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

Episode Date: June 21, 2021

Dr. Patricia Corby is Associate Professor of Oral Medicine and Associate Dean of Translational Research at Penn Dental Medicine. Her work focuses on the importance of providing dental services alongside critical public healthcare services, like cancer treatment. In this episode, Pat provides an overview of dental anatomy, the importance of oral hygiene to overall health, and the association of poor oral health and systemic diseases like cancer and diabetes. She addresses tooth decay, oral hygiene in children, the utility of dental products, and ideal oral care regimens for different populations. She also discusses issues specific to immunocompromised patients and those with chronic illnesses as well as her own research with cancer patients undergoing radiation treatment.   We discuss: Anatomy of teeth and the purpose of the dental pulp—a highly vascularized and innervated region of the tooth [3:00]; Types of teeth and the different purpose they serve [14:15]; Anatomy of the oral cavity, bacteria in the mouth, and what a healthy mouth looks like [18:10]; Pat’s study demonstrating the importance of flossing [23:00]; Detrimental effects of sugar and the importance of fluoride and oral hygiene [31:45]; Oral health challenges for cancer patients and immunocompromised people [39:45]; Pat’s current research on cancer patients undergoing radiation treatment and the oral health risks associated with human papilloma virus (HPV) [50:00]; Periodontal disease: caries and root canals [57:30]; The relationship between poor oral health and systemic health diseases [1:11:00]; Potential connection between oral hygiene and COVID-19 [1:17:45]; Dry mouth leading to oral infections and ways to prevent it [1:22:30]; What determines the appearance of teeth, methods of teeth whitening, and whether you should remove mercury fillings [1:27:30]; Importance of fluoride for preventing tooth decay, and dental care for children [1:32:45]; Useful dental products: floss, electrics toothbrushes, and more [1:39:15]; Ideal oral care regimens [1:47:30]; and More. Learn more: https://peterattiamd.com/   Show notes page for this episode: https://peterattiamd.com/patriciacorby    Subscribe to receive exclusive subscriber-only content: https://peterattiamd.com/subscribe/   Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/   Connect with Peter on Facebook | Twitter | Instagram.

Hey everyone, welcome to the Drive Podcast. I'm your host, Peter Atia. This podcast, my website, and my weekly newsletter, I'll focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, full stop, and we've assembled a great team of analysts to make this happen. If you enjoy this podcast, we've created a membership program that brings you far more in-depth content if you want to take your knowledge of this space to the next level. At the end of this episode, I'll explain what those benefits are, or if you want to learn

more now, head over to peteratia MD dot com forward slash subscribe. Now without further delay, here's today's episode. My guess this week is Patricia Corby. Pat is an associate professor of oral medicine and associate dean of translational research at Penn dental medicine. Pat received her doctor of dental surgery from Union Corps University in Brazil and her master's in biomedical informatics from the University of Pittsburgh School of Medicine. She completed her postdoctoral training and molecular biology and microbiology genetics at Harvard.

I wanted to have Pat on this podcast for some time because I've wanted to interview somebody on the broader theme of two things. One being oral health, what are the important things to be able to actually care for your mouth? Because as we think about longevity, there are a handful of things that I don't think get enough attention. So if you wanna live to be 90 or 100,

imagine a world where you do that with high quality teeth and without. It's sort of like imagining a world where you don't get cancer or heart disease or Alzheimer's disease, but you're too frail to get up and walk around. And I think the same sort of applies to your teeth. If your mouth is not in good health,

I think your quality of life is quite compromised. And in the same vein, I wanted to understand, to some extent, if there is any relationship between poor oral health and systemic diseases, it seems that there is an association, but I want to at least probe a little bit this idea of could there be a causal relationship. So, in this episode, we discuss all of these things, and we conclude the discussion with what I think of as a very high yield list of best practices around oral care. I was surprised to learn that, for example,

maybe fewer than 50% of people regularly floss, meaning floss daily. I was also very surprised to learn the importance of flossing. I always knew it was important. I don't think I realized how important it was. We also talked about certain things that are popular and trendy that may not actually be that beneficial.

Talk about teeth whitening. We talk about the use of mouthwash. What type of floss is better, what type of floss is better, which type of toothbrush is better. All these things and more are discussed in this episode. So without further delay, please enjoy my conversation with Patricia Corby. Oh!

Oh! Oh! Oh! Oh! Oh! Oh! Hey Pat, thanks so much for sitting down with me today. I've been wanting to sit down with you for quite some time.

And I know we've scheduled and rescheduled on several occasions and between one thing or another, it took a while, but I am pretty confident it's going to be worth the wait. How are you? I'm good. Thank you. I'm very happy to be here. That's something that I have a lot of pleasure talking about oral health with MDs. That's my life is trying to do this connection. So I'm very excited to be here.

It's gonna be interesting. I don't know much about what to do. And I think I can bring something new about dentistry and oral health and things, which is so important. Yeah, well, I think it is important. And that's certainly why I've wanted to talk about this for a while.

And I've been trying to figure out who would be the right person to speak with. And you came very highly recommended because I think it's actually a very underappreciated part of health. I think it's easy to think of the mouth as this sort of thing. And we go to the dentist and hopefully we don't have cavities. And obviously we have a whole bunch of cosmetic concerns with the spacing of our teeth and the whiteness of our teeth, et cetera. But I'd like to sort of tie that all together.

But I want to start with a little bit of your background. So obviously you grew up in Brazil. I shouldn't say obviously, but I recognize your accent. And I know your history a little bit. When did you leave Brazil? So it was a long time, over 20 years ago. So I had my dental degree in Brazil, and then I had my specialty in paleontics

and implant dentistry, which is one of the fields that is more connected with systemic health. I always wanted that. And then I went, I came to US mostly for personal reasons, and my passion for research, because that's what I do my whole life. And I never went back because I got fascinated by the opportunities and everything that I could have near that unfortunately we don't have the resources in Brazil to do. And I'm still doing research

up to today many years. So this is a bit off topic, but tomorrow is a very sad anniversary. Do you remember where you were 27 years ago, tomorrow? No, remind me. Sunday, May 1st, 1994, was the day I Art on Sena died. Oh, wow! I remember that daya died. Oh wow! I remember that they really clear me. Wow. Yeah, where were you that morning? I were you like everybody watching the race on TV? Yes, I was still there in Brazil. Yeah, I have so many Brazilian friends and we're just fortunate. So many people in our life are Brazilian,

our nanny is Brazilian and I've never met a person from Brazil who was anything over about four or five years old on that day. It's etched in their minds forever. Yeah, well, yeah, he has a big legend. And I think in a time that made Brazil so visible for the world and all those things. So everybody was always very proud of him. Yeah, well, he's my personal hero. And so for you today, I wore one of my Santa bracelets here. So let's start a little bit with tooth anatomy. Unfortunately, I have teeth that my wife

refers to as a tea teeth, which she jokingly means like I just have genetically horrible teeth. Like I always seem to be at the dentist for something. Some things always going wrong. I'd like to think she's exaggerating a little bit, but there was a period in my life, unfortunately, of maybe 10 years when I didn't go to the dentist once. And I think I sort of ended up paying a bit of the price for that going on, which sounds like a stupid thing to say. Imagine somebody not going to the dentist for 10 years, but that's sort of

what happened for largely much of my medical school and residency. I just never made the commitment to go. Still brushed my teeth and did all that stuff, but obviously wasn't getting regular checkups. And now that I find myself taking dental care so seriously, the first thing I realized is I had to understand the anatomy. I had to understand what they meant by pulp and dentin and all of these things, but I think it might make sense to give people a decent overview over the semantics of the tooth at the individual level and then sort of at the level of how all of the teeth fit into the mouth. Is that, can we start with something like that?

Yeah, yeah, yeah. Of course, I think which is strictly important. They all have a reason to be. So you have 32 children in your mouth. All of them, of course, they have very specific functions. So if you think about the anatomy of the truth, you can think about one unique truth only, which is the anatomy of you have the root carries. If you think about between what you see in the oral cavity

and what you don't see is like the crown and the roots, as you see in this figure. And then you have all the parts that surround you, the two, very called the supports where this sits on top, which is the period don't, which is another very complex system as well. And then, if you think about this whole system together and you have multiplied that by 32, then you have this amount of very unique set of different, think about individuals inside

your mouth and they all have very specific functions. Can you pull that slide up again of the individual tooth? I have some questions about that, because the first thing that jumps out to me is that there's a vascular supply that is quite high in the tooth. If I didn't know better, I would assume that when I look in my mouth and I see that

white crown that everything inside it is a bone. In other words, I would assume the entire tooth is an avascular amorphous thing that serves one purpose and one purpose alone, which is just to basically break down food. So why is it that this tooth is so much more complex than just having an amyl? Why does it have this dentin and this pulp? Yeah, it's a very complex structure and sort of reason. So the amyl is minerals. So it's a very hard surface. It's actually the hardest surface on the human body is the anemone. And then actually the hardest surface on the human body is the NMO. And then underused the NMO, you have the cement, and then the dentine, and then you have the poke,

and the cement is everything part of the pedodontium. But there's three layers of the tooth itself. The NMO protects the underneath layers. The second one that you see is just like cushion, and has a lot of tube rules as well. So it's hypersensitive. And then the heart of the tube is actually the cold. You see a lot of nerves and they all connect to the body. That's why you have a lot of took pains one of the most detrimental type of pains that we

have because you have all those nerves connecting everywhere. And then you have the bone as well. And the ligaments around the roots, they protect, it's that question that protects against the impact and gives you all that biological, symbiotic. So you can chill and you can function. But why is it that we need a nervous connection to the the tooth because I understand that like if you had a dental implant Obviously, you've given up the nerve and vascular supply to the tooth correct Yes, so we can still carry out the function of breakdown without that or so the first

signs Have of course, lost, as you start with the decay, and then if the decay takes the pulp, then you have to excise the pulp, and you can still preserve the root. So the main thing, the way you wanna think and then frustrates that you wanna preserve health

as much as you want, because you wanna preserve function. So you don't wanna extract teeth, because they have a very precise reason, because they want to preserve function. So you don't want to extract teeth because teeth, they have a very precise reason because they need to hold this face, you need to chew. There's a lot of things that's part of the mouth. So you need to have the teeth. You can do root canal or if you don't have any more the crown

because you lost 2.0. You can take it out the crown, you can put some metals and then you can put a nutric ratio crown. The moment that you lose its infected, and you have to extract the whole tooth, then you need to put the implants on. But not that implants is better, it will never be better than your natural function

and your teeth, because it's a metal, and it has many other issues. And you still have to get rid of the tightest risk of infection of the implant. It doesn't mean that, oh, I'm going to take my teeth out and I would never going to get inflammation for the whole disease. It's not true. You still have that. I think my question is more that if you have an implant and therefore you have a de-nervated tooth, it seems to still be able to carry out the function of breaking down food. I think the thing I'm trying to understand is, you

pointed out something that unfortunately most people listening to this can relate to, which is dental pain is some of the worst pain in the world. And it speaks to, I think, that highly, highly-intervated pulp that you showed. I'm trying to understand what the function is of having something so highly innervated. Like, for example, our fingers are highly innervated because they serve such an important function. Our ability to have fine motor control with our fingers

is why we have so much innervation here. So why is it that we have so much innovation in a surface beneath this enamel, which as you said is the hardest surface in the body? What is the purpose that that innovation serves? That's an interesting question. It's the vital part of the truth that preserves blood flow and keeps the truth alive. And it's a connection, now that I'm thinking through, it's how you protect it. So it's a connection with your immune response.

