podcast Peter Attia 2021-06-21 topics

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

Audio

Show notes

Dr. Patricia Corby is Associate Professor of Oral Medicine and Associate Dean of Translational Research at Penn Dental Medicine. Her work focuses on the value of integrating dental services into other healthcare and public health settings. 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.

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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.

Show Notes

Anatomy of teeth and the purpose of the dental pulp—a highly vascularized and innervated region of the tooth [3:00]

Pat likes to talk about oral health with MDs because the connection to health is important
Peter has long wanted to discuss oral health, which is “a very underappreciated part of health” that is more than just cavities and cosmetic concerns

Pat’s background

Pat grew up in Brazil
Wanted a career involving systemic health
specialty is in periodontics and implant dentistry
Always wanted to do research
Stayed in US because so many professional opportunities
Peter mentions the anniversary of the death of Ayrton Senna Pat was watching the race on TV Peter says he’s never met a Brazilian person who was over 5 on that day who doesn’t remember it Peter says Senna is his personal hero, and he is wearing a Senna bracelet for the occasion
Peter did not go to the dentist for about 10 years during medical school and residency, but now he takes dental care very seriously
Pat was watching the race on TV
Peter says he’s never met a Brazilian person who was over 5 on that day who doesn’t remember it
Peter says Senna is his personal hero, and he is wearing a Senna bracelet for the occasion

Anatomy of teeth [6:15]

The periodontium is very complex system
Peter points out that there’s a vascular supply quite high in the tooth even though many people might assume that the white crown is just bone
Tooth enamel, made of minerals, is the hardest surface in the human body

Figure 1. Individual tooth anatomy. Image courtesy of Pat Corby.

On the top is enamel and cementum (around the root), then dentin , then pulp The enamel protects the layers underneath (hardest surface of the human body) The second layer provides cushioning and is hyper sensitive the heart of the tooth is the pulp, which has a lot of nerves – explains why tooth pain can be so bad ligaments around the roots provide cushioning against impact
The enamel protects the layers underneath (hardest surface of the human body)
The second layer provides cushioning and is hyper sensitive
the heart of the tooth is the pulp, which has a lot of nerves – explains why tooth pain can be so bad
ligaments around the roots provide cushioning against impact

Figure 2. Anatomy of a tooth showing cementum. Image credit: Wikipedia

The role of the nervous connection and vascular supply to the tooth [10:40]

Tooth decay Tooth decay first affects the pulp If you excise the pulp, you can preserve the root
Tooth decay first affects the pulp
If you excise the pulp, you can preserve the root

“The way you want to think in dentistry is that … you want to preserve function.” —Pat Corby

Try not to extract teeth because the space they hold is important
If necessary, do a root canal or put in an artificial crown

Figure 3. Progression of a root canal treatment. Images courtesy of Pat Corby.

Put implants in if you have to extract an entire tooth; not as good as a real tooth but can still hold the space and provide some function
Can still get inflammatory periodontal disease with an implant
Peter wonders why teeth are so highly innervated Implants without nerves can still break down food Our fingers are highly innervated because we need fine motor control, but why so much beneath the hard enamel? Pat says it preserves blood flow and connection with the immune response to fight infection
Implants without nerves can still break down food
Our fingers are highly innervated because we need fine motor control, but why so much beneath the hard enamel?
Pat says it preserves blood flow and connection with the immune response to fight infection

Function and innervation of the pulp ( this section contains additional information provided by Pat after the podcast was recorded )

The main four functions of the pulp: formation of dentin – one the most important roles, carried out by odontoblasts support of dentin through nutritional support (albumin, transferrin, tenascin, and other proteoglycans) innervation of the tooth immune system protection of tooth: occurs through the development of new dentin, which can provide a barrier between irritants and slow the rate of carious decay
Two main types of nerves are found in the pulp: Sympathetic autonomic fibers to the smooth muscle cells of pulp arterioles control contractile forces that regulate blood flow Afferent fibers are involved in temperature sensing and mechanical nociception
formation of dentin – one the most important roles, carried out by odontoblasts
support of dentin through nutritional support (albumin, transferrin, tenascin, and other proteoglycans)
innervation of the tooth
immune system protection of tooth: occurs through the development of new dentin, which can provide a barrier between irritants and slow the rate of carious decay
Sympathetic autonomic fibers to the smooth muscle cells of pulp arterioles control contractile forces that regulate blood flow
Afferent fibers are involved in temperature sensing and mechanical nociception
Peter reflects that dental pain seems to serve as such an early warning indicator as a breach of a barrier
He says, “Having been through so many miserable dental experiences, I’ve often cursed our evolutionary gods for giving us so much innervation in that tooth”

Types of teeth and the different purpose they serve [14:15]

Types of human teeth

Humans have 32 teeth with very specific functions

Figure 4. Dental anatomy. Image courtesy of Pat Corby.

Incisors 4 each in both the maxillary (upper) and the mandibular (lower) part of the jaw Used to bite and tear apart food
Canines 2 each in both upper and lower jaw very strong (longer root), further tearing apart
Premolars / bicuspids 4 each in both upper and lower jaw start to break down food
Molars used for chewing 6 in the upper and 6 in the lower jaw
4 each in both the maxillary (upper) and the mandibular (lower) part of the jaw
Used to bite and tear apart food
2 each in both upper and lower jaw
very strong (longer root), further tearing apart
4 each in both upper and lower jaw
start to break down food
used for chewing
6 in the upper and 6 in the lower jaw

Figure 5. Close up of the position of teeth in the mouth. Image courtesy of Pat Corby.

