preference for which type of floss a person uses?

Well, what I tell my patients, I have like 10 different ones, and what I tell them which one you're more comfortable using. It's a mechanical. The brightening, it's disruption of the biofume and taking the food away from in between your teeth. So there are people who have perfect teeth very close together. They might need to use the one that has the wax because they're going to go in and out very quick and you don't want to harm your gums. Trying to pull in something very strong and then it's going to cut your ground has to be done very carefully. There are people who have prosthetics or big holes. They're like little brushes that they can put inside. There are people who have like, teeth. They're connected to each other and they have another type of device that they can go inside the bridge and clean. It doesn't really matter. You just need to clean and you can clean. Most people don't floss.

Really. What does the literature suggest? What percentage of the US Adult population does floss once a day?

If I tell something, I might not be right, but I know by the whole population that I've treated, it's like half of the people floss. Or they floss twice a week or something gets stuck, they go in floss. But if you ask people, do you floss every day? Most people don't floss every day. Another consideration is that floss costs money. So need to keep buying all those supplies and you might not have the fund might be used for different things. But if you think about flossing and brushing, I still think the flossing is even more important than brushing because it's all the research that I did. People can stop Brushing and you recover help easily. People stop flossing. It's the gingivitis. Inflammation comes so quick because the plaque that is in between your teeth, you can never change or clean if you don't have a device. The plaque that is on in your top of the surface, your teeth, you eating your cat and apple things that have fibrous. You somehow you just clean, you drink water, the saliva is constant, cleaning your mouth, the flossing. One thing is a bad bacteria because they love is the anaerobic bacteria that causes most of the systemic health, such cardiovascular disease, diabetes. They're all anaerobic. And they're the ones that are hiding there. They hide in the tongue, they hide in between your teeth. They can hide back in your throat as well because they like those niches that the oxygen don't go.

Is a water pick an additional benefit to flossing? Is it at all a substitute? I mean, obviously there are some cases where it's very valuable. Kids that have braces, things like that. But how do you incorporate the Waterpik into your oral care regimen?

I like it, but I would say it's only if you're not able to use the traditional. The brushing is the best because the water is more. If you brush, then do the water pick. Don't do just the water pick with the without brushing because the water pick is that flushing of all the toxins that are in between your teeth and between your gums and all that. But you cannot do just waterpick. It's a benefit. But don't do alone any harm or.

Benefit to using toothpicks. This is just a personal obsession of mine. I love toothpicks. It sounds crazy, but when I find toothpicks I like, I buy them in massive quantities. And there's like this one toothpick I got at a steakhouse 10 years ago, and I became so enamored by it that I had to find out where they got it from. And I found the company that made it. But the minimum order was something like 20,000 packages. So I had to buy 20,000 packages of this toothpick, which I still have to this day. I love them. Point is, I always have a toothpick in my mouth. Am I hurting myself? Am I helping myself? What am I doing?

I don't think you're hurting yourself. They even had research in the past that they say that stimulates your gums and things like that.

Well, honestly, that's part of what it is. There's a use case which is anytime I have Food in my teeth. I love doing it. But what I've also realized is I find myself massaging my gums with the side of the pick. So I put the toothpick in and I'm sort of grinding it on my gum surface. And it just feels so good to me. I still floss every day. So it's not a substitute for flossing.

That's what I was going to say.

Yeah, it's not a substitute. Yeah, I still floss every day.

It doesn't do the same job because the floss goes around the tube, then go up and down. But it's benign. It's nothing that I don't think any wrong of doing.

That's good because I have enough to last me, my children, my children's children and their children for the rest of our people. Talk about generational wealth. I don't have generational wealth, but I have generational toothpicks.

Well, talking about that, the electric toothbrush, I like it a lot, too.

I was going to ask you about that. Okay, so I'm an oral B guy. I've tried the Braun and I've tried the oral B. Something about the Braun one bothered me. I don't know if the frequency that it vibrated at resonated too much with my head, but it didn't feel good.

I had the same.

But I love the oral B. Okay, so is one superior?

I actually did clinical trials with both. They equally good. The difference is the technology. One is sonic. So when you're doing that, it's almost. You feel the vibration in your head. And the oral B is much more like. The vibration is much more natural.

It's mechanical.

