Gateway to Health

Beyond The Mouth

EPISODE 4: BEYOND THE MOUTH

PEDRAM SHOJAI

Welcome back to Gateway to Health. I’m your host, Dr. Pedram Shojai, here looking deeper through the mouth into the overall health of the body. Not so long ago the US surgeon general called the mouth the mirror of health and disease. He called America’s poor oral health, a silent epidemic. It’s estimated that 97% of the systemic diseases we’re seeing appear in the mouth. Think about that. It’s like a portal we could look into that shows us how the inside of the body is doing. Traditional Chinese and Ayurvedic doctors always looked in the mouth in their assessment of their patients. It’s been known for a long time.

So, we forgot. We compartmentalized and moved all things mouth over to dentists, almost as an afterthought. Those days are over. In this episode, we’re going to delve deep into the implications of all of this. We’re going beyond the mouth and looking at all the various diseases linked to oral pathology. Stay with this. It’s the most important part.

The mouth has been this marker for health that we’ve realized for a very long time as being crucial for overall body health.

It has so many excellent things. It has bacteria which are healthy and good. However, when we have infection or things like that in our mouth, what happens is that our bloodstream is so easily accessed.

The mouth is really both a mirror and a gateway, so it’s got this bi-directional relationship to the entire human body.

The mouth in many ways is not just a window, it’s a portal. Literal portal and figurative portal. It is very much a way of looking at what might be lurking and going on elsewhere.

The oral cavity can be an indication of eating disorders. Some of the basic things: bulimics, anorexics. You can see it in their teeth probably before you can see it anywhere else. People that have osteoporosis or bone loss, we’ll often see it in our patients’ mouths.

The surgeon general called the mouth the mirror of health and disease. The mouth is the gateway to the body. The surgeon general years ago, David Satcher, when he realized that the young boy, Deamonte Driver died of dental decay, he stated that Americans’ poor oral health is a silent epidemic and that forces need to be put together and efforts need to be made to make a difference in the area of oral health. And so, I can look in the mouth and diagnose disease. As a matter of fact, 97% of systemic diseases show up in the mouth.

In the last 12 to 15 years, there’s been a paradigm shift. The paradigm shift has been the realization that there’s more bacteria in our guts than there are human

STEVEN LIN BREANNE BARRINEAU

GERRY CURATOLA DAVID RELMAN

GERARD KUGEL

HAZEL GLASPER

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TOM O’BRYAN MARY E. CHALMER

LEIGH ERIN CONNEALY FLOYD DEWHIRST MARY ALEXANDER

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ELMIRA SHOJAI HAZEL GLASPER

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cells in the body. More cells of bacteria. Well, the gut starts at the mouth and goes to the other end and it’s called the microbiome.

An oral microbiome is a combination of different bacteria that live symbiotically together. So you have a combination of good bacteria that help you with your digestive system, with your immunity, with your ability to taste food. And then you also have the possible pathogenic bacteria that, if their number goes up, then you’re dealing with disease and inflammation.

So the mouth is the first area that we can identify and screen for what the bacterial population is like.

When we consider the oral microbiome, we must consider the fact that we swallow one trillion bacteria a day. And so when you have a dysbiotic oral microbiome, it stands to reason that you may possibly, and most likely, will have a dysbiotic gastrointestinal tract. After all, it’s all the same tube. We’re just at the top end of it.

We have viruses, bacteria, fungi, protozoa, we have all these different ones that are working in symbiosis, meaning in harmony with us.

The bacteria that live on and in us are not altruistic. They’re trying to survive and we just happen to be where they live.

What’s unique with the oral cavity is the different niches or the environment in which bacteria can live. You have your teeth, your tongue, your gums, all of the different tissues and the relationship of the bacteria that exist on all these tissues are different.

The reason that certain bacteria come to dominate and cause disease, unlike something like tuberculosis or leprosy, it’s not some particular external bug coming in and causing disease, but rather it’s the organisms within us that start malfunctioning or it’s called a dysbiosis.

Oral dysbiosis is when the balance between the bacterial community is in dysfunction.

So what causes dysbiosis? It’s a host of things. It could be that a person has a genetic disposition to something, maybe immunocompromise, a lower resistance for whatever reason. Maybe that when it comes to conditions such as periodontal disease, maybe the colony of organisms have been there too long undisturbed, so then those organisms get a chance to grow in size and number. So, it’s a lot of reasons. Diet, absolutely. I mean again, the mouth is the gateway to the body. What you take into your body is going to throw off that equilibrium, or it promotes harmony in the mouth.

What do we know about the oral microbiome’s link to overall health in the body?

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HELEN MESSIER

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One of the articles written in a Journal of Dental Research in 2015 was, we identified the bugs, now we’re trying to figure out what they do. So, the research into the oral microbiome is relatively new, but it’s wide-ranging and impacts, I think, every aspect of health.

The mouth is a reflection of our overall health. We know that there’s a big connection between periodontal disease, so people with periodontal disease, and people who have other chronic diseases, there’s a huge connection. We know that the infections in the mouth, the health of the teeth, all of that actually, it’s almost like a window into your overall health.

Look at all the patients who have periodontal disease. Their doctor just goes, “Oh, we need to do a graft and we need to do this.” And I’m like, no, no, no, no. We’ve got to ask, what are your hormones? How do you brush your teeth? How do you eat? How often do you eat, if you eat more frequently, for example.

People with periodontal disease, for example, have much higher incidence of rheumatoid arthritis. They have a higher incidence of fatty liver, of Alzheimer’s, of diabetes. There’s a lot of these chronic systemic diseases that are associated with periodontitis or diseases in the mouth.

In some ways, some people have a tendency to look at the oral cavity and dentistry in general as an area that’s isolated and distinct from medicine. But, increasingly we’re seeing more of a link between periodontal disease and cardiovascular health. That’s been shown in some studies.

Chronic infections in the oral cavity can also cause infections in the heart muscles, so there’ve been a lot of indications that if you don’t take care of your teeth and the periodontium and the gums, it can affect the heart. It’s funny, Men’s Health recently, I will admit I read Men’s Health, they had, they do it every year, they do the top 10, and I think last year number four was taking care of your teeth to prevent your heart from having issues.

People have looked at things like atherosclerosis, which, well, there’s a possibility that the bacteria from the mouth can get into the bloodstream, stick to the lining of the walls of blood vessels and promote or precipitate the formation of these atherosclerotic plaques.