The digestive process starts in the mouth
Chewing is key because it brings the food in contact with saliva to start digestion
Roots Incisors and laterals and first premolars (the ones in front) have a single root Second premolars (in back) have two Molars have three or four depending on how big the tooth is Much stronger and a lot of pressure Peter reflects that molars would have the greatest opposition to other teeth and would need greater sensory input to sense the relative spacing and force
The mouth is a very elaborate system like a bridge, it has to be very well balanced occlusion has to be precise to avoid straining the ligaments and causing inflammation if don’t have good vertical occlusion, get facial pain and headaches
Peter learned the hard way that he had 4 rather than 3 molar roots when he still had pain after root canals on the first 3 roots
Incisors and laterals and first premolars (the ones in front) have a single root
Second premolars (in back) have two
Molars have three or four depending on how big the tooth is Much stronger and a lot of pressure Peter reflects that molars would have the greatest opposition to other teeth and would need greater sensory input to sense the relative spacing and force
Much stronger and a lot of pressure
Peter reflects that molars would have the greatest opposition to other teeth and would need greater sensory input to sense the relative spacing and force
like a bridge, it has to be very well balanced
occlusion has to be precise to avoid straining the ligaments and causing inflammation
if don’t have good vertical occlusion, get facial pain and headaches

Anatomy of the oral cavity, bacteria in the mouth, and what a healthy mouth looks like [18:10]

The oral cavity is a complex system Teeth Gums Gingival crevicular fluid that allows for bacteria to go in and out Tongue And much more
Teeth
Gums
Gingival crevicular fluid that allows for bacteria to go in and out
Tongue
And much more

Figure 6. Anatomy of the oral cavity. Image credit: Quizlet

Saliva plays a protective role When patients have dry mouth (perhaps due to medications, radiation treatment, or other toxic cancer treatments), the oral microbiome is altered The constant washing and flushing maintain microbiome homeostasis and prevent buildup of harmful bacteria
Oral hygiene is the key to oral health and regular bushing makes you healthier There are aerobic, anaerobic, and facultative bacteria in the mouth over 700 different bacteria live in symbiosis they naturally coexist in the human mouth without causing disease but if stop brushing your teeth, get dry mouth, etc., get changes in abundance and diversity can get overgrowth of harmful bacteria and suppression of beneficial bacteria
In a healthy mouth, ~ 30-40% of bacteria can play both aerobic and anaerobic roles and the rest are split roughly evenly between the two
When patients have dry mouth (perhaps due to medications, radiation treatment, or other toxic cancer treatments), the oral microbiome is altered
The constant washing and flushing maintain microbiome homeostasis and prevent buildup of harmful bacteria
There are aerobic, anaerobic, and facultative bacteria in the mouth over 700 different bacteria live in symbiosis they naturally coexist in the human mouth without causing disease
but if stop brushing your teeth, get dry mouth, etc., get changes in abundance and diversity
can get overgrowth of harmful bacteria and suppression of beneficial bacteria
over 700 different bacteria live in symbiosis
they naturally coexist in the human mouth without causing disease

Pat’s study demonstrating the importance of flossing [23:00]

Pat’s study of flossing in twins Two-week study of twins between the ages of 12 and 21 Had the same pathogens and pre-gingivitis that adults with periodontal disease have These pathogens became abundant when stopped flossing They are always present but only cause problems when you have a shift in the microbiome
Utility of twin studies Identical twin pairs have the same environment, age, gender, genes, etc. Dizygotic (fraternal) twins have 50% of the same genes In twin studies, can give twins two different treatments to compare them, or can give them same treatment to see if it’s more influenced by environment or genes
For her study, twins came in every day for brushing (one group) or brushing plus flossing (another group) Group that did not floss had gingival inflammation and bleeding Had periodontal bacteria in abundance, in particular the 3 main disease-causing ones: Porphyromonas gingivalis , Treponema denticola , and Aggregatibacter actinomycetemcomitans
Most periodontal disease is inflammation caused by anaerobes that thrive in in periodontal pockets
Periodontal disease starts with inflammation around the gums in healthy people, the periodontal ligament is tight if stop brushing, gums get inflamed and will bleed if resume flossing
At the initial stage of periodontal disease, it’s highly modifiable but if disease continues to develop, the ligament gets inflamed and will detach from the tooth, allowing bacteria in ligaments deteriorate and form a pocket culminates in bone loss
In acute periodontal disease, the gums are bleeding and inflamed but still attached to the tooth in more severe disease, you see a large gap where the bone has eroded and there is a pocket if you probe it, see gaps of maybe 3 to 7 mm
Once the pocket gets inflamed with chronic periodontitis, the gums are affected Gums recede, see more of teeth and eventually exposed roots bacteria can colonize and get root caries (cavities) can also get coronal caries on the top of teeth where you chew
In bottle-fed children who have the bottle overnight, get rapid development of caries on the anterior teeth One of the most common dental diseases Breast milk causes less decay because all formula has sugar
Two-week study of twins between the ages of 12 and 21
Had the same pathogens and pre-gingivitis that adults with periodontal disease have
These pathogens became abundant when stopped flossing
They are always present but only cause problems when you have a shift in the microbiome
Identical twin pairs have the same environment, age, gender, genes, etc.
Dizygotic (fraternal) twins have 50% of the same genes
In twin studies, can give twins two different treatments to compare them, or can give them same treatment to see if it’s more influenced by environment or genes
Group that did not floss had gingival inflammation and bleeding
Had periodontal bacteria in abundance, in particular the 3 main disease-causing ones: Porphyromonas gingivalis , Treponema denticola , and Aggregatibacter actinomycetemcomitans
Porphyromonas gingivalis ,
Treponema denticola , and
Aggregatibacter actinomycetemcomitans
starts with inflammation around the gums
in healthy people, the periodontal ligament is tight
if stop brushing, gums get inflamed and will bleed if resume flossing
but if disease continues to develop, the ligament gets inflamed and will detach from the tooth, allowing bacteria in
ligaments deteriorate and form a pocket
culminates in bone loss
in more severe disease, you see a large gap where the bone has eroded and there is a pocket
if you probe it, see gaps of maybe 3 to 7 mm
Gums recede, see more of teeth and eventually exposed roots
bacteria can colonize and get root caries (cavities)
can also get coronal caries on the top of teeth where you chew
One of the most common dental diseases
Breast milk causes less decay because all formula has sugar

