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

00:00:00.000 Hey, everyone. Welcome to the drive podcast. I'm your host, Peter Atiyah. This podcast,

00:00:15.480 my website, and my weekly newsletter all focus on the goal of translating the science of longevity

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00:00:41.740 head over to peteratiyahmd.com forward slash subscribe. Now, without further delay,

00:00:47.740 here's today's episode. My guest this week is Patricia Corby. Pat is an associate professor

00:00:55.420 of oral medicine and associate dean of translational research at Penn Dental Medicine. Pat received her

00:01:01.720 doctor of dental surgery from Unincor University in Brazil and her master's in biomedical informatics

00:01:07.860 from the University of Pittsburgh School of Medicine. She completed her postdoctoral training

00:01:12.320 in molecular biology and microbiology genetics at Harvard. I wanted to have Pat on this podcast for

00:01:19.100 some time because I've wanted to interview somebody on the broader theme of two things,

00:01:25.140 one being oral health. What are the important things to be able to actually care for your mouth?

00:01:29.500 Because as we think about longevity, there are a handful of things that I don't think get enough

00:01:33.700 attention. So if you want to live to be 90 or a hundred, imagine a world where you do that with

00:01:39.980 high quality teeth and without. It's sort of like imagining a world where you don't get cancer or heart

00:01:45.920 disease or Alzheimer's disease, but you're too frail to get up and walk around. And I think the

00:01:49.980 same sort of applies to your teeth. If your mouth is not in good health, I think your quality of life

00:01:54.700 is quite compromised. And in the same vein, I wanted to understand to some extent if there was any

00:02:00.120 relationship between poor oral health and systemic diseases. It seems that there is an association,

00:02:06.660 but I wanted to at least probe a little bit this idea of could there be a causal relationship?

00:02:10.760 So in this episode, we discuss all of these things and we conclude the discussion with what I think of

00:02:16.900 as a very high yield list of best practices around oral care. I was surprised to learn that, for

00:02:24.420 example, maybe fewer than 50% of people regularly floss, meaning floss daily. I was also very surprised

00:02:31.100 to learn the importance of flossing. I always knew it was important. I don't think I realized how

00:02:34.940 important it was. We also talked about certain things that are popular and trendy that may not

00:02:40.440 actually be that beneficial. Talk about teeth whitening. We talk about the use of mouthwash,

00:02:44.760 what type of floss is better, which type of toothbrush is better. All these things and more

00:02:48.900 are discussed in this episode. So without further delay, please enjoy my conversation with Patricia Corby.

00:02:54.560 Hey, Pat, thanks so much for sitting down with me today. I've been wanting to sit down with you for

00:03:05.020 quite some time. And I know we've scheduled and rescheduled on several occasions and between

00:03:09.980 one thing or another, it took a while, but I am pretty confident it's going to be worth the wait.

00:03:14.940 How are you?

00:03:15.940 I'm good. Thank you. I'm very happy to be here. That's something that I have a lot of pleasure

00:03:20.800 talking about oral health with MDs. That's my life is trying to do this connection. So

00:03:26.900 I'm very excited to be here. It's going to be interesting. I don't know much about what to do.

00:03:33.020 And I think I can bring something new about dentistry and oral health and things, which is so important.

00:03:40.780 Yeah. Well, I think it is important. And that's certainly why I've wanted to talk about this for a

00:03:45.040 while. And I've been trying to figure out who would be the right person to speak with. And you came very

00:03:49.440 highly recommended because I think it's actually a very underappreciated part of health. I think

00:03:55.440 it's easy to think of the mouth as this sort of thing. And we go to the dentist and hopefully we

00:04:00.640 don't have cavities. And obviously we have a whole bunch of cosmetic concerns with the spacing of our

00:04:05.920 teeth and the whiteness of our teeth, et cetera. But I'd like to sort of tie that all together.

00:04:10.140 But I want to kind of start with a little bit of your background. So obviously you grew up in

00:04:13.080 Brazil. I shouldn't say obviously, but I recognize your accent and I know your history a little bit.

00:04:17.380 When did you leave Brazil?

00:04:19.440 So it was a long time ago, over 20 years ago. So I had my dental degree in Brazil,

00:04:25.840 and then I had my specialty in periodontics and implant dentistry, which is one of the fields that

00:04:32.080 is more connected with systemic health. I always wanted that. And then I went, I came to US mostly

00:04:39.740 for personal reasons and my passion for research, because that's what I do my whole life. And I never

00:04:46.440 went back because I got fascinated by the opportunities and everything that I could

00:04:52.660 have here that unfortunately we don't have the resources in Brazil to do. And I'm still doing

00:04:59.720 research up to today, many years. So this is a bit off topic, but tomorrow is a very sad anniversary.

00:05:07.780 Do you remember where you were 27 years ago tomorrow?

00:05:12.180 No, remind me.

00:05:14.180 Sunday, May 1st, 1994 was the day Ayrton Senna died.

00:05:21.700 Oh, wow. I remember that day really clearly. Wow.

00:05:27.540 Yeah. Where were you that morning? Were you like everybody watching the race on TV?

00:05:33.180 Yes. I was still there in Brazil.

00:05:36.040 Yeah. I have so many Brazilian friends and we're just fortunate. So many people in our life are

00:05:40.860 Brazilian. Our nanny is Brazilian. And I've never met a person from Brazil who was anything over 1.00

00:05:49.440 about four or five years old on that day. It's etched in their minds forever.

00:05:55.000 Yeah. He's a big legend. And I think in a time that made Brazil so visible for the world and all

00:06:03.000 those things. So everybody was always very proud of him.

00:06:06.980 Yeah. Well, he's my personal hero. And so for you today, I wore one of my Senna bracelets here.

00:06:14.760 So let's start a little bit with tooth anatomy. Unfortunately, I have teeth that my wife refers 1.00

00:06:25.080 to as a Tia teeth, which she jokingly means like I just have genetically horrible teeth. Like I always 1.00

00:06:32.080 seem to be at the dentist for something. Something's always going wrong. I'd like to think she's

00:06:36.920 exaggerating a little bit, but there was a period in my life, unfortunately, of maybe 10 years when

00:06:44.660 I didn't go to the dentist once. And I think I sort of ended up paying a bit of the price for that

00:06:50.180 going on, which sounds like a stupid thing to say. Imagine somebody not going to the dentist for 10

00:06:55.020 years. But that's sort of what happened for largely much of my medical school and residency. I just

00:07:02.120 never made the commitment to go. Still brushed my teeth and did all that stuff, but obviously wasn't

00:07:07.620 getting regular checkups. And now that I find myself taking dental care so seriously, the first

00:07:13.180 thing I realized is I had to understand the anatomy. I had to understand what they meant by pulp and

00:07:18.720 dentin and all of these things. But I think it might make sense to give people a decent overview over the

00:07:27.500 semantics of the tooth at the individual level and then sort of at the level of how all of the teeth

00:07:33.960 fit into the mouth. Can we start with something like that? Yeah, yeah, yeah. Of course, I think,

00:07:38.980 which is strictly important. They all have a reason to be. So you have 32 teeth in your mouth. All of them,

00:07:46.840 of course, they have very specific functions. So if you think about the anatomy of the tooth,

00:07:54.280 you can think about one unique tooth only, which is the anatomy of, you have the root caries.

00:08:03.280 If you think about between what you see in the oral cavity and what you don't see is like the crown

00:08:10.800 and the roots, as you see in this figure. And then you have all the parts that surrounded the tooth,

00:08:17.840 where we call the supports where this sits on top, which is the periodontum, which is another

00:08:23.700 very complex system as well. And then if you think about this whole system together and you have

00:08:33.200 multiplied that by 32, then you'll have this amount of very unique set of different, think about

00:08:42.400 individuals inside your mouth, and they all have very specific functions.

00:08:46.340 Can you pull that slide up again of the individual tooth? I have some questions about that.

00:08:51.920 Because the first thing that jumps out to me is that there's a vascular supply that is quite high

00:09:00.040 in the tooth. If I didn't know better, I would assume that when I look in my mouth and I see that

00:09:05.940 white crown, that everything inside it is a bone. In other words, I would assume the entire tooth

00:09:12.560 is an avascular amorphous thing that serves one purpose and one purpose alone, which is just to

00:09:20.620 basically break down food. So why is it that this tooth is so much more complex than just having

00:09:28.140 enamel? Why does it have this dentin and this pulp?

00:09:31.660 Yeah, it's a very complex structure and it's for a reason. So the enamel is minerals. So it's a very

00:09:38.200 hard surface. It's actually the hardest surface on the human body is the enamel. And then underneath

00:09:45.820 the enamel, you have the cement, and then the dentin, and then I have the pulp, and the cement is

00:09:52.500 everything part of the periodontum. But there's three layers of the tooth itself. The enamel protects

00:09:59.180 the underneath layers. The second one that you see is just like cushion and has a lot of tubules as well.

00:10:07.120 So it's hypersensitive. And then the heart of the tooth is actually the pulp. You see a lot of nerves

00:10:14.120 and they all connect to the body. That's why you have a lot of tooth pain is one of the most

00:10:18.880 detrimental type of pains that we have because you have all those nerves connecting everywhere.

00:10:24.940 And then you have the bone as well. And the ligaments around the roots, they protect. It's that

00:10:30.580 cushion that protects against the impact and it gives you all that biological symbiotic

00:10:37.120 so you can chew and you can function. But why is it that we need a nervous

00:10:43.540 connection to the tooth? Because I understand that if you had a dental implant, obviously you've given

00:10:51.400 up the nerve and vascular supply to the tooth, correct? Yes.

00:10:55.800 So we can still carry out the function of breakdown without that?

00:10:59.200 So the first signs when you have a tooth loss is you start with the decay. And then if decay

00:11:07.880 takes the pulp, then you have to excise the pulp and you can still preserve the root. So the main

00:11:15.020 thing, the way we want to think in dentistry is that you want to preserve health as much as you want

00:11:21.000 because you want to preserve function. So you don't want to extract teeth because teeth, they have a very

00:11:26.420 precise reason because they need to hold this face. You need to chew. There's just a lot of things

00:11:31.540 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

00:11:38.280 any more the crown because you lost to the decay, you can take it out the crown. You can put some

00:11:44.000 metals and then you can put an artificial crown. The moment that you lose, it's infected and you have

00:11:50.140 to extract the whole tooth, then you need to put the implants on. But not that the implants is better.

00:11:57.420 It will never be better than your natural function in your teeth because it's a metal and it has many

00:12:03.480 other issues. And you still have periodontitis, which is an infection of the implant. It doesn't

00:12:08.980 mean that, oh, I'm going to take my teeth out and I'm never going to get inflammation periodontal

00:12:14.120 disease. It's not true. You still have that.

00:12:16.460 I think my question is more that if you have an implant and therefore you have a de-nervated

00:12:23.140 tooth, it seems to still be able to carry out the function of breaking down food. I think the thing

00:12:28.780 I'm trying to understand is you pointed out something that unfortunately most people listening

00:12:33.680 to this can relate to, which is dental pain is some of the worst pain in the world. And it speaks to,

00:12:41.060 I think, that highly, highly innervated pulp that you showed. I'm trying to understand what the

00:12:47.560 function is of having something so highly innervated. Like for example, our fingers are

00:12:53.380 highly innervated because they serve such an important function. Our ability to have fine motor

00:12:58.680 control with our fingers is why we have so much innervation here. So why is it that we have so much

00:13:05.260 innervation in a surface beneath this enamel, which as you said, is the hardest surface in the body?

00:13:12.540 What is the purpose that that innervation serves?

00:13:16.160 That's an interesting question. It's the vital part of the tooth that preserves blood flow and

00:13:25.640 keeps the tooth alive. And it's connection. Now that I'm thinking through, it's how you protect it.

00:13:33.800 So it's the connection with your immune response. If you have, let's say, if you have a caries

00:13:38.700 infection. Interesting.

00:13:40.680 So probably that's how your body might be able to respond and fight against infection inflammation.

00:13:48.080 So the moment you don't have that anymore, so it's just a damp piece of...

00:13:52.800 I see. I see. That's a good point.

00:13:54.500 That's what I think now that we're talking.

00:13:57.160 So maybe it serves as such an early warning indicator as a breach of a barrier, basically,

00:14:05.900 an important barrier. Okay. That's interesting. I just have to tell you, having been through so many

00:14:11.480 miserable dental experiences, I've often cursed our evolutionary gods for giving us so much

00:14:18.840 innervation in that tooth. So you've already started to talk a little bit about the pathology

00:14:24.060 that can go wrong here. Before we do that, I want to get a little bit more on understanding

00:14:28.720 of the function. Can you show me again that slide that has all of the teeth and maybe explain

00:14:34.960 how different teeth serve a different purpose in the mouth?