If you have, let's say, if you have a carries infection. Interesting. So probably that's how your body might be able to respond and fight again some factual information. So the moment you don't have there anymore, so it's just a doubt piece of. I see. I see. That's a good point. That's what I think now that we're talking. So maybe it serves as such an early warning indicator as a breach of a barrier, basically an important barrier. Okay, that's interesting. I just have to tell you, having been through so many

miserable dental experiences, I've often cursed our evolutionary gods for giving us so much innovation in that tooth. So you've already started to talk a little bit about the pathology that can go wrong here. Before we do that, I want to get a little bit more on understanding of the function. Can you show me again that slide that has all of the teeth and maybe explain how different teeth serve a different purpose in the mouth? So technically you have thingsizers, so you have four of them in each part of your jaw, in the maxiura and the menjibur.

Then you have the canines, they are another four, so the insiders is mostly in your mouth so you can cut your foot in any animal. That's how you bite and how you separate pieces of fruit. And then you have the canine that is a very strong, that's the longer root that you have in your mouth, that's the cheer so you can see animals when they're eating meat and all of that that you tend to go to the side because it's a very strong anatomy that they have. And then you have four, we go pre-molars or bicuspids. So that's where you start to break down the element, the food that you eat to tear them apart. And then the mollors, they do the whole three-teration. That's the way you have

to chew. And I always talk about chews because the digest process starts in the mouth. So it's very important that people chew their food in contact with the saliva and all the nutrients that we have, but it's a completely different subject talking about saliva, but it's mainly to chew your food, to start the digestive product. So then you can get most of the nutrients out of your food. Now, looking at the lower part of this figure,

it seems that the different teeth have different numbers of roots. Is that correct? Yes, that's correct. So in sizes and larrals and primalers, they're one in front. They have single group. Then if you go to primalers, they will have two. And the molars itself, they might have three or four depending on how big the truth is. So it's

a much more complex because they're much more strong and they have to get much more pressure and to function so they need to have much more like sustainability so they can chew and treat to eight hour food. I see. So that actually probably explains another reason why these things are innervated, which is the harder they have to oppose other teeth. So the molars would have the greatest opposition to another tooth, then they need greater sensory input to understand the relative spacing and force. Would that be part of the difference as well? As well, if you think like in your mouth, it's like a bridge

has to be very well balanced. The occlusion is to be perfect, because then you're gonna hurt all your ligaments and cause inflammation in your mouth. So it's a very elaborated system. And if you think about the occlusion, they connect. They have to be very perfect aligned. So if you start having issues like your team,

they don't have a perfect occlusion. You start losing your vertical occlusion. And then you have a lot of other issues like pain on your face and headdinks, then many other issues that can happen if you don't have a good function in your office. Okay. By the way, I learned the hard way that I have four roots in my mola, not three, because I've had two root canals, and the first one, they missed one of the roots. They only went after three roots, and I still had endless persistent pain.

And I went to finally then see an endodontist who realized I had a very hidden fourth root, but we'll get to root canals later, my least favorite procedure in the world. So let's talk about what a healthy mouth looks like. You alluded to saliva. I assume that that plays a very important role in oral health, and I assume it does something beyond lubricating food. Does it play another role? So they all have it as a very complex system. If you think that you have cheap, you have the gums, you have the genji-dokrivut purfu, that is an open and allows you back here to go in and out, you have the thong, which is a completely different texture

structure. You have a throat which is interesting to your body. So all this whole complex system, they need to be in a very organized way. And on top of that you have the saliva. A saliva is again, we could have a completely other podcast just about saliva. But in the context, what we, they preserved help because we know today that people with dry mouth, if you have, I treat patients with radiation, they're going through radiation college. We can talk about that later, but the moment you dry your mouth

for any reason, systemic conditions, medication who causes dry mouth, the many of them that causes, or toxicities, do cancer care, radiation, right now, it's a completely shaped auto microbiome in your mouth. Because saliva protects, is that biofruit that is constant, washing and splashing in your mouth, and maintaining a very homestasianist

on the microbiome as well. It prevents just the odds on the auto microbiome. So this whole complex needs to be balanced on every single aspect that we look, you need to have a cheese, you need to brush, you need to have a lot of saliva, and you need to eat well. So it's a combination of a lot of factors that makes people say to be in health when you look at oral health, but the primary is so simple. It's actually oral hygiene. If you brush your team, you're going to be technically you preserve a little bit more of health

than people who don't. I want to go back to what you said about the dysbiosis and the microbiome of the mouth. So my recollection is that the mouth actually has a significant amount of anaerobic bacteria, is that correct? Well, they're both. You have aerobic, you have anaerobic, you have facutative bacteria that can play both roles because it's strong, they can change,

but we have over 700 different bacteria that leads in a perfect symbiotic habit that in our, in a kindle we call that. And they can be really well with the host without causing disease if you can maintain the state of health. Because in the past people think that what causes disease or disease is this specific bacteria, but it's not true. We all have all those bacteria in your mouth.

It's indigenous to you. It's not that it's from something external. You have that. It's that. The normal habitat is your mouth. But for some reason, you start brushing or you start taking a medication, your mouth becomes dry. You have a health condition that allows inflammation to be more prevalent. You might, all those things might change the whole cavity environment.

And that allows some bad bacteria to grow and supersede the good ones. And then that's what happens with this disease. So, we talk about your things, abundance, changes in abundance and diversity, which is allowing bad bacteria to flourish and suppress the good ones that helps us to serving health. So that's mainly what's going on. Of course, there are other corporate states. So in an ideal state, directionally, what amount of bacteria are aerobic and aerobic and facultive? What's the approximate distribution in a relatively healthy mouth? It's probably half and a half between aerobic and aerobic and another maybe 30 to 40% of them, they can play both roles.

But those, let's say, a clear example, and we can talk about that in a completely different section, but like even children, when I did my studies with the twins, and then we asked them to stop rushing for two weeks, all the pure don't do pathogens, pit and jabalya, children to call for scientists that we only see in adults with pre-adontal disease. In two weeks, they became abundant in their mouth. So they were there. I couldn't see a baseline. They wanted to stop flossing.

They became abundant. So they are there, but they will never cause disease unless you have a shift on their oral microbiome. So let's talk about that study. So how old were these twins? So we go back. It was a long time ago. That's when I first started my research because I was healthy, interesting dental case. So there were between 12 and maybe 16 years old. I wanted to have a adolescence because that's where they don't like to rush the floss. It's a very hard to do that.

So when you do studies, I'm going to talk a little bit about the twins. So I understand why we use the twins. So they are the perfect module to do clinical trials. That's my passion is clinical trials. Because they share, especially on that age, the same household, the same home. There is no clinical founders. You don't need to adjust for age.

The identical twins, you don't even need to adjust for gender because they share the same sex, and they share 100% of the genes. So when you look at models I got, and these are 100% of the genes. So when you look at monosigotic twins, the monosigotic twins, they share 100% of the genes. Some of them are the perfect clones of each other. Right, and to your point, as adolescents, they're still in the same house.

It would be different if you did this with 30-year-old monosigotic twins, because at least there might be some environmental differences. And the environment takes place, and then a lot, you know, epigenetics might change even in mutations. And then when you look at the dyes I got at twins, they're 50-50. They share 50% of their genes. It's the same as two brothers' siblings.

So there's two ways that you can do studies with twins. You either get the twin set, and then you do treatment A and B to see response to treatment, because they're very similar, or the way I like when you wanna see trains, and how a trait can modify by genetics or environment factors, you get the same set of twin,

and you get the same set of twin and you give the same drug medication or treatment. Because then when you look before and after, if you see that the identical twins, they behave in the same way, you're going to say, well, genetics modulating that trait. But then if you look at both of them and say they're all over the place, they behave in the same way as the identical and the fraternal twins, they say, well, here the environment is playing a big role because genetics are holding anymore.

So when we do this, philosophy in twins, that's how we did this study. We didn't wanna give separate treatments for the twins because they're going to the same house. And I did very controlled. So for two weeks, we asked the twins to come're going to the same house. And I did very controlled. So for two weeks, we asked the twins to come every day to the center, and I had dental hygienists and my clinical people trained, and they do brushing

and or flossing because they're two groups. One group, we wanted them just to brush. The other group, we wanted them to brush and floss. So the hygienists would floss and watch them doing, it was very supervised and controlled. And when they go home, I asked them to do at night at home. But if you think about, that's a very hard, clinical trial to do, because we have to bring the kids

every single day with their parents to the center. So we could actually watch them doing the intervention. So when we finished the study, what happens there was a, is that the children that did not floss, we saw elevated levels of gingable information, which was represented by a gingable bleeding, we measured gingable bleeding, and what was most striking was all those

who don't go back to here, they just came in abundance in their mouth. we measured the range of bleeding. And what was most striking was all those scurodontal bacteria they just came in abundance in their mouth. Which ones in particular over expressed in the non-flossing group? It's the three big guys, we call Pigeongeviles, Tidentical A, Actinomythensis. They're very complicated names, but it's the top bacteria

that causes pre-dontogenic disease and gender bias we found in a very young population. Are those all facultative anaerobes or any of those? Yeah, anaerobic species. Most of the bacteria, so cares and pre-dontogenic disease are very similar in the way they behave and they risk factors, but they can be separated that care is most aerobic species because they live in the presence of the oxygen. So they're free on the oxygen because of the oral cavity. Most bacteria that cause perodontal disease

they're aerobic. All the factors that they can go up and they can hide again inside the guns So they and their lobby that's why they love hiding in the parental pockets It's a perfect reserve for them to just grow and causing inflammation And just to be clear the paradontal pocket is Inside the tooth and the gingival pocket is between the gum and the tooth? It's all the same thing. So the way periodontal disease manifests is that first it starts with inflammation around the gums. So the way the periodontal works is that it seals by the periodontal ligament and patches.