People don’t realize that their mouth drains into their thyroid. So, any disease here in your mouth drains right here where your thyroid is.

The one where I think we found the strongest link so far, and by that we know that patients who have bad bacteria in the mouth have this disease. We know there’s a biological connection and we know where a treatment could be beneficial, are certain types of lung infections like pneumonia and maybe other things such as emphysema, bronchitis, that’s a pretty strong link.

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PEDRAM SHOJAI GERRY CURATOLA

There are a number of conditions that are systemic in nature, whether they’re GI problems primarily or endocrine issues that do have oral manifestations. In some cases the oral manifestations that a patient’s dentist or other oral health care provider may detect could be the first sign of a patient’s underlying systemic problem. And so from that standpoint, dentists and other oral health care providers may be able to, if not diagnose the patients initially with whatever the systemic condition is, at least participate in that diagnosis.

Once again, because the mouth is one of the filthiest or is the filthiest place in the body, and it’s a place where you have conditions like gingivitis, periodontitis, which is a chronic inflammation. I think in particular the bacteria, when you have inflamed gum tissue can readily penetrate into that gum tissue, get into the bloodstream, and start lodging in other parts of the body.

Are the diseases in the mouth causative of the other chronic systemic diseases, or are they sort of both occurring at the same time? And the answer is both. Poor health makes you more susceptible to periodontitis, poor nutrition, lack of nutrients and sleep and the foundations of health will also be associated with higher rates of periodontitis and also chronic disease, systemic chronic disease. But, we also know that periodontal disease can be causative in many cases of these systemic diseases.

You can’t think of a mouth as a separate entity and not being part of your whole body. So, it will make sense for what’s going on as far as the bacterial colony in your mouth and how it reflects and mirrors the health of your overall body.

Our mouth organisms, when we swallow them, when they get down into our gut microbiome, they can cause dysbiosis or imbalance in our gut microbiome, which then in turn can lead to leaky gut or holes, increased permeability of our gut membrane, which can lead to these bacteria leaking across the gut membrane. And because 70 to 80% of our immune system lives right on the other side of that gut membrane, it can cause this huge inflammatory response and many of these diseases are associated with inflammation. And so that’s one of the connections.

How much do we know about this connection between oral dysbiosis and inflammation in the rest of the body?

Originally we looked at the relationship of the mouth to the body as sort of like the mouth as a mirror of what’s going on in the body. And now we now know actually the mouth is a gateway to disease and dysbiosis and disease in the body. Time Magazine in, I think it was 2004, had a cover and the entire cover of the magazine was about inflammation. The fires that burn within.

Inflammation is a normal metabolic process in the body. It’s a normal process where you get a splinter in your finger, it gets inflamed and there’s this immune metabolic immune function where it resolves. That’s a normal process of inflammation. The inflammation that’s the most debilitating to the human body,

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to Alzheimer’s disease, to heart disease, to stroke, diabetes, pregnancy disorders and cancer is this chronic low-grade inflammation. Chronic low-grade inflammation is a dysregulation that goes on and in the mouth, Time Magazine identified gum disease as among the body’s largest source of chronic low-grade inflammation.

There is plausibility that the bacteria in the oral cavity are linked to systemic health and systemic disease, because of all the variability in these disease models is not direct. But, I do believe that it’s one extra factor that we’re adding bacteria within the body. We’re adding to the inflammatory burden and we know that general inflammation in the body is linked to many, many chronic diseases.

Diseases in the mouth such as gum disease, we know, links to heart disease. We know that tooth decay can even link to certain other conditions in the body as well.

So, when you have certain bacteria in the mouth, they signal our body to create these inflammatory mediators and those inflammatory mediators are what can really do the damage. This chronic load of inflammation in the body. IL-1 beta, for example, is an example of meta inflammation. So, not only is it being created in our mouth, it’s being created throughout our body and IL-1 beta is associated with many issues of chronic systemic illnesses, heart disease, as well as periodontal disease, bone degeneration, bone resorption when you have this inflammation in the mouth.

The mouth is the first sign of inflammation and we can see it first. Dentists are up to their wrists in saliva every day and we see this inflammation first and we say, oh, the mouth is this connection to the body, yet we’ve been unable to really make that connection in a meaningful way.

So, in summary, again, if we think about the bacteria in the mouth, we know they can spread to the bloodstream and not only can the bacteria spread, but a lot of their byproducts can also get into the bloodstream. We believe that that can add to that total inflammatory load that we’re carrying at any given time, and that therefore can link to certain medical conditions.

What chronic diseases have been actually linked to oral health?

We are seeing more and more evidence in the connection between oral bacteria and oral pathogenic bacteria and other health problems, and there is a multitude of health problems that actually we’re seeing issues with. We’re more and more aware of these systemic connections and we are more and more aware that dentists and medical professionals should be working together. Specifically, I’m talking about cardiovascular disease. Patients that have periodontal disease, they’re more susceptible to inflammation and have inflammatory markers and bacteria that can actually travel and get into circulatory system and get to other parts of the body such as the heart and can cause bacterial endocarditis in some patients, which can be actually fatal within 24 hours.

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When you have infection and you have inflammation, that inflammation that we’re experiencing is then transferred to other parts of our body and that’s why there’s a huge association and correlation with oral infections such as periodontal disease or infection at the tips or the apices of our roots, endodontic infections with cardiovascular disease. So, it’s a gateway to really allowing infection within our mouth to really just spread and multiply throughout our body.

The most common class of microbes to cause heart valve infection are oral microbes and it’s believed that they got there by getting into the bloodstream, through the gums and then circulating until they happen to find a heart valve that was sticky and a nice home for them. And heart valves are particularly worrisome to us because if infected, we don’t have good defenses there. And at the same time, these are critical, critical tissues where a small amount of damage can lead to a major catastrophic outcome.

We also know that inflammation in the oral cavity contributes to the release of certain reactive proteins such as C-reactive protein, which is also a marker of cardiovascular disease and other potential diseases in the body.

There’s different theories about how periodontal disease triggers systemic disease. There’s a metastatic injury or inflammation and it has to do with bacteria getting into the bloodstream and then circulating systemically, or toxins produced by the bacteria getting into the rest of the body and producing inflammation. So, in theory, if these hypotheses are correct and our understanding of how this happens in heart disease are correct, if you can maintain this balance in your oral microbiome, you will reduce and/or eliminate your propensity to some of these diseases.