00:14:39.600 So technically, you have the incisors. So you have four of them in your jaw, in each part of your

00:14:48.880 jaw, in the maxillary and the mangibur. Then you have the canines. There are another four. So the

00:14:53.920 incisors is mostly in your mouth where you can cut your fruit in any animal. That's how you bite and

00:15:00.260 how you separate pieces of fruit. And then you have the canine that is a very strong. That's the

00:15:05.720 longer root that you have in your mouth. That's the tear. So you can see animals when they are eating

00:15:11.240 meat and all of that, that you tend to go to the side because it's a very strong anatomy that they

00:15:17.320 have. And then you have four, we call premolars or bicuspids. So that's where you start to break

00:15:23.920 down the element, the food that you eat to tear them apart. And then the molars, they do the whole

00:15:31.000 trituration. That's where you have to chew. And I always talk about chewings because the digest

00:15:37.280 process starts in the mouth. So it's very important that people chew their food in contact with the

00:15:43.520 saliva and all the nutrients that we have. But it's a completely different subject talking about

00:15:49.000 saliva, but it's mainly to chew your food to start a digestive product. So then you can get most of the

00:15:56.740 nutrients out of your food. Now, looking at the lower part of this figure, it seems that the different

00:16:02.880 teeth have different numbers of roots. Is that correct? Yes, that's correct. So incisors and

00:16:11.280 laterals and premolars, the one in front, they have single group. Then if you go to premolars,

00:16:18.260 they will have two and the molars itself, they might have three or four, depending on how big the

00:16:25.500 tooth is. So it's a much more complex because they are much more strong and they have to get much more

00:16:32.320 pressure and to function. So they need to have much more like sustainability so they can chew and

00:16:39.480 frituate our food. I see. So that actually probably explains another reason why these things are

00:16:46.120 innervated, which is the harder they have to oppose other teeth. So the molars would have the greatest

00:16:54.540 opposition to another tooth. Then they need greater sensory input to understand the relative spacing and

00:17:03.220 force. Would that be part of the difference as well? As well. If you think like in your mouth,

00:17:08.860 it's like a bridge has to be very well balanced. The occlusion needs to be perfect because then

00:17:15.840 you're going to hurt all your ligaments and cause inflammation in your mouth. So it's a very

00:17:21.220 elaborated system. And if you think about the occlusion, they connect, they have to be very perfect

00:17:27.540 aligned. So if you start having issues like your teeth, they don't have a perfect occlusion, you start

00:17:34.400 losing your vertical occlusion. And then you have a lot of other issues like pain on your face and

00:17:40.660 headaches. There are many other issues that can happen if you don't have a good function in your mouth.

00:17:46.460 Okay. By the way, I learned the hard way that I have four roots in my molars, not three, because

00:17:53.900 I've had two root canals and the first one, they missed one of the roots. They only went after three

00:18:00.420 roots and I still had endless persistent pain. And I went to finally then see an endodontist who

00:18:06.160 realized I had a very hidden fourth root, but we'll get to root canals later. My least favorite

00:18:11.460 procedure in the world. So let's talk about what a healthy mouth looks like. You alluded to saliva.

00:18:18.060 I assume that that plays a very important role in oral health. And I assume it does something

00:18:23.400 beyond lubricating food. Does it play another role?

00:18:26.700 So the oral cabbage is a very complex system. If you think that you have teeth, you have the gums,

00:18:35.680 you have the gingivocravicular fluid that's open and allows the bacteria to go in and out.

00:18:43.280 You have the tongue, which is a completely different texture and structure. You have the throat,

00:18:47.720 which is entrance to your body. So all this whole complex system, they need to live in a very

00:18:55.040 organized way. And on top of that, you have the saliva. Saliva is, again, we could have a completely

00:19:00.540 other podcast just about saliva, but in the context where we, they preserve health because

00:19:06.340 we know today that people with dry mouth, if you have, I treat patients with radiation,

00:19:12.920 they're going through radiation oncology. We can talk about that later, but the moment you dry your

00:19:18.540 mouth, for any reason, systemic conditions, medication who causes dry mouth, there are many

00:19:24.960 of them that causes, or toxicity is your cancer care, radiation drives mouth. It's a completely

00:19:31.380 shipped all microbiome in your mouth because saliva protects. It's that bio food that is constant

00:19:38.760 washing and flushing your mouth and maintaining a very homeostasis on the microbiome as well.

00:19:46.140 It prevents dysbiosis on the oral microbiome. So this whole complex needs to be balanced on every

00:19:53.220 single aspect that we look. You need to have your teeth, you need to brush, you need to have a lot

00:19:58.900 of saliva and you need to eat well. So it's a combination of a lot of factors that makes people

00:20:04.980 say to be in health when you look at oral health, but the primary is so simple. It's actually oral hygiene.

00:20:12.160 If you brush your teeth, you're going to be technically, you preserve a little bit more of

00:20:17.120 health than people who don't.

00:20:19.460 I want to go back to what you said about the dysbiosis and the microbiome of the mouth. So

00:20:23.520 my recollection is that the mouth actually has a significant amount of anaerobic bacteria. Is that

00:20:29.940 correct?

00:20:30.740 Well, they're both. You have aerobic, you have anaerobic, you have facultative bacteria. They can

00:20:37.140 play both roles because it's so strong. They can change. But we have over 700 different

00:20:43.100 bacteria that leads in a perfect symbiotic habitat in our, in a kinder, we call that. And they can

00:20:52.200 live really well with the host without causing disease if you can maintain the state of health.

00:20:59.000 Because in the past, people think that what causes a disease or a disease is this specific

00:21:06.220 bacteria, but it's not true. We all have all those bacteria in your mouth. It's indigenous to you.

00:21:13.400 It's not that it's from something external. You have that. It's a, their normal habitat is your mouth.

00:21:20.280 But for some reason you stop brushing or you start taking a medication and your mouth becomes dry.

00:21:27.220 You have a health condition that allows inflammation to be more prevalent in your mouth. All those

00:21:33.440 things might change the auto-carbity environment. And that allows some bad bacteria to grow and 0.99

00:21:40.760 supersede the good ones. And then that's what happens with the dysbiotic. So it's, we talk about two 0.55

00:21:47.360 things, abundance, changes in abundance, and diversity, which is allowing bad bacteria to flourish

00:21:54.660 and suppress the good ones that helps us preserving health. So that's mainly what's going on. Of course,

00:22:01.260 there are the couple of things. So in an ideal state, directionally, what amount of bacteria are

00:22:08.820 aerobic, anaerobic, and facultive? What's the approximate distribution in a relatively healthy mouth?

00:22:15.400 It's probably half and a half between aerobic, anaerobic, and another, maybe 30 to 40% of them,

00:22:25.280 they can play both roles. But those, let's say a clear example, and we can talk about that in a

00:22:33.100 completely different section, but like even children, when I did my studies with the twins, and then we

00:22:39.460 asked them to stop brushing for two weeks, all the periodontal pathogens, P-dingivali, T-denticola,

00:22:46.340 fursitis, that we only see in adults with periodontal disease, in two weeks, they became abundant in

00:22:53.000 their mouth. So they were there. I couldn't see a baseline. The moment they stopped flossing,

00:22:58.640 they became abundant. So they are there, but they will never cause disease unless you have a shift

00:23:05.240 on their oral microbiome. So let's talk about that study. So how old were these twins?

00:23:11.020 So let me go back. It was a long time ago. That's when I first started my research because I was

00:23:17.080 highly interested in dental caries. So they were between 12 and maybe 16 years old. I wanted to

00:23:26.320 have adolescence because that's where they don't like to brush the floss. It's a very hard population

00:23:32.320 to do that. So what we did was, so when you do studies, I'm going to talk a little bit about the

00:23:38.900 twins, so I understand why we use the twins. So they are the perfect model to do clinical trials.

00:23:45.440 That's my passion is clinical trials because they share, especially on that age, the same households,

00:23:52.700 the same home. There is no confounders. You don't need to adjust for age. They're identical twins. You don't

00:23:57.820 even need to adjust for gender because they share the same sex and they share 100% of the genes. So

00:24:04.060 when you look at monozygotic and dizygotic twins, the monozygotic twins, they share 100% of their

00:24:11.060 genes. It's almost the perfect clones of each other. Right. And to your point, as adolescents,

00:24:15.960 they're still in the same house. It would be different if you did this with 30-year-old monozygotic 0.99

00:24:21.400 twins, because at least there might be some environmental differences.

00:24:24.080 And the environment takes place. And then a lot of, you know, epigenetics might change even

00:24:29.720 mutate genes. And then when you look at the dizygotic twins, they're 50-50. They share 50%

00:24:36.220 of their genes. It's the same as two brothers, siblings. So there's two ways that you can do

00:24:42.180 studies with twins. You either get the twin set and then you do treatment A and B to see response

00:24:50.660 to treatment because they're very similar. Or the way I like when you want to see traits and how a

00:24:57.600 trait can modify by genetics or environmental factors, you get the same set of twin and you

00:25:04.520 give the same drug, medication, or treatment. Because then when you look before and after,

00:25:10.640 if you see that the identical twins, they behave in the same way, you're going to say, well,

00:25:15.680 genetics is modulating that trait. But then if you look at both of them and say,

00:25:19.920 they're all over the place, they behave in the same way as the identical and the fraternal

00:25:25.300 twins, you say, well, here the environment is playing a big role because genetics is not

00:25:30.560 holding anymore. So when we do this flossing in twins, that's how we did this study. We

00:25:37.000 didn't want to give separate treatments for the twins because they're going to the same

00:25:41.700 house. And I did very controlled. So for two weeks, we asked the twins to come every day

00:25:47.760 to the center and I'd have dental hygienists and my clinical people trained and they do brushing 0.73

00:25:54.340 and or flossing because there are two groups. One group, we wanted them just to brush. The other 0.82

00:26:00.260 group, we wanted them to brush and floss. So the hygienists would floss and watch them doing. It was

00:26:07.280 very supervised and controlled. And when they go home, I asked them to do at night at home.

00:26:12.580 But if you think about it, it's a very hard clinical trial to do because we had to bring

00:26:17.480 the kids every single day with their parents to the center so we could actually watch them

00:26:23.320 doing the intervention. So when we finished the study, what happened that we saw is that

00:26:30.780 the children that did not floss, we saw elevated levels of gingival inflammation, which was

00:26:37.720 represented by a gingival bleeding. We measured gingival bleeding. And what was most striking

00:26:44.020 was all those periodontal bacteria, they just came in abundance in their mouth.

00:26:50.140 Which ones in particular overexpressed in the non-flossing group?

00:26:55.440 It's the three big guys. We call P. gingivalis, T. denticle, A. actinomitans. They're very

00:27:03.240 complicated names, but it's the top bacteria that causes periodontal disease and gingivitis

00:27:09.480 we found in a very young population.

00:27:12.800 Are those all faculty of anaerobes or any of those?

00:27:16.180 Yeah, anaerobic species. Most of the bacteria, so caries and periodontal disease are very similar

00:27:22.880 in the way they behave and they're risk factors, but they can be separated. Their caries is most

00:27:29.340 aerobic species because they live in the presence of the oxygen. So they're free on the oxygen because

00:27:35.980 of the oral cavity. Most bacteria that cause periodontal disease, they're anaerobic. All the

00:27:41.780 faculties that they can go up and they can hide again inside the gums. So they're anaerobic. That's why

00:27:48.560 they love hiding in the periodontal pockets. It's the perfect reservoir for them to just grow and cause

00:27:56.820 inflammation. And just to be clear, the periodontal pocket is inside the tooth and the gingival pocket

00:28:05.560 is between the gum and the tooth? It's all the same thing. So the way periodontal disease manifests

00:28:14.080 is that first it starts with inflammation around the gums. So the way the periodontal works is that

00:28:22.680 it's sealed by the periodontal ligament attaches. If you are in health, your periodontal ligament is

00:28:28.920 very healthy. It's like a muscle. It's very tied to you. If you stop brushing, which is the primary cause

00:28:36.620 that your gums get inflamed, you stop flossing or you relapse, you're going to immediately, if you floss,

00:28:43.420 you're going to see some bleeding. That's the initial stage of periodontal disease, but it's highly

00:28:49.980 modifiable. If you have only gingivitis, you can refer to health. So if you keep going and you

00:28:57.600 continue with the traits of the disease, the ligament is going to get inflamed and they're

00:29:02.980 going to deattach from the tooth. The bacteria is going to come in. And then that whole process of

00:29:08.620 inflammation, bacteria, and deterioration of the ligaments, that's where you form the pocket.

00:29:14.580 That cumulative harm to the periodontal culminates in bone loss. So the initial, the acute periodontal

00:29:25.260 disease, you're going to see someone is that they come to your office, you take radiographs,

00:29:30.040 the gums are still somehow attached to the tooth, very inflamed. It bleeds a lot. You touch, it bleeds.

00:29:37.920 But if you go and look at the radiograph, you're going to see a big gap. The bone is all done. And

00:29:44.560 then that's the pocket. It's when the bone goes down. And then if you put a probe, you're going to

00:29:50.540 see three millimeters, five millimeters, seven millimeters. It keeps going down.

00:29:55.180 Now, how does that relate to the carry? Because the carry typically occurs on the sort of top surface

00:30:02.720 of the tooth typically, correct? And everything you're describing is often actually below the gum

00:30:08.020 line, yes?