If you are in health, your periodontal ligament is very healthy, it's like a muscle. It's very tight to you. If you stop brushing, it's the primary cause that your gums get inflamed. If you stop flapping or you relax, you're going to immediately, if you floss, you're going to see some bleeding. That's the initial stage of paleontal disease, but it's highly modifiable. If you have only a change of bodies, you can refer to health. So if you keep going and you continue with the traits of the disease, the ligament is going to get inflamed and they're going to be attached to it. The bacteria is going to come in and then that whole process of inflammation bacteria and

the duration of the ligaments, that's why we've formed the pocket. That cumulative, like, harm to the parodontal, culminating bone loss. So the mission, the acute parodontal disease, you're going to see someone is that they come to your office, if they're retrographs, they come that still somehow attached to the tube, very inflamed, it bleeds a lot, you touch it bleeds. But if you go and look at the retrograph, you're going to see a big gap. The bone is all done. And then that's the pocket. It's when the bone goes down. And then if you put a probe, you're going to see three millimeters, five millimeters, seven millimeters, it keeps going down. Now, how does that relate to the

carry? Because the carry typically occurs on the sort of top surface of the tooth typically, correct? And everything you're describing is often actually below the gum line, yes? Well, that's the next stage. So once the pocket gets influenced, the chronic period of tired, as well happens, is that they're at the top of the gums. So the gums, they're going to receive

and they're going to keep going down. So it's very typical that if look. If I look at someone, I know they have to go to disease just by looking at their gums because you're going to see the teeth that become bigger and then you're going to see the gap that you're going to expose their root. So usually the root of your teeth they're not meant to be exposed because once they expose, the bacteria can colonize and you can have root gins well So you can add the coronacraris which is just on the crown of the future But when the root get exposed due to the dental disease are the forms of trauma Malacruzion and things like that then you can get care used to pay over the root of your teeth as well

so in children the sort of typical caries that we see are on the occlusive surface correct? Mostly, but one of the most common caries we call early childhood caries, which is caused by baby bottle children that like got the breastfeeding but the bottle overnight and many times a day. So it's mostly on the antigen. I don't know if you had a chance to see it, but the care developed very rapid because the milk of coma late in that area and extremely painful is actually one of the most common then the diseases, the most common disease worldwide due due to that, carries, everybody has dental care. Why did you say it doesn't happen with breast milk?

Because the breast milk, we have studies showing that it causes much less decay than formula, because every formula has sugar. So what is it about sugar? We all grew up knowing that sugar was the worst thing for your teeth, but what is it about sugar? We all grew up knowing that sugar was the worst thing for your teeth, but what is it about sugar? Is it the fructose? Is it the glucose? Is it the combination of them that leads to an

a rapid overgrowth of the carry causing bacteria? It's all of them. It's fructose, sucrose, lactose, macromplex, starch. They are even worse. All the complex starch, they are even worse. All the drinks today, they have added sugar, you name it, everything has sugar. But the main mechanism is very simple actually, is that the carogenic bacteria, they love sugar, they metabolize the sugar, it's actually energy for them. Every time that they see it, so they have capability

to attach it to the surface, all the spectators. So they get together, they stick to each other, and they have the ability to secrete that extra cellular matrix that is like a glue and we call biofilm, and that attach to the tube. So every time that you put sugar, they take that sugar, they metabolize that sugar as energy source and they multiply and they grow with other food that

we put it on on the other captives as well. But what happens that when they might metabolize sugar, they say, creep acid and that acid is the one who just saw the mammal future. So that's exciting. So that suggests that they're metabolizing sugar anaerobically to produce lactate. If they're increasing the acidity of the environment, presumably hydrogen ion is coming out with lactate. They're doing this not in mitochondria. They're doing this outside of mitochondria. This is almost like the warberg effect

where whether oxygen is present or not, they always choose anaerobic metabolism. Do we know if that's been looked at? Probably yes, but I don't remember. And also, you say sugar, but I just want to be clear, do these bacteria have a preference for glucose over fructose? Obviously sucrose is both. It's an equal mix of them, but I want to get very specific on this point is fructose specifically more harmful, because if that's true, then sucrose would be more damaging than say starch, which would just be pure glucose.

I think the glucose is the worst, especially when they do zero, when they intensify with high concentrations of sugar, but technically all of them can be metabolized, even the fruit dose from fruits, they can metabolize that as well. Do you have a sense of how our species survived before we brushed our teeth? How they survived? Yeah, I mean, when you think about it today, if after two weeks of twins not flossing their teeth, never mind not brushing, just two weeks of not flossing, you're able to induce significant parodontal disease where you actually had

gingival disease that would induce bleeding in the gums. And now let's go back in time, 300 years, which our species looked the exact same as we do 300 years ago. It's not like we're talking Neanderthals, but presumably 300 years ago we didn't have tooth brushes and dental floss, did we? Like do we know what oral care consisted of three or 400 years ago? Well, we know that for 100 years ago, we see from research that people have,

we don't do disease, they have dental cares. This is not new. But like, if I look at populations from developed countries, for example, I go to Africa and I do a lot of research there. They have like some plants, they have like a stick that they use and they clean their teeth with that tree that they find. So I'm assuming that people just use

different devices to clean their teeth because if you think about the removal of plants, they can't cope the brightening. You need to just drop the biofume. devices to clean their teeth because if you think about the removal of a plaque is mechanical the bright need. You need to just drop the biofume. What we do with brushing, we're just trying to just drop that matrix of the biofume, but they form again. Research shows that you clean, you can have the mouth with zero plaque in two hours, you

have them all formed again, they colonize back, but we're trying to do it with the brushing, just constructing that we don't that lack that accumulate and be like overwhelmed in the other cavity. Yeah, I would assume that the food consumed somehow, even though obviously people hundreds of years ago still consumed glucose and fructose, maybe the form in which they consumed it was less concentrated and refined, which I suppose we know it was. And so they had less of an insult to the tooth. Every time I've had a bad dental pain, I've said to myself, how would I be functioning right now if this was hundreds of years ago? And I didn't have modern medicine with lidocaine and a very good dentist who could take care

of this. Like, again, I want to go back to this point earlier, it is the single most uncomfortable pain imaginable. It's horrible. To have pulpitus or any of these things, you can't function. And highly preventable. Well, yes, yeah. We'll certainly get to that. But again, I'm just constantly amazed that our species would have had to presumably suffer quite a bit until we figured out this ability to clean these things. Because it's counterintuitive, I think, now it seems obvious, but if you're sitting in a cave 10,000 years ago, I don't know that it would have been the most obvious thing

that you need to remove this thin film biolayer on your teeth. Yeah, but I think the diet fibers, everything was very different back there. So they were the modernization and the amount of sugar everywhere that look. Sometimes you can even buy anything because everything has sugar. I think it's a big change on the culture and what we eat, how we do things today. I think it's much worse. So let's talk about the brushing. I once heard somebody say that the toothpaste is far less important than the tooth brush. In other words, you could almost brush your teeth without toothpaste, but if you did a good enough job just using a wet brush to brush you were getting most of the benefit.

Is that true? I tend to disagree. I think both are equally important and I'll tell why because the toothpaste is the main source of fluorite. So the fluorite protects your team and hardening the lemon and from that's against cavity, especially in children. It's extremely important that you get exposed to flu, right? If they have high risk of care, there are other sources you can paint, you can have vernis,

you have a bunch of approaches that you can preserve oral health in children, just by brushing and flu, right? It's all about education. So, in the philosophy, it's a combination. You have to clean in between your teeth, you have to clean the surface of your teeth, It's all about education. So in the philosophy, it's a combination. You have to clean in between your teeth. You have to clean the surface of your teeth and you need to put four right. And I'll tell you more, now on my new clinical trial,

I'm actually brushing the olo mucosa to decontaminate against bacteria. So I still think that is another neglected surface of the arachabative, is all the olo mucosa, the arachabotus, all the oil and the coca-de-tongue. Most people don't brush the tongue. And there's a lot of bacteria that accumulates in the tongue. You need to clean every single surface and just a brush itself is not going to be the job.

When you say brushing the tongue is the purpose to remove bacteria? Yeah. Okay. And what about the rest of the oral mucus? Do you mean brushing the gums as well? Technically, that's not standard care. So the way research has done and proved that you can maintain an optimal oral health just by brushing your teeth, by flossing really well and having good nutrition and all those things. Of course, there are phases in your life where like, in the specific case of my population, they're undergoing radiation

college, they have a lot of osuers in their mouth and they can drink, they can eat, or they cannot brush their teeth because it's so painful, because of all the osuers. And then there is a whole just the osu, there are h that occurs in the oral cavity on top of this has radiation and a bunch of things. So on that specific population, they need a more intense oral care program where we clean the period of dawn too, we clean the teeth and we contaminating and brushing the oral composer. So it depends, it depends on the risks. It depends on the population that you're treating. It depends on their ability to brush every oral hygiene program. I think needs to be personalized to the person, to the age, to the risks that

they have, if they have dry mouth, if they have different diseases that affect your cavity. So it's a holistic approach that not one regime would fit all. Is the importance of flossing the mechanical removal of food particles between the teeth, or is it the actual transient irritation of the gum that actually provides the benefit. Because you can imagine a thought experiment where a person's subsided on an all-liquid diet, so there would never be food particles that are between the teeth, but where they might still benefit from flossing, or more directly, they might still experience a harm from not flossing.

At least that's my hypothesis, which would suggest that the benefit of flossing is not just the actual removal of the gross large particle, but it's the transient irritation that's created at the gum surface. Do you have a point of view on that? There have been research on that. Some people on the opposite direction, that my, if your floss, for example, a mouth, someone who is immune compromised,

you might see nurses and doctors saying, don't floss. Yeah, what about non-immun compromised people? I don't think that is any harm on flossy. In my, give you more resistance to those constant exposure to bacteria, but mainly is to clean that anaerobic bacteria that is really hiding in between your teeth. So that's the main function of flossing. And the brushing, if you think about brushing, is also stimulates the gum. The gum is not different from any other muscle or in your body because it needs to be really strong and attached around your cheek.