Detrimental effects of sugar and the importance of fluoride and oral hygiene [31:45]

Harmful dental effects of sugar fructose, sucrose, lactose, small complex starches are all harmful most drinks have added sugar cariogenic bacteria metabolize the sugar for extra energy bacteria attach to the tooth secrete an extracellular matrix (biofilm) when they metabolize sugar, they secrete acid which destroys the enamel of the tooth
Peter postulates that the bacteria are metabolizing sugar anaerobically to produce lactate (and presumably hydrogen ions if the acidity of the environment is increasing) Similar to the Warburg effect , where bacteria default to anaerobic metabolism whether oxygen is present or not
Both glucose and fructose can be metabolized, even fructose from fruit
Given that the twins developed periodontal disease after 2 weeks of not flossing, how did we survive before toothbrushes and flossing? It was common to have dental caries 400 years ago But Pat has seen people use other things to clean their teeth in developing countries: plants, sticks, etc. removal of plaque is mechanical and even after brushing can get plaque back within two hours
fructose, sucrose, lactose, small complex starches are all harmful
most drinks have added sugar
cariogenic bacteria metabolize the sugar for extra energy
bacteria attach to the tooth secrete an extracellular matrix (biofilm)
when they metabolize sugar, they secrete acid which destroys the enamel of the tooth
Similar to the Warburg effect , where bacteria default to anaerobic metabolism whether oxygen is present or not
It was common to have dental caries 400 years ago
But Pat has seen people use other things to clean their teeth in developing countries: plants, sticks, etc.
removal of plaque is mechanical and even after brushing can get plaque back within two hours

“[What] we’re trying to do with the brushing is just [making sure] that we don’t let that accumulate and overwhelm and develop a cavity.” —Pat Corby

Peter points out that the form in which our ancestors consumed fructose and glucose was less concentrated and refined and thus probably less harmful to teeth
But every time he’s had a dental problem he wonders how he would function before dentists and lidocaine
“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” – Peter Attia
Pat says that our diets are much worse today – much higher in sugar
Pat says that both toothbrush and toothpaste are equally important
Toothpaste is the main source of fluoride Hardens the enamel and protects against cavities, especially in children Kids must get fluoride, even if have to paint it on
Important to combine with flossing Need to clean in between teeth as well as surface
Pat is doing a trial now where they are brushing the oral mucosa to decontaminate against bacteria She says oral mucosa and the tongue are neglected surfaces – most people don’t brush the tongue but need to get rid of the bacteria that accumulates there “You need to clean every single surface. And just the brush itself is not going to do the job”
Hardens the enamel and protects against cavities, especially in children
Kids must get fluoride, even if have to paint it on
Need to clean in between teeth as well as surface
She says oral mucosa and the tongue are neglected surfaces – most people don’t brush the tongue but need to get rid of the bacteria that accumulates there
“You need to clean every single surface. And just the brush itself is not going to do the job”

“You can maintain optimal oral health just by brushing teeth, by flossing really well, and having good nutrition.” —Pat Corby

Oral health challenges for cancer patients and immunocompromised people [39:45]

Patient undergoing radiation treatment have mouth ulcers that make it painful to eat, drink, or brush their teeth In that population, Pat’s team will clean the periodontium, cheek and oral mucosa Oral hygiene programs need to be tailored to the specific needs and risks of the specific person
Peter asks if flossing is important because of the mechanical removal of food particles between the teeth or transient irritation of the gum – would someone on an all-liquid diet still need to floss? You probably should not floss if you are immunocompromised Otherwise it’s mainly is to clean anaerobic bacteria in between your teeth Brushing also helps with gums – massages them and helps them stay strong It’s ideal to brush, then floss, then brush again to remove all bacteria Also need to brush the tongue
Different parts of the mouth have different bacteria: buccal mucosa (inside of the check), tongue, the floor of mouth, throat
There is also the human papilloma virus (HPV), which is highly associated with oropharyngeal cancer
Patients undergoing radiation ideally would see a periodontist for a periodontal treatment every week But insurance (like Medicaid and Medicare) doesn’t pay for this, even though it does pay for the oncologist, speech therapy, nutritionist, etc. Pat is currently doing research to establish the benefit of oral care treatments for these patients, hoping it might become a standard of care
Peter notes that cancer patients are at greater risk of systemic infections that start in the mouth They are immunocompromised in general and also have increased susceptibility to infection from the loss of the immune barrier in the mouth Pat adds they also often have dry mouth from the treatment, and some cannot produce saliva anymore They get fungal infections, which “escalates a lot of local infection and inflammation in the oral cavity and affects them systemically”
Pat is doing a study looking at saliva, inflammatory markers, and the oral microbiome before and three months after radiation treatment Data Pat is collecting now shows that most of the cytokines in saliva are completely suppressed in patients who received comprehensive periodontal care (unlike those who did not receive the care) Pat noted that no doctors were looking at cancer patients’ mouths even though they have “horrible oral hygiene” These cancer patients are also depressed
In that population, Pat’s team will clean the periodontium, cheek and oral mucosa
Oral hygiene programs need to be tailored to the specific needs and risks of the specific person
You probably should not floss if you are immunocompromised
Otherwise it’s mainly is to clean anaerobic bacteria in between your teeth
Brushing also helps with gums – massages them and helps them stay strong
It’s ideal to brush, then floss, then brush again to remove all bacteria
Also need to brush the tongue
But insurance (like Medicaid and Medicare) doesn’t pay for this, even though it does pay for the oncologist, speech therapy, nutritionist, etc.
Pat is currently doing research to establish the benefit of oral care treatments for these patients, hoping it might become a standard of care
They are immunocompromised in general and also have increased susceptibility to infection from the loss of the immune barrier in the mouth
Pat adds they also often have dry mouth from the treatment, and some cannot produce saliva anymore
They get fungal infections, which “escalates a lot of local infection and inflammation in the oral cavity and affects them systemically”
Data Pat is collecting now shows that most of the cytokines in saliva are completely suppressed in patients who received comprehensive periodontal care (unlike those who did not receive the care)
Pat noted that no doctors were looking at cancer patients’ mouths even though they have “horrible oral hygiene”
These cancer patients are also depressed