There is another interesting linkage between the mouth and an adverse condition elsewhere and that is with this vexing major public health problem of premature birth.

Periodontal bacteria and periodontal status have been linked to preeclampsia, to low birth weight and also premature birth. So, we know that patients that have good periodontal health are much more likely to go through an easier pregnancy.

The consequence of premature birth, especially for very premature births, is huge. The babies suffer from all kinds of developmental problems later in life, but also suffer from early acute infection and other kinds of calamities that could be life-ending for them. The link with the mouth is interesting. Many years ago, a number of epidemiologists happened to notice that women with gum disease have a higher risk, higher likelihood, of a premature birth than do women with healthy gums.

Yeah, my lab at the Columbia Medical Center, focuses on studying host pathogen interaction. I have been studying oral systemic health for over a decade. So, what we have found is the bacteria in our mouth can travel to the pregnant uterus

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through blood circulation. So, for instance, if you have a bleeding gum that gives the bacteria an entry point into the blood circulation and bleeding gums actually happen quite often among pregnant women. There’s a condition called pregnancy-associated gingivitis. So, that’s characterized by inflammation and bleeding. So, the bacteria enters the blood circulation and we call that dental bacteremia, which happens quite often where you have gum disease.

The mechanism to this day is still unclear. It may be this mechanism involving a local immune response that’s now chronic, affecting the gums, setting in motion a series of immune responses elsewhere in the body that’s provoking an inflamed situation in and near the placenta, which is where labor is controlled.

There are organisms from the mouth, particularly Fusobacterium nucleatum, that seem to travel and possibly get to the placenta and other things and then cause pre-term birth.

We find it in the amniotic fluid. We can see it in the placenta in a lot of cases where there’s premature birth or where there’s stillbirth, we can see that organism being there.

So, once the bacteria get into the circulation, they have an opportunity to invade into the uterus and once they’re in the uterus, it’s very difficult to get rid of them because part of the characteristics of pregnancy is immune suppression, so that you don’t have many immune cells inside a uterus to get rid of these bacteria so they can grow very quickly and then cause infection and pregnancy complications.

There was an interesting study published in the New England Journal some years ago that said if gum disease is a risk for premature labor, let’s see what happens when we take women early in pregnancy who have gum disease and treat them. We send them to a dentist. We have them undergo some very aggressive cleaning procedures. Let’s see if we can reduce the likelihood of premature birth. They had a control group, just normal brushing, normal hygiene, and the answer was no effect. Some people looked at that and said, “Aha, maybe this isn’t real.” Some of us look at it and say, but what if it’s real and the only way to get ahead of an inflammatory process is to turn it off before a woman becomes pregnant, not after. Then the answer is, we don’t know, because the study was done after pregnancy has begun, so the jury is still out. We don’t know exactly how this works, but it’s an important enough kind of connection to warrant further study, as we say.

I think that the bacteria will go wherever they can find a place to stay. So, when you have a pregnant uterus that’s an immune suppressed organ, you don’t have a lot of immune cells to kill the bacteria, so they’re happy there. I think that they can also go to other places like the heart, the synovial, the joint, so wherever they can find places to stay. Some of the bacteria, they can bind to certain molecules that’s quite widely expressed in our body, so that explains why they can colonize at different body sites.

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PEDRAM SHOJAI

ELMIRA SHOJAI MARY ALEXANDER

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MARY ALEXANDER

ELMIRA SHOJAI

ALINA KRIVITSKY TOM O’BRYAN

We now know of connections between periodontal disease and heart disease, pregnancy issues. What else do we know it’s linked to?

There is a strong correlation between diabetes and periodontal disease.

A1C is a measure of the control of diabetes over a three-month period. It’s a blood test that’s done on patients and the A1C for someone who’s normal or healthy is five.

When somebody has diabetes, they have a harder time because their immune system is more vulnerable, so they have a higher risk of having a periodontal disease. Someone that already has diabetes and gets periodontal disease on top of it, it’s much harder for their overall body’s health to control the diabetes.

I’ve had patients that come in with severe periodontal disease with A1Cs of 14, 12, 10 and their endocrinologist would have sent them to me to have their periodontal disease treated in order to try to control their diabetes. After full mouth therapy and compliance by the patients, their A1C will automatically decrease. Patients feel better. So, that’s one instance in which I’ve seen, clinically, the importance of periodontal disease or relationship of periodontal disease and other systemic diseases.

We do know that if you control your periodontal disease and the environment and the microbiome of your mouth, then you have a higher chance of controlling your diabetes.

Keeping things healthy in the mouth will really help to make sure that you don’t have as much morbidity and mortality with some of these diseases.

The key to success in dealing with oral microbiome or dealing with any condition in the body is one hour a week. You allocate one hour because everybody’s so busy. You can’t change your lifestyle today unless you’ve gotten a fatal diagnosis that scares you to such a degree that whatever it takes, I’ll do it right now. But if that’s not the case, one hour a week to learn a little more about how my lifestyle is affecting my oral microbiome.

Every week you allocate one hour, just one hour, but eventually within four to six months by doing that, you’ve learned so much of how to have a healthy microbiome and your kids are the ones with no cavities and your kids are the one that dentists say, “Wow, these are the healthiest gums I’ve seen in a while,” because you’ve applied the principles that you’ve learned over time.

The other piece I would say is making sure that the providers and the patients are identifying who is at higher risk, and if you are a patient at higher risk, making sure that your checkups and recall appointments are done more frequently so that your oral health health care providers can do the treatments that they need to do to also monitor disease progression and prevent it from causing more

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severe forms of the disease.

We just learned that gum disease is the body’s largest source of chronic inflammation. We’ve known for decades that this type of inflammation is what’s killing millions of people in our society. Now, we begin to understand the mouth’s role in this. The bacteria in the mouth can enter the bloodstream linking to systemic inflammation and the many diseases we just heard about from our experts.

Another huge revelation here is that healthy gums help with healthy pregnancy and a foul mouth can lead to premature birth and early stage infections in the baby. All of this is a really big deal. Clinically fixing periodontal disease helps bring down hemoglobin A1C, a huge marker for higher morbidity and mortality. We understand that diabetes and gum disease are somehow linked. Again, huge implications here. Check out some of the key takeaways from this segment.

