Today's first session is titled Vital Considerations in Oral Hygiene , Bridging the Dental Medical Divide and presented by Navy Commander Karima Aye . Navy Commander Karima Aye is the dental service point of contact command , fitness leader , and active duty dental program , orthodontic service consultant for the health care operations division of the defense health agency . She is a board certified general dentist . So please joining me and welcome Commander Aye . Good morning , everyone . Um Hopefully everyone can hear me . Thank you so much uh for sharing your time with me . I'm so excited . Um uh I uh graduated uh from uh uh fiu um Bachelor of Science , biology , chemistry . Then I went to dental school in Florida . Um I practiced for eight years in the civilian world . Uh And then one of my navy friends from dental school uh was like telling me about all her Navy experiences and I said that sounds really great . So uh I've never looked back since it's been wonderful . Uh And I hope to share more years uh in the military moving forward . So , um some disclosures , I have no relevant financial or non-financial relationships to disclose , relating to the content of this activity the views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the Department of Defense nor the US government . The continuing education activity is managed and accredited by the Defense Health Agency J seven Continuing Education Program office . Uh DH AJ seven ce po and all accrediting organizations do not support or endorse any product or service mentioned in this activity . DH AJ seven ce po staff , as well as activity planners and reviewers have no relevant financial or non-financial interest to disclose commercial support was not received for this activity . OK . Slide five . So what is the goal today ? So I want to share um you know , some light on how , you know , dental is part of overall health . We wanna look at and analyze systemic correlations between oral health , overall health . We want to deconstruct the ideology of caries and periodontitis , which are two of the main diseases that plague the dental world . Um explain how to carefully take care of both pediatric and adult dentists and then identify when dental clearance is indicated . OK . Next slide please . So uh just a little uh dental humor , right ? Um So uh you know , we all like to have white teeth , even the snowman , I guess next slide please . And so I I'm gonna start with this . So teeth are organs and they're specialized organs . Um And they're to me they're just fantastic because they have nerves , they have uh blood supply , they have uh ability to have uh pain perception , uh pressure sensation , they have fibers . Um So , uh they're , they're really , you know , fantastic . And I show this picture because there is a connection between the cranial nerves and the teeth . That's how they get sensation , you know , between our brain that , you know , tells us , hey , we're sensing pain . Um , you know , and it's one of the things that I think in uses , it's not obvious but for civilians , when they , you know , they're in medical school in the auditoriums . If you look around , it's not just medical students in there for the first two years . Dental students are taking all the same classes as medical students . And it's for a reason , a really good reason . It's because we have to know medical very well in order to be a good dentist . Um uh out of , you know , all the specialties , you're gonna find that dentists , we know how to do a cranial nerve exam . We know our cranial nerves well , because those are the branches that we deal with , um , us numbing patients . Um , looking at trauma and kind of figuring out , um , you know what happened here . Um That's why cranial nerve exams for us . It's our bread and butter , head and neck anatomy is something that they focus on with us a lot . So while we are all with the , you know , medical students , you'll have some optometry thrown in there , maybe veterinary students if your school has that . Um But we're all taking , you know , histology and pathology altogether , gross anatomy , right ? We also take uh additional including neuroanatomy . We also take head and neck anatomy and , you know , so first , you know , we had the whole body that was ours and , you know , we dissected it , but then we move on to just the head and neck and , you know , dissect that . Um because the , you know , head and neck has some of the , it's the area that has the most concentrated amount of structures in the body . So uh for us , it is super important that we understand that because that's how we can look at . OK , what is the , the connection here between the teeth and the rest of the body ? Um So they do , you know , teeth do serve a function , they aren't just pretty . Um and they can really , when they go bad , they go bad next slide , please . So this was just a clip that I saw and I said , wow , this is good . I like it . We're getting , you know , the message is getting out that teeth aren't just hanging in there . They , they do things , they , you know , they have fluid in them . Um you know , that basically transmits nutrients to the teeth . They have the nerves , they are connected . And so this was a quote from a phd student . Um And so basically , you know , it shows that the brain is wired to monitor the teeth and he even said we've drastically underestimated the importance of teeth . So I , I couldn't agree more . Um And , and that's just , you know what the diagram is , is indicating there , right ? The brain teeth connection , you know , next slide , please . All right . So just briefly the homunculus , right ? That's , you know , kind of the representation of , you know , sensory info and you can see that just looking at the tongue that is like 45% of the cortical space that our brain uses to monitor muscle and the face . That's the part that takes up the most area of the sensory homunculus . And so again , head and neck face , that's , that's our jam in dentistry , right ? Um But not to say that the rest of the body that also plays a big part and we have to know that as well next slide , please . Ok . So we have a little poll . Um You can either join by web by text , you can click the little , click your phone onto the QR S code . Um But uh so that I promise I have a point here . So in your experience , what percent of patients enjoy healthy eating and exercising ? Just just curious . And then the second question is in your experience , what percent of patients enjoy undergoing things like gastric bypass and um you know , cardiac surgery ? Ok . So like great . All right . So I see that we've got ABC D and E . So , yeah , exactly . So 100 about 100% of you said only about like 25% right ? Ok . And then , all right . Oh , we're getting , we're getting some more in . Ok . We're at 88 . Ok . 13% . Yes . All right . So some varied answers here . But I know these questions sound like , well , why is she bringing this up ? Only because ? Right . A lot of patients , at least in my experience I see that , you know , the the the things that I think are low hanging fruit , which is , you know , get your sleep , getting in your exercise , brush and floss , you know , uh do the preventative things , right ? So that the catastrophic things don't occur um is where I'm going with this , right ? So I think we've got like 92% is like , you know , basically 25% of the patients . So I'm with you , the majority of people they don't really like doing the healthy eating and the exercising and basically all the other things that we have to do to stay healthy and prevent the most stuff . So now the other question , right ? Is how many people enjoy having gastric bypass or cardiac bypass or the many other uh treatments and modalities that we have to endure once we actually are in a disease phase , right ? We're no longer prevention . Now we're having to treat . Um I'm cur you know , I'm curious to see , I would think the answer is gonna be universally , you know , I'm hoping zero but we'll , you know , we'll see . But it just , I guess , and , and again , in my experience , it is just very interesting because I have so many patients that are dental phobic hate going to the dentist . Um , you know , not that they like going to the , you know , physician side either . But yet , you know , and they have tons of , you know , cavities , periodontal disease , a lot of ailments . And yet it is interesting to me that there is such an easy preventative way to stop all of this . But then they don't do the things , right . They don't undertake the very simple and cheap floss in the toothbrush is very cheap . Exercise is very cheap , right ? These are not expensive , difficult uh preventative interventions . And yet I find that the , you know , the very same patients that are afraid of going to the dentist because they have so many cavities are the ones that aren't implementing these very simple techniques . So , and I think in medicine , we see that as well . Right , again , I don't think most patients that are undergoing surgical procedures are going . Yes , this is what I want . But yet they're , you know , before they got to that point , there were so many preventative things that could have been done . So I think part of , you know , integrating everything is really looking at , you know , can we make sure that we're kind of beating the drum constantly um and making sure that , you know , our patients know what is in their control , what they can do because prevention really is key and I know we say that , um but I see that , you know , the results make sense , right ? That an overwhelming majority of patients , they don't want to be undergoing these procedures . So I , I think , you know , the disconnect here is that , I don't think patients realize that a lot of this is in their control . Um I , you know , I think a lot of this , I would say , I don't know , 80% of the procedures that I do and probably a lot of it , you know , 80% or so the procedures that are um happening in medicine are things that were totally preventable . And I think that's the message that we have to drive home , right ? Instead of treating , let's prevent . Ok . So those questions made sense . All right . Next slide . Ok . So we have lots of diseases of head and neck , but the two most commonly found in the mouth , right ? Are caries and periodontal disease . All right . And this is the , the take home message . It's largely preventable , right ? Both of these diseases , they are the two biggest threats to oral health . They are the most common chronic diseases in the US , right ? Amongst Children , it's the most common chronic disease and totally preventable . Uh It's five times as common as asthma , seven times as common as hay fever , right ? And adults the most common cause of tooth loss . It's just untreated gum disease . Right . So , then we have periodontal disease . Right . So , 90% of the population has it . Right . And there's two forms , there's gingivitis , periodontitis . I'll talk more about those in a bit . But 90% of the population is afflicted with this . That is large and it's preventable , just brush and floss and I pro it'll go away or won't even occur in the first