So the brushing as well, it helps a lot with that dynamic constant because in massage is all your gums you appear don't do. And I believe that is a good benefit as well. Is there a benefit or a rationale to flossing before brushing, which for some reason is the way I've always done it, I don't know why. Yes, I love that. Because that's usually how we recommend. Actually, I asked them, you've brushed your floss and your brush again. If you want to be perfect, because when your brush you remove all the biofilm of the bacteria and your surface your beauty, then you need to rinse your mouth well to just get everything out,

and then your floss, but imagine your floss and then you throw in all that bacteria back in your cavity, then my populate and recover nice again. So that's what I say. You just brush your floss. We either rinse your mouth really well after that or you just quick brush again. That would be the way if you want to be obsessed. And then you need to brush your tongue because back here, even the ones that you're flossing and throwing out the mouth, they might just colonize the tongue

as well. Some people have fishers on their tongue and then allows them to get in. When we do studies and I collect bacteria, for example, swaps from different parts of the mouth, every study that we do, we collect that. Buckle, left, buckle, right, tongue, thought of mouth, throat, every surface of your mouth, you find your

convective. So your tongue has a different colonization from your buckle, from the floor of mouth, from the throat. Troll, do we know colonized by bacteria and vitals, the HBV vitals, it's highly associated with all of our angel cancer. So all those variations they do different things. But you don't recommend also brushing the buckle surfaces or other surfaces if they're also a great source of bacteria. I don't think I can recommend because it's not a standard care. So everything that you recommend, for example, the trial that I'm doing right now, are implementing an oral care that doesn't exist. So no one tells people, patients who are going radiation treatment that they need to see

a periodontist and do a periodontal treatment every week. That's how intense it is. They come, we do the whole development of the periodontal, we clean the oral cause, we clean the teeth, that doesn't exist. And if you ask a dentist, they're going to say, why I need to do that. And that type of procedure as well is not insured. So if you get a patient who you're doing undergoing radiation treatment, they can get speech pathology.

They go to see the oncology, they go to see their nutrition. This is all part of the healthcare system. And this is all they can charge to the insurance or Medicaid, Medicaid. All health is not part of that. And I want that to be part of a magically compromised patient that same way that they need to see a nutrition, they need to see all health specialists.

Because that's gonna help them respond to the cancer treatment. They're not going to have the burden of infection, information in the amount and of course, they're going to perform better. They're going to eat better because if they have ulcer, they're not going to be able to eat. So there's a whole benefit around that, but there is no insurance would pay and there is not a standard of care procedure. So I'm doing the research, I'm collecting all those buying markets and I want to prove the benefit of that. And once I prove the benefit of that because now I do the

clinical trial, I might be able to push and get all the centers and other people to do it. And that might become a standard of care for this specific population. Now, is there evidence that cancer patients, because of two things, their immune compromise through treatment, coupled with the increased susceptibility and the loss of immune barrier in the mouth, are actually at greater risk of systemic infections that arise from the mouth? Yes, there's a lot of systemic infections that arise from the mouth.

Yes, there's a lot of research on that. And that's what I believe as well. And when they're going on top of everything that is going on with them, they have horrible dry mouth week two or three, the some patients cannot produce saliva anymore because the radiation damage they salivary glands. And that's changed the whole oral microbiome allows opportunists organisms to prevail so they have a lot of

full-go infection because of the issue that they have with dry mouth and that escalates a lot of local infection and inflammation and they are a cavity and affects them systemically because I don't have data from 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 trial that I'm doing now, I saw that main inflammatory markers. I look at saliva, inflammatory markers and microbiome, before they started the trial and three months after they completed the last dose of radiation. And then when I look at cytokines, I sample several cytokines in saliva.

Most of them, they are completely suppressed on the oral cavity. They all cancer patients, but the group that I didn't do the incredible dental disease, they all had even increased on those. But the ones that I did this very comprehensive, they all gone suppressed on the negative. So it's clearly showing that that's something going on, systemic on those patients, that is just because I'm brushing your teeth. And the way my studies started, that's why I always say that you make me so happy when I'm discussing auto health with MD like you, smart that understands a lot about those things,

is that I started my life when I was at NYU and I used to work with all the radiation college and all the surgeons that you're doing surgeries on the patient. So they diagnosed the cancer and because I was doing research, I would go to the OR, collect the samples and take over the patients throughout the whole research when they're looking for all the cancers and all those things. And I started looking at those patients now and they said, I can't believe that there is not a single doctor who is looking at their mouth. They have horrible oral hygiene.

They got the cancer, they depressed, they start radiation right after surgery, which they already can't brush their teeth, because sometimes they lose half of their jaw, they take their tongue. So they're high with their ability, they're so they start brushing, and they're going to radiate. When they take their tongue, so how your diabetes, so they stop brushing and they're going to radiate. When they get into radiation, then comes

with arching, radiation also changes the microbiome and they develop horrible ulcers in their mouth and then they become immune compromised. So it's a whole cascade of things that happen in those patients. And then I started, one of them, I came to the oral surgery and I said, do you mind if I start cleaning your patient's mouth? And I said, why do you want to clean? And I said, well, I know he's going to go into radiation. Let me do a dental clean. I can't look at any more the way to say,

I said, Pat, do it. Whatever you want to do it. So I start doing my cleaning, periodontal disease, and after I treat it, and they were going through radiation. Some of them, I'd say, well, I'm going to clean your mouth twice a week. Radiation is usually sticks to eight weeks. So if I clean your mouth,

have it two weeks, at least you're going to get a baseline, middle-adreation, and end. And others will say, well, if he's not responding well, I was just starting to frame, say, what can I do to get a good oral health. Others I start every week. And then after I treated like 10 patients, I got a call in my office with the, he was a head, his name is Nikos Samphalipo. He was the head of the, had in that crew. And he said, I never had not talked to him, but he was the refers from our

patients because you have the cancer, you have the surgery or not. And then you radiation on colleagues like it refers. So you need to find a radiation on a college that can see your patients. So he called me and said, Pat, can you tell me what you're doing with my patients? And I was like scared because I knew that wasn't like a perfect, like a standard of care. And then he said, well, I have maybe eight patients that you treat it and they don't develop exercise.

And they're sitting on my waiting area and they're talking to each other, well, I went to CPAT, that's just doing that, that's just doing that. And then I said, can you tell more what you're doing? And I said, Nick, you're going to laugh, but I'm brushing your teeth. Of course, it wasn't that brushing, but it's oral hygiene. And he was going to say, Pat, can you do a pilot and fascinating by that? Then we did. We saw 16 patients. That's the pilot that I submitted and we got the grant.

But there was how everything started. Was him? Call you and say, what's going on? Now, how in depth was the oral care you delivered to these patients? Is it the type of thing that they could do for themselves if taught or did it have to be done while they're sitting in a dental chair and by someone who was highly trained?

It's a combination. Actually, on the current trial, I'm trying both approaches. If I can just give a baseline to me, because if you someone has a lot of plaque for a long period of time and you haven't brushed for six months, for example, the plaque becomes harder and becomes doctors. No one can remove that unless we have a very specific ultrasound, it's an instrumentation and it's very hard. That's what we do every six months when we go and get our dental cleaning.

Yeah, they either scrape your teeth with a very sharp instruments or they use the electronic one to disrupt and take it back. So at a minimum, you have to do once in a dental office. But in my trial, I'm doing both because I don't know which one is better. Nobody ever did before. So one group I'm doing the mechanical, the Brightman as appeared because I don't know which one is better. Nobody ever did before. So one group I'm doing the canicle the brine as appeared you don't just. It's the same even I go sub-gente for. I'm trying to flush every toxins that I have sitting on the ormokosa inside their gums,

all the gums on the tongue I brush and floss's, there is not a single surface on the aircraft that you don't clean. How long does that take? Takes one hour on the chair. The other group, we give them dental hygienics come every week. She in reinforced the importance of brushing, flossing, and she flosses the patient now, tell them how to

try to do that. So it's just to blind the study. They both come to the clinic. They didn't have to pop it because it's just a brush. But we want to blind so both groups come to the chair and the hygienist does a light, clean, flossing only and brushing or she does this comprehensive approach that I put together which is Something that is striking going on right now my patients in Arden who they're not the following their disease

Just to make sure understand how many of these patients are patients with head and neck cancer Where they're either directly receiving radiation to the mouth or this area, which is resulting in the deterioration of the environment versus patients with other cancers whose chemotherapies are rendering them susceptible due to the mouth sores that are pretty common with chemotherapy coupled with the anticolynergics that can dry the mouth out. On my population, because I wanted to do a more controlled clinical trial, they all had an ac cancer, scheduled to undergo radiation, the had an ac cancer can be different areas of the had an ac, but I have a very strict inclusion criteria that at a minimum 50 grades of

radiation is to be delivered to the oral cavity due to the cancer. Because I know that in this particular condition, 90% of them will develop mecosides. And this is male and female? Male and female. And we have RT only and we have combined treatment. RT plus chemo, 100% get hucosis. There's not a single patient. If you have a combined program,

regimen like that, it's very aggressive. They all, and they're on top of that, they get immune compromised. So. But these are mostly squamous cell, not lymphomas and head and neck lymphomas, correct? This is mostly squamous cell. Yeah.

And how many of these patients are HPV positive? Probably 90% of them. All of our angel. All of cancer, it's very more incidence, which is known by research, as only the all of our angel cancer that has been linked to the HPV. Most of them are HPV positive. This is an interesting epidemic that's getting very little attention and I don't know why, but I think these HPV driven, squamous cell carcinomas of the Oro-Ferengil region really frightened me because we don't have really adequate ways to screen for them the way we can screen for HPV cancers of the pelvis and women unless people are doing very advanced imaging like MRIs, they're often caught quite late.

What do you think accounts for the rise and incidents we're seeing of this cancer? I mean, it's obvious that it's the HPV, but is it just sexual transmission? Like why are we seeing? It is sexual transmission. So we were in condoms. It's all sex. We know today that is sexual transmission.

Of course, combined with poor oral health, they might cause disease or not, because we know there are like several cases of bacteria they have a very symbiotic relationship. They allow virus to grow, like the Pigeon Surveillance and several studies that show that they can allow other virus to grow. Immune system deficient as well. We know that every time that immune system is not strong, allows virus and bacteria full-reflection to grow. So, but it is, it's just, you need to modify habits so you can prevent.