The mouth is the mirror and the gateway of the human body. There are more bacteria in our gut than there are human cells in our bodies. The gut starts in the mouth. The mouth is the first area we can identify and screen the microbiome. There’s a big connection with periodontal disease and other chronic diseases like higher incidence of rheumatoid arthritis, Alzheimer’s, cardiovascular disease, pneumonia, and bronchitis.

I want to take a moment to thank you for being here and being part of this revolutionary event. Nobody is talking about this stuff. It’s the cutting edge of science and the marriage of the dental and medical professions bringing together what the latest research is showing us is critical, because on average it takes 17 years for new research to make it into your doctor’s office. If you have diabetes, heart disease, or want to have a baby, the wisdom of these interviews can save your life or the life of your child. At the very least, it’ll put you on a path to better health, which means more energy and vitality.

You need to know this now. You need to share this information with your doctor and your dentist and help shortcut the nearly two decades it takes for this new information to get into practices. That’s why I ask you to get the entire series right now and start making the necessary changes to bring optimal health back to your mouth and your body. It all starts in the mouth, and this series is the ultimate resource to help you heal and recover. It’s currently 50% off, but only during the event. Please get yourself a copy right now.

Let’s get back on the highway to health and disease part two. There’s so many connections in the body that we’re not done sharing all the profound links that have been discovered. Bacteria in the mouth are culprits now linked to Alzheimer’s disease, leaky gut, dementia, brain abscesses, autoimmune disease, cancer, and much more. Let’s take a closer look at some of these interconnections.

There are thousands of bacteria that live in our mouth. Some are good, some are bad, some cause strep throat, some cause periodontal disease, and a very

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MARY E. CHALMER MARK BURHENNE

healthy mouth leads to a very healthy individual. We’re now finding that there are biomarkers that you can find in the saliva that predict wellness that may affect our central nervous system that had been linked to Alzheimer’s and related dementias. The Alzheimer’s Association is working with billions of dollars of research money to actually find a cure for Alzheimer’s disease using biomarkers and other bacteria in the mouth.

There’s also a link between a certain species of bacteria that cause gum disease, gingivitis, bleeding gums, and they’re showing that it might be critical in the latest stages of Alzheimer’s disease. And so this is now the gut-brain connection where the mouth is participating in this and the ecological balance of bacteria plaque is really important in the mouth.

The microbes that are found in your mouth such as P gingivalis which produces periodontal disease, has been linked to disease of the brain because it affects the central nervous systems.

P gingivalis, Treponema denticola, Fusobacterium nucleatum, can have a negative impact upon cognition and predispose patients for Alzheimer’s.

Let’s talk about Alzheimer’s. That’s very, very in vogue today as it should be because it is a preventable disease. Part of that preventable aspect of it is what do we do with our mouth? So, we have found even though we think of the brain as a very sterile area, we in the autopsies of brains, and my mother died of Alzheimer’s and she did have gum disease. The P gingivalis bug, which very readily populates the oral cavity and is a good bug, generally speaking, but can have bad behavior if there’s a dysbiosis. So, if there’s a disorganization or a revamp of the colonies and the numbers and the ratios of these bugs to each other, maybe from a hit of mouthwash to just poor overall health, poor diet, inflammation somewhere else throughout the body, that bug actually will get into the bloodstream and will cross the blood brain barrier and end up in the brain.

We know that microbes can get out of the mouth into the bloodstream. We also know that people who develop bacterial abscess in the brain, and this is not such a crazy, farfetched kind of condition, this actually happens. Those organisms that we see in brain abscesses are typically mouth organisms. How did they get there?

Some people postulate that they get from a rotted tooth up into the root of the tooth and then travel, even perhaps if it’s the upper jaw, up through the anatomic compartments that are just adjacent to the meninges, the lining of the brain. So, that would be a direct local extension from a tooth. But in other cases you don’t see that. And yet you’ve got an abscess of bacterial infection, a gross spectral infection in the brain, and it’s all oral microbes.

That bug, the way the body responds to that is by producing a substance. It’s a protease actually that breaks. It’s a neurotoxin. It’s called gingipain and it breaks down neurons in the brain. And then of course there’s that the reaction of the brain

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by laying down the amyloid proteins and it goes south from there. All from neglecting or not paying attention to this thing, the oral microbiome in your mouth.

But you could imagine where other things are getting into the bloodstream, not just the bacteria but the bacterial products, and that’s where I think there’s a whole world of potential interesting biology that we know very little about out of the gut. We know we find in the bloodstream hundreds or even thousands of small molecules that were definitely made by the gut microbes. They’re in the bloodstream. Some of those probably can get across the blood brain barrier into the brain. Same is probably true for the organisms in the mouth. They make small molecules, they get into the bloodstream. Some of those could get into the brain. What is their effect?

The plot keeps thickening here. So many interconnections. What do we know about the links between oral bacteria and autoimmune disease?

There’s a number of autoimmune diseases that may present with oral manifestations, some more clinically significant than others. Some are relatively innocuous and patients may be only dimly aware that they have any symptoms. For some of the autoimmune conditions the earliest signs may mimic closely those of typical gingivitis or periodontal disease, and from that standpoint patients may have been seen by their general dentist or by a gum specialist, a periodontist, before they ever make their way to see me as an oral pathologist.

There are autoimmune diseases that may exclusively involve the mouth and there are others that can involve any one of a number of other organ systems throughout the body. There are autoimmune diseases that involve the mouth and the skin. There are autoimmune diseases that involve the mouth and the salivary glands or the lacrimal glands of the eyes.

So when I was in dental school, it was well known that there was a connection between advanced periodontal disease and cardiac disease or heart disease. But since that time, we have found many more connections between what’s happening in the mouth and what’s going on in the rest of the body, specifically with connections between systemic autoimmune disease. These diseases, a few of the common ones that you may have heard of might be lupus, rheumatoid arthritis, psoriatic arthritis, Crohn’s disease, ulcerative colitis and Sjogren’s disease.

Most people think that these autoimmune diseases are rare and they’re not. If you put on your Wall Street hat and begin to look at the market and you bring all autoimmune diseases together, you actually see that there’s anywhere around 50 million people, which is 16% of the population and it’s more than cancer and heart disease combined. The reason most people don’t think about it that way is because they’ve never taken the time to aggregate the diseases and think of them as a continuum.