“They start radiation right after surgery, … they already can’t brush their teeth because sometimes they lose half of their jaw, they take their tongue. So they’re highly debilitated, so they stop brushing and they go into radiation. When they get into radiation [it’s] changing the microbiome and they develop horrible ulcers in their mouth. And then they become immunocompromised. And so it’s a whole cascade of things that happen in those patients.” —Pat Corby

Pat’s current research on cancer patients undergoing radiation treatment and the oral health risks associated with human papilloma virus (HPV) [50:00]

Research on cancer patients undergoing radiation

Pat started doing a dental cleaning on patients about to start radiation treatment and then throughout treatment The radiation oncologist, Nicholas Sanfilippo , noticed that his patients whom Pat treated did not develop mucositis She did a preliminary study on a small group of patients and later got a grant to do a larger study
Some of the dental care must be done by someone trained and some can de done by patients at home
If someone doesn’t brush for a long period of time and plaque builds up, it can become tartar Then has to be removed with a specific vibrating ultrasound In a routine dental cleaning, they either scrape your teeth with very sharp instruments or they use the electronic one to disrupt and break up plaque
Pat is doing both in a current study as well a cleaning the entire oral cavity Complete cleaning takes about an hour In the other group, the hygienist does a light clean or a holistic, comprehensive approach to education in order to make the study blind Neither group has been developing disease
Pat’s study is focusing specifically on patients of both sexes with head and neck cancer receiving a minimum of 50 grades of radiation to the oral cavity due to the cancer In that circumstance, 90% of them will develop mucositis Have both RT only and RT + chemo groups 100% of patients in the RT + chemo group get mucositis Mostly squamous cell head and neck cancers
The radiation oncologist, Nicholas Sanfilippo , noticed that his patients whom Pat treated did not develop mucositis
She did a preliminary study on a small group of patients and later got a grant to do a larger study
Then has to be removed with a specific vibrating ultrasound
In a routine dental cleaning, they either scrape your teeth with very sharp instruments or they use the electronic one to disrupt and break up plaque
Complete cleaning takes about an hour
In the other group, the hygienist does a light clean or a holistic, comprehensive approach to education in order to make the study blind
Neither group has been developing disease
In that circumstance, 90% of them will develop mucositis
Have both RT only and RT + chemo groups
100% of patients in the RT + chemo group get mucositis
Mostly squamous cell head and neck cancers

HPV (56:00) ( this section contains additional information provided by Pat after the podcast was recorded )

HPV is believed to cause 70% of cancers of the oropharynx the (back of the throat, including the base of the tongue and tonsils) in the US

Figure 7. The Oropharynx . Image credit: Centers for Disease Control

It’s unknown if HPV infection alone can cause oropharyngeal cancers or if other risk factors (such as tobacco use) must also be present
Most (~90%) HPV-related oropharyngeal cancers are positive for a specific strain called HPV-16
Peter finds the rising incidence of HPV-driven squamous cell carcinomas of the oropharyngeal region concerning we do not have adequate screening procedures like we do for HPV-driven cancer of the pelvis in women Unless you do advanced imaging like an MRI, they’re often found quite late
Oral sex is the primary mode of transmission, and there may also be other unknown ways These cancers are often the result of oral sex combined with poor oral health As with other mouth infections, it’s about the balance of various microbes Some, like P. gingivalis , allow virus to grow
Immune system deficiency also allows viruses, bacteria, and fungi to develop into infections
The HPV vaccine The HPV vaccine protects against the types of HPV that can cause oropharyngeal cancers The CDC currently recommends that everyone be vaccinated around age 11-12 (and through age 26 years if not already vaccinated)
we do not have adequate screening procedures like we do for HPV-driven cancer of the pelvis in women
Unless you do advanced imaging like an MRI, they’re often found quite late
These cancers are often the result of oral sex combined with poor oral health
As with other mouth infections, it’s about the balance of various microbes
Some, like P. gingivalis , allow virus to grow
The HPV vaccine protects against the types of HPV that can cause oropharyngeal cancers
The CDC currently recommends that everyone be vaccinated around age 11-12 (and through age 26 years if not already vaccinated)

Periodontal disease: caries and root canals [57:30]

Stages of dental disease (58:30)