I want to go deeper into this, but before we do, I want to actually go back to some of the more mundane stuff, the blocking and tackling of dentistry, and talk about carries again, and what the stages of carries look like when the tooth can be preserved. So when you're just replacing a little bit of an amul, and then what that next layer of damage looks like that ultimately leads to a root canal, presumably once the pulp is irreversibly damaged.

And then ultimately, when even that can't be reserved and a crown is no longer sufficient and you have to replace the whole tooth, can you? I know you have some nice figures on that. Can we kind of go through those different stages of dental care? Because I think it is important to see these images. It certainly helps me understand what's going on. Give me one second. Can you see the image? Perfect.

So technically, the first initial stage of the end of decay is the one that breaks through the memo. The very sipiently case, they haven't got to the second layer of the tooth. And those are the ones, some of them, even like we call white spot vision, you start the decalsification, they can be reversed. If you have a child, you can have a very intense war, right? Vernis application, they are in reverse. So most of those very simple visions we should be touching or treat. And to be clear, is this the type of thing where the dentist will use a little probe and say it's a little bit soft there, but I think it's okay or it's a shadow on the tooth. Yeah, they are like some controversial that in the past they would have that very pointy probe and they would poke

and do inspection. Today, most people, they would clean and they look with air because you don't want to break the animal more. Yeah, because if the animal is already with loss of minerals, you don't want to be poking. So you need to be very careful when it's a very superficial case like that because you might want to restore in a different way. But this is not painful. The enamel carries have come nowhere near the pulp so no one feels anything. There's no cold insensitivity or heat insensitivity. Very, very minimal. Most people, they just don't even know it's there. And then when it gets close, the more it gets

closed, the poke because it has so many nerve, the more painful it's going to be. The dentching now is very soft. So it's more like a sponge that it's there with very rich inside. So the moment it is the dentching, it's painful. So that's when you're going to start feeling like you get something cold and say hmm something is different my two. Hot is more signs of inflammation if you feel the hot surfaces, things that you put in your mouth or when it gets infected in the bacteria can come to that hole and start colonizing then it starts the inflammation and is that pulsation that you feel and the pain now doesn't stop. Before you get to full-blown pain, when you're just dealing with temperature and sensitivity,

is there anything that can be gleaned clinically between the cold versus the hot and sensitivity versus both? I'm not an end of the dentist expert, but most tests that they do to look for inflammation and infection, when you have more of that hot sensation that is painful, you know that you most likely might need to do the good canal because it's highly infected inflamed. The cold, it's a little bit better because it's not

in more advanced stage. And then when you go, if the decay progresses, that's when you see on this other two figures is that it hits the pulp. The moment it hits the pulp, there is no way you can not do the root canal because now everything is already infected. And most root canals are done when the pulp is chewer like they just excise the pulp and clean it, just in fact. So it's not from a dead tissue that has been there for a long time because it's hard to keep up with the pain. But just to be clear, the dentin carry can be fixed without a root canal. Yes. If it is not as close to the pole that you got to the point that is infected and broke through,

you can restore. So this is my own personal misery. Both root canals I've had were from what I now believe were dentin carries. The first one was actually a dentist that wanted to change an old filling that I had from when I was a child. So I had an old mercury filling from when I was a kid and fast forward 20 years. He said, you know, your insurance will cover the changing of this to a white filling. We should just change this out.

Keep in mind, for 20 years, I had no complaint of this filling whatsoever. And the moment he changed that mercury filling over to a white one in the process of mucking around, that tooth started really hurting. And over the next couple of weeks, the pain got worse and worse and worse. And ultimately, I needed a root canal on that tooth. So needless to say, I was very unhappy about that. Let's sleeping dogs lie. The next one I had was the same thing. It was another filling that the dentist thought, in this case, hey, I think there's another little carry next to it. It should be an easy fix. And it actually was on a wisdom tooth, but my mouth seems to be big enough

that I'm able to tolerate having all my wisdom teeth. So he said, look, we can do a root canal. I'm sorry, this was before we needed the root canal. This was just, hey, we'll just fix the carry there. But same thing, I ended up hurting and hurting and hurting so they ended up doing the root canal. I still have that tooth with a, they didn't even put a crown on that one actually, which is amazing on a wisdom tooth, not to have a crown, I assume. So you said something very interesting that's counterintuitive, I suppose, which is most times you do a root canal, the pulp is actually alive, but you still have to remove it all. I mean, once they anesthetize you, they kill all that pulp. So the process is remarkably crude. They're using these little fine, I don't know what you want to call them,

they're almost like needles, but they're a bit bigger, and they're sort of serrated. I remember wanting to play with these things after I had my root canal, but it's like these little, you wind these little serrated jagged tools into the end of the root. It's basically a very mechanical procedure. It is, but today they're very sophisticated. They do all microscopically. I think in the past they had a lot of the issues from 100 years ago, is because we're not sophisticated enough. So they would put those fine things and they would break through the roots because they couldn't see well and they caused immediately like the inflammation they reaction because you're just perforating everything but today if you look today how they treat pyrodynamic disease it's a microscopic surgery so they just put the truth under the microscope they're completely as septic and violent because they put their strebub and to isolate, to not let the bacteria

from their economy to get inside, and they do the whole excision of the probe. They just infect everything and they feel in with special materials to just feel the whole. It becomes like just a cast, the truth, because there is no more vitality on that tube. But yet, preserved function, which is extremely important, that's why you shouldn't be extracting all your team, unless you really need it, because it's not even that influence is better than your, even without having a root canal, it's not better than your natural.

Yeah, I mean, I think that's probably one takeaway here, which is, and I wanna talk about the concerns that people have around root canals because it seems to be one of these very controversial topics in some small circles. But if you're going to have a root canal, it seems to me that you have to have this done under a microscope by an endodontist. I just think the days of freewheeling root canals where a dentist is looking through his or her regular glasses and ramming these things through just doesn't make any sense.

And I know that both of my root canals were done initially in that way. Ultimately, both of them needed to be corrected by endodontists who did it with microscopes in a much more aseptic fashion. Ultimately, one of them ended up developing an abscess many years later. That tooth needed to be extracted. Which, by the way, after that tooth was extracted, I was relieved of so much pain that I decided in a temporary moment of insanity. I wanted to, in that moment, have all of my teeth extracted and replaced by implants so

I could never deal with this again. Of course, that's an idiom. Yeah, yeah, yeah. No. So let's talk about the controversy around root canals, notwithstanding the discomfort of them and things like that. Basically, the controversies are root canals, are a dangerous procedure, and they lead to kind of fill in the blank.

And fill in the blank is, I've heard everything, right? I've heard people say, oh, root canals cause cancer, they cause Alzheimer's disease, they cause sore toes, you, it root canals cause cancer. They cause Alzheimer's disease. They cause sore toes. You name it. What is the state of evidence about the safety of root canals? Or frankly, the state of evidence that root canals are indeed potentially hazardous? It's hard to say in a nice way.

But I think it's a total nonsense. It's been for it's 100 years ago that all those focal theories that they said that would exist, there is zero evidence, a Nick, there is no research, there is nothing that can prove that this is true. If you think about, I was even the other day talking to one of my faculty because I said I'm not an end of don'tess so I've done you can out but it was a long time ago but I was asking him what do you think about that and he said the same thing to bet that's there's no common sense on what's going on is that focal point of infection but what he said is that if you think about the most root canons, the way they start is through

the crowns and the same bacteria that colonize your tooth, goes inside the pulp and then comes and goes inside the root and that's the infection that we are saying, that it's causing all those infections. But this is all in your body already. And if that's the case, every time that you have dental cares, you need to extract the tooth because it's all the same route of infection. So when I think about all those things and talking to them, I think this makes no sense. There's no way you can explain that.

And again, I still think if it is well done, of course, there are a lot of root canals out there that people don't know they're doing. They don't clean well. They leave things behind or they perforate. And we see if you how many radiographs we take and we see a fuck or infection on the dirt. But that's because it's small cracks or someone or not even they couldn't see well to do a proper way. But in today, most root canals, if you walk in the clinic today, they all under a microscope, and I can guarantee it is really well done, the process. And people don't have issues after that if it is well done. Yeah, I mean, I guess the question is, even in the cases of root canals, which were not done

ideally, such as mine, beyond the local complication, which is the need for subsequent root canals, which were not done ideally, such as mine, beyond the local complication, which is the need for subsequent root canals, ultimately the need for even an extraction, does that pose a systemic risk, even when it's done poorly? I don't believe so. Most have localized, there are few surgeries that they do, and they open through the gum and they clean that area

And you see that improve with this root canal for example There are other papers who say that people with root canal have breast cancer for example But then they look at a hundred of women that didn't have root canal and also had breast cancer Yeah, these epidemiologic sort of I call them bottom of the birdcage papers, because that's about what they're good for. They're the papers that say, well, if you look at the number of women who have had a root canal on the same side that they get breast cancer, it demonstrates the relationship. But these papers always fail to look at the numerator,

which is all the women who develop breast cancer who did not have root canals. Yeah, so it's true, true and unrelated. And it's unfortunate because I think it, I think what bothers me the most about this type of pseudoscience is when a woman gets breast cancer, it's already upsetting enough. I think the last thing she needs to be told is

this is because you had a root canal five years ago. That's probably the biggest issue I take with this sort of nonsensical science. And unfortunately, it tends to aggregate from the same group of people who tend to have other beliefs that are very unsubstantiated, such as vaccines causing autism and things like that. So there tends to be kind of a core group of beliefs like that. So let's go back a bit to the kind of broader theme of these systemic diseases. When you think about major chronic diseases, is it safe to say that the greatest causal relationship we have between poor oral health and poor systemic health would be with cardiovascular disease.

Or do you think there are, first of all, how strong do you think that relationship is causally and how does it compare to others? There is a lot of research showing association. We don't know what comes first. So they show the relationship that's proven with dental disease and diabetes. But all those diseases in low birth weight. They don't know disease and heart. There is a hypothesis, of course, it's all based on the insult of the bacteria causing inflammation and systemic health.

We know that. And other things, Alzheimer's, for example, I'm like in the brain and I feel started that we did showed markers as well, don't the disease and markers of Alzheimer's. So they all associations, but the only way you can say casualty is if you do a clinical trial, you need to treat those patients and see changes on those markers. And then you say, see, I changed their behavior, their brushing machine, now look how better they became.