But if you reflect on our understanding of cancer, where we used to think it was

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by body part and now we know it’s by cell, we have similar things happening in autoimmune disease. We used to separate these diseases by body part, but then we began to realize that the same medicines worked for diseases that were in different body parts. For example, they use similar biologics for Crohn’s disease and a lupus patient. So, that gave us the idea that these autoimmune diseases may be a spectrum of diseases. So, if you take that thesis, then you can better understand how inflammation out of balance oral microbiome can be an early trigger to some of these systemic autoimmune diseases.

So, your immune system trying to protect you, fights this bug bacteria, virus, food, whatever it is that got into the bloodstream that’s not good for you for whatever reason, it’s not good for you. When you fight that bacteria, the antibodies, the missiles that are prepared by your immune system to attack that substance, whatever it is, those antibodies can attack your own tissue and that’s called an autoimmune mechanism and that’s the basis of rheumatoid, and MS, and psoriasis, lupus. All of our autoimmune diseases may have a molecular mimicry to something else you’ve been exposed to, that’s the trigger that setting it off.

Foods are a really common one and we know that if you have a sensitivity to wheat and if your body is making antibodies to wheat trying to protect you, you are highly at risk to making antibodies to amelogenin which is a peptide that makes up the enamel of your teeth. So, those are the people that have dental enamel defects, or they’re vulnerable to having dental enamel defects. They’re vulnerable to cavities. They’re vulnerable to demineralization. You lose the strength of your teeth because of a sensitivity to a food.

One patient that comes to mind that’s a great representation of that, is a patient that found her way to me from the Peninsula who in her early 40s was suffering from tremendous horizontal bone loss in periodontal disease and was well on the way to losing her teeth. We started with an oral DNA test, which is a salivary test that uses DNA PCR technology to measure the periodontal pathogens in her mouth. Mind you, this was a woman who has impeccable home care. It wasn’t a mouth that was loaded with plaque or anything else. It was just that her gums persistently bled and she had horizontal bone loss as a result of that.

So, we got her oral DNA results back. Negative, no pathogens, minimal pathogens. So there was no bacterial evidence of periodontal disease. What our next step then was to test for celiac disease and gluten sensitivity. And so we tested her anti-gliadin antibodies, her tissue transglutaminase antibodies and we did a blood test to identify whether she carried the celiac gene. And what came back was that her anti-gliadin antibodies were elevated. Her tissue transglutaminase antibodies, which is an autoimmune measure, so not only was she reactive to gluten, her body was developing an autoimmune response to it.

So, those two entities were positive and she was an HLA-DQ8 celiac. So, it wasn’t the traditional periodontal disease that was driving her gingival inflammation in her bone loss. It was in fact the fact that she was consuming wheat. We have to

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consider that leaky mouth and the presence of, and the reaction to the mouth to gluten is going to be along the same lines. We maintain her teeth with three to four-month recalls and she is religious about a gluten-free diet and slowly over time we began to see a dramatic drop in the inflammatory levels in her tissues and more to the point, her bone has become stable.

So cancer is obviously a scary diagnosis. What do we know about the links between oral pathology and cancer?

Oral cancer and oropharyngeal cancers are not nearly as common as breast cancer or prostate cancer or lung cancers, but oral cancers and oropharyngeal cancers are diagnosed in about 50,000 or so Americans every year.

Unfortunately, esophageal cancer is the sixth leading cause of death in the world and the reason is by the time you find out you have esophageal cancer, it’s kind of too late. You’re stage three or stage four is when you actually see the symptoms.

The most common clinical presentations of oral cancer involve either a white area in the mouth or a red area in the mouth, or a mixed white and red area in the mouth or a non-healing sore. And a lot of patients, unfortunately, have the misconception that if it doesn’t hurt, it can’t really be cancer because they have the perception that cancer tends to hurt when we see it in the mouth. Unfortunately, by the time cancer hurts in the mouth, it typically hurts because it’s at a more advanced clinical stage and maybe it already involves the muscle or the regional nerves. But, if we can catch some of these oral cancers while they’re still asymptomatic before they cause any discomfort for the patients, we have a better chance at a good outcome for the patients.

Dysregulation from inflammation can cause everything and it’s actually been linked and they’ve shown a causal link with cancer. So, I often, I’m amused when people say, “Oh, you know, so-and-so got cancer.” Like he just, you know, like he caught a virus and caught a cold. “Yeah, he got cancer.” It’s like, no, no, you don’t catch cancer. Cancer is the end stage of a dysregulation. It starts as inflammation. It’s not resolved. It keeps going. And there is a dysplasia. And then an anaplasia or what we call cancer. So, dysplastic is kind of irregular. Anaplastic is cancer. It’s out of control. We are making so much headway in our understanding of treatment and cancer and the prevention of cancer by preventing inflammation.

Outside of the typical risks of tobacco usage and alcohol, a compromised immune system is a risk factor for cancers, oral cancers among other types of cancers. It’s not what people often think of off the top of their heads if they’re thinking about risks for cancer, but people who may have a compromised immune system for any one of a number of reasons are at risk for oral cancer among other types of cancers.

In the past maybe 15 years we also know that oral cancer could actually be

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looked at as two different diseases. There is the traditional, if you will, oral cancer which is associated with elderly, with smoking and alcohol that occur particularly in certain parts of the mouth, but recently in the 15 years as a virally associated form of oral cancer, human papillomavirus in particular that’s associated with a much younger age group and sexual habits as well. That’s becoming an epidemic in the world, in the country.

Over 40% of head and neck cancers are related to HPV.

Today we know that about three quarters of all oropharyngeal cancers, cancers in the back of the throat, are HPV-driven and pertain to this sexually transmitted infection. A smaller number of cases of tongue cancer and oral cancer are related to HPV as well. Probably about 5% or so of cases of oral cancer are related to the human papillomavirus.

Of interest is that both of these oral cancers are notoriously difficult for early detection even though they’re in the mouth. You would think that someone has oral cancer they would see it early. Most oral cancer in the United States will be discovered in stage three. There are four stages of cancer. Early stage, stage one, stage two, stage three and stage four. Most oral cancer in the United States were identified, were discovered if you will, in stage three.

It just goes to tell you that how often people are being sort of visiting the dentist for one and secondarily they may not want to sort of have physicians to examine their oral lesions. And perhaps what’s more telling is when an oral cancer reaches stage three, which is late, it could have been likely metastasized the sequelae are very guarded.