Figure 8. Development of dental caries. Image courtesy of Pat Corby

The initial stage of dental decay is breaking through the enamel Hasn’t reached second layer of the tooth White spot lesions when decalcification has started Can be reversed at this stage Most we shouldn’t be touching or treating, in kids can do a fluoride varnish application Used to poke it with a probe, now mostly use air to inspect so don’t break the enamel Minimal discomfort because enamel caries have not reached the pulp no cold or heat sensitivity
When it reaches the dentin, it’s painful and cold sensitive when bacteria start colonizing, can get constant pain cold sensitivity occurs earlier in the process dentin caries can be fixed without a root canal
Once an infection reaches the pulp, a root canal is required Must excise the live pulp and then clean and disinfect A hot sensation is usually a sign of inflammation
Hasn’t reached second layer of the tooth
White spot lesions when decalcification has started
Can be reversed at this stage
Most we shouldn’t be touching or treating, in kids can do a fluoride varnish application
Used to poke it with a probe, now mostly use air to inspect so don’t break the enamel
Minimal discomfort because enamel caries have not reached the pulp
no cold or heat sensitivity
when bacteria start colonizing, can get constant pain
cold sensitivity occurs earlier in the process
dentin caries can be fixed without a root canal
Must excise the live pulp and then clean and disinfect
A hot sensation is usually a sign of inflammation

Root canal treatment

Peter regrets switching out a mercury filling for a white one because it started hurting and ultimately he needed a root canal
Many times when you do a root canal, the pulp is still alive but is removed Used to be a crude procedure when they would break through the roots Today it’s essentially a microscopic surgery Excise the pulp in an aseptic environment Fill the hole with special materials Preserves function
Used to be a crude procedure when they would break through the roots
Today it’s essentially a microscopic surgery
Excise the pulp in an aseptic environment
Fill the hole with special materials
Preserves function

Figure 9. Cross-section of a tooth before and after a root canal treatment. Image credit: American Association of Endodontists

Peter says “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”

Controversies around root canals [1:06:45]

There is no evidence that root canals cause the plethora of problems people claim they do (cancer, Alzheimer’s disease , etc.) The infection in your tooth is from microbes that were already in your body They are effective if they are done microscopically and should not cause long-term issues There’s a paper associating root canals with breast cancer which Peter calls a “bottom of the birdcage paper” because it did not look at a control group of women who did not have a root canal but did have cancer
The infection in your tooth is from microbes that were already in your body
They are effective if they are done microscopically and should not cause long-term issues
There’s a paper associating root canals with breast cancer which Peter calls a “bottom of the birdcage paper” because it did not look at a control group of women who did not have a root canal but did have cancer

“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 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.” —Peter Attia

The relationship between poor oral health and systemic health diseases [1:11:00]

Peter asks if the greatest causal relationship we have between poor oral health and poor systemic health would be with cardiovascular disease Pat says there is a lot of research showing association but we don’t know which comes first
Periodontal disease has been associated low birth weight, heart problems, and diabetes
Some markers of periodontal disease and Alzheimer’s disease are similar
Pat says that “ It’s all based on the insult of the bacteria, causing inflammation and systemic health [problems] .”
We really need to do clinical trials to establish causality
Pat says there is a lot of research showing association
but we don’t know which comes first

Down syndrome

Pat has worked with Mony de Leon and Angela Kamer from NYU
They did a study on kids with Down Syndrome They have motor skill and cognition issues so it’s hard to maintain good oral hygiene children with Down syndrome are very susceptible to Alzheimer’s disease and cardiovascular disease and usually do not live a normal life span (die as early as their 40s or 50s) but hard to tell if the increase in amyloid-β in the brain is an independent process that’s being driven by the chromosomal abnormalities that are found in Down syndrome versus related to poor oral hygiene
Peter says 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 standard of care
They have motor skill and cognition issues so it’s hard to maintain good oral hygiene
children with Down syndrome are very susceptible to Alzheimer’s disease and cardiovascular disease and usually do not live a normal life span (die as early as their 40s or 50s)
but hard to tell if the increase in amyloid-β in the brain is an independent process that’s being driven by the chromosomal abnormalities that are found in Down syndrome versus related to poor oral hygiene

A preventative approach

Pat says we need to focus on “a very intense preventive approach”
At Penn Dental, the dean ( Mark Wolff , whom Pat calls “a visionary” in his focus on prevention) prioritized the opening of the Care Center for People with Disabilities He and Pat are creating a program to do research on how to create effective oral hygiene programs for people with disabilities, especially cognitive and motor skills It focuses on caregivers But hard to know what to measure: “There is no outcome assessment that you can use for this specific population because they’re so neglected”
Peter asks about a hypothetical experiment in subjects without cancer and who are not immunocompromised Of one group receives best-in-class oral care and the other bad or mediocre care Would you see a difference in inflammatory markers (including cytokines, macrophages , and monocytes ) across those two groups? If so, that alone could explain the increase in systemic disease The relationship between inflammation and cardiovascular disease is well established If two people have identical lipoprotein profiles but one has inflammation, the one with inflammation will have a greater burden of disease it plays a role in cancer and Alzheimer’s disease
He and Pat are creating a program to do research on how to create effective oral hygiene programs for people with disabilities, especially cognitive and motor skills
It focuses on caregivers
But hard to know what to measure: “There is no outcome assessment that you can use for this specific population because they’re so neglected”
Of one group receives best-in-class oral care and the other bad or mediocre care
Would you see a difference in inflammatory markers (including cytokines, macrophages , and monocytes ) across those two groups?
If so, that alone could explain the increase in systemic disease The relationship between inflammation and cardiovascular disease is well established If two people have identical lipoprotein profiles but one has inflammation, the one with inflammation will have a greater burden of disease it plays a role in cancer and Alzheimer’s disease
The relationship between inflammation and cardiovascular disease is well established
If two people have identical lipoprotein profiles but one has inflammation, the one with inflammation will have a greater burden of disease
it plays a role in cancer and Alzheimer’s disease