00:30:09.020 Well, that's the next stage. So once the pocket gets influenced with chronic periodontitis,

00:30:15.700 what happens is that the atrophy of the gums. So the gums, they're going to recede and they're

00:30:21.420 going to keep going down. So it's very typical that you look, if I look at someone, I know they have

00:30:26.580 periodontal disease just by looking at their gums, because you're going to see the teeth, they become

00:30:31.080 bigger. And then you're going to see the gap that you're going to expose the root. So usually the

00:30:37.120 roots of your teeth, they're not meant to be exposed because once they expose, the bacteria can colonize

00:30:43.400 and you can have root caries as well. So you can have the coronacaries, which is just on the crown

00:30:49.060 of your tooth. But when the root get exposed due to periodontal disease, other forms of trauma,

00:30:55.160 malocclusion and things like that, then you can get caries to take over the root of your teeth as

00:31:00.960 well. So in children, the sort of typical caries that we see are on the occlusive surface, correct?

00:31:09.680 Mostly, but one of the most common caries we call early childhood caries, which is caused by baby

00:31:18.500 bottle. Children that like, not the breastfeeding, but the bottle overnight and many times a day.

00:31:25.020 So it's mostly on the anterior teeth. I don't know if you had a chance to see it, but they carry the

00:31:30.420 value very rapid because the milk accumulates in that area and it's extremely painful. It's actually

00:31:38.000 one of the most common. Dental disease is the most common disease worldwide due to that caries. 1.00

00:31:46.300 Everybody has dental caries.

00:31:47.820 Why did you say it doesn't happen with breast milk?

00:31:50.440 Because the breast milk, we have studies showing that it causes much less decay than formula because

00:31:58.060 every formula has sugar.

00:32:00.060 So what is it about sugar? We all grew up knowing that sugar was the worst thing for your teeth,

00:32:05.800 but what is it about sugar? Is it the fructose? Is it the glucose? Is it the combination of them

00:32:12.340 that leads to a rapid overgrowth of the carie-causing bacteria?

00:32:18.160 It's all of them. It's fructose, sucrose, lactose, more complex starch. They are even worse. All the

00:32:26.460 drinks today, they have added sugar, you name it. Everything has sugar. But the main mechanism is

00:32:32.560 very simple, actually, is that the cariogenic bacteria, they love sugar. They metabolize the

00:32:41.120 sugar. It's that extra energy for them. Every time that they see it, so they have capability of

00:32:46.620 attaching the tooth surface, all the spectators. So they get together, they stick to each other,

00:32:52.400 and they have the ability to secrete that extra cellular matrix that is like a group,

00:32:59.340 and we call biofilm, and that attaches to the tooth. So every time that you put sugar,

00:33:04.860 they take that sugar, they metabolize that sugar as energy source, and they multiply and they grow.

00:33:11.120 With other food that we put it on the outer cavity as well. But what happens is that when they might

00:33:18.100 metabolize sugar, they secrete acid, and that acid is the one who destroyed the enamel future.

00:33:24.740 So that's the cycle. So that suggests that they're metabolizing

00:33:29.040 sugar anaerobically to produce lactate. If they're increasing the acidity of the environment,

00:33:34.780 presumably hydrogen ion is coming out with lactate, they're doing this not in mitochondria.

00:33:41.520 They're doing this outside of mitochondria. This is almost like the Warburg effect,

00:33:46.180 where whether oxygen is present or not, they always choose anaerobic metabolism. Do we know

00:33:51.160 if that's been looked at? Probably yes, but I don't remember.

00:33:55.240 And also, you say sugar, but I just want to be clear. Do these bacteria have a preference for

00:34:02.080 glucose over fructose? Obviously, sucrose is both. It's an equal mix of them. But I want to get very

00:34:07.820 specific on this point. Is fructose specifically more harmful? Because if that's true, then sucrose

00:34:16.360 would be more damaging than, say, starch, which would just be pure glucose.

00:34:20.720 I think the glucose is the worst, especially when they do syrup, when they intensify with

00:34:29.560 higher concentrations of sugar. But technically, all of them can be metabolized. Even the fructose

00:34:37.480 from fruits, they can metabolize that as well. Do you have a sense of how our species survived

00:34:44.000 before we brushed our teeth? How they survived?

00:34:47.780 Right. Yeah. I mean, when you think about it today, if after two weeks of twins not flossing

00:34:55.420 their teeth, nevermind not brushing, just two weeks of not flossing, you're able to induce

00:35:01.900 significant periodontal disease where you actually had gingival disease that would induce bleeding in

00:35:08.600 the gums. And now let's go back in time 300 years, which our species looked the exact same as we do 300

00:35:15.340 years ago. It's not like we're talking Neanderthals. But presumably 300 years ago, we didn't have

00:35:20.700 toothbrushes and dental floss, did we? Do we know what oral care consisted of 300 or 400 years ago?

00:35:27.540 Well, we know that 400 years ago, we see from research that people have their dental disease,

00:35:35.620 they have dental care. This is not new. But if I look at populations from developing countries,

00:35:42.880 for example, I go to Africa, and I do a lot of research there, they have like some plants,

00:35:48.960 they have like a stick that they use, and they clean their teeth with that tree that they find. So

00:35:56.040 I'm assuming that people just use different devices to clean their teeth. Because if you think about

00:36:02.960 removal of flap is mechanical, the bright meat, you need to just drop the biofilm. What we do with

00:36:09.240 brushing, we're just trying to disrupt that matrix of the biofilm. But they form again,

00:36:14.200 research shows that you clean, you can have the mouth with zero plaque in two hours, you have them

00:36:20.340 all formed again, they colonize back. But what we're trying to do with the brushing is just

00:36:25.220 disrupting that we don't let that accumulate and be like overwhelmed in the other cavity.

00:36:31.060 Yeah, I would assume that the food consumed somehow, even though obviously people hundreds

00:36:38.160 of years ago still consumed glucose and fructose, maybe the form in which they consumed it was less

00:36:43.280 concentrated and refined, which I suppose we know it was. And so they had less of an insult to the

00:36:49.060 tooth. Every time I've had a bad dental pain, I've said to myself, how would I be functioning right

00:36:55.760 now if this was hundreds of years ago and I didn't have modern medicine with lidocaine and a very good

00:37:03.500 dentist who could take care of this? Again, I want to go back to this point earlier. It is the single

00:37:08.760 most uncomfortable pain imaginable. It's horrible.

00:37:12.640 To have palpitus or any of these things, you can't function.

00:37:17.140 And highly preventable.

00:37:18.920 Well, yes. Yeah. We'll certainly get to that. But again, I'm just constantly amazed that our

00:37:23.920 species would have had to presumably suffer quite a bit until we figured out this ability to clean 0.84

00:37:29.440 these things. Because it's counterintuitive, I think. Now it seems obvious, but if you're sitting

00:37:36.020 in a cave 10,000 years ago, I don't know that it would have been the most obvious thing that you need

00:37:41.040 to remove this thin film biolayer on your teeth. Yeah. But I think the diet fibers, everything was

00:37:48.360 very different back there today with the modernization and the amount of sugar everywhere

00:37:54.280 that you look. Sometimes you can't even buy anything because everything has sugar. I think

00:37:59.660 it's a big change on the culture and what we eat, how we do things today. I think it's much worse.

00:38:07.020 So let's talk about the brushing. I once heard somebody say that the toothpaste is far less

00:38:12.680 important than the toothbrush. In other words, you could almost brush your teeth without toothpaste,

00:38:18.100 but if you did a good enough job just using a wet brush to brush, you were getting most of the

00:38:24.500 benefit. Is that true? I tend to disagree. I think both are equally important. And I'll tell why,

00:38:31.860 because the toothpaste is the main source of fluorite. So the fluor protects your teeth and harden the

00:38:39.660 memo and protects against cavity, especially in children. It's extremely important that children

00:38:45.500 get exposed to fluorite. If they have high risk of care, there is other sources. You can paint,

00:38:51.580 you can have varnish, you have a bunch of approaches that you can preserve oral health in children just

00:38:57.960 by brushing and fluorite. It's all about education. So, and the flossing is a combination. You have to

00:39:05.560 clean in between your teeth. You have to clean the surface of your teeth and you need to put fluorite.

00:39:10.860 And I'll tell you more. Now on my new clinical trial, I'm actually brushing the oral mucosa to

00:39:17.280 decontaminate against bacteria. So I still think that is another neglected surface of the oral cavity,

00:39:23.520 which is all the oral mucosa, the tongue. Most people don't brush the tongue and there's a lot of

00:39:28.800 bacteria that accumulates in the tongue. You need to clean every single surface and just the brush itself

00:39:35.140 is not going to do the job. When you say brushing the tongue, is the purpose to remove bacteria?

00:39:42.040 Yeah. Okay. And what about the rest of the oral mucosa? Do you mean brushing the gums as well?

00:39:47.960 Technically, that's not standard of care. So the way research has done and proved that you can

00:39:54.520 maintain optimal oral health just by brushing teeth, by flossing really well and having good nutrition

00:40:03.260 and all those things. Of course, there are phases in your life where, like in the specific case of

00:40:10.160 my population, they're undergoing radiation oncology. They have a lot of ulcers in their mouth

00:40:15.260 and they can't drink, they can't eat, or they cannot brush their teeth because it's so painful

00:40:21.600 because of all the ulcers. And then there is a whole just the ozone that occurs in the oral cavity

00:40:27.220 on top of this has radiation and a bunch of things. So on that specific population, they need a more

00:40:33.860 intense oral care program where we clean the periodontum, we clean the teeth, and we're

00:40:40.180 contaminating and brushing the oral mucosa. So it depends. It depends on the risks. It depends on the

00:40:46.800 population that you're treating. It depends on their ability to brush. Every oral hygiene program, I think,

00:40:54.480 needs to be personalized to the person, to the age, to the risks that they have if they have dry mouth,

00:41:03.280 if they have different diseases that affect the oral cavity. So it's a holistic approach that not

00:41:08.800 one regime would fit for. Is the importance of flossing the mechanical removal of food particles

00:41:17.700 between the teeth? Or is it the actual transient irritation of the gum that actually provides the

00:41:25.600 benefit? Because you can imagine a thought experiment where a person subsided on an all-liquid

00:41:31.700 diet, so there would never be food particles that are between the teeth, but where they might still

00:41:38.400 benefit from flossing, or more directly, they might still experience a harm from not flossing.

00:41:44.700 At least that's my hypothesis, which would suggest that the benefit of flossing is not just the

00:41:50.700 actual removal of the gross, large particle, but it's the transient irritation that's created

00:41:57.560 at the gum surface. Do you have a point of view on that?

00:42:01.680 There have been research on that. Some people on the opposite direction, that if you floss,

00:42:09.920 for example, someone who is immune-compromised, you might see nurses or doctors saying, don't floss.

00:42:18.320 Yeah, what about non-immune-compromised people?

00:42:20.880 I don't think that it's any harm on flossing. It might give you more resistance to those constant

00:42:27.380 exposure to bacteria, but mainly is to clean that anaerobic bacteria that it's really hiding in

00:42:36.500 between your teeth. So that's the main function of flossing. And the brushing, if you think about

00:42:41.620 brushing, it also stimulates the gum. The gum is not different from any other muscle or in your body

00:42:47.860 because it needs to be really strong and attached around your teeth. So the brushing as well, it helps

00:42:54.700 a lot with that dynamic constant because it massages all your gums, your periodontum, and I believe that

00:43:02.340 it's a good benefit as well. Is there a benefit or a rationale to flossing before brushing?

00:43:08.740 Which for some reason is the way I've always done it. I don't know why.

00:43:11.980 Yes, I love that because that's usually how we recommend. Actually, I ask them, you brush,

00:43:18.720 you floss, and you brush again if you want to be perfect. Because when you brush, you remove all the

00:43:26.220 biofilm of the bacteria on your surface of your teeth, and you need to rinse your mouth well to

00:43:31.900 just get everything out. And then you floss. But imagine if you floss, and then you throw in all

00:43:37.540 that bacteria back in the outer cavity, that might populate and recolonize again. So that's why I say

00:43:43.420 you just brush, you floss. We either rinse your mouth really well after that, or you just quick brush

00:43:50.240 again. That would be the way if you want to be obsessed. And then you need to brush your tongue

00:43:54.660 because bacteria, even the ones that you're flossing and throwing inside the mouth, they

00:44:00.140 might just colonize the tongue as well. Some people have fissures on their tongue and then

00:44:05.880 allows them to get in. When we do studies, and I collect bacteria, for example, swabs from different

00:44:14.120 parts of the mouth, every study that we do, we collect that. Buckle left, buckle right, tongue,

00:44:20.940 floor of mouth, throat, every surface of your mouth, you find different bacteria. So your tongue has a

00:44:29.060 different colonization from your buckle, from the floor of mouth, from the throat. Throat, we know,

00:44:35.420 colonized by bacteria and virus, the HPV virus. It's highly associated with oropharyngeal cancer. So

00:44:43.060 all those variations, they do different things. But you don't recommend also brushing the buccal

00:44:51.140 surfaces or other surfaces if they're also a great source of bacteria? I don't think I can recommend

00:44:58.060 because it's not a standard of care. So everything that you recommend, for example, the trial that I'm

00:45:03.960 doing right now, I'm implementing an oral care that doesn't exist. So no one tells people,

00:45:11.920 patients, when they're going radiation treatment, that they need to see a periodontist and do a

00:45:17.220 periodontal treatment every week. That's how intense it is. They come, we do the whole debridement of

00:45:22.180 the periodontal, we clean the oral coals, we clean the teeth. That doesn't exist. And if you ask a

00:45:26.740 dentist, they're going to say, why I need to do that? And that type of procedure as well is not

00:45:32.200 insured. So if you've got a patient who's undergoing radiation treatment, they can get speech

00:45:38.980 pathology. They go to see the oncologist, they go to see their nutrition. This is all part of the

00:45:43.740 healthcare system. And this is all they can charge to the insurance or Medicaid, Medicaid. Oral health

00:45:50.520 is not part of that. And I want that to be part of a magically compromised patient that same way that

00:45:57.940 they need to see a nutrition, they need to see our health specialists, because that's going to help

00:46:03.320 them respond to the cancer treatment. They're not going to have the burden of infection, inflammation

00:46:08.440 in their mouth. And of course, they're going to perform better. They're going to eat better, because

00:46:12.880 if they have ulcers, they're not going to be able to eat. So there's a whole benefit around that. But

00:46:19.140 there is no insurance would pay. And that is not a standard of care procedure. So I'm doing the

00:46:25.380 research, I'm collecting all those biomarkers. And I want to prove the benefit of that. And once I prove

00:46:31.640 the benefit of that, because now I did a clinical trial, I might be able to push and get all the

00:46:37.560 centers and other people to do it. And that might become a standard of care for this specific population.