They go to their doctor, and the ENT doctor or the head and neck surgeon says, “Okay, you need surgery, chemo and radiation.” Okay, you might need some of those treatments. I don’t know because every person’s very unique. But, if you didn’t address the HPV, is that cancer going to go away? No, because that HPV is going to create chronic inflammation and then you just weaken the immune system through surgery, chemo and radiation. So, absolutely that’s not going to work. You’re going to get rid of the cancer for three months and it’s going to all come back.

What’s interesting is that for the oropharyngeal cancers that are related to human papillomavirus, these patients do seem to have a better prognosis than the patients whose oropharyngeal cancers are not associated with the human papillomavirus. Whether the same improved outcome holds true for patients with oral cancer as it does for oropharyngeal cancer in the patients that do have human papillomavirus related disease hasn’t really been demonstrated yet. But, for such an emerging area of interest, it’ll be fascinating to see whether some of these things hold true.

So, early detection is truly a Holy Grail. A dollar invested in early detection in

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prevention is worth a thousand dollars that needs to go into a therapeutic intervention.

Talking about the mouth as a mirror, but the mouth is also a very big gateway to disease in the body. As a matter of fact, the number one bacteria found in colorectal tumors was Fusobacterium nucleatum, the most common bacteria in the mouth. And when that bacteria is in a balanced environment, it behaves and when that bacteria is in an imbalanced environment, it becomes what we call a pathogen, it becomes a thug.

There’s been a lot of research done specifically on colon cancer and they’ve actually shown that Fusobacterium nucleatum is causative of colon cancer, so not just associated but causative and we know that that comes from the mouth.

We’re actually still trying to sort out what kind of Fusobacterium is the most virulent in exacerbating cancer progression and what kind of Fusobacterium is most likely to leave the mouth to go into other places.

The way that this organism gets to all of these places is in two ways. We can either get it when we have periodontal disease, it can enter into our bloodstream directly from our mouth. One of the ways that this organism, the reason we look at it so much is that it produces an enzyme that actually breaks down the junctions between the cells in the blood vessels.

And so this organism, kind of think of it like punching holes in the blood vessels, and so it gains entry into the bloodstream. We can also swallow it and again, when we don’t have enough stomach acid it can take up residence in our gut, and also that way can get absorbed into our bloodstream directly from our gut when we have something called leaky gut or can directly cause things like colon cancer directly in the gut.

When I went to dental school we were taught to do oral cancer screenings and that was the extent of the other areas of the mouth that we looked at. Now, with new information around metabolomics, genomics, proteomics, and other advanced testing, I think dentists should be looking for some of the information around personalized nutrition based upon your genomics. Lifestyle modification once again, based upon your genomics. That’s the type of exercise that works for you. The type of eating that works for you. I think it should be part of an oral cancer and/or systemic disease discussion, whether it’s directly with your dentist or with your hygienist. I think we should change our mindset around what the dentist is thinking about. They should be thinking about our overall oral health, not just our teeth.

Give us some basic oral care things to do to help avoid these diseases. I mean, this stuff sounds really scary. What can we do to prevent it?

To maintain good oral health like a lot of other things, preventive care is often one

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of the best measures. Making sure that patients go to see their general dentist regularly and not to wait until they have a specific acute concern is often one of the best things that they can do. Discontinuing smoking if that’s an option for people who do have that habit. Limiting consumption of alcohol is more helpful than we often had thought of historically. There have been studies that have been done in the last number of years showing that there’s an increased risk of cancer even among moderate consumers of alcohol. Whereas, previously people often thought that only heavy drinkers might be at more of a risk for cancer.

There are good and bad bacteria in your mouth and that we can’t change, but we can limit the bad bacteria by keeping our mouths healthy. I tell my patients, floss only the teeth you want to keep.

What’s really important is that we should be looking at replenishing our oral microbiome and the studies show that in weeks of changing our diet, our bacteria will change. So, what we should be thinking is about the bacteria we put into our mouth by the second changing our, the environment in our mouth and then the environment in the gut as well.

I say this so often, the most common trigger to inflammation in your body and inflammation is the mechanism behind practically every disease that we get. The most common trigger is what’s on the end of your fork.

Now, when we’re eating foods it’s very important to have foods rich in fat soluble vitamins, and if you’re not thinking about fat soluble vitamins, you’re likely not eating them. They come from organ meats. They come from egg yolks. They come from grass-raised dairy. They come from certain fermented foods. Fermented foods will have Vitamin K2.

Someone that has a great microbiome because the vast majority of their time is a strong vibrant one, maybe you’re not going to see any impact if you have a piece of key lime pie once a month. Who cares?

And one big factor is the non-bacterial contributions as well. And so when we put an antibacterial product into our mouth, then we really don’t know what it’s doing and we have to be very conscious of that. I feel that we need to be thinking about replenishing the natural balances instead of scrubbing and cleaning.

I think we need to shift our mindset away from a disease system to a more preventive system. And at the same time I think dentists and doctors need to collaborate around the focus on the oral microbiome and allowing the public to learn more about it so that we can appreciate its connection to systemic disease. And maybe with that level of collaboration between all the specialties, we can establish better information about why these behavior changes are important.

Holy cow. The substances that our mouth bacteria excrete can get into our bloodstream and possibly cross into our brains. I don’t even know where to

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start with this, but I’m guessing that there’s much more involvement here with chronic disease than we understood. It’s a whole new era of research that’s

showing us just how important good oral health truly is. Here are several important takeaways to remember.

The most common class of microbes that cause heart valve infections are oral microbes. Inflammation in the oral cavity contributes to the release of C-reactive protein, which is a marker of cardiac disease. Periodontal disease has been linked to preeclampsia and premature birth. There’s a direct relationship between periodontal disease and Type 2 diabetes. Bacterial abscesses in the brain are typically traced back to mouth organisms. There’s a strong connection between periodontal disease and systemic autoimmune diseases like rheumatoid arthritis, lupus, psoriatic arthritis, Crohn’s Disease, and atherosclerosis.

About 50,000 Americans are diagnosed with oral or oropharyngeal cancer each year. Unfortunately, when they come in with pain it’s already typically in an advanced stage. Periodontal disease can get into our bloodstream directly from our mouths or by breaking cell junctions.