“To me, 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” – Peter Attia

Pat points out that, despite this relationship, doctors do not routinely ask their patients about oral hygiene

Potential connection between oral hygiene and COVID-19 [1:17:45]

COVID is transmitted by saliva / the mouth Studies show that the ACE2 receptors (to which COVID binds to enter the body) are highly expressed in the oral cavity But when a COVID patient goers into the hospital they are put in a mask in a supine position Never brush their teeth or ask if they have periodontal disease
Periodontal disease would be the “perfect reservoir” for the virus COVID patients aren’t particularly congested – it goes directly from the mouth to the lungs Oral hygiene should be a priority for these patients
There aren’t any oral epidemiologists or periodontists on COVID committees Experts on oral health could help us do much better prevention than masks When COVID hit, dental care was not considered essential
Pat had to suspend her trials for 3-4 months and the clinics were completely closed for almost a year Procedures were suspended “and we saw really detrimental things because people couldn’t get access to care”
Also, because of masks, people brush their teeth less and get dry mouth from breathing through a mask
Studies show that the ACE2 receptors (to which COVID binds to enter the body) are highly expressed in the oral cavity
But when a COVID patient goers into the hospital they are put in a mask in a supine position
Never brush their teeth or ask if they have periodontal disease
COVID patients aren’t particularly congested – it goes directly from the mouth to the lungs
Oral hygiene should be a priority for these patients
Experts on oral health could help us do much better prevention than masks
When COVID hit, dental care was not considered essential
Procedures were suspended “and we saw really detrimental things because people couldn’t get access to care”

Dry mouth leading to oral infections and ways to prevent it [1:22:30]

Can actually get oral thrush even if not immunocompromised Sometimes related to a medication like inhaled steroids It’s also highly associated with candida infection Primary reason is lack of saliva (i.e., dry mouth) Generally speaking, can be a result of poor oral hygiene (and certain medications) that allows opportunistic species (sometimes both virus and fungus) to grow People with HIV have constant episodes of fungal infection in their mouth
Anticholinergics and dry mouth A class of drugs that inhibit the parasympathetic nervous system and are used to treat digestive issues, respiratory problems, dizziness, and other conditions one of the most popular classes of drugs that can cause dry mouth There is an association between anticholinergics and Alzheimer’s disease but we don’t have data to indicate whether it’s causal
Interesting to speculate if the systemic effect of changes in resistance of bacteria that dry mouth causes plays a role
Sometimes related to a medication like inhaled steroids
It’s also highly associated with candida infection Primary reason is lack of saliva (i.e., dry mouth)
Generally speaking, can be a result of poor oral hygiene (and certain medications) that allows opportunistic species (sometimes both virus and fungus) to grow People with HIV have constant episodes of fungal infection in their mouth
Primary reason is lack of saliva (i.e., dry mouth)
People with HIV have constant episodes of fungal infection in their mouth
A class of drugs that inhibit the parasympathetic nervous system and are used to treat digestive issues, respiratory problems, dizziness, and other conditions
one of the most popular classes of drugs that can cause dry mouth
There is an association between anticholinergics and Alzheimer’s disease but we don’t have data to indicate whether it’s causal

Preventative measures

Keeping mouth lubricated with SUGAR FREE chewing gum or lozenges can be useful for people who have dry mouth
Continual hydration is also key (sip water all day long)
Xylitol (a sugar substitute) might be specifically be beneficial Peter chews gum with xylitol in place of brushing his teeth when he is out Pat has done research on mother-to-child transmission of dental caries Caregivers with caries tasting food and then giving it the child can affect the child’s oral health Also found could prevent vertical transmission by having pregnant women chew xylitol Xylitol may also prevents tooth decay because bacteria do not metabolize it Peter’s favorite xylitol brand is PÜR gum and mints
Peter chews gum with xylitol in place of brushing his teeth when he is out
Pat has done research on mother-to-child transmission of dental caries Caregivers with caries tasting food and then giving it the child can affect the child’s oral health Also found could prevent vertical transmission by having pregnant women chew xylitol
Xylitol may also prevents tooth decay because bacteria do not metabolize it
Peter’s favorite xylitol brand is PÜR gum and mints
Caregivers with caries tasting food and then giving it the child can affect the child’s oral health
Also found could prevent vertical transmission by having pregnant women chew xylitol

What determines the appearance of teeth, methods of teeth whitening, and whether you should remove mercury fillings [1:27:30]

What people notice most about teeth is how straight and white they are
The color of someone’s teeth is somewhat genetically determined
But environment plays a role as well Pat’s research has shown that drinking coffee and tea had an effect can modify by brushing and using whitening products Peter says black tea and red wine are the worst for him
Whitening the teeth can be detrimental if bleach excessively and cause mineral loss Better to do it at the dentist rather than at home to protect the gums dentists will not to do it if you have periodontal disease, but people buying over-the-counter products don’t know what they’re doing doing it frequently results in constant demineralization use FDA-approved products under a dentist’s supervision
can also be preventative by minimizing the things that really discolor your teeth
Pat’s research has shown that drinking coffee and tea had an effect
can modify by brushing and using whitening products
Peter says black tea and red wine are the worst for him
Better to do it at the dentist rather than at home to protect the gums
dentists will not to do it if you have periodontal disease, but people buying over-the-counter products don’t know what they’re doing
doing it frequently results in constant demineralization
use FDA-approved products under a dentist’s supervision

Should you remove mercury fillings?