00:46:44.140 Now, is there evidence that cancer patients, because of two things, their immune compromise

00:46:50.640 through treatment, coupled with the increased susceptibility and the loss of immune barrier in the

00:46:59.000 mouth are actually at greater risk of systemic infections that arise from the mouth?

00:47:05.460 Yes, there's a lot of research on that. And that's what I believe as well. And when they're going on top

00:47:12.280 of everything that is going on with them, they have horrible dry mouth. Week two or three, some patients

00:47:18.560 cannot produce saliva anymore, because the radiation damage the salivary glands. And that's changed the

00:47:25.660 whole oral microbiome allows opportunist organisms to prevail. So they have a lot of fungal infection

00:47:32.760 because of the issues that they have with dry mouth. And that escalates a lot of local infection

00:47:40.920 and inflammation in the oral cavity and affects them systemically, because I don't have data from

00:47:47.040 the trial that I'm doing right now. But the reason I'm doing is that on my small pilot that I did to lead to this large

00:47:55.660 trial that I'm doing now, I saw that main inflammatory markers, I look at saliva, inflammatory markers and

00:48:03.500 microbiome before they started the trial and three months after they completed the last dose of radiation.

00:48:13.500 And then when I look at cytokines, I sampled several cytokines in saliva, most of them, they're completely

00:48:20.440 suppressed on the oral cavity. They're all cancer patients. But the group that I didn't do the

00:48:26.480 periodontal disease, they all had even increased on those. But the ones that I did, this is very

00:48:32.540 comprehensive. They're all gone, suppressed on the negative. So it's clearly showing that that's

00:48:38.880 something going on systemically on those patients. That is just because I'm brushing your teeth.

00:48:45.080 And the way my study started, that's why I always say that it makes me so happy when I'm discussing

00:48:51.800 auto health with MD, like you, the smart that understands a lot about those things, is that

00:48:59.180 I started my life when I was at NYU, and I used to work with all the radiation college and all the 0.93

00:49:06.840 surgeons that were doing surgeries on the patient. So they had diagnosed the cancer. And because I was

00:49:12.440 doing research, I would go to the OR, collect the samples and take over the patients throughout the

00:49:18.240 whole research, when they're looking for oral cancers and all those things. And I started looking

00:49:23.320 at those patients' mouths and said, I can't believe that that is not a single doctor who is looking at

00:49:28.260 their mouth. They have horrible oral hygiene. They got the cancer, they're depressed. They start

00:49:34.440 radiation right after surgery, which they already can't brush their teeth because sometimes they lose

00:49:40.220 half of their jaw, they take their tongue. So they're highly debilitated. So they stop brushing and

00:49:45.840 they go into radiation. When they get into radiation, then comes with RT. The radiation also

00:49:51.480 changes the microbiome and they develop horrible ulcers in their mouth. And then they become immune

00:49:57.380 compromised. And so it's a whole cascade of things that happen in those patients. And then I started,

00:50:03.860 one of them, I came to the oral surgery and I said, do you mind if I start cleaning your patient's mouth?

00:50:10.920 And I said, why do you want to clean? And I said, well, I know he's going to go into radiation. Let me do

00:50:16.340 a dental cleaning. I can't look at anymore the way it is. And I said, Pat, do it, whatever you want to do it.

00:50:22.620 So I started doing my cleaning, periodontal disease. And after I treated, and they were going through

00:50:28.300 radiation, some of them, I'd say, well, I'm going to clean your mouth twice a week. Radiation is

00:50:35.160 usually six to eight weeks. So if I clean your mouth every two weeks, at least you're going to get

00:50:41.520 a baseline, middle of radiation and end. And others would say, well, if he's not responding really

00:50:47.980 well, I always just start training, say, what can I do to get a good oral health? Others, I start

00:50:54.540 every week. And then after I treated like 10 patients, I got a call in my office with the, he was

00:51:01.160 the head. His name is Nico Sanfilippo. He was the head of the head and neck crew. And I said, Pat, I never

00:51:09.660 had talked to him, but he was the referrer from our patients because you have the cancer, you have the

00:51:16.880 surgery or not. And then radiation oncology is like a referral. So you need to find a radiation oncologist

00:51:23.100 that can see your patients. So he called me and said, Pat, can you tell me what you're doing with

00:51:27.460 my patients? And I was like scared because I knew that wasn't like a perfect, like standard of care.

00:51:34.720 And then he said, well, I have maybe eight patients that you treated and they don't develop

00:51:40.920 mucocytes and they're sitting on my waiting area and they're talking to each other. Well, I went to see

00:51:46.520 Pat, Pat is doing that, Pat is doing that. And then I said, can you tell me what you're doing?

00:51:51.740 And I said, Nick, you're going to laugh, but I'm brushing your teeth. Of course, it wasn't that

00:51:58.680 brushing, but it's oral hygiene. And he was going to say, Pat, can you do a pilot? I'm fascinated by

00:52:04.540 that. And then we did, we saw 16 patients. That's the pilot that I submitted and we got the grant,

00:52:11.680 but that was how everything started was him calling and say, what's going on?

00:52:17.460 Now, how in depth was the oral care you delivered to these patients? Is it the type of thing that

00:52:23.680 they could do for themselves if taught, or did it have to be done while they're sitting in a dental

00:52:29.240 chair and by someone who was highly trained? It's a combination. Actually on the current trial,

00:52:36.360 I'm trying both approaches. If I can just give a baseline to me, because if someone has a lot of

00:52:44.920 plaque for a long period of time and you haven't brushed for six months, for example, the plaque

00:52:51.920 becomes harder and becomes torturous. No one can remove that unless we have a very specific

00:52:58.280 ultrasound that vibrates. It's an instrumentation and it's very hard.

00:53:02.300 That's what we do every six months when we go and get our dental cleaning.

00:53:05.800 Yeah. They either scrape your teeth with very sharp instruments or they use the

00:53:10.660 electronic one to disrupt and take your plaque. So at a minimal, you have to do once in a dental

00:53:17.820 office, but in my trial, I'm doing both because I don't know which one is better. Nobody ever did

00:53:24.180 before. So one group I'm doing mechanical debridement as a periodontist. It's the same. Even I go

00:53:31.120 subjunctible. I'm trying to flush every toxins that I have sitting on the oral mucosa, inside their gums,

00:53:41.000 on the gums, on the tongue. I brush and floss. There is not a single surface on the outer cavity that you don't

00:53:47.240 clean. How long does that take?

00:53:49.600 It takes one hour on the chair. The other group, we give them a dental hygienist come every week.

00:53:57.280 She reinforced the importance of brushing, flossing, and she flosses the patient's mouth, 0.90

00:54:06.080 tell them how to properly do that. So it's just to blind the study. They both come to the clinic.

00:54:11.560 They didn't have to talk because it's just a brush, but we want to blind. So both groups come to the 0.99

00:54:16.660 chair and the hygienist does a light cleaning, flossing only, and brushing, or she does this

00:54:23.480 holistic, comprehensive approach that I put together, which is something that is striking

00:54:29.960 going on right now. My patients in either group, they're not devouring the disease.

00:54:35.280 Just to make sure I understand, how many of these patients are patients with head and neck cancer

00:54:39.580 where they're either directly receiving radiation to the mouth or this area, which is resulting in

00:54:46.460 the deterioration of the environment versus patients with other cancers whose chemotherapies

00:54:52.480 are rendering them susceptible due to the mouth sores that are pretty common with chemotherapy

00:54:58.240 coupled with the anticholinergics that can dry the mouth out?

00:55:02.940 On my population, because I wanted to do a more controlled clinical trial, they're all head and neck

00:55:08.600 cancer scheduled to undergo radiation. The head and neck cancer can be different areas of the head and neck,

00:55:16.080 but I have a very strict inclusion criteria that at a minimum 50 grades of radiation needs to be

00:55:23.620 delivered to the oral cavity due to the cancer. Because I know that in this particular condition,

00:55:30.860 90% of them will develop myocytes. And this is male and female?

00:55:36.260 Male, female. And we have RT only, and we have combined treatment. RT plus chemo, 100% get myocytes.

00:55:45.100 There's not a single patient. If you have a combined program, regime like that, it's very aggressive.

00:55:51.440 They all, and then on top of that, they get immune compromised.

00:55:54.660 But these are mostly squamous cell, not lymphomas and head and neck lymphomas, correct? This is

00:55:59.800 mostly squamous cell. Yeah. And how many of these patients are HPV positive?

00:56:04.760 Probably 90% of them. Oropharyngeal. Oral cancer, it's very low incidence, which is known by research

00:56:12.880 as only the oropharyngeal cancer that has been linked to the HPV. Most of them are HPV positive.

00:56:19.720 This is an interesting epidemic that's getting very little attention, and I don't know why,

00:56:24.760 but I think these HPV-driven squamous cell carcinomas of the oropharyngeal region really

00:56:32.060 frighten me because we don't have really adequate ways to screen for them the way we can screen for

00:56:37.140 HPV cancers of the pelvis in women. Unless people are doing very advanced imaging like MRIs,

00:56:44.580 they're often caught quite late. What do you think accounts for the rise in incidents we're

00:56:49.320 seeing of this cancer? I mean, it's obvious that it's the HPV, but is it just sexual transmission?

00:56:54.800 Yeah.

00:56:54.980 Why are we seeing?

00:56:56.120 It is sexual transmission. So we're wearing condoms. It's oral sex. We know today that 0.99

00:57:01.960 it's sexual transmission. Of course, combined with poor oral health, they might cause disease or not,

00:57:08.500 because we know there are several clodontal bacteria. They have a very symbiotic relationship.

00:57:14.440 They allow virus to grow. Like the p-gingivales, there are several studies that show that

00:57:19.780 they can allow other virus to grow. Immune system deficiency as well. We know that every time that

00:57:28.020 the immune system is not strong, allows virus and bacteria, fungal infection to grow. But it's just

00:57:35.760 you need to modify habits so you can prevent. I want to go deeper into this, but before we do,

00:57:41.380 I want to actually go back to some of the more mundane stuff, the blocking and tackling of dentistry,

00:57:46.280 and talk about caries again, and what the stages of caries look like, when the tooth can be preserved.

00:57:54.420 So when you're just replacing a little bit of enamel, and then what that next layer of damage

00:58:00.220 looks like that ultimately leads to a root canal, presumably once the pulp is irreversibly damaged.

00:58:05.820 And then ultimately, when even that can't be reserved and a crown is no longer sufficient and

00:58:11.480 you have to replace the whole tooth. I know you have some nice figures on that. Can we kind of go

00:58:16.040 through those different stages of dental care? Because I think it is important to see these

00:58:21.520 images. It certainly helps me understand what's going on. Give me one second. Can you see the image?

00:58:29.240 Perfect. So technically, the first initial stage of dental decay is the one that breaks through the

00:58:39.300 mammal. They're very incipient decays. They haven't got to the second layer of the tooth. And those are

00:58:48.060 the ones, some of them, even like if we call white spot lesion, you start the decalcification,

00:58:54.720 they can be reversed. If you have a child, you can have a very intense fluoride

00:58:59.900 varnish application, it would reverse. So most of those very incipient lesions, we shouldn't be

00:59:06.840 touching or tweak. And to be clear, is this the type of thing where the dentist will use a little

00:59:13.060 probe and say it's a little bit soft there, but I think it's okay, or it's a shadow on the tooth?

00:59:19.260 Yeah, there are like some controversy on that. In the past, they would have that very pointy probe,

00:59:26.160 and they would poke and do inspection. Today, most people, they would clean and they look with air,

00:59:32.540 because you don't want to break the enamel more yet. Because if the enamel is already with loss of

00:59:38.900 minerals, you don't want to be poking. So you need to be very careful when it's a very superficial

00:59:44.380 case like that, because you might want to restore in a different way. But this is not painful. The

00:59:50.820 enamel carries have come nowhere near the pulp, so no one feels anything. There's no cold insensitivity

00:59:56.620 or heat insensitivity. Very, very minimal. Most people, they just don't even know it's there.