This brings us to an important point. If the mouth is such an important area for health prevention, detection and treatment, why has it been ignored so badly by the medical profession? And more importantly, how do we fix this? Let’s delve into the reunion of dentistry and medicine and talk about a better future for all of us.

So the separation between dentistry and conventional medicine started in around the 1840s when some self-trained dentists went to the University of Maryland in Baltimore and asked physicians to include dentistry into the medical curriculum. And they were told no, that dentistry was no more than a mechanical challenge. That means that we were good with our hands, but it had no medical significance.

It wasn’t until 125-126 years ago when the first dental school was allowed to exist in a university, because another Baltimore situation resulted in a separation of the dental school from the mother university until about 1926 when they reunited. And the absence of a strong tie with a research intensive university made dentistry second class focusing on procedures, understanding comes second and only if needed. And that has hurt the intellectual environment within which dentistry actually functions to a large extent.

Those that took care of the mouth came out of the tradition of dentistry as did surgeons out of the profession of barbers. They were separate from those that took care of the internal parts of the body.

These are other doctors saying the mouth does not matter and so they wouldn’t include it. So dentists had to go and start their own schools. One of the problems initially is that we were technically sound. We can do the mechanics of dentistry,

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but we were for a very long time, biologically weak. We weren’t getting the science behind it.

It was all about mechanics and just doing a lot of mechanical treatment rather than diagnostic type of workup.

So you see how kind of we can work with our hands and technically we’re dentists, right? We get that. We know how to drill a tooth and we know how to pull a tooth and we know those things. But the science behind what was happening didn’t come. Didn’t really come with real force until maybe the mid-1900s, around I think 1920 when William Guy started focusing on bringing, making it more science base.

Back in dental school at Tufts in 1977 Dr. Stanley Schwartz, who was our head of oral medicine at that point, implored us to be physicians of the mouth. He said to us way back then, he said there are so many conditions in the body that manifest in the oral cavity and that there isn’t a single profession, there is no other medical or health care practitioner who knows more about this area than the dentist. And so he said that we should never take a back seat to our medical brethren and that we in fact needed to practice physicians of the mouth as opposed to more to molar mechanics.

I always found it incredibly illogical that dentistry and medicine were separated 150 years ago. It’s time to end that divide. It really is and in my opinion, dentistry, especially biologic dentistry has become among the most important elements of your ability to be well. Of your ability to be healthy.

We’ve sort of siloed the human body and divided it up. We have medicine on one side and dentistry on the other. They go to separate schools, separate training. Even within the medical profession we have different specialties. We have cardiology and gastroenterology and dermatology and they’re all separate from each other and very often don’t talk to each other. And then that’s very much separate from the dental profession. That’s an artificial construct because we can’t separate the human body. We’re all one system and we have to think of it in a systems biology approach where everything’s connected to everything else. And so to try to separate the mouth from the rest of our body is really not even realistic.

And that separation in reimbursement has critical to how dentistry has been perceived. Because a lot of people believe if this is really a medical issue, the government would be behind it. They would really support it.

We’ve had a very illogical separation between doctors and dentists and you notice that when you’re out in the world because this is actually shown to me with one of my patients early in my career. He was going to see the heart surgeon for a quadruple bypass. And so what the surgeon had done is he’d sent him to me to get a dental clearance to make sure that there was going to be no problems during his surgery because if they have a dental infection in the hospital,

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it’s obviously going to interfere with his treatment.

And so he had a few teeth left standing, chronic gum disease and we had to take his last teeth out. And what I noticed then was that this chronic gum disease was affecting why Norman had heart disease. And so the fact that the heart surgeon had sent him to me at this very late stage of disease really was illogical. Today our healthcare system is very separated. We go to a digestive doctors. We go to brain doctors. We go to endocrinologists. All of this is connected and dentists and doctors have a very powerful thing in that we can project to patients if we show that the body works together.

It’s a slow walk. It’s a very slow walk. I give conferences with other doctors and they’re still looking at us as if you’re just a dentist. And many of them believe that we became dentists because we couldn’t go to medical school and it’s tough to go to dental school. It’s not easy at all.

The dental school and medical school, the students often take the basic science courses together. Histology, physiology, biochemistry and so forth. The barriers to fully integrating the two are substantial so, I’m not sure that I see them merging completely anytime soon.

This has resulted almost for much of the United States in a separation that led to a profession that became so focused on procedures as opposed to understanding prevention and the role of contributing science to understanding what you’re talking about, the microbiome, the relationship to other diseases and so on.

From the microbiologist point of view, there’s clearly been a very distinct community of investigators that’s always looked at the mouth as their fiefdom, their place of study. They have their own literature. They have their own journals. Those journals, and here’s an interesting telltale indication of the fact that there is such a divide. If I go to PubMed and I find an interesting article that’s published in the oral literature, my medical school library which grants me permission to look at most journals in PubMed, hasn’t bought the subscriptions to the oral microbiology literature. I can’t read those so easily. I have to ask my friends up at UC San Francisco in the dental school to send me those papers because I can’t get them.

They’re separate journals. It’s a separate set of meetings, separate societies. It’s cultural, historic and maybe even professional distinctness that that keeps us all separate. And for this very reason physicians learn very little about the mouth and dentists learn some about the rest of the body, but not nearly as much as physicians do. So, we’ve kept apart mechanisms and for reasons that just don’t make any sense today.

Now that we know all this stuff is linked, medical insurance doesn’t cover the mouth. You have to get separate dental insurance. Do you see that as folly? Do these things need to come together as well?

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So, as these systems have developed differently with their own organizations, I think the American Medical Association, the American Dental Association representing the different fields, the fee structures have been different and that certainly cause different practice models.

Historically, the reasons why there were dental schools and medical schools were separate when the health care came into the United States, the Congressmen decided that they wanted to keep the two separate, I think in part because dentistry was expensive for everybody needed dentistry. And when they first brought in healthcare, they didn’t want to add the cost of dentistry to the health care proposal. So, it was excluded. For all of these reasons dentistry and health care have sort of evolved along parallel but separate paths.

We have tests for oral cancer. We have tests that kind of break down what is the oral microbiome and what is the population? How much strep mutans is there compared to like P gingivalis? How high is the bacteroides population, that kind of thing? Unfortunately, the patient pays for that. It’s hard to get dental insurance or dental companies that give out a benefit for dentistry, dental work. It’s hard for them to pony up for this so the patient pays for it.