place . Right ? And this is the key with dental is that most of these afflictions are silent until they get really bad . So patients can be falsely led to believe that they're healthy because nothing hurts , they're like nothing hurts . I'm fine , I'm great . You know , and so it can be very surprising when they get to a dental visit and the x-rays point out that no , you're not fine , you're not healthy and you got a lot going on because dental disease again , we something has to hurt . It has to get to a nerve , right . And so , you know , the enamel isn't gonna have a nerve . So it really takes until it gets into the tissues or gets into the pulp , which is the nerve of the tooth where the pain starts . And by the time a patient has pain , it is not a simple fix , we now have to really take heroic measures to fix the teeth . And that's why again , having no pain is not an indication of health , at least not in dental . Next slide , please . Ok . So carries right . Uh also known as cavities . Uh but it is infectious and it is transmissible . All right . So this is a , is a disease that is transmitted from human to human . And we know this because we are born with a sterile mouth , right ? So when we're born , we have no colonization of any of the oral uh bacteria . And what ends up happening , which is inevitable and it's totally fine . We all go through it . We all get inoculated because as soon as we start to eat solid foods , caregiver will maybe taste the spoon or the food to make sure that the food isn't too hot for baby . And then they put it in our mouth and we have now been infected with Carry's bac causing bacteria and that's OK . That's what it's gonna happen , right ? And it's just a part of life for the most part . If you keep the bacteria in check , this is not a major problem . All right . So why do cavities happen ? Cavities happen ? You have to have two things , you have to have bacteria and you have to have a substrate and bacteria love carbohydrates much like I do . Um So they take the carbs that any that you leave behind in your mouth and they make acid and they do that by fermentation . That is what causes carries , but that is not the only uh causal agent , right ? It's basically , it's repeated exposure to acids over time and it can be exogenous or endogenous . So , gird . Right . Um , any sort of acid reflux that's gonna come onto the teeth and it's going to erode away that enamel . Um , any acidic foods beverages . Right . I'm not saying don't eat these things . I enjoy these things too , but in moderation and , you know , I'll go over some tips later on how to reduce this . But certainly also things like , uh morning sickness , which isn't really morning sickness , it's all day sickness . But that is something that will also destroy teeth or even patients that um have uh eating disorders , right ? Uh bulimia , you know , things like that will also destroy the teeth because it's an exogenous uh endogenous source of acid , right ? So it could be from foods , it could be from things that we're doing . Um And additionally , you know , the carbohydrates that the bacteria are fermenting . Next slide , please . We're on slide 15 . So this is just a very basic breakdown , but this is how cavities happen , right ? And we're we're gonna talk about fluoride . So , right , with bacterial glycolysis , you have um little diagram there that shows you . But basically , you know what happens is the bacteria eat the carbs when they're going through glycolysis and fermentation . There is an enzyme called Ella and that enzyme is what is responsible for the breakdown into eventually the acid that destroys our teeth . So fluoride is our hero because it inhibits that step that takes the place of Ella . And so it doesn't allow that conversion to happen . And so ta da less carries , right ? Um And we love it because it helps re mineralize enamel and enamel is precious . It doesn't grow back . So once you've lost it , you've lost it and no amount of dental or can put it back , it's just one of those things . So we love fluoride at all ages throughout life . Super important , it increases resistance to acid because most teeth can withstand acid levels of about like 5.5 . But by incorporating fluoride into the teeth , you can now resist to like 4.5 . So that's a pretty big deal , increased hardness . And how does this happen ? Because so you know , fluoride in the womb is great because teeth are starting to form fluoride out of the womb . Great too because again , the teeth are forming especially the permanent teeth , right ? So as they're forming , they if you're um getting fluoride either in the water through prescription , however , it is that child is forming um these strong connections because the fluoride replaces that hydroxyl ion . So , enamel is made of hydroxy appetite . And then if you marry it up with fluoride , it becomes fluro appetite and that is just fantastic because now you have harder , stronger teeth that are more resistant to all the insults that we've talked about . Next slide , please . Gingivitis . All right . So again , it's inflammation , please think of dental diseases , specifically gingivitis , periodontal disease . These are inflammatory diseases . These are infections . All right . Think of wound healing , think immune systems and we'll talk more about that later , but gingivitis is reversible . That's the take home message you can see in these photographs that you have the ginger . Um the first uh picture . Um it's like a mild to moderate gingivitis . This other picture is severe gingivitis , right where you can see that it's just bright