01:00:03.220 And then when it gets close, the more it gets close to the pulp, because it has so many nerves,

01:00:08.320 the more painful it's going to be. The dentine now is very soft. So it's more like a sponge that

01:00:15.680 it's there with very rich inside. So the moment it hits the dentine, it's painful. So that's when

01:00:22.560 you're going to start feeling like you get something cold and say, something's different,

01:00:28.060 my tooth. Hot is more signs of inflammation. If you feel the hot surfaces, things that you put in

01:00:35.080 your mouth, or when it gets infected and the bacteria can come to that hole and start colonizing,

01:00:43.080 then it starts the inflammation and it's that pulsation that you feel. And the pain now doesn't

01:00:49.020 stop. Before you get to full-blown pain, when you're just dealing with temperature insensitivity,

01:00:55.060 is there anything that can be gleaned clinically between the cold versus the hot insensitivity versus

01:01:02.360 both? I'm not an endodontist expert, but most tests that they do to look for inflammation and

01:01:10.880 infection, when you have more of that hot sensation that is painful, you know that you most

01:01:18.620 likely might need to do the root canal because it's highly infected, inflamed. The cold, it's a

01:01:24.580 little bit better because it's not in more advanced stage. And then when you go, if the decay progresses,

01:01:33.120 that's when you see on this other two figures is that it hits the pulp. The moment it hits the pulp,

01:01:40.120 there is no way you can not do the root canal because now everything's already infected. And most root

01:01:46.200 canals are done when the pulp is still alive. They just excise the pulp and clean and disinfect.

01:01:54.280 So it's not from a dead tissue that has been there for a long time because it's hard to keep up with

01:02:00.900 the pain. But just to be clear, the dentin carry can be fixed without a root canal. Yes. If it is not

01:02:08.560 as close to the pulp that got to the point that is infected and broke through, you can restore.

01:02:15.580 So this is my own personal misery. Both root canals I've had were from what I now believe

01:02:23.260 were dentin carries. The first one was actually a dentist that wanted to change an old filling

01:02:28.500 that I had from when I was a child. So I had an old mercury filling from when I was a kid. And

01:02:34.160 fast forward 20 years, he said, you know, your insurance will cover the changing of this to a

01:02:40.320 white filling. We should just change this out. Keep in mind for 20 years, I had no complaint of this

01:02:46.800 filling whatsoever. And the moment he changed that mercury filling over to a white one in the process

01:02:53.840 of mucking around, that tooth started really hurting. And over the next couple of weeks, the pain

01:02:58.880 got worse and worse and worse. And ultimately I needed a root canal on that tooth. So needless to

01:03:04.740 say, I was very unhappy about that. Let sleeping dogs lie. The next one I had was the same thing,

01:03:12.840 was another filling that the dentist thought in this case, hey, I think there's another little carry

01:03:19.040 next to it. It should be an easy fix. And it actually was on a wisdom tooth, but my mouth seems to be big

01:03:25.360 enough that I'm able to tolerate having all my wisdom teeth. So he said, look, we can do a root

01:03:30.300 canal on a, or sorry, this was before we needed the root canal. This was just, hey, we'll just

01:03:34.040 fix the carry there. But same thing, it ended up hurting and hurting and hurting. So they ended up

01:03:38.740 doing the root canal. I still have that tooth with a, they didn't even put a crown on that one

01:03:43.460 actually, which is amazing on a wisdom tooth, not to have a crown, I assume. So you said something

01:03:48.260 very interesting that's counterintuitive, I suppose, which is most times you do a root canal,

01:03:51.800 the pulp is actually alive, but you still have to remove it all. I mean, once they anesthetize you,

01:03:57.100 they kill all that pulp. So the process is remarkably crude. They're using these little

01:04:03.220 fine, I don't know what you want to call them. They're almost like needles, but they're a bit

01:04:07.600 bigger and they're sort of serrated. I remember wanting to play with these things after I had my

01:04:12.540 root canal, but it's like these little, you wind these little serrated, jagged tools into the end of

01:04:20.060 the root. It's basically a very mechanical procedure. It is, but today they're very

01:04:25.020 sophisticated. They do all microscopically. I think in the past they had a lot of the issues

01:04:32.680 from a hundred years ago is because we're not sophisticated enough. So they would put those

01:04:37.780 fine things and they would break through the roots because they couldn't see well. And they

01:04:43.700 cause immediately like the inflammation, the reaction, because you're just perforating

01:04:49.360 everything. But today, if you look today, how they treat periodontal disease, it's a microscopic

01:04:54.120 surgery. So they just put the tooth under the microscope. They're completely a septic environment

01:05:00.760 because they put those rubber bands and to isolate, to not let the bacteria from the aracharya

01:05:06.700 to get inside. And they do the whole excision of the pulp. They disinfect everything and they fill in

01:05:12.980 with special materials to just fill the hole. It becomes like just a cast, the tooth, because there

01:05:19.980 is no more vitality on that tooth, but yet preserves function, which is extremely important. That's why

01:05:28.040 you shouldn't be extracting all the teeth unless you really need it because it's not, even the

01:05:34.120 implants is better than your, even without having a root canal is not better than your natural tooth.

01:05:39.760 Yeah. I mean, I think that's probably one takeaway here, which is, and I want to talk about the

01:05:45.240 concerns that people have around root canals because it seems to be one of these very

01:05:49.320 controversial topics in some small circles. But if you're going to have a root canal, it seems to me

01:05:55.160 that you have to have this done under a microscope by an endodontist. I just think the days of freewheeling

01:06:00.360 root canals where a dentist is looking through his or her regular glasses and ramming these things

01:06:06.020 through just doesn't make any sense. And I know that both of my root canals were done

01:06:10.200 initially in that way. Ultimately, both of them needed to be corrected by endodontists who did it

01:06:16.400 with microscopes in a much more aseptic fashion. Ultimately, one of them ended up developing an

01:06:22.900 abscess many years later. That tooth needed to be extracted, which by the way, after that tooth was

01:06:27.820 extracted, I was relieved of so much pain that I decided in a temporary moment of insanity,

01:06:33.740 I wanted to, in that moment, have all of my teeth extracted and replaced by implants so I could

01:06:39.280 never deal with this again. Of course, that's an idiotic. No. Yeah, yeah, yeah. No. So let's talk

01:06:45.380 about the controversy around root canals, notwithstanding the discomfort of them and things

01:06:49.700 like that. Basically, the controversies are root canals are a dangerous procedure and they lead to

01:06:55.740 kind of fill in the blank. And fill in the blank is, I've heard everything, right? I've heard people say,

01:07:00.280 root canals cause cancer, they cause Alzheimer's disease, they cause sore toes, you name it.

01:07:05.920 What is the state of evidence about the safety of root canals or frankly, the state of evidence

01:07:11.880 that root canals are indeed potentially hazardous? It's hard to say in a nice way,

01:07:18.980 but I think it's a total nonsense. It's been for, it's a hundred years ago that all those focal

01:07:27.240 theories that they said that would exist, there is zero evidence, there is no research, there is

01:07:35.360 nothing that can prove that this is true. If you think about, I was even the other day talking to one

01:07:42.580 of my faculty, because I said, I'm not a endodontist. So I've done root canals, but it was a long time

01:07:49.320 ago, but I was asking him, what do you think about this? And he said the same thing, in fact, there's

01:07:54.840 no common sense on what's going on, is that focal point of infection. But what he said is that if you

01:08:01.120 think about the most root canals, the way they start, it's through the crowns and the same bacteria

01:08:08.900 that colonize your tooth goes inside the pulp and then comes and goes inside the root. And that's

01:08:15.600 the infection that we're saying that it's causing all those infections, but this is all in your body

01:08:21.340 already. And if that's the case, every time that you have a dental case, you need to extract the tooth

01:08:26.820 because it's all the same route of infection. So when I think about all those things and talking to

01:08:33.420 them, I said, this makes no sense. There's no way you can explain that. And again, I still think if

01:08:39.600 it is well done, of course, there are a lot of root canals out there that people don't know what

01:08:45.000 they're doing. They don't clean well. They leave things behind or they perforate. And we see how many

01:08:52.780 radiographs we take and we see a focal infection on the tooth, but that's because it's malpractice or

01:08:58.980 someone, or not even they couldn't see well to do a proper way. But in today, most root canals,

01:09:06.120 if you walk in the clinic today, they're all under a microscope and I can guarantee it's really well

01:09:12.660 done, the process. And people don't have issues after that if it is well done.

01:09:17.200 Yeah. I mean, I guess the question is, even in the cases of root canals, which were not done

01:09:22.400 ideally, such as mine, beyond the local complication, which is the need for subsequent root

01:09:28.780 canals, ultimately the need for even an extraction, does that pose a systemic risk,

01:09:36.000 even when it's done poorly?

01:09:38.020 I don't believe so. Most have localized. There are a few surgeries that they do and they open

01:09:44.760 through the gum and they clean that area and you see that improve. With this root canal,

01:09:50.300 for example, there's another paper who's saying that people with root canal have breast cancer,

01:09:56.700 for example. But then they look at a hundred of women that didn't have root canal and also had 1.00

01:10:02.300 breast cancer. Yeah. These epidemiologic sort of, I call them bottom of the birdcage papers,

01:10:08.820 because that's about what they're good for. They're the papers that say, well, if you look at the number

01:10:14.480 of women who have had a root canal on the same side that they get breast cancer, it demonstrates

01:10:20.920 the relationship. But these papers always fail to look at the numerator, which is all the women 1.00

01:10:26.740 who develop breast cancer who did not have root canals. Yeah. So it's true, true, and unrelated.

01:10:32.120 And it's unfortunate because I think what bothers me the most about this type of pseudoscience is when

01:10:38.480 a woman gets breast cancer, it's already upsetting enough. I think the last thing she needs to be told 1.00

01:10:43.700 is this is because you had a root canal five years ago. That's probably the biggest issue I take with

01:10:48.040 this sort of nonsensical science. And unfortunately it tends to aggregate from the same group of people

01:10:55.440 who tend to have other beliefs that are very unsubstantiated, such as vaccines causing autism

01:11:00.640 and things like that. So there tends to be kind of a core group of beliefs like that. So let's go back

01:11:08.160 a bit to the kind of broader theme of these systemic diseases. When you think about major chronic

01:11:15.600 diseases, is it safe to say that the greatest causal relationship we have between poor oral health

01:11:25.500 and poor systemic health would be with cardiovascular disease? Or do you think there are, first of all,

01:11:31.720 how strong do you think that relationship is causally and how does it compare to others?

01:11:35.420 There is a lot of research showing association. We don't know what comes first. So they show the

01:11:44.600 relationship that's proven with periodontal disease and diabetes, periodontal disease in low birth

01:11:51.040 weight, periodontal disease and heart. That is the hypothesis, of course, it's all based on the

01:11:56.820 insult of the bacteria causing inflammation and systemic health. We know that. And other things,

01:12:04.020 Alzheimer's, for example, amyloid in the brain and a few studies that we did showed markers as well,

01:12:12.120 periodontal disease and markers of Alzheimer's. So they're all associations, but the only way you can

01:12:19.160 say casuality is if you do a clinical trial. You need to treat those patients and see changes on those

01:12:26.160 markers. And then you say, see, I changed their behavior. They're brushing their teeth. Now look how

01:12:30.940 better they became. So we need to do those things. We have a group of people that I work with

01:12:35.140 from NYU since I was at NYU. Moni de Leon is his name. And Dr. Kamer. She's been for over 10 years

01:12:43.720 trying to make the point. She has all those papers. She saw, for example, children that have

01:12:49.980 motor skills or I think she, her study was in, I just blinked here now the name of the disease,

01:12:58.040 but we found in children that they have amyloid beta, amyloid in the brains accumulation. And we

01:13:05.700 know this population has very poor oral health. They have periodontitis and six years old, it's

01:13:12.600 Down syndrome. So the first study that she looked, it was Down syndrome. So we know because they have

01:13:19.300 motor skills, they have cognition issues. It's a very hard to brush and to have mundane and good oral hygiene.

01:13:27.100 So that's interesting. So because we know that children with Down syndrome are very susceptible

01:13:32.640 to Alzheimer's disease and cardiovascular disease. In fact, people with Down syndrome usually do not

01:13:38.060 live a normal lifespan and they usually succumb to these chronic conditions much sooner as early as

01:13:46.280 in their forties or fifties. So you're saying that, well, again, it's hard to know if the increase

01:13:52.120 that she sees in amyloid is an independent process that's being driven by the chromosomal abnormalities

01:13:59.500 that are found in Down syndrome versus related to the poor oral care, which could be true, true,

01:14:06.240 and unrelated. It could be that they have poor oral care because they don't have the life skills

01:14:10.820 developed to provide oral care. So an interesting experiment would be a longitudinal study of two

01:14:16.860 groups of peers with Down syndrome, one that are provided intensive support for oral care and one

01:14:22.860 that are sort of standard of care. But again, those are very difficult studies to do because they're

01:14:27.680 very time consuming. Well, they are, but it's all about prevention. How about if you intensify a very

01:14:35.760 intense preventive approach so you don't let that child be with caries and periodontal disease and pain

01:14:43.680 inflammation and inflammation and all of that? It's not only that disease, it's any people with

01:14:49.680 disability. So like we just opened at Penn right now because the dean's visionary. He's really focused

01:14:59.640 on prevention. He opens a center for people with disabilities. So any person who has any moral 1.00

01:15:07.580 skills or have any disease that impacts cognition, we're going to create this program that we can

01:15:14.040 do a lot of research. How is the best way of cleaning? Toothpaste, toothbrushes, what can intensify

01:15:20.560 in this population? Which through caregivers, it's a whole educational process because it's not them.