So you need to do those things. We have a group of people that I work with from NYU, since I was at NYU, Moni De Leonis, his name, and Dr. Camer. She's been for over 10 years trying to make the point. She has all those papers. She's sought, for example, children that have mortal skills or I think she has studied was in, I just blinked here now, the name of the disease. But we found in children that they have, I'm not better, I'm not in the brain, it's aulation, and we know this population has very poor oral health. They have cold untighted and six years old, it's down syndrome.

So the first study that she looked, it was down syndrome. So we know because they have motor skills, they have cognition issues, it's a very hard to brush and you have a mundane and good all hygiene So that's interesting so because we know that children with Down syndrome are very susceptible to Alzheimer's disease and Cardiovascular disease in fact people with Down syndrome usually do not live a normal life span and they usually succumb to These chronic conditions much sooner as early as in their forties or fifties. So you're saying that, well, again, it's hard to know if the increase that

she sees in Amaloid is an independent process that's being driven by the chromosomal abnormalities that are found in Down syndrome versus related to the poor oral care, which could be true, true and unrelated. It could be that they have poor oral care because they don't have the life skills developed to provide oral care. So an interesting experiment would be a longitudinal study of two groups of peers with Down syndrome,

one that are provided intensive support for oral care and one that are sort of standard of care. But again, those are very difficult studies to do because they're very time consuming. Well, they are, but it's all about prevention. How about to be intensified, a very intense, preventive approach so we don't let their child be with carries and productive disease and pain and inflammation and all of that. It's not only that disease. It's any people with disability. So like we just opened at Pan right now because the jeans Vision Mary really he's really focused on prevention. He opens a center for people with disabilities. So any person who has any model skills or had any disease that impact cognition, we're going

to create this program that we can do a lot of research. How is the best way of feeling took place, took brushes, what can intensify this population which through care givers is a whole education process because it's not them. We need to educate people who are taking care of those individuals to do an optimal oral hygiene. It's simple as that. Can we just brush, brush, brush, who arrive intensifying?

Because you can prevent all those things are highly preventable. But I was looking for, say, what are we gonna measure? There is no outcome assessment that you can use for this specific population because they're so neglected. But going back to your earlier point, just to make sure I understood,

did you say that if you took two groups of people and one group received excellent oral care and the other group did not. And this is not in cancer patients. Let's just say patients who are not immune compromised and whose oral mucusa is not compromised. So if this hasn't been done, consider it a thought experiment. One group receives best in class oral care, which I want to come back and define. The other group receives horrible oral care or mediocre at best.

Would you expect to see a difference in inflammatory markers, including cytokines and inflammatory cells, macrophage, monocyte, derived lineage cells across those two groups? Because if that's true, that alone could explain the increase in systemic disease. In other words, that could be a causal factor. It's undeniably well-established, the relationship between inflammation and cardiovascular disease. You could take two people that have virtually

an identical profile of lipoproteins, but in one group, the high amount of inflammation will lead to a greater burden of disease than in the other. Inflammation plays an important role in cancer, and certainly inflammation plays an important role in Alzheimer's disease. So that, to me, seems, that's the Occam's Razor approach here, which is poor oral health leads to poor or substandard amounts of inflammatory environment, and that's the driver of these diseases.

That would be my guess. Yeah, it's very simple. But think about, when did you ever go to a doctor, you are MD, that the doctor asks you, how's your mouth? You have a dental disease. How do you brush your teeth? Think about when. Sure, it's not at all part of the doctor's toolkit ever

So look what's going on with COVID COVID is a Infection disease. What is the transmission of COVID? saliva as the mouth now their papers coming up because of the AC two receptors Which is the COVID bind to enter the body, they are highly expressed in your practice. Look at the literature, they're in the tongue, floor of mouth, gingibu, kruviku, food, they're everywhere in your mouth. So, a patient gets COVID, the two things that I'm like very like surprised and saying why people are not doing anything. So, people get COVID, they go to the hospital, the first thing

that they do, they put them on a mask, they never brush their teeth, they don't look if they have preventative symptoms, how is the quality of the oral cavity, they put on the subpoena position because they need to free up the lungs and their patients spend a lot a month, some people more than that in a very critical condition. I think this is going to lead to promenary infection, of course, if someone has periodontal disease and already have a lot of bacteria and pockets, all the periodontal pockets is a perfect reservoir for the virus to thrive. And even like the new, you know, if you saw there is a publication that just came out only hypothesis because nobody ever tested that it might be, if you look at the characteristics

of COVID, the way manifests, the upper respiratory tract in terms of secretion, how congested you have is very minimal. You might have a stuffed nose, but from the mouth goes directly to the lungs. So there is a huge connection there. No one is doing anything for tell people, can you brush your teeth? Do a mouthwash, clean your mouth. If you have COVID, you have to have an excellent, and the hospitals give the nurses,

you have to ask the patient to brush because no one is doing that. Look at the committee. So of course now science is going back because our new president they have the very they fostering all those prevention max and everything. Look at the committee that we have that was being put into support COVID. Is there any one of them is a oral expert? that any one of them is an oral expert. I'm guessing not. Or a epidemiologist, an oral periodologist,

is anyone there, if there are anyone there that understands a little bit about the mouth, if you connect the mouth with the body, I can guarantee that you can prevent. Look up, it's going on in Brazil, China. It's just ridiculous because there's no prevention. The only prevention is the mask, which we could do something better.

Some argue that last year, we saw a great increase in the rise of dental carries. Some suggest that it had to do with mask wearing. To me, it seems the most obvious explanation would be simply that people sought less dental care last year. Do you have a point to view on, first of all, is it true that dental care he's went up last year? So what happened, it's, that we're still dealing with that, is that when COVID hit, dentists

was considered not essential. So they shut down everything that wasn't essential, which helped care and places that you can buy food and things like that. So, dentist was left behind. So, dental clinics, I know because I had to suspend my finger trial for three or four months. I came back immediately, the moment they allowed me to open the clinic, but dental clinics, they were closed closed, completely closed, were about almost a year. And on top of that, they suspended every single type of procedure that produces a result, because they thought that was a way of effect people. So people couldn't go to the dentist. You saw horrible things on the internet.

We had left our emergency clinic open only and we saw really detrimental things because people couldn't get access to care. So combined with, of course, putting masks and if you wear your mask at work a whole day, you forget to brush because you can't drink too much because you need to hide because you have to drink water or eat. So everything is detrimental You might breathe more through your mouth because the mask people don't know how to breathe well through the mask So it drives your mouth you have dry mouth because you're breathing so this combination of

Or hygiene you have dry mouth you have a mask So it's not the mask that is calls you anything, but it's just a homoolative effect of everything that is going on. Yeah, that makes a ton of sense. You mentioned Thresh earlier, right? So oral Canada, and you mentioned it in the obvious context of people who are immune compromised. But from time to time, I've seen people with a totally normal immune system develop oral Thush. Now I will say there's usually something going on like they're usually on an inhaled steroid for asthma or

something like that so maybe that's partially explaining it but do you have any other explanations for how a person with a normal immune system could develop oral candidate or thrush? It's highly associated with candidate infection. And it can be through, I think the primary reason is lack of saliva because your mouth is dry. So that's why in MDs, they show up at their patients and how much much they have. And ask the question, you have trauma. They might have in other complications

that you don't even know why, but primarily, I would think it's poor oral hygiene, because if you have no dental disease and poor oral hygiene, you're gonna allow those opportunistic species to grow and medication, they don't have a specific cause but Mainly I'll say medication and poor or health would allow virus to grow. You mean fungus Fungo. Yeah, I've said virus because virus and fungal they walk really well together like people with HIV They have episodes

together, like people with HIV, they have episodes constant of fungal infection in their mouth. So there are lots of reasons why people could have dry mouth. Certainly, one of the most popular classes of drugs that would do it are anticolynergics. It's also interesting, by the way, that there's some strong associations between anticolynergics and Alzheimer's disease. It hasn't been demonstrated whether that's causal, but if indeed anticolynergics, which lead to a very dry mouth would increase, the, or rather decrease the resistance of the bacteria in the mouth to the systemic system, and that could play a role. So it becomes very interesting.

But for an individual who has dry mouth, is there a downside in using sugarless chewing gum or Laws and jizz or sort of having something in the mouth to induce saliva? Is there a downside to that? Is that considered one of the effective methods that someone can use to keep their mouth lubricated? Yeah, I don't see any Wrong doing that, but never use anything that it's sugar content. A lot of sugar substances that you can do because you can stimulate the salivary glands and you constant moving your tongue and your mouth and I always say hi-draination, it's extremely important

as well. If you don't like to drink just get a sip water all day long We always washing the all-acabit the gas intestinal tract because it's all one system It starts in the mouth and go to the back here. They are all together So always hydration and drinking what I think it's very important for all health as well Now have you looked into very important for all health as well. Now have you looked into xylitol specifically? I've seen some literature to suggest that xylitol may actually not only not be harmful because I think there are lots of things out there that are not harmful, aspartame or

any other things that might be thrown into gum that are sugar substitutes, but that xylitol specifically could be beneficial. And so I've always kind of, my practice has been to have some xylitol-based chewing gum that if I'm out and I eat, I can chew it for a while to serve two purposes. One is get saliva there, but two also kind of clean the food out of teeth. Do you recommend anything like that?

Because a person can't brush their teeth four times a day presumably at some point it becomes counterproductive. Yeah, that thing I like the most. I actually did some research a long time ago where we are looking for mothers to child transmission of dental caries. We know that as mutants can be highly transmissible for mothers to child. For different things like the mom who proved the food and put in the child's mouth. It's proven that it can transmit the strength, the child. They've done some research about kissing in the mouth. They didn't find a

huge correlation, but they know that proving and tasting the food and which is you should take a look at none is and people who are watching children, but I really like Zalipov and we found that we prevented the transmission because we gave the Zalipov to the monks. During the gestation time we asked them to chill on Zalipov just to prevent that vertical transmission of the mutants that start muting. And it prevents the cake too because the bacteria does not metabolize that. That's great great so I'll plug my favorite brand of it I use one called pure you are e you can buy it on Amazon and I like the pure gum and the pure mints so pat teeth appearance is

something that obviously people have a lot of concern about I mean we've spent everything that we've talked about to date has really been about the function of the tooth, the health of the tooth, etc. But generally, the two things people notice about somebody's teeth when they smile is how straight are they and how white are they? So let's talk a little bit about the latter. Is the color of a person's tooth genetically determined? Somehow, yes. We can see see that different races they might have more white, but it's relative as well because let's say with this person with a dark skin they keep going to come much more wider. So it's almost blend with someone who has a very white skin. Most of

the changes on tooth color can either be done by some genetic factors that people who might have a lot of very yellow and that will never change. It seems they're born or sometimes they're like in a few countries they have four in the water. So excess of the right might have some stains on your teeth, but mostly the color of the teeth, it's highly environmental determined, because we talked about my study with the twins, where when we gave the same product for the two twins, they behaved completely different. So even they were identical

100% of their genes. If the kid who had like drink a lot of tea, coffee, and things they had much more stain your teeth. And of course, the white man wasn't at the fission of another one who had last. So the environment takes place, and it's highly, you can modify just with those whitely products, brushing, things like that.