red , it's magenta . I mean , I'm looking at it and it bleeds . Ok . But gums should never have a red outline around them . Erythema is not good in the mouth . It's not really good anywhere else , but especially not in the mouth . So , um but the good thing is it's reversible , meaning this is an inflammation of ginger and ginger is mucosa as you know , mucosa has a quick turnover rate . So it means it heals pretty nice , pretty quick . Um And there's no bone loss on the x-rays and that's what differentiates gingivitis from periodontal disease . And again , ginger VIIS what causes it ? It's caused by bacteria . They form dental plaques which turn into calculus . We'll talk about that , that irritates the ginger V and it causes an immune response and it can be chronic or acute infection , but it's reversible . Next slide please . Periodontitis , right is the other type of gum disease . This is irreversible . This is the loss of bone and you can see differentiate between the pictures that are the , well , the , you know , you can see that the teeth look pretty long . It's not that they're long , it's that they've lost the bony housing and that's why you can see the roots . That's your roots are showing and they shouldn't be . So that should be covered by bone and gum . But unfortunately , periodontal disease has destroyed the bone . So once you destroy the bone , that's it , it's not coming back . I can't put it back . It is precious just like enamel . So super important because bone is what holds your teeth in your mouth . So if you have no bone , you have no teeth and hello , dentures and it doesn't have to be that way . This can also be a chronic or acute infection and it is the sixth most common disease worldwide . All right . Next slide , please . All right . So these are just , it's just a little diagram to show the stages of periodontal disease . But you can sort of see , you know , in health what it should look like . Um And you can see that the progression of the photographs , but you can also see the progression of the x-rays . What I'm looking at is where sort of the necks of the teeth . You know , the part that you can see , you can see that in the photographs , they get longer and longer . It's not that the teeth are growing , it's that they're losing their bony support . And in the radiographs , you can also see that between the different stages , you have gingivitis , there is no bone loss reversible . And as you go through the stages of periodontitis , it is no longer reversible and it is chronic , the more severe it gets the more um issues you're gonna have both localized effects and systemic effects . Next slide , please . Ok . So the oral cavity , it's like a wonderful just microflora jungle . You name it in theirs about 700 or so species , right ? And the wonderful thing about this is , is that , you know , when this conversation started , I don't know , 2030 years ago , right ? We didn't have a lot of , you know , evidence based medicine , but we love evidence based medicine . That is what they preach in dental school . I'm sure it's what they preach in medical school and we have it . The science is here and I love it because we can culture things , we can show things . And so that's gonna be a lot of what we talk about today . And so the bacterial species um we've seen in lots of systemic diseases , bacterial endocarditis , the vegetative growth on valves , um aspiration , pneumonia , osteomyelitis , preterminal birth weight , uh cardiovascular disease . It's just a few of the things . And so periodontal disease is an independent risk factor for head and neck cancer . So , patients that are periodontology compromised , right ? And they already have coexisting risk factors that are lifestyle habits . They should be encouraged to monitor and maintain periodontal health to minimize cancer risk next slide please . And we're on slide 20 . So some of these systemic implications , right ? Cardiovascular disease , we talked about inflammation and inflammation is what plagues some of these diseases . Uh It's a big correlation between the two . So you're gonna see higher levels of CRP imperial patients versus healthy and in cardiovascular disease and periodontal patients versus either condition by itself . So it's , it's aggregate , right ? It's like inflammation , right ? If you've got more c reactive protein in one , because you have pero you also have cardiovascular disease and you're gonna have more , it's an additive effect . Um And we see that oral bacteria is found in arterial plaques , right ? Um when they have uh basically done uh you know , autopsy bio , you know , biopsy , however , but they can see that part of those plaques are made up of oral bacteria . 91% of patients with cardiovascular disease demonstrate moderate to severe periodontitis . And it's bidirectional . If you have one , you're at higher risk for the other and vice versa . Type two diabetes , same thing , the same , the same things that plague your surgeries plague mine decreased immune response , wound healing . Just , you know , all of those things , you know , type two diabetic , essentially uncontrolled . It's going to be very hard to do a surgery . Um , you know , and , and have a good result . It's , it's tough , you have advanced glycated in products . Of course , our body doesn't like that . It makes more inflammation and that too is bidirectional pregnancy , gingivitis . This is a biggie . Um And I , I think , I don't think a lot is known about it . Uh Hopefully I'm wrong . But again , you have , you know , during pregnancy , you're gonna have increased blood flow , increased circulation . All right . And so basically , you're gonna have these markers of inflammation that are easily crossing the placenta causing fetal toxicity , um resulting in preterm delivery , you know , low birth weight babies and even stillbirth . And I have an example that will show that um and then osteoporosis , that's another uh thing that is associated with periodontitis . So that is by way of cytokines . Um you have inflammation inhibition of osteoblasts , right ? And so , you know , the balance of bone , you know , uh is basically between osteoblasts that are gonna build bone and osteoclast that are destroying bone . And so that balance between the two is how we stay healthy . But if you have where you're now leaning towards more osteoblastic activity , then you're going to see osteoporosis , right ? And then you have aging on top of it , right ? Usually osteoporosis is in an older population . You have oxidative stress , you have aging cells , right ? And that drives the progression of osteoporosis which aggravates periodontal disease . Um And so that's some of the systemic implications . Um Next slide , please . All right . So , looking at some of the implications , um we talked about periodontal disease , right ? These are the things that stem from the mouth . Um we have uh carries we also have something called a primary endon infection , meaning it's an infection from the root of the tooth . Ok . So it's basically the nerve , the pulp has been infected . And so we will see that in the form of an abscess , this is an issue because untreated abscesses can turn into a life threatening medical emergency . It can progress into a cavernous sinus , thrombosis , which if not treated and caught , it can become deadly within hours . A Ludwig's angina which is inflammation um by way of your um the abscess going into the submandibular spaces , basically cutting off the airway . And again , this can go from 0 to 60 in , you know , 12 hours . So it really becomes life threatening . We've talked about atherosclerotic plaques and how we found bacteria in there . Um And then we even have things again , inflammatory diseases like um in uh autoimmune conditions like rheumatoid arthritis , uh lupus and even shores , all of these have manifestations . And so , um it is important that these patients , they have to have even more impeccable hygiene because they're already at risk for inflammation , right ? So if you add more inflammation , it doesn't matter if it's coming from the mouth of your toe , um It's going to aggravate these existing conditions and then of course , the shores we have to be able to manage , you know , obviously you have dry eyes , you have dry mouth , the zero Stoia and then if you add other medications , right ? Uh that possibly can cause zero Stoia , you know , like a a hypertensive medication , something like that or patients that need to take uh Ritalin et cetera , that's just gonna make it worse and a lot harder to control what's going on in the mouth again , creating more inflammation . So it's interesting how it , it all ties together next slide , please . So , um these are some of the systemic implications . Um and so just it goes into a little bit more detail . So as far as the atherosclerotic plaques , you have specifically the , you know , the bacteria that uh cause these issues , we have Ping Javal , we have a a tanel for , you know , all of those are the ones that we mainly see in periodontal disease and we see them in the plaques when you know , they've biopsied or , you know , done an autopsy and that increases your levels of inflammation , your immune response and basically increase risk for coronary artery disease . Um some of these same um uh species , right ? We see them kind of over , over and we got a new player . Um I canella , right ? But again , they are thought to have something to do with pneumonia and it makes sense , right ? The mouth , the lungs , it's not that hard of a stretch , it's kind of in the same neighborhood , right ? Um And then when we're looking at Lupus right now , it's the players have changed a little bit , but we see that the salivary levels of these microorganisms they increase in patients with lupus . Um and they're , it's a direct correlation with increased inflammatory cytokines and number in osteoporosis . We talked about cytokines and it's gonna be the same thing over and over . It's gonna be inflammation , inflammation , inflammation , cytokines , et cetera . So , you know , interesting enough when we look at , you know , lupus , um we're looking and , and show burns right . There's a few things . So we're looking at the ratio between uh hermit cutie to back to Rory did D ratio . All right . And so we see a lower ratio in patients with lupus and grins and that potentially increases inflammation because again , you know , bacteria , we need them , right ? But we need them in the right ratios , the right amounts , right ? They can't be out of control and if the ratios are off , then that's what's gonna create an issue with , with anything else in the body , right ? Um We also look at FC and bar and that's something that creates autoreactive antibodies . And again , it's but can be responsible for um Lupus andro and immune responses . And then um some of these bacteria looking at bifidobacterium lactobacillus . Um we look at the salivary concentration in primary urns . Um you know , we see that the lepto tria species , um they were reduced in shogren . So those those might have like a protective effect . Um But then we look at uh and fio bacterium type species and we can see that those were more elevated