01:15:26.660 We need to educate people who are taking care of those individuals to do an optimal oral hygiene.

01:15:34.360 It's simple as that. Can we just brush, brush, brush, fluoride, intensify? Because you can prevent.

01:15:41.160 All those things are highly preventable. But I was looking for, say, what are we going to measure?

01:15:47.500 There is no outcome assessment that you can use for this specific population because

01:15:52.300 they're so neglected. But going back to your earlier point, just to make sure I understood,

01:15:57.980 did you say that if you took two groups of people and one group received excellent oral care,

01:16:04.180 and the other group did not, and this is not in cancer patients, let's just say patients who are

01:16:09.580 not immune compromised and whose oral mucosa is not compromised. So if this hasn't been done,

01:16:15.000 consider it a thought experiment. One group receives best-in-class oral care, which I want to come back

01:16:20.400 and define. The other group receives horrible oral care or mediocre at best. Would you expect to see a

01:16:28.000 difference in inflammatory markers including cytokines and inflammatory cells, macrophage monocyte-derived

01:16:37.860 lineage cells across those two groups? Because if that's true, that alone could explain the increase

01:16:46.820 in systemic disease. In other words, that could be a causal factor. It's undeniably well-established,

01:16:52.940 the relationship between inflammation and cardiovascular disease. You could take two

01:16:57.400 people that have virtually an identical profile of lipoproteins, but in one group, the high amount

01:17:03.660 of inflammation will lead to a greater burden of disease than in the other. Inflammation plays an

01:17:08.780 important role in cancer, and certainly inflammation plays an important role in Alzheimer's disease.

01:17:14.460 So that to me seems, that's the Occam's razor approach here, which is poor oral health leads to poor

01:17:20.720 or substandard amounts of inflammatory environment, and that's the driver of these diseases. That would

01:17:26.280 be my guess. Yeah, it's very simple. But think about when did you ever go to a doctor? You are MD,

01:17:35.180 that the doctors ask you, how's your mouth? Do you have predontal disease? How do you brush your teeth?

01:17:41.860 Think about when. Sure, it's not at all part of the doctor's toolkit. Ever. So look what's going on

01:17:48.700 with COVID. COVID is an infectious disease. What is the transmission of COVID? Salive. It's the mouth.

01:17:57.420 Now there are papers coming up because the AC2 receptors, which is the COVID bind to enter the

01:18:03.900 body, they are highly expressed in the orthopathy. Look at the literature. They're in the tongue,

01:18:09.140 floor of mouth, the gingivocervicular fluid, they're everywhere in your mouth. So a patient gets COVID.

01:18:15.560 There are two things that I'm like, very like surprised and saying why people are not doing

01:18:21.060 anything. So people get COVID, they go to the hospital. The first thing that they do,

01:18:26.620 they put them on a mask. They never brush their teeth. They don't look if they have predontal disease,

01:18:31.540 how is the quality of the oral cavity. They put on the supinal position because they need to free up

01:18:36.660 the lungs. And that patient spends a month, some people more than that, in a very critical condition.

01:18:43.180 Do you think this is going to lead to pulmonary infection? Of course it will. If someone has

01:18:49.300 predontal disease and already have a lot of bacteria in pockets, all the predontal pocket is a perfect

01:18:56.120 reservoir for the virus to thrive. And even like the new, you know, if you saw, there is a publication

01:19:02.600 that just came out, only hypothesis because nobody ever tested, that it might be, if you look at the

01:19:08.780 characteristics of COVID, the way it manifests, the upper respiratory tract in terms of secretion,

01:19:16.120 how congested you have is very minimal. You might have a stuffed nose, but from the mouth goes directly

01:19:22.720 to the lungs. So there is a huge connection there. No one is doing anything to tell people,

01:19:30.120 can you brush your teeth? Do a mouthwash, clean your mouth. If you have COVID, you have to have

01:19:34.600 excellent. In the hospitals, give the nurses, you have to ask this patient to brush, to floss. No one

01:19:41.160 is doing that. Look at the committee. So of course now science is going back because our new president,

01:19:48.240 they have, they're very, they're fostering all those prevention masks and everything. Look at the

01:19:54.400 committee that we have, that has been put to support COVID. Is that any one of them is an oral expert?

01:20:03.460 I'm guessing not.

01:20:05.340 Or epidemiologist, an oral periodontist. Is there anyone there? If there are anyone there that

01:20:12.260 understands a little bit about the mouth, if you connect the mouth with the body, I can guarantee

01:20:17.940 that you can prevent. Look what's going on in Brazil, China. It's just ridiculous because there's

01:20:23.820 no prevention. The only prevention is the mask, which we could do something better.

01:20:28.320 Some argued that last year we saw a great increase in the rise of dental caries. Some suggested it

01:20:34.860 had to do with mask wearing. To me, it seems the most obvious explanation would be simply that people

01:20:40.500 sought less dental care last year. Do you have a point of view on, first of all, is it true that

01:20:45.680 dental caries went up last year?

01:20:47.720 So what happened, it's that we're still dealing with that, is that when COVID hit,

01:20:54.100 dentist was considered not essential. So they shut down everything that wasn't essential,

01:21:02.500 which healthcare and places that you can buy food and things like that. So dentist was left

01:21:08.820 behind. So dental clinics, I know because I had to suspend my clinical trial for three or four months.

01:21:17.140 I came back immediately the moment they allowed me to open the clinic, but dental clinics, they were

01:21:23.120 closed, completely closed for about almost a year. And on top of that, they suspended every single

01:21:30.180 type of procedure that produces a result because they thought that was a way of infecting people.

01:21:36.300 So people couldn't go to the dentist. You saw horrible things on the internet. We had left our emergency

01:21:42.640 clinic open only. And we saw really detrimental things because people couldn't get access to care.

01:21:50.320 So combined with, of course, putting masks. And if you're wearing a mask at work a whole day,

01:21:57.200 you forget to brush because you can't drink too much because you need to hide because you have to drink

01:22:03.140 water or eat. So everything is detrimental. You might breathe more through your mouth because the mask,

01:22:09.780 people don't know how to breathe well through the mask. So it dries your mouth. You have dry mouth

01:22:14.840 because you're breathing. So this combination of hygiene, you have dry mouth, you have a mask.

01:22:21.780 So it's not the mask that is causing anything, but it's just a cumulative effect of everything that is

01:22:28.620 going on. Yeah, that makes a ton of sense. You mentioned thrush earlier, right? So oral candida,

01:22:35.000 and you mentioned it in the obvious context of people who are immune compromised. But from time

01:22:40.040 to time, I've seen people with a totally normal immune system develop oral thrush. Now, I will say

01:22:46.800 there's usually something going on, like they're usually on an inhaled steroid for asthma or something

01:22:53.580 like that. So maybe that's partially explaining it. But do you have any other explanations for how a

01:22:59.320 person with a normal immune system could develop oral candida or thrush?

01:23:04.440 It's highly associated with candida infection. And it can be through, I think the primary reason

01:23:12.420 is lack of saliva, because your mouth is dry. So that's why MDs, they should look at their patients

01:23:20.340 and how much medication they have and ask the question, do you have dry mouth? They might have

01:23:26.260 in other complications that you don't even know why. But primarily, I would think it's poor oral

01:23:33.040 hygiene, because if you have neurodontal disease and poor oral hygiene, you're going to allow those

01:23:38.640 opportunistic species to grow. And medication, they don't have a specific cause, but mainly I would say

01:23:48.700 medication and poor oral health would allow virus to grow.

01:23:53.000 You mean fungus?

01:23:54.560 Fungal, yeah. I've said virus because virus and fungal, they work really well together. Like

01:24:00.780 people with HIV, they have episodes constant of fungal infection in their mouth.

01:24:08.080 So there are lots of reasons why people could have dry mouth. Certainly one of the most popular

01:24:12.620 classes of drugs that would do it are anticholinergics. It's also interesting, by the way, that there's

01:24:17.760 some strong associations between anticholinergics and Alzheimer's disease. It hasn't been demonstrated

01:24:23.960 whether that's causal, but if indeed anticholinergics, which lead to a very dry mouth, would increase

01:24:31.720 the, or rather decrease the resistance of the bacteria in the mouth to the systemic system,

01:24:37.900 and that could play a role. So it becomes very interesting. But for an individual who has dry mouth,

01:24:42.360 is there a downside in using sugarless chewing gum or lozenges or sort of having something in the

01:24:50.340 mouth to induce saliva? Is there a downside to that? Is that considered one of the effective

01:24:55.180 methods that someone can use to keep their mouth lubricated?

01:24:59.500 Yeah. I don't see any wrong doing that, but never use anything that it's sugar content. There are a lot

01:25:07.460 of sugar substitutes that you can do because you can stimulate the salivary glands and you're constant

01:25:13.460 moving your tongue and your mouth. And I always say hydration, it's extremely important as well.

01:25:20.160 If you don't like to drink, just get a sip water all day long. You're always washing the oil cavity,

01:25:27.980 the gastrointestinal tract, because it's all one system. It starts in the mouth and go to the bacteria.

01:25:34.420 They are all together. So always hydration and drinking water, I think it's very important for

01:25:40.880 auto health as well. Now, have you looked into xylitol specifically? I've seen some literature

01:25:47.980 to suggest that xylitol may actually not only not be harmful, because I think there are lots of things

01:25:53.260 out there that are not harmful, aspartame or any other things that might be thrown into gum that are

01:25:58.140 sugar substitutes, but that xylitol specifically could be beneficial. And so I've always kind of,

01:26:03.280 my practice has been to have some xylitol-based chewing gum that if I'm out and I eat, I can

01:26:09.860 chew it for a while to serve two purposes. One is get saliva there, but two, also kind of clean the

01:26:15.680 food out of teeth. Do you recommend anything like that? Because a person can't brush their teeth four

01:26:19.880 times a day, presumably. At some point, it becomes counterproductive.

01:26:23.220 Yeah, that's the one that I like the most. I actually did some research a long time ago,

01:26:28.920 where we are looking for mothers to child transmission of dental caries. We know that

01:26:35.140 as mutants can be highly transmissible for mothers to child. For different things like the mom who

01:26:42.440 proved the food and put it in the child's mouth. It's proven that you can transmit the

01:26:47.560 transmittance of the child. They've done some research about kissing in the mouth. They didn't

01:26:53.340 find a huge correlation, but they know that proving and tasting the food and which is, you should take a

01:27:01.040 look at nannies and people who are watching children. But I really like xylitol and we found that we

01:27:07.720 prevented the transmission because we gave the xylitol to the moms. During the gestation time,

01:27:13.960 we asked them to chew on xylitol just to prevent that vertical transmission of the mutants, that 0.55

01:27:20.660 strat mutants. And it prevents decay too, because the bacteria does not metabolize that.

01:27:27.080 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

01:27:33.400 on Amazon. And I like the Pure gum and the Pure mints. So Pat, teeth appearance is something that

01:27:38.900 obviously people have a lot of concern about. I mean, we've spent everything that we've talked about to

01:27:43.340 date has really been about the function of the tooth, the health of the tooth, et cetera. But

01:27:49.200 generally, the two things people notice about somebody's teeth when they smile is how straight

01:27:54.120 are they and how white are they? So let's talk a little bit about the latter. Is the color of a

01:27:59.160 person's tooth genetically determined? Somehow, yes. So we can see that different races, they might have

01:28:05.920 more white, but it's relative as well. Because let's say for this person with the darker skin,

01:28:12.780 the teeth are going to come much more whiter. So it's almost blend with someone who has a very

01:28:17.900 white skin. Most of the changes on tooth color can either be done by some genetic factors that people

01:28:27.300 might have a lot of very yellow and that will never change since they're born. Or sometimes they're like

01:28:35.040 in few countries, they have floor in the water. So excess of fluoride might have some stains on your

01:28:42.540 teeth, but mostly the color of the teeth, it's highly environmentally determined. Because we talked about

01:28:51.240 my study with the twins, where when we gave the same product for the tooth twins, they behave

01:28:58.640 completely different. So even they were identical 100% of their genes. If the kid who had like,

01:29:04.220 drink a lot of tea, coffee, and things, they have much more stained your teeth. And of course,

01:29:10.920 the whitening wasn't as efficient of another one who had less. So the environment takes place and it's

01:29:17.620 highly, you can modify just with those whitening products, brushing, things like that.