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

Does it bleach the enamel away or do something that's dangerous? Yeah, it's bleach. And it's, of course, in excess, which most people do because they want to always have an achieve wine. It's detrimental because somehow it has lots of minerals because of this depression very strong. Also, if you're allowed to touch the gums, it's very aggressive because you're bleaching and it cannot be for a long time. So what I tell people is that if you want to do it at home, because it's less expensive, ideally you should do it at the dentist. If you care about your team to do it at the dentist, they're going to protect your gum. They are going

to apply the product if you have a dental disease, if you have root care, and all those things, they'll know exactly what is the population who can have that. But people just go and buy out of the counter and they don't know what they're doing. Sometimes they place that and they wash the, they spend hours or every time they have a party, oh, I want my chief why they could again. And then becomes that post and demonization. Of course, I'm going to substitute you. You're going to harm your gums and things like that. So if you want to do, talk to your dentist, ask them, am I a candidate for that?

And do at the dentist, do at the correct timeline. Look at the prescription. Don't do cheap or produce. They're not FDA approved. So all those considerations, if you do the right way, it's OK. It's just when they go outside to do things that they should do. But it still seems that prevention is worth a lot here. If you minimize the things that really

discolor your teeth, it would at least reduce the need to do those other things. I alluded to it earlier that one of my most miserable, not one of my hands down my most miserable dental experience of my life went as follows mercury filling placed when I was whatever 10 30 years later Someone comes along and says you really ought to have that removed because your insurance company will now cover the replacement of these and you can have something white instead of something silver and That damaged the dentin and or pulp enough that I needed a root canal, that root canal. I mean, eventually, that's the one where they missed the root. I got to go back and back and back and back and ultimately led to an injury that required

the tooth coming up. Okay, let's go back to the jugular question. Should we remove mercury fillings? If there is highly functioning, there is no decay under. There are several statements and research that has been done and that's the minimum, they're afraid about the mercury that gets in the, it's proven that there is no harm with that. So if it's working fine, if you make function and it doesn't affect the appearance,

the aesthetics of the two, just leave it there. I don't think you should. You also talked about fluoride earlier. This might sound like a naive question, but does all toothpaste have fluoride in it? No, you have to look for and not all of them have the correct amount. and not all of them have the correct amount. You want to like 1,000 PPM to 1,500 PPM of four. So that's very important. And the ADA, the American Environmental Association,

if you go to their website, they have all the two places that they endorsed, not for political reasons or anything because we've done research and we know they work, they have the correct amount of fluoride that prevents decay. So it's just need to get from a good source and it's extremely important to have fluorides in any two-phase. Usually, children, before one year, they recommend not to put it because they swallow all the time, but as long as they have the first tooth in their mouth, you can start putting very small amounts and start to brush the child gets used to,

but other than that, everybody should use the right. And is there fluoride at all in any small amount in drinking water? It depends. I know that the US is very particular with fluorite in many regions. People don't like to have most countries. The drinking water is fluorated. But there are additional sources of fluorite that the nutrition they can do, like drops,

that you, even when you're breastfeeding, you can just put drops on the child or vernis which I think is extremely preventive for children. It's so simple, it's like a vernis that paint in your teeth every six months and guess what? It's about decay because it's just protecting more and more. So I do that myself also. I have discovered that I have one area in my mouth where my gum has receded just a little bit. And as opposed to putting a filling there, I just use every three to six months,

a little bit of what you said, like sort of a fluoride varnish. And it reduces any sensitivity. And my goal is obviously just to prevent any decay there. Yeah, the fluor fluoride burners. If someone is highly susceptible to decay, we have a, it's a prescription bank, so you have to ask the dentist. It's a one of the ones that we have in the market is prevalent. I give to my cancer patients, but they are highly concentrated fluoride. And we recommend that they use once every night

for people who are high risk of cares, which is people undergoing radiation. And then you do a regular or hygiene with the regular fluoride toothpaste, you floss and everything, and then you put that toothpaste on a toothbrush and then you brush and don't rinse with water. You want the product to treat

the cabbages and everything overnight. So that's very efficient as well. And mainly, and it's a very fun story to ask my son because I have two kids and none of them have never had decay. How old are they? Today they are... How old are they? Today they are, oh, 30, 34. So, but they never had decay, but if you think French is which my youngest, because I was telling stories about microbial that they're going to eat your tea, if you have food, they're going to eat the food, they're going to just go down and make holes in your teeth. So I would tell them those stories overnight and how many times they're kids. In the middle of the night,

because he would fall asleep and I'll put him like three years old in the bed. And I would, what the, the middle of the night rush the bathroom and brush the teeth because I always told them. Because the most important time of the day is actually the night's crush and never give your child baby bottles and things overnight because when you

sleep, you have a stress or saliva production and that's the perfect environment to the bacteria to grow. That's why child have baby bottle decay because when they are sleeping and they put the bottle in their mouth, the milk concentrates all on the anterior teeth and they get severe decay. So, brushing before you go to bed and you floss, you'd like a hoop that you have me up to or hygiene is really high and you're going to prevent. It's a very important Russian time. What are the implications of children having

carries in their baby teeth? I mean, for example, I assume we would never do a root canal in a child, you just yank the tooth out because you know that the adult tooth is coming right behind it. Do people put fillings into children's teeth? It's highly complicated to treat those kids. First, because you traumatize

them, you cannot do local anesthesia. They'll never come back to the dentist. If you try to do that in a regular way, because they don't understand, they have very young. It's one, two, three years old that will start with the care appear. So they do end the hospital under sedation. The teeth that they can't treat, they treat, they would extract the ones that cause a lot of pain. Some of them just treat the pulp, put some education there, and wait until the tooth exfoliates, just to preserve function, because otherwise they're not going to be able to chew. So every case they need to approach, there is another type of fluoride as well. It's a highly concentrated that they put it with a marrow together, but the tea becomes black.

That's another resource that they have because they cannot open, put a hole, and restoration, because the children have allowed us to do. So, excessive fluoride, darkens teeth? Just this specific time. Because the child will never allow us to do. So excessive fluoride darkens teeth? Just this specific time. It's mixed with a metal that the moment it gets in contact with the soft dentum, it hardens and becomes that very hard layer. Okay, so it doesn't affect their adult teeth.

It's just a temporary barrier until the tooth falls out. Yeah, our rest is dedicated in a very nice way, but you need to tell the mom, say, I know it's going to take the pain away, it's going to rest decay, but the teeth is going to become black. So it's a trait because we know that a couple of years later, the tooth is going to exfoliate. It's not going to be black forever. So it's an approach that we can do for this age of two. There's an entire cottage industry of products out there, like oil for pulling through the teeth and tongue scraping things. Are you aware of any research that supports the use of such devices? You've obviously talked about brushing the tongue, but any research that suggests scraping the tongue is efficacious or I don't even understand what oil pulling is, although I've seen the oils and I don't think I fully understand what the

claim is about why oil pulling is beneficial. Honestly, I've seen, I have no idea, there is no I have no idea. There is no clinical or research evidence that shows that it's good or bad. I've seen a few studies on the tongue scraping, which is similar with whatever the brush is doing, but I really like much better the brush because I asked the patients to put a little bit of toothpaste, because toothpaste is also until back to here. And then you just brush, it doesn't harm the cells or anything, you just brush in the surface. If I had to choose between this toothbrush, brushing your tongue, it's scraping out, say, just brush. It's simple and easy. Okay. Is there a difference between the types of dental flosses out there? So the two most common that I see, actually, let's say three.

One is like kind of the ribbon, you know, it's like a very soft, almost looks like a Gore-Tex like ribbon. The other is like a rope, a miniature rope, and then the third one would be like kind of a miniature rope that's coated in wax. Are they all basically the same and you just pick the one that is the most comfortable to you or do you have a preference for which type of floss a person uses? Well what I tell my patients, I have like 10 different ones and what I tell them, if you chew one you're more comfortable using it's a mechanical the brightening it's just rupture of the biofume and taking the food away

from in between you. So there are people who have perfecting very close together. They might need to use the one that has a wax because they're going to go in and out very quick. And you don't want to harm your gums trying to pull in something very strong and then it's going to cut your ground. It has to be done very carefully. There are people who have prosthetics or because they're like a little brushing that they can put inside, the people who have like cheap, they're connected to each other and they have another type of device

that they can go inside the bridge and clean, it doesn't really matter, you just need to clean. And you can clean most people, don't floss. Really, what does the literature suggest? And you can clean most people don't floss. Really? What does the literature suggest? What percentage of the US adult population does floss once a day? If I tell something, I might not be right,

but I know by the whole population that I treated, it's like half of the people floss. Or they floss twice a week week or something gets stuck, they go in floss, but if you ask people, do you floss every day? Most people don't floss every day. Another consideration is that floss costs money. So, me to keep buying all those supplies

and you might not have the funds might be used for different things. But if you think about flossing and brushing, I still think the flossing is even more important than brushing, because it's all the research that I did. People can stop brushing and you recover health easily. If you stop flossing, as the ginger virus, inflammation comes so quick.

Because the plaque that is in between your chin, you can never change or clean if you don't have a device. The plaque that is on top of the surface of your chin, you're eating, you're getting an apple, think they have fibers. You somehow, you just clean, you drink water, the saliva is constant cleaning your mouth. The flossing, one thing is a bad bacteria because they love, is the anaerobic bacteria that causes most of the systemic health, such cardiovascular disease, diabetes, they all are anaerobic and they are the ones that hide in the tongue, they hide in between your teeth,

they can hide back in your throat as well, because they like those niche that the oxygen don't go. Is a water pick an additional benefit to flossing? Is it at all a substitute? I mean, obviously, there are some cases where it's very valuable, kids that have braces, things like that. But how do you incorporate the water pick

into your oral care regimen? I like it, but I would say it's only if you're not able to use the traditional, the brushing is the best. Because the water is more, if you brush, then do the water pick. Don't do just the water pick without brushing. Because the water pick. Don't do just the water pick without brushing. Because the water pick is that blushing of all the toxins that are in between your teeth and

between your gums and all that, but it cannot do just water pick. It's a benefit, but don't do alone. Any harm or benefit to using toothpicks. This is just a personal obsession of mine. I love toothpicks. It sounds crazy, but when I find toothpicks I like, I buy them in massive quantities. And there's like this one toothpick I got at a steakhouse 10 years ago. And I became so enamored by it that I had to find out where they got it from. And I found the company that made it. But the minimum order was something like 20,000 packages. I had to buy 20,000 packages of this toothpick, which I still have to this day. I love them. Point is, I always have a toothpick in my mouth. Am I hurting myself? Am I helping myself?