Mechanical. And I love the mechanical because it's chimal. There are people who love doing the other one. It's very fast and cleans very quick. I like the oral B a lot. That's the one that I have.

So bottom line is they're both efficacious. If you can use them both and use the one that you enjoy more.

Yes, it is just whatever you're comfortable and whatever you know, you're going to clean your mouth. That's what I say. I've done anything, all types, of all types of toothpaste. And it's a device that is there for you to do your oral hygiene.

So let's now talk about the ideal reasonable regimen of oral care. Let's start with what I do and use me as an example of how I could do it better. When I wake up in the morning, I do nothing and the reason is I don't usually eat in the morning, but I drink coffee. So I don't know why. For some reason I think it's a waste of time to brush my teeth first thing in the morning because all I'm going to go to do is drink coffee. So let's say I get up and I drink my coffee. Oh, by the way, I used to scrape my tongue. I have one of those tongue scrapers. I used to do that and then my wife got so mad at me because she said that's so disgusting it makes me sick. Get rid of that stupid tongue scraping piece of expletive. So I still have it. Don't tell her. But I don't use it anymore. So I go and I drink my coffee and I kind of do all my. I usually exercise in the morning and I usually don't eat my first thing until maybe 11 o' clock in the morning. At that point I then go and I get my oral B toothbrush and I brush my teeth. And as you probably know, the oral B toothbrush has like this little 30 second timer that allows you to go two minutes. So I'm very, very robotic about this. 30 seconds on the top, 30 seconds on the top, 30 Seconds on the bottom inside 30 seconds on the bottom and then I'm done. And then I don't do anything again except use my toothpick all day until dinner. After dinner, I then floss. I like both. I like any floss actually. I just love flossing. So I'll use the little ropey floss and I'll use the tape floss, whatever I've got. And then I do the same thing with the oral B toothbrush. By the way, I'm using a xylitol based toothpaste. For what it's worth, if that matters.

It has fluoride.

It has fluoride. That's my only oral care regimen. I don't use mouthwash, I don't use a water pick. I used to, but then I gave it to my daughter because she got braces. I figured she needed it more than I do. That's all I'm doing. So what could I do to be. AM I getting 80% of the benefit a person can have? AM I at 60% benefit? And what else should I be doing?

So one little adjustment. So usually bacteria, the biofilm, it takes like overnight. That's where you have the most suspicious bacteria. They start growing in your mouth for all those reasons that I said your mouth is closed, no oxygen, reduce saliva Flow. Salivary flow is almost zero because you're sleeping and things like. So people, when you wake up, you feel. If you stop and think, you're gonna see. Yes, my mouth is dry. If you cross your tongue on the surface of your teeth, you're gonna feel the biofilm. Biofilm is invisible to your eyes, but you can feel with your tongue. That's the morning that you're gonna see. So there's nothing wrong of you. I do that as well. I like to take my coffee in my bed. I just read a little bit and I take my coffee without breaking brushing.

I love that Brazilian coffee, I hope.

Exactly. Espresso. So then you get out of the bed and you brush your teeth. You have to wash out from your night.

Okay, so the change you're suggesting is before I begin my day, do a first brush. So I'm going to be now brushing my teeth three times a day. I'm going to do.

That's the ideal.

Okay. And is it okay if that. Should they all be done with the oral B toothbrush or is there a time and a place to just use a regular toothbrush?

You can use any toothbrush if you out. If you're in a place where you can brush, you can use any because the mechanical toothbrush, they do such a good job.

Although I have to be honest with you, I've never been able to brush my tongue with the mechanical toothbrush because I. No, yeah. I have to use. Okay, all right, I got it.

I like a children toothbrush because they're more soft.

Yeah. So you want a soft Bristol toothbrush, right?

Soft for the tongue. Yeah. Just get a separate one. And I tell people that every time that you use a toothbrush, which most people don't do as well, you rinse your toothbrush. You can even rinse with soap. Like put water soap. You decontaminate. You need to clean your toothbrush.

Oh, I never thought of that. You're literally going to add another four minutes to my day. You realize that? Four minutes to my day, 28 minutes to my week. Do you know how many hours you're adding to my year? This is ridiculous. Well, look, it's worth it, though. So I'm going to now be rinsing my toothbrush with soap and water.

If you don't want to put the soap, just rinse with warm water.