There is no need to remove mercury fillings if there is no decay underneath
The mercury in fillings is not harmful

Importance of fluoride for preventing tooth decay, and dental care for children [1:32:45]

Fluoride (1:32:45)

Want to use toothpaste with 1000-1500 parts per million (ppm) of fluoride The American Dental Association (ADA) lists toothpaste brands with fluoride to prevent decay Kids under 1 swallow toothpaste so you should not use fluoride for them
In many countries the drinking water is fluoridated, but it varies by region in the US
Can also use drops or varnish for kids (painted on every 6 months) as well
There are highly concentrated fluoride varnishes available (e.g., PreviDent ) Pat recommends using them every night for people at high risk of caries like patients undergoing radiation treatment
The American Dental Association (ADA) lists toothpaste brands with fluoride to prevent decay
Kids under 1 swallow toothpaste so you should not use fluoride for them
Pat recommends using them every night for people at high risk of caries like patients undergoing radiation treatment

Dental care in children

Pat’s now-grown kids never had tooth decay She would tell her kids stories about the microbiome that was going to eat their teeth so they would brush
Night is an important time for tooth decay Don’t give kids baby bottles overnight when you’re sleeping, you have suppressed saliva production, creating the perfect environment for the bacteria to grow critical to brush before you go to bed
Peter asks how to handle tooth decay in children Pat says you must be very careful not to traumatize them; use sedation Can extract a baby tooth if causing a lot of pain Can’t put a hole in the tooth and do restoration in a young child
Can use a very concentrated type of fluoride as a temporary measure, but it turns the cheek black It’s mixed with a metal that hardens when it comes into contact with the soft dentin will control pain and arrest decay until the tooth falls out warn the parents that the tooth will turn black but it will not affect the adult tooth
She would tell her kids stories about the microbiome that was going to eat their teeth so they would brush
Don’t give kids baby bottles overnight
when you’re sleeping, you have suppressed saliva production, creating the perfect environment for the bacteria to grow
critical to brush before you go to bed
Pat says you must be very careful not to traumatize them; use sedation
Can extract a baby tooth if causing a lot of pain
Can’t put a hole in the tooth and do restoration in a young child
It’s mixed with a metal that hardens when it comes into contact with the soft dentin
will control pain and arrest decay until the tooth falls out
warn the parents that the tooth will turn black but it will not affect the adult tooth

Useful dental products: floss, electrics toothbrushes, and more [1:39:15]

Peter asks about the cottage industry of products Things like oil for pulling through the teeth and tongue scraping Pat says there’s not much research, but brushing the tongue should be enough
Things like oil for pulling through the teeth and tongue scraping
Pat says there’s not much research, but brushing the tongue should be enough
Dental floss
Seem to be different types: ribbon, miniature rope, and types coated in wax Pat says it’s largely a matter of patient preference If your teeth are close together, may need to use a wax-coated type to protect the gums Also make kinds that work well with bridges
Pat estimates that most of her patients don’t floss every day, but it’s even more important than brushing You can’t really clean the plaque that is in between your teeth Anaerobic bacteria that cause systemic health problems like cardiovascular disease and diabetes are found in niches without oxygen like in between teeth and the back of the throat
Pat says it’s largely a matter of patient preference
If your teeth are close together, may need to use a wax-coated type to protect the gums
Also make kinds that work well with bridges
You can’t really clean the plaque that is in between your teeth
Anaerobic bacteria that cause systemic health problems like cardiovascular disease and diabetes are found in niches without oxygen like in between teeth and the back of the throat
Pat likes the Waterpik but it should not be used without brushing
Peter wonders if his toothpick habit is bad for him Pat says it can stimulate the gums But it cannot substitute for flossing
Pat also likes electric toothbrushes Sonicare and Oral B are equally effective Peter and Pat prefer Oral B because the vibrations are more gentle Use whichever you prefer
Pat says it can stimulate the gums
But it cannot substitute for flossing
Sonicare and Oral B are equally effective
Peter and Pat prefer Oral B because the vibrations are more gentle
Use whichever you prefer

Ideal oral care regimens [1:47:30]

Peter’s regimen brushes his teeth in the morning only after he drinks coffee and then eats around 11 He uses his Oral B toothbrush for 30 seconds on top inside, 30 seconds top outside, and then same on the bottom Uses his toothpick during the day After dinner he flosses and then uses the Oral B again (with a xylitol-based fluoride toothpaste) Does not use mouthwash or a Waterpik Pat says he needs to brush after his coffee to clean his mouth from overnight
Soft bristle toothbrushes can be better for the tongue
You should also rinse your toothbrush after using it, and then dry it because bacteria thrive in moisture Rinse in warm water You can even rinse with soap (toothpaste has soap in it but taste is blocked)
Mouthwash wipes out all your microbiome, including the good ones Good to use when can’t brush, but don’t overuse so microbes won’t become resistant There is not good data on whether mouthwash can cause fungal or other overgrowth But it changes the microflora, so if you’re healthy you don’t want to interfere with it
The take-home message is that prevention is key The only way to prevent dental caries throughout life is chronic preventive oral care Go to the dentist every 6 months for a cleaning and to ensure no cavities Research shows 6 months is good for healthy people If you are high risk with systemic health problems (e.g., diabetes), maybe 3 times a year instead
Pat’s own research has shown that the rate of progression of periodontal disease varies It’s closely tied to the body, so a systemic issue will exacerbate inflammation See worse periodontal disease in patients with systemic diseases
brushes his teeth in the morning only after he drinks coffee and then eats around 11
He uses his Oral B toothbrush for 30 seconds on top inside, 30 seconds top outside, and then same on the bottom
Uses his toothpick during the day
After dinner he flosses and then uses the Oral B again (with a xylitol-based fluoride toothpaste)
Does not use mouthwash or a Waterpik
Pat says he needs to brush after his coffee to clean his mouth from overnight
Rinse in warm water
You can even rinse with soap (toothpaste has soap in it but taste is blocked)
Good to use when can’t brush, but don’t overuse so microbes won’t become resistant
There is not good data on whether mouthwash can cause fungal or other overgrowth
But it changes the microflora, so if you’re healthy you don’t want to interfere with it
The only way to prevent dental caries throughout life is chronic preventive oral care
Go to the dentist every 6 months for a cleaning and to ensure no cavities
Research shows 6 months is good for healthy people
If you are high risk with systemic health problems (e.g., diabetes), maybe 3 times a year instead
It’s closely tied to the body, so a systemic issue will exacerbate inflammation
See worse periodontal disease in patients with systemic diseases