What am I doing? I don't think you've hurting yourself. They even have research in the past that they say that it stimulates your gums and things like that. Well, honestly, that's part of what it is. There's a use case which is anytime I have food in my teeth, I love doing it. But what I've also realized is I find myself misaging my gums with the side of the pick. So I put the toothpick in and I'm sort of grinding it on my gum surface and it just feels so good to me. I still floss every day so it's not a substitute for flossing. That's what I was going to say. Yeah, it's not a substitute. Yeah. I still floss every day, so it's not a substitute for flossing. That's what I was gonna say.

Yeah, it's not a substitute. Yeah, I still floss every day. It doesn't do the same job, because the floss goes around the tube, then go up and down, but it's benign, it's nothing that I don't think any wrong of doing. That's good,

because I have enough to last me, my children, my children's children, and their children for the rest of our lives. This is, people talk about generational wealth. I don't have generational wealth, but I have generational toothpicks. Well, talking about that, the electric toothbrush, I like it a lot too. I was going to ask you about that.

Okay. So, I'm an oral bee guy. I've tried the bronze, and I've tried the oral bee. Something about the bronze one bothered me. I don't know if the frequency that it vibrated at resonated too much with my head, but I didn't feel good. I have the same. But I love the oral bee.

Okay. So is one superior? I actually did clinical trials with both. They equally good. The difference is that technology one is sonic. So when you're doing that that it's almost a few the vibrations in your head and the all of the vibrations much more natural. It's mechanical.

Mechanical and I love the mechanical because it stimulates your gum. There are people who love doing the other one. It's very fast and cleans very quick. I like the all-o-b a lot. That's the one that I have. So bottom line is they're both efficacious if you can use them both and use the one that you enjoy more. Yes, it is just whatever you comfortable and whatever you know you're going to clean your mouth. That's what I say. I've done anything, all types of flaws, all types of toothpaste, and it's a device that is there for you to do your oral hygiene. So let's now talk about the ideal reasonable regimen of oral care. Let's start with what I do and use me as an example of how I could do it better. When I wake up in the morning, I do nothing. And the reason is, I don't usually eat in the morning,

but I drink coffee. So I don't know why for some reason, I think it's a waste of time to brush my teeth. First thing in the morning, because all I'm gonna go to do is drink coffee. So let's say I get up and I drink my coffee, oh by the way, I used to scrape my tongue. I have one of those tongue scrapers, I used to do that.

And then my wife got so mad at me, because she said that's so disgusting. It makes me sick. Get rid of that stupid tongue scraping piece of expletive. So I still have it. Don't tell her, but I don't use it anymore. So I go and I drink my coffee and I kind of do all my, I usually exercise in the morning.

And I usually don't eat my first thing until maybe 11 o'clock in the morning. At that point, I then go and I get my oral B toothbrush and I brush my teeth. And as you probably know, the oral B toothbrush has like this little 30-second timer that allows you to go two minutes. So I'm very, very robotic about this. I 30 seconds on the top, 30 seconds on the top, 30 seconds on the bottom inside,

30 seconds on the bottom. And then I'm done. And then I don't do anything again except use my toothpick all day until dinner. After dinner, I then floss. I like both. I like any floss actually. I just love flossing. So I'll use the little ropey floss and I'll use the tape floss, whatever I've got. And then I do the same thing with the oral B-toothbrush'll use the tape floss, whatever I've got. And then I do the same thing with the oral B tooth brush. By the way, I'm using a xylitol-based toothpaste for what it's worth if that matters. It has fluid. It has fluid.

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

And what else should I be doing? So one little adjustment. So usually back to your year, the biofilm it takes like overnight, that's where you have the most suspicious bacteria they start growing them up. But all those reasons that are said, your mouth is closed, no oxygen, reduce saliva flow, saliva flow is almost zero because you're sleeping and things like so.

When you wake up, you feel if you stop and and think you're gonna see, yes, my mouth is dry. If you cross your tongue on the surface of your cheek, you're gonna feel the biofilm. Biofilm is invisible to your eyes, but you can feel with your tongue. That's the morning that you're gonna see. So there's nothing wrong of you. I do that as well. I like to take my coffee in my bag. I just read a little bit and I take my coffee without brushing. I love that. Brazilian coffee, I hope. Exactly. Spreads so. So then you get out of bed and you brush your teeth. You have to wash out from your night.

Okay, so the change you're suggesting is before I begin my day, do a first brush. So I'm going to be now brushing my teeth three times a day. I'm going to do that's the idea. Okay, and is it okay if that should they all be done with the oral B toothbrush or is there a time and a place to just use a regular toothbrush? You can use any to brush. If you're out, you can replace where you can brush. You can use any toothbrush. If you're out, if you're in a place where you can brush, you can use any.

Because the mechanical toothbrush, they do such a good job. Although I have to be honest with you, I've never been able to brush my tongue with the mechanical toothbrush, because I, yeah, I have to use, okay, all right, I got it. I like it.

Children toothbrush, because they're more soft. Yeah, so you want a soft to be a soul toothbrush, right? Soft for the tongue. Yeah, just get a separate one. And I tell people that every time that you use a toothbrush, most people don't do as well, you rinse your toothbrush. You can even rinse with soap. Like put water soap, you decontaminate,

you need to clean your toothbrush. Oh, I never thought of that. You're really adding, you're literally going to add another four minutes to my day. You realize that? Four minutes to my day, 28 minutes to my week. Do you know how many hours you're adding to my year? This is ridiculous. Well, look, it's worth it, though. So I'm going to now be rinsing my toothbrush with soap and water. You don't want to put the soap just rinse with warm water. Well, I always do that, but now I'm committed to doing this. Maybe salt would salt water be beneficial?

You don't need. No, just even hand soap just rinse with water and so and dry. You have to dry because bacteria loves the moisture in bio. I hate the taste of soap because as a child my mom Would often wash my mouth out with soap because of how foul a mouth I had so I'm still traumatized by the taste of soap It really it's an awful taste with like hot hot water it is very hot so that is soap into paste because soap just rubs my cold water like the coffee and be disrupted by soap so every

toothpaste has soap because of that because most bacteria had the lipid protein in their surface so that's why we have but they put all the flavors they put the fluoride so that's why they don't feel that soap, but that is soaked and antibacterial. Any role for mouthwash? I don't, my wife loves it. I don't, I just, it's one more dumb thing that I don't do. The thing that I just like with mouthwash is that it kills every single. It just wipes out all your microbeom, including the good ones, because they're all antibacterial. So I am in favor, if you like, in a situation that you're not going to be able to brush much, like short pews of time, let your body normal, like recolonize without any interference, the same thing with antibiotics.

If you take too much antibiotics, you's going to be resistant to bugs and bacteria. So if you use every day, in one point, you're going to have a virus in your cavity, but that's going to be very resistant. That's very interesting. Is there any evidence that excessive use of mouthwash, for example, leads to Candidal Overgrowth or Fungal Overgrowth? I mean, that would

certainly be one hypothesis worth testing. I don't remember Peter. So I don't want to say anything that I don't remember, but I can go back and look. But the studies that I did, it changes the micro floor. So that's why I'm very concerned about changing in all environment that is healthy. So if you're healthy, why are you going to use the mouthwash?

Don't need that. Okay. Anything else that we would consider best practices for the average person who is looking to preserve the quality function of their teeth and by extension their overall health besides what we've discussed. Well, I think everything that we discussed and we talked so many times about prevention. So dental care is a chronic, non-communical disease and then it's through life. People have dental care is their whole life. The only way to control is preventing. So preventing means every six months you need to go to a dentist and you need to do a clean at a

meaning. At that time they're going to look to have any cavities because the cavities is a niche for the bacteria to grow as well. By the way, is six months a magic number? I mean the only reason most of us go every six month is because that's what insurance covers for free. But if you decided you were willing to pay out of pocket, would it be better to go every three months or every four months to do an overall cleaning? Well, there is a lot of research about if you maintain a good oral health, you don't need to do more often. Someone who is a high risk you have a systemic health you have diabetes you can do three times a year for example but the six month is how bent is recommended and it's true research that shows because we don't do disease as a very slow progression it's not a disease that you have today in

three months you're gonna have two millimeters upon disease that you have today. In three months, you're going to have two millimeters of bone loss. Unless you have something else in your body that combined with the inflammation that is triggering systemically, then your bones are going to go away very quickly. But I think because pre-dota disease is a slow progression, and I know we did a study three years ago that we looked at people and we imagined that all your disease every two months. We held the treatment, we didn't do the treatment and we watched how people would progress. And it's crazy. There are people who progress very quick. There are people who never progress and there are people who take two years to progress. What do you think explain those differences? Systemic, because period of the disease is a highly communicative case with your body.

If you have a systemic issue, it's gonna exacerbate information. So. Wait, so you could predict the extent of disease that person has if you knew how systemically healthy or sick they were? Yeah, you can. If you have a lot of infection,

if you have diabetes, we know you're most susceptible to have a donor, don't do disease. So there are groups of risk that those particular group, they need to see a dentist more often, they need to do more cleanings and they need to prevent. It was a huge study that was done five years ago, but was not compulsive. They never know when they finish they say they don't know which way it's coming. If it is the diabetes, the triggers of it is they're burdened and they are a cavity that is strictly the diabetes that couldn't die sad. I mean, I think the good news is they're both preventable diseases. So again, goes back to the point of prevention. Yeah. Well, Pat, this has been super interesting. Just on a

purely selfish basis, I learned a lot that will immediately go into practice effective, I guess, tonight and tomorrow morning. So thank you very much for the insights you've shared, and I think people will take a lot of practical information from this. They're welcome. It was my pleasure. Thank you for listening to this week's episode of The Drive. If you're interested in diving deeper into any topics we discuss, we've created a membership program that allows us to bring

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