Well, I always do that, but now I'm committed to doing this. Maybe salt. Would salt water be beneficial?

You don't need. No, just even hand soap. Just rinse with water and soap and dry. You have to dry because bacteria loves the moisture environment.

I hate the taste of soap because as a child my mom would often wash my mouth out with soap because of how foul a mouth I had. So I'm still traumatized by the taste of soap. It. It's an awful taste.

Rinse with like hot water. It is very hot. So that is soap in toothpaste. Because soap disrupts microbial like the COVID can be disrupted by soap. So every toothpaste has soap because of that. Because most bacteria had the lipid protein in their surface. So that's why we have. But they put all the flavors, they put the fluoride. So that's why they don't feel that soap taste. But that is soap and antibacterial.

Any role for mouthwash? I don't. My wife loves it. I don't. I just. It's one more dumb thing that I don't do.

The thing that I just like with mouthwash is that it kills every single. It just wipes out all your microbiome, including the good ones because they're all antibacterial. So I am in favor, if you like, in a situation that you're not going to be to. Able. Able to brush much, like for short periods of time, let your body normal, like recolonize without any interference. The same thing about antibiotics. If you take too much antibiotics, you're going to be resistant to bugs and bacteria. So if you use every day, in one point you're going to have a virus in your cavity, but that's going to be very resistant.

That's very interesting. Is there any evidence that excessive use of. Of mouthwash, for example, leads to candidal overgrowth or fungal overgrowth? I mean, that would certainly be one hypothesis worth testing.

I don't remember Peter, so I don't want to say anything that I don't remember, but I can go back and look. But the studies that I did, it changes the microflora. So that's why I'm very concerned about changing an oral environment that is healthy. So if you're healthy, why are you going to use the mouthwash? You don't need that.

Okay. Anything else that we would consider best practices for the average person who is looking to preserve the quality function of their teeth and by extension their overall health. Besides what we've discussed.

Well, I think everything that we discussed and we talked so much many times about prevention. So dental care is a chronic, non communicable disease and then it's through life people have dental care their whole life. The only way to control is preventing. So preventing means every six months you need to go to a dentist and you need to do a cleaning at a mini. At that time they're going to look, do you have any cabbages? Because the cabbages is a niche for the the bacteria to grow as well.

By the way, is six months a magic number? I mean, the only reason most of us go every six months is because that's what insurance covers for free. But if you decided you were willing to pay out of pocket, would it be better to go every three months or every four months to do an overall cleaning?

Well, there is a lot of research about if you maintain a good oral health, you don't need to do more often someone who is at high risk. You have a systemic health. You have diabetes, you can do three times a year, for example, but the six month is how dentists recommend it. And it's through research that shows because periodontal disease is a very slow progression, it's not a disease that you have today. In three months you're gonna have 2 millimeters of bone loss. Unless you have something else in your body that combines combined with the inflammation that is triggering systemically, then your bone is going to go away very quick. But I think because periodontal disease is slow progression and I know we did a study three years ago that we looked at people and we measured periodontal disease every two months. We helped the treatment, we didn't do the treatment and we watched how people would progress. And it's crazy. There are people who progress, progress very quick. There are people who never progress and there are people who take two years to progress.

What do you think explain those differences systemic.

Because periodontal disease is a highly communicates with your body, if you have a systemic issue, it's going to exacerbate inflammation.

Wait, so you could predict the extent of disease a person has if you knew how systemically healthy or sick they were?

Yeah, you can. If you have a lot of infection, if you have diabetes, we know you're more susceptible to have periodontal disease. So there are groups of risk that those particular group, they need to see a dentist more often, they need to do more cleanings and they need to prevent. There was a huge study that was done five years ago, but was not conclusive. They never know when they finish. They say they don't know which way it's coming. If it is the diabetes that triggers or if it is the burden and the oral cavity that is triggering the diabetes, they couldn't dissect that.

I mean, I think the good news is they're both preventable diseases. So again, goes back to the point of prevention.

Yeah.

Well Pat, this has been super interesting just on a purely selfish basis. I learned a lot that will immediately go into practice, effective I guess tonight and tomorrow morning. So thank you very much for for the insights you've shared and I think people will take a lot of practical information from this Very welcome.

It was my pleasure.

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