01:29:23.480 Yeah. I have found that for me, the two worst actors by far in terms of darkening my teeth are

01:29:31.040 black tea and red wine. We're going to talk about whitening in a second, because I want to ask you

01:29:36.340 about it. I don't whiten my teeth due to sheer laziness. So my approach has been to just try to

01:29:41.380 minimize how dark they get by always rinsing my mouth out with water or chewing gum or something like

01:29:46.220 that after I consume those things. So is whitening a safe procedure? Is it something that harms the

01:29:53.200 tooth in an effort to produce this aesthetic? Does it bleach the enamel away or do something that's

01:29:59.260 dangerous? Yeah, it's bleach. And it's, of course, in excess, which most people do, because they want

01:30:06.460 to always have my teeth. Wine, it's detrimental because somehow it has loss of minerals because of

01:30:13.960 the product is very strong. Also, if you're allowed to touch the gums, it's very aggressive because

01:30:20.000 you're bleaching and it cannot be for a prolonged time. So what I tell people is that if you want to

01:30:26.420 do at home, because it's less expensive, ideally you should do at the dentist. If you care about your

01:30:32.180 teeth, do at the dentist. They're going to protect your gum. They are going to apply the drug if you

01:30:37.040 have pre-adult disease, if you have root caries and all those things. They'll know exactly what is the

01:30:42.520 population who can have that. But people just go and buy out of the counter and they don't know what

01:30:47.680 they're doing. Sometimes they place that and they watch TV, they spend hours or every time they have

01:30:53.980 a party, oh, I want my teeth white, they put it again. And then it becomes that constant

01:30:58.620 demeneralization. Of course, you're going to susceptible to it. You're going to harm your gums and

01:31:03.780 things like that. So if you want to do, talk to your dentist, ask them, am I a candidate for that?

01:31:09.640 And do at the dentist, do at the correct timeline, look at the prescription, don't do chink or 1.00

01:31:15.140 products that are not FDA approved. So all those considerations, if you do the right way,

01:31:20.880 it's okay. It's just when they go outside to do things that they should do.

01:31:27.200 But it still seems that prevention is worth a lot here. If you minimize the things that really discolor

01:31:32.400 your teeth, it would at least reduce the need to do those other things. I alluded to it earlier that

01:31:38.140 one of my most miserable dent, not one of my hands down, my most miserable dental experience of my

01:31:43.940 life went as follows. Mercury filling placed when I was whatever, 10, 30 years later, someone comes

01:31:52.720 along and says, you really ought to have that removed because your insurance company will now

01:31:57.800 cover the replacement of these. And you can have something white instead of something silver.

01:32:02.160 And that damaged the dentin and or pulp enough that I needed a root canal, that root canal.

01:32:08.680 I eventually, that's the one where they missed the root. I got to, had to go back and back and back

01:32:13.540 and back and ultimately led to an injury that required the tooth coming up. Okay. Let's go back

01:32:18.460 to the jugular question. Should we remove mercury fillings?

01:32:21.600 If they're highly functioning, there is no decay under, there are several statements and research

01:32:28.420 that has been done. And it's the minimal, they're afraid about the mercury that gets in the, it's

01:32:36.060 proven that there is no harm with that. So if it's working fine, if you ain't functioning and it doesn't

01:32:44.280 affect the appearance, the aesthetics of the tooth, just leave it there. I don't think you should.

01:32:49.260 You also talked about fluoride earlier. This might sound like a naive question, but does all

01:32:55.580 toothpaste have fluoride in it? No, you have to look for, and not all of them have the correct

01:33:01.900 amount. You want to like a thousand PPM to 1500 PPM of fluor. So that's very important. And the ADA,

01:33:13.140 the American Venture Association, if you go to their website, they have all the toothpaste that they

01:33:18.320 endorsed, not for political reasons or anything, because we've done research and we know they work.

01:33:24.480 They have the correct amount of fluoride that prevents decay. So you just need to get from a

01:33:29.820 good source. And it's extremely important to have fluoride in any toothpaste. Usually children,

01:33:35.980 before one year, they recommend not to put it because they swallow all the time. But as long as they have

01:33:43.800 the first tooth in their mouth, you can start putting very small amounts and start to brush

01:33:49.900 that the child gets used to. But other than that, everybody should use fluoride.

01:33:56.060 And is there fluoride at all in any small amount in drinking water?

01:33:59.900 It depends. I know that U.S. is very particular with fluoride in many regions. People don't like to

01:34:07.840 have. Most countries, the drinking water is fluoridated. But there are additional sources of

01:34:15.500 fluoride that pediatrician, they can give you like drops that you, even when you're breastfeeding,

01:34:21.640 you can just put drops on the child or varnish, which I think is extremely preventive for children.

01:34:30.260 It's so simple. It's like a varnish that you paint in their teeth every six months. And guess what?

01:34:37.800 They develop decay because it's just protecting more and more.

01:34:41.360 So I do that myself also. I have discovered that I have one area in my mouth where my gum

01:34:47.400 has receded just a little bit. And as opposed to putting a filling there, I just use every three

01:34:54.600 to six months, a little bit of what you said, like sort of a fluoride varnish. And it reduces

01:35:00.240 any sensitivity. And my goal is obviously just to prevent any decay there.

01:35:04.420 Yeah. They're fluoride varnish. If someone is highly susceptible to decay, we have a,

01:35:11.360 it's a prescription base. You have to ask the dentist. It's a, one of the ones that we have

01:35:16.940 in the market is Prevident. I give to my cancer patients, but they're highly concentrated fluoride.

01:35:22.680 And we recommend that they use once every night for people who are high risk of cares,

01:35:29.360 which is people undergoing radiation. And then you do a regular oral hygiene with the regular

01:35:35.220 fluoride toothpaste, your floss and everything. And then you put that toothpaste on a toothbrush,

01:35:40.740 and then you brush and don't rinse with water. You want the product to treat the cavities and

01:35:47.760 everything overnight. So that's very efficient as well. And mainly, and it's a very fun story if you ask

01:35:55.820 my son, because I have two kids and none of them have never had decay.

01:36:01.280 How old are they?

01:36:02.680 Today they are, oh, 30, 34. So, but they never had decay. But if you think Francis, which my youngest,

01:36:13.380 because I was telling the stories about microbial, that they're going to eat your teeth. If you have

01:36:18.780 food, they're going to eat the food that they're going to just go down and make holes in your teeth.

01:36:23.260 So I would tell them those stories overnight. And how many times that kid in the middle of the night,

01:36:29.940 because he would fall asleep and I'll put him on like three years old in the bed. And I would watch

01:36:34.340 him in the middle of the night, brush the bathroom and brush the teeth because you're afraid. I always

01:36:40.040 told them because the most important time of the day is actually the night brush and never give your

01:36:48.080 child baby bottles and things overnight. Because when you're sleeping, you have a suppressed

01:36:54.700 saliva production. And that's the perfect environment to the bacteria to grow. That's why

01:37:00.660 child have baby bottle decay, because when they're sleeping and they put the bottle in their mouth,

01:37:07.300 the milk concentrates all on the anterior teeth and they get severe decay. So brushing before you go to bed

01:37:16.160 and you floss, you'd like a hood that you have an optimal oral hygiene is really high and you're

01:37:22.520 going to prevent. It's a very important rushing time. What are the implications of children having

01:37:27.460 caries in their baby teeth? I mean, for example, I assume we would never do a root canal in a child.

01:37:34.240 You just yank the tooth out because you know that the adult tooth is coming right behind it.

01:37:38.440 Do people put fillings into children's teeth? 0.60

01:37:40.840 It's highly complicated to treat those kids. First, because you traumatize them. You cannot do

01:37:47.760 local anesthesia. They will never come back to the dentist. If you try to do that in a regular way,

01:37:53.460 because they don't understand. They're very young. It's one to three years old that will start

01:37:59.480 decay. So they do. And the hospital under sedation, the teeth that they can treat, they treat, they will

01:38:06.380 extract the one that's causing a lot of pain. Some of them just treat the pulp, put some medication

01:38:12.700 there and wait until the tooth exfoliates just to preserve function because otherwise they're not

01:38:18.960 going to be able to chew. So every case they need to approach, there is another type of fluoride as

01:38:25.180 well. It's a highly concentrated that they put with a metal together, but the teeth becomes black.

01:38:33.400 That's another resource that they have because they cannot open, put a hole and restorations

01:38:40.240 because the child would never allow us to do. So excessive fluoride darkens teeth?

01:38:44.780 Just this specific time. It's mixed with a metal that the moment it gets in contact with this soft

01:38:53.660 dentine, it harden and becomes that very hard layer. Okay. So it doesn't affect their adult teeth.

01:39:00.880 It's just a temporary barrier until the tooth falls out. Yeah. Arrestes the decay in a very nice way,

01:39:07.700 but you need to tell the mom and say, I know it's going to take the pain away. It's going to arrest

01:39:13.100 the decay, but the teeth is going to become black. So it's a trait because we know that a couple of

01:39:19.320 years later, the tooth is going to exfoliate. It's not going to be black forever. So it's an

01:39:24.340 approach that we can do for this age of children. There's an entire cottage industry of products

01:39:30.660 out there like oil for pulling through the teeth and tongue scraping things. Are you aware of any

01:39:38.780 research that supports the use of such devices? You've obviously talked about brushing the tongue,

01:39:44.460 but any research that suggests scraping the tongue is efficacious or I don't even understand what oil

01:39:50.560 pulling is, although I've seen the oils and I don't think I fully understand what the claim is about why

01:39:57.160 oil pulling is beneficial. Honestly, I've seen, I have no idea. There is no clinical or research

01:40:05.340 evidence that shows that it's good or bad. I've seen a few studies on the tongue scraping,

01:40:13.360 which is similar with whatever the brush is doing, but I really like much better the brush because I

01:40:19.920 asked the patients to put a little bit of toothpaste because toothpaste is also anti-bacteria. And then

01:40:26.180 you just brush. It doesn't harm the cells or anything. You're just brushing the surface. If I had to

01:40:32.060 choose between this toothbrush, brushing the tongue, the tongue scraping outside, just brush. It's simple

01:40:38.460 and easy. Okay. Is there a difference between the types of dental flosses out there? So the two most

01:40:44.520 common that I see, actually, let's say three. One is like kind of the ribbon, you know, it's like a very

01:40:50.640 soft, almost looks like a Gore-Tex like ribbon. The other is like a rope, a miniature rope. And then

01:40:57.360 the third one would be like kind of a miniature rope that's coated in wax. Are they all basically

01:41:02.340 the same? And you just pick the one that is the most comfortable to you? Or do you have a preference

01:41:06.500 for which type of floss a person uses? Well, what I tell my patients, I have like 10 different ones.

01:41:12.860 And what I tell them, which one you're more comfortable using? It's a mechanical, the brightening,

01:41:18.960 it's disruption of the biofilm and taking the food away from in between your teeth. So there are people

01:41:24.780 who have perfect teeth very close together. They might need to use the one that has the wax because

01:41:31.100 they're going to go in and out very quick. And you don't want to harm your gums trying to pull in

01:41:36.960 something very strong and then it's going to cut the ground. It has to be done very carefully.

01:41:42.240 There are people who have prosthetics or big holes. There are like little brushes that they can put

01:41:47.340 inside. There are people who have like teeth that are connected to each other and they have another type

01:41:53.640 of device that they can go inside the bridge and clean. It doesn't really matter. You just need to

01:42:00.000 clean and you can clean. Most people don't floss. Really? What does the literature suggest? What

01:42:07.420 percentage of the U.S. adult population does floss once a day? If I tell something, I might not be

01:42:14.260 right, but I know by the whole population that I've treated, it's like half of the people floss 0.76

01:42:20.340 or they floss twice a week or something gets stuck. They go and floss. But if you ask people,

01:42:27.700 do you floss every day? Most people don't floss every day. Another consideration is that floss costs

01:42:35.140 money. So you need to keep buying all those supplies and you might not have the fund might be used for

01:42:43.020 different things. But if you think about flossing and brushing, I still think the flossing is even

01:42:50.880 more important than brushing because it's all the research that I did. People can stop brushing

01:42:57.780 and you recover health easily. People stop flossing. It's the gingivirus. Inflammation comes so quick

01:43:05.420 because the plaque that is in between your teeth, you can never change or clean if you don't have a

01:43:12.780 device. The plaque that is on in your top of the surface of your teeth, you're eating your cat and

01:43:18.660 apple, things that have fibers. You somehow, you just clean, you drink water. The saliva is constant

01:43:26.420 cleaning your mouth. The flossing, one thing is a bad bacteria because they love is the anaerobic 0.99

01:43:32.680 bacteria that causes most of the systemic health, such cardiovascular disease, diabetes. They're all

01:43:38.940 anaerobic and they're the ones that are hiding there. They hide in the tongue. They hide in between 1.00

01:43:44.240 your teeth. They can hide back in your throat as well because they like those niches that the oxygen don't

01:43:52.540 go. Is a water pick an additional benefit to flossing? Is it at all a substitute? I mean, obviously,

01:44:00.420 there are some cases where it's very valuable, kids that have braces, things like that. But how do you

01:44:06.180 incorporate the water pick into your oral care regimen? I like it, but I would say it's only if you're not

01:44:12.980 able to use the traditional. The brushing is the best because the water is more, if you brush, then do the

01:44:21.040 water pick. Don't do just the water pick without brushing because the water pick is that flushing of all the

01:44:27.660 toxins that are in between your teeth and between your gums and all of that. But you cannot do just

01:44:35.540 water pick. It's a benefit, but don't do alone. Any harm or benefit to using toothpicks? This is just

01:44:42.900 a personal obsession of mine. I love toothpicks. It sounds crazy, but when I find toothpicks I like,

01:44:49.160 I buy them in massive quantities. And there's like this one toothpick I got at a steakhouse 10 years ago,

01:44:55.380 and I became so enamored by it that I had to find out where they got it from. And I found the company

01:45:01.000 that made it, but the minimum order was something like 20,000 packages. So I had to buy 20,000 packages

01:45:06.720 of this toothpick, which I still have to this day. I love them. Point is, I always have a toothpick in my

01:45:12.160 mouth. Am I hurting myself? Am I helping myself? What am I doing? I don't think you're hurting yourself.