in patients with shores . Um so promising this , you know , studies are showing we're not there yet , but it could be a biomarker that we could detect rens early . So these are all wonderful things . Um you know , your mouth and saliva , they can tell you so much . And then , you know , ginger Valli is also a source um of , you know , inflammation and you know , uh cross reactivity . Um and then in , you know , in closing , you know , we've seen that patients that have rheumatoid arthritis are gonna have elevated antibody levels against some of these periodontal pathogens . P ginger AIS P intermedia tanel for um and so increased levels of c reactive protein , right ? And just inflammatory components . Next slide , please . Ok . So how is this , this happened ? Right . And I have a slide , the slide that follows will have the picture , but we'll go over the words first . But basically we think it's by these potential pathogenic me mechanisms . So there's kind of four theories on how this happens , right ? Like a low level bacteremia , right ? Patients aren't maintaining really good hygiene , then they're allowing this chronic bacteria and them , you know , in the mouth and that enters the bloodstream because the mouth is the gateway to the circulatory system . It is right there . So that's how we've seen that they've been able to invade arteries , systemic inflammation , right ? Because we've got inflammatory Meteors that are released from the places in the mouth that have oral inflammation so directly from the carries , right , the bacteria that are the infection that are making the cavity in the tooth that goes right to the bloodstream or like an endo abscess or a periodontal abscess where the nerve or the supporting tissues have become infected , that abscess is a direct production of inflammatory mediators . And if not treated , it's chronic and it's just hanging out , right . Um We've also seen another mechanism is autoimmunity to host proteins , right ? And so now your host immune response is responding specifically to the components of the oral pathogens , right ? And then the last one is pro apogen effects because you have bacterial toxins , right ? That all these different gram negative gram positive bacteria are producing and that's also going straight into the circulatory system . So , you know , with that said , right , patients with lots of comorbidities , right ? Chronic kidney disease , coupled with diabetes and you had periodontitis , right ? Periodontitis is associated with significantly reduced survival from all cause and cardiovascular mortality . Let's pause just for a second to think about that . So it appears then that it would make sense that perent titi , it's a modifiable nontraditional risk factor for cardiovascular disease . It's something that we may not have been thinking , but I think we should be . And so it's it's an easy , it's low hanging fruit . I just need you to brush and floss . That's it pretty simple . Next slide , please . So these are just the the diagram showing basically the words on the last slide , but shows you you have carries you have periodontitis , right . So cavities gum disease , we have ended tonic lesions which are abscesses , right , that form at the roots of teeth and how they contribute to atherosclerosis , generating those plaques . And in turn , right , it's like because you have the atherosclerosis right now , you have inflammation that is making a systemic inflammatory response which now the mouth doesn't like . Right ? Because the mouth has inflammation because its own diseases that's making more inflammatory mediators . The liver is having to deal with this and it's pumping out other things c reactive protein , right ? And so it just shows the shared risk factors between metabolic syndrome , smoking , obesity , diabetes , you know , a genetic predisposition . Um you know , so all of these things play uh a part next slide , please . And we're on slide 25 . So again , the science , I love the science because you can prove things right . And so looking at a genetic locus , right , if you look at chromosome nine , it's associated with coronary artery disease , type two diabetes , ischemic stroke and Alzheimer's but is also consistently associated with periodontitis . This is not surprising to me because inflammation is what causes all of these diseases . So why not periodontitis ? It it you know , it's uh it does not surprise me . Um you know , thrombotic factors , right . So you have significantly higher levels of fibrinogen imperial patients versus healthy patients . And in cardiovascular disease and perio patients compared with either condition alone . So again , it's this , it's it sums up all the things are additive , right ? And if you treat Pero , which is simple , I mean , early to moderate perio can be treated with a deep cleaning . That's it and it reduces those fibrinogen levels . So , not only does it reduce fibrinogen levels ? Ok . In periodontal disease , but it also it's like multifactorial because it reduces it in terms of cardiovascular disease and all the other inflammatory conditions and reduces , you know , your thrombotic potential . Right . We've also seen that anticardiolipin antibodies is what is significantly associated with perio patient . And if we were able to reverse it following perio thera , now , if periodontal disease gets too severe , we do have to treat it surgically . But again , prevention , we'd rather it not get to that point , catch it before it becomes uh surgical . And we just have to do indeed cleaning , right . And again , because periodontal disease is permanent