Dental insurance is not the same as medical insurance. We have limitations. $1500 versus a million. And a lot of people only want what the insurance will cover. That’s one thing.

And unfortunately we live in a society where if insurance doesn’t pay for it, the patient probably is thinking well maybe it’s not necessary. But, there are tests coming. We need more. We need more sophisticated tests and they have to come down in cost and they have to be more available. They also have to be introduced into the dental curriculum so that the dentists of tomorrow will have this and be very at ease with it and won’t think twice about testing their patients.

Training. It’s important that you continue to have continuing education and you understand what happens if you’re not up-to-date with the current research. So, with that, some of the old school ways of doing things just do not apply anymore. Sometimes volume. When we’re trying to see 30 patients in a day, we’re only one person, because we’re trying to make up for what the insurance will not compensate us for. So, sometimes insurances only pay us a quarter or a third of what our usual and customary fees are. And they market this by saying, “We’ll send you more patients.” So, you have all this volume.

You look at health care costs that every country is facing. We’re talking about billions to trillions of dollars of public money going into treating chronic disease. We’re not going to fix this with this reactive model we have. We need people who know how to get people better and it needs to happen soon or we’re going to fall off the proverbial cliff.

Dentistry takes time. It takes time to restore a tooth to look like a tooth so it could

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function like a tooth. It takes time when you have to probe every single tooth in order to find out, does this patient have gum disease? What stage of gum disease? What testing needs to be done to determine what bacteria is present in this particular patient and what concentration of bacteria? So, it’s a lot of reasons why we haven’t always practiced at the level that we’re responsible for practicing at, but we’re getting better.

Are things changing? Do you see dentistry and medicine coming together in the near future?

I see that probably in the next 10 years we will make significant strides towards integration and to opening up the vital communication that is needed to support the public with respect to diseases that don’t exclude the mouth. That the mouth is part of the body and the mouth is part of the health same as you said, it’s the mirror for many diseases.

So, what’s happened in the last 10 to 20 years is that there is a whole new model of physiology there that understands the oral systemic connection. And I think we’re going to start to see that there are practitioners within this looking at this new physiology because there are certainly areas for dental practitioners and general practitioners that treat chronic diseases and end-stage diseases with medications. Medications and treatments are wonderful for people for solutions. But, to get to the root cause we need physicians that understand how all these things happen, and how we can reverse them.

I think younger dentists get it. Older dentists are getting it. We’re even seeing health care providers now, pediatricians, pediatric nurses doing oral exams on patients because it works both ways.

So, I think we’ve seen now a progression in terms of our understanding and links between medicine and oral health care that in the coming 10, 15, 20 years, I do believe that collaborative care, more integrated approaches to oral health and medical health will become a lot more common.

I really think dentistry is part of being a medical professional. It’s really, those two cannot be separated. As a matter of fact, they’re so importantly linked together where I feel that now I work with physicians just as much as referrals as much as I work with general practitioners.

As dentists we collaborate, we reach out and we speak with our colleagues in medicine and then we speak to their physicians. And I think physicians even now in medical school the amount of training that they’re learning about the mouth that’s really growing. And there certainly is, I think, really they are tied together. And there are even residency programs out there that are in hospitals that are dentistry based, but in a hospital setting for very sick patients.

As much as I need to be aware of the medical issues related, the medical

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community needs to take their oral cavity into account. They are, I think it’s gotten to the point where it’s routine but it wasn’t always.

Just the other day I spoke with an oncologist and I spoke with a radiologist and you start and you speak with the patient’s physician and you try to figure out what can we do to help them together? Because my treatment that I use as a dentist can adversely affect the patient’s overall wellbeing or can complicate a treatment that they’re currently undergoing. So, I think health care professionals whether it’s dentists or MDs alike, we do understand that there is, we do have a relationship and you know there is, we all understand the link between oral and systemic health.

So, the integration of functional medicine I think will not only will help with the reintegration of medicine and dentistry, it can also build that bridge between the evidence-based part of our profession and the biological part of our profession and make this true oral systemic connection that can really only benefit our patients.

I can’t even imagine where dentistry will be 25 years from now because it’s amazing now. We have AAOSH, the American Academy of Oral and Systemic Health. That’s huge. But the fact that we need an academy is very interesting and they are doing some phenomenal things around bringing other dentists along with this fight. So, it’s a lot of us out there.

It’s a slow-turning wheel, but it doesn’t need to be. Too much is at stake. It’s time to put the egos aside and bring the well-intentioned people together. People are dying and that can be prevented. It must be. We’re seeing good progress in this area as we just learned from our expert, but there’s a lot of work to do. Talk to your doctor about this. Also, speak with your dentist about it. You, the consumer or the end user can really drive change faster.

Let’s go through some of the key takeaways from this act. The professions of dentistry and medicine were together 150 years ago and then they were separated. The chasm happened in Baltimore where the local government granted dentists their own lane to practice in. Dentistry became far more mechanical and technical. They became great surgeons of the mouth, but not necessarily asking why things were happening. Today’s renewed emphasis on etiology, or cause of disease, is changing the profession. Now the specialties are coming together in a collaborative environment of research and better patient care.

I hope you’re enjoying the series. Now’s the time to click on the link on this page and get yourself a copy of all the episodes, bonuses, and resources we’ve put together for you. Short of going to dental school and reading thousands of peer- reviewed papers and journals, you’ll save hundreds of hours learning what you need to know by watching this entire series and taking great notes.

The good news is in our packages we’ve that for you. We’ve summed up the key

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points in research and saved you countless hours. Take it home. Watch it over again. Listen to the interviews. Read the transcripts. There’s nowhere else you’ll be able to find all of this put together for you in such a succinct way. The entire series is 50% off right now during the event. Just click on the image below and you’ll see which package is best for you.

We learned a lot about oral health’s connections to the rest of the body in this episode. Next time we’re going to take a look at some of the controversial topics in the field. There’s been a lot of talk and finger-pointing around mercury amalgams, fluoride, botched root canals, cavitations and much more. We’re here for the truth, not hype.

As you can tell, we’ve gone to the top experts in the profession. Deans of dental schools, top clinicians, researchers, and thought leaders. We’ve asked them about the controversial issues, and I can’t wait to share that with you in the next episode.

This is Dr. Pedram Shojai signing off for now and excited to see you again soon in our exclusive free screening of Gateway to Health. Bye for now.