Oral hygiene and diabetes ( this section contains additional information provided by Pat after the podcast was recorded )

Diabetics have more periodontal disease, so need more frequent cleanings
Both Type I (T1DM) and Type II (T2DM) diabetes are associated with periodontal disease Most of the studies have looked at T2DM and found a strong association both types of diabetes involve increased inflammation and reactive oxygen species (ROS) in the gingiva Hyperglycemia (high blood sugar), high levels of advanced glycation end products ( AGEs), and possibly hypoinsulinemia (low blood insulin ) or insulin resistance may all contribute
The largest clinical trial addressing this question did not find any effects of periodontal treatment on improving glycemic control [as measured by glycated hemoglobin (HbA1c)] in patients with T2DM This was a surprising finding the trial was stopped early because of futility
But both diabetes and periodontal disease are preventable, so that is the key
Most of the studies have looked at T2DM and found a strong association
both types of diabetes involve increased inflammation and reactive oxygen species (ROS) in the gingiva
Hyperglycemia (high blood sugar), high levels of advanced glycation end products ( AGEs), and possibly hypoinsulinemia (low blood insulin ) or insulin resistance may all contribute
This was a surprising finding
the trial was stopped early because of futility

Selected Links / Related Material

Summary of pulp function and innervation : Anatomy, Head and Neck, Pulp (Tooth) StatPearls (Ghannam, Alameddine & Bordoni 2021) [12:15]

Pat’s study of flossing in twins : Treatment outcomes of dental flossing in twins: molecular analysis of the interproximal microflora Journal of Periodontology (Corby et al. 2008) [22:15]

Pat’s preliminary study on regular dental cleanings for cancer patients undergoing radiation treatment : Oral Care Protocol for the Management of Chemotherapy and Radiation Therapy-Induced Oral Mucositis (OMDP) | ClinicalTrials.gov (#NCT02608879) [52:00]

CDC statistics and information on HPV-related cancer : HPV and Oropharyngeal Cancer Centers for Disease Control (CDC) (cdc.gov) [56:00]

Study of periodontal disease and Alzheimer’s in Down Syndrome patients : Periodontal disease’s contribution to Alzheimer’s disease progression in Down syndrome Alzheimer’s & dementia (Kamer … Corby … de Leon 2016) [1:13:00]

Study showing an association between anticholinergics and Alzheimer’s disease : Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study JAMA Internal Medicine (Coupland et al. 2019) [1:24:00]

Pat’s research on mother-child transmission of dental caries : On the Acquisition of Periodontopathic Bacteria by Children from Mothers: A Randomized Double-Masked Placebo-Controlled Trial in Bauru, Brazil Suom Hammaslaakarilehti (Bretz … Corby et al. 2006) [1:26:15]

Pat’s research on the progression of periodontal disease : [1:55:30]

Patterns of periodontal disease progression based on linear mixed models of clinical attachment loss Journal of Clinical Periodontology (Teles … Corby et al. 2017)
Modelling changes in clinical attachment loss to classify periodontal disease progression Journal of Clinical Periodontology (Teles … Corby et al. 2016)

Clinical trial finding that periodontal treatment did not improve HbA1c levels in patients with T2DM : The effect of nonsurgical periodontal therapy on hemoglobin A1c levels in persons with type 2 diabetes and chronic periodontitis: a randomized clinical trial JAMA (Engebretson et al. 2013) [1:57:15]

People Mentioned

Ayrton Senna [5:00]
Nicholas Sanfilippo [51:00]
Mony de Leon [1:12:30]
Angela Kamer [1:12:30]
Mark Wolff [1:14:45]

Dr. Patricia Corby is an Associate Professor of Oral Medicine and the Associate Dean of Translational Research at the University of Pennsylvania Dental Medicine. She is also the Director of the Penn Dental Medicine Center for Clinical and Translational Research. She is an experienced researcher with over 20 years of experience designing and running high-impact clinical research projects and has served as Principal Investigator, Co-Investigator, or Consultant on a number of projects funded by the National Institutes of Health (NIH), foundations, and industry. Dr. Corby’s work focuses on the value of integrating medical and dental services in different healthcare and public health settings to prevent systemic complications of populations with unmet oral health needs and associated chronic diseases. After receiving her DDS and completing her residency in Periodontics and Implants in her native Brazil, she obtained her MS in Biomedical Informatics from the University of Pittsburgh School of Medicine completed a postdoctoral training in Molecular Biology and Microbial Genetics at Harvard University and the Forsyth Institute.

Professional website : https://www.dental.upenn.edu/faculty/patricia-corby/

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