01:45:17.460 They even had research in the past that they say that stimulates your gums and things like that.

01:45:23.820 Well, honestly, that's part of what it is. There's a use case, which is anytime I have food in my teeth,

01:45:28.660 I love doing it. But what I've also realized is I love, I find myself massaging my gums with the

01:45:34.100 side of the pick. So I put the toothpick in and I'm sort of grinding it on my gum surface and it just

01:45:40.200 feels so good to me. I still floss every day. So it's not a substitute for flossing.

01:45:45.440 That's what I was going to say.

01:45:46.660 Yeah. It's not a substitute. Yeah. I still floss every day.

01:45:48.820 It doesn't do the same job because the floss goes around the tube and go up and down, but it's

01:45:55.360 benign. It's nothing that I don't think any wrong of doing. 0.91

01:45:59.580 That's good because I have enough to last me, my children, my children's children and their

01:46:04.460 children for the rest of our lives. People talk about generational wealth. I don't have generational

01:46:10.480 wealth, but I have generational toothpicks.

01:46:12.540 Well, talking about that, the electric toothbrush, I like it a lot too.

01:46:16.320 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

01:46:21.840 the Oral-B. Something about the Braun one bothered me. I don't know if the frequency that it vibrated

01:46:27.660 at resonated too much with my head, but it didn't feel good.

01:46:31.620 I had the same.

01:46:32.160 But I love the Oral-B. Okay. So is one superior?

01:46:35.900 I actually did clinical trials with both. They're equally good. The difference is the technology.

01:46:42.260 One is sonic. So when you're doing that, it's almost to feel the vibration in your head. And

01:46:49.320 the Oral-B is much more like, the vibration is much more natural.

01:46:54.160 It's mechanical.

01:46:55.020 It's mechanical. And I love the mechanical because it stimulates your gum.

01:46:59.460 There are people who loves doing the other one. It's very fast and cleans very quick.

01:47:05.500 I like the Oral-B a lot. That's the one that I have.

01:47:08.820 So bottom line is they're both efficacious if you can use them both and use the one that you enjoy

01:47:15.320 more.

01:47:16.140 Yes. It is just whatever you're comfortable and whatever you know you're going to clean

01:47:20.260 your mouth. That's what I say. I've done anything, all types of floss, all types of toothpaste.

01:47:26.060 And it's a device that is there for you to do your oral hygiene.

01:47:30.800 So let's now talk about the ideal reasonable regimen of oral care. Let's start with what I do

01:47:39.820 and use me as an example of how I could do it better. When I wake up in the morning, I do nothing.

01:47:44.580 And the reason is I don't usually eat in the morning, but I drink coffee. So I don't know why,

01:47:49.600 for some reason, I think it's a waste of time to brush my teeth first thing in the morning because

01:47:52.800 all I'm going to go to do is drink coffee. So let's say I get up and I drink my coffee. Oh,

01:47:57.220 by the way, I used to scrape my tongue. I have one of those tongue scrapers. I used to do that.

01:48:01.640 And then my wife got so mad at me because she said, that's so disgusting. It makes me sick.

01:48:06.860 Get rid of that stupid tongue scraping piece of expletive. So I still have it. Don't tell her,

01:48:15.700 but I don't use it anymore. So I go and I drink my coffee and I kind of do all my,

01:48:20.700 I usually exercise in the morning and I usually don't eat my first thing until maybe 11 o'clock in the

01:48:25.540 morning. At that point, I then go and I get my Oral-B toothbrush and I brush my teeth. And as you

01:48:31.820 probably know, the Oral-B toothbrush has like this little 30 second timer that allows you to go two

01:48:37.400 minutes. So I'm very, very robotic about this. I 30 seconds on the top, 30 seconds on the top,

01:48:44.440 30 seconds on the bottom inside, 30 seconds on the bottom. And then I'm done. And then I don't do

01:48:49.660 anything again except use my toothpick all day until dinner. After dinner, I then floss. I like

01:48:57.960 both. I like any floss actually. I just love flossing. So I'll use the little ropey floss and

01:49:02.660 I'll use the tape floss, whatever I've got. And then I do the same thing with the Oral-B toothbrush.

01:49:07.820 By the way, I'm using a xylitol based toothpaste for what it's worth, if that matters.

01:49:12.140 It has fluoride.

01:49:12.880 It has fluoride. That's my only oral care regimen. I don't use mouthwash. I don't use

01:49:19.780 a water pick. I used to, but then I gave it to my daughter because she got braces. I figured she

01:49:24.200 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

01:49:30.140 benefit a person can have? Am I at 60% benefit? And what else should I be doing?

01:49:34.740 So one little adjustment. So usually bacteria, the biofilm, it takes like overnight. That's where

01:49:43.320 you have the most suspicious bacteria. They start growing in your mouth for all those reasons that

01:49:49.680 I said, your mouth is closed, no oxygen, reduce saliva flow. Salivary flow is almost zero because

01:49:57.440 you're sleeping and things like that. So people, when you wake up, you feel, if you stop and think

01:50:03.600 you're going to see, yes, my mouth is dry. If you cross your tongue on the surface of your teeth,

01:50:10.140 you're going to feel the biofilm. Biofilm is invisible to your eyes, but you can feel with

01:50:16.220 your tongue. That's the morning that you're going to see. So there's nothing wrong of you. I do that

01:50:22.140 as well. I like to take my coffee on my bed. I just read a little bit and I take my coffee without

01:50:26.820 brushing. I love that.

01:50:28.740 Brazilian coffee, I hope.

01:50:30.580 Exactly. Espresso.

01:50:32.140 So then you get out of the bed and you brush your teeth. You have to wash out from your night.

01:50:41.700 Okay. So the change you're suggesting is before I begin my day, do a first brush. So I'm going to

01:50:48.260 be now brushing my teeth three times a day. I'm going to do...

01:50:51.620 That's the ideal.

01:50:52.580 Okay. And is it okay if that... Should they all be done with the Oral-B toothbrush or is there a time

01:50:59.280 in a place to just use a regular toothbrush? You can use any toothbrush. If you're out,

01:51:05.080 if you're in a place where you can brush, you can use any. Because the mechanical toothbrush,

01:51:09.560 they do such a good job.

01:51:11.000 Although I have to be honest with you, I've never been able to brush my tongue with the mechanical

01:51:14.980 toothbrush because I... No.

01:51:16.620 Yeah. I have to use... Okay. All right. I got it.

01:51:20.320 I like a children toothbrush because they're more soft.

01:51:23.860 Yeah. So you want a soft Buracil toothbrush, right?

01:51:27.240 Soft with the tongue. Yeah. Just get a separate one. And I tell people that every time that you use

01:51:33.720 a toothbrush, which most people don't do as well, you rinse your toothbrush. You can even rinse with

01:51:39.360 soap. Like put water, soap. You decontaminate. You need to clean your toothbrush.

01:51:44.480 Oh, I never thought of that. This is... You're really adding... You're literally going to add

01:51:48.600 another four minutes to my day. You realize that? Four minutes to my day. 28 minutes to my week.

01:51:56.980 Do you know how many hours you're adding to my year? This is ridiculous. Well, look,

01:52:01.520 it's worth it though. So I'm going to now be rinsing my toothbrush with soap and water.

01:52:05.780 Yes. If you don't want to put the soap, just rinse with warm water.

01:52:10.140 Well, I always do that, but now I'm committed to doing this. Maybe salt? Would salt water be

01:52:14.860 beneficial? You don't need... No. Just even hand soap, just rinse with water and soap. And dry. 0.76

01:52:21.800 You have to dry because bacteria loves the moisture environment. I hate the taste of soap because as a

01:52:28.380 child, my mom would often wash my mouth out with soap because of how foul a mouth I had. So I'm still

01:52:35.280 traumatized by the taste of soap. It's an awful taste.

01:52:39.560 Rins with like hot water. It is. Very hot. So there is soap in toothpaste because soap disrupts

01:52:47.360 microbial. Like the COVID can be disrupted by soap. So every toothpaste has soap because of that,

01:52:54.700 because most bacteria have the lipid protein in their surface. So that's why we have... But they put

01:53:00.240 all the flavors. They put the fluoride. So that's why they don't feel that soap taste,

01:53:04.940 but that is soap and antibacterial.

01:53:07.000 Any role for mouthwash? I don't... My wife loves it. I don't... I just... It's one more dumb thing that 1.00

01:53:11.800 I don't do.

01:53:12.320 The thing that I just like with mouthwash is that it kills every single... It just wipes out all your

01:53:19.880 microbiome, including the good ones, because they're all antibacterial. So I am in favor,

01:53:27.520 if you're like in a situation that you're not going to be able to brush much, like for short periods of

01:53:33.920 time, let your body normal, like recolonize without any interference. The same thing with

01:53:39.960 antibiotics. If you take too much antibiotics, you're going to be resistant to bugs and bacteria.

01:53:46.500 So if you use every day, one point, you're going to have a virus in your cavity, but that's going to

01:53:52.140 be very resistant. That's very interesting. Is there any evidence that excessive use of mouthwash,

01:53:58.400 for example, leads to candidal overgrowth or fungal overgrowth? I mean, that would certainly

01:54:03.200 be one hypothesis worth testing. I don't remember, Peter. So I don't want to say anything that I don't

01:54:11.620 remember, but I can go back and look. But the studies that I did, it changes the microflora. So that's

01:54:18.360 why I'm very concerned about changing in oral environment that is healthy. So if you're healthy,

01:54:25.100 why are you going to use the mouthwash? You don't need that.

01:54:28.720 Okay. Anything else that we would consider best practices for the average person who is looking to

01:54:37.160 preserve the quality function of their teeth and by extension, their overall health, besides what

01:54:43.940 we've discussed? Well, I think everything that we discussed and we talked so many times about

01:54:50.380 prevention. So dental care is a chronic, non-communicable disease. And then it's through

01:54:57.160 life. People have dental care their whole life. The only way to control is preventing. So preventing

01:55:04.980 means every six months, you need to go to a dentist and you need to do a cleaning at a minute. At that time,

01:55:11.920 they're going to look. Do you have any cabbages? Because the cabbages is a niche for the bacteria

01:55:16.380 to grow as well.

01:55:18.380 By the way, is six months a magic number? I mean, the only reason most of us go every six months is

01:55:22.760 because that's what insurance covers for free. But if you decided you were willing to pay out of

01:55:27.920 pocket, would it be better to go every three months or every four months to do an overall cleaning?

01:55:32.660 Well, there is a lot of research about if you maintain a good oral health, you don't need to do

01:55:40.140 more often. Someone who is a high risk, you have a systemic health, you have diabetes, you can do three

01:55:49.840 times a year, for example. But the six months is how dentists recommend it. And it's through research

01:55:56.980 that shows because periodontal disease is a very slow progression. It's not a disease that you have

01:56:01.960 today. In three months, you're going to have two millimeters of bone loss. Unless you have something

01:56:06.800 else in your body that combined with the inflammation that is triggering systemically, then your bone is

01:56:13.060 going to go away very quick. But I think because periodontal disease is slow progression. And I know we did

01:56:18.980 a study three years ago that we looked at people and we measured periodontal disease every two months.

01:56:25.320 We held the treatment. We didn't do the treatment. And we watched how people would progress. And it's

01:56:32.360 crazy. There are people who progress very quick. There are people who never progress. And there are

01:56:36.540 people who take two years to progress. What do you think explained those differences?

01:56:41.860 Systemic. Because periodontal disease is a highly common case with your body. If you have a systemic

01:56:49.040 issue, it's going to exacerbate inflammation. So...

01:56:52.860 Wait, so you could predict the extent of disease a person has if you knew how systemically healthy or

01:57:00.240 sick they were?

01:57:00.900 Yeah, you can. If you have a lot of infections, you have diabetes, we know you're more susceptible to

01:57:05.860 have periodontal disease. So there are groups of risk that those particular group, they need to see a

01:57:13.020 dentist more often. They need to do more cleanings and they need to prevent. There was a huge study that

01:57:17.820 was done five years ago, but was not conclusive. They'll never know. When they finish, they say they

01:57:24.040 don't know which way it's coming. If it is the diabetes that triggers, or if it is the burden and

01:57:30.740 the oral cavity that is treating their diabetes, they couldn't dissect that.

01:57:35.480 I mean, I think the good news is they're both preventable diseases. So again, it goes back to the

01:57:40.140 point of prevention.

01:57:40.860 Yeah.

01:57:41.480 Well, Pat, this has been super interesting. Just on a purely selfish basis, I learned a lot that

01:57:45.920 will immediately go into practice effective, I guess, tonight and tomorrow morning. So thank you

01:57:51.040 very much for the insights you've shared. And I think people will take a lot of practical

01:57:55.160 information from this.

01:57:56.280 Very welcome. It was my pleasure.

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02:00:50.360 You

The Peter Attia Drive - June 21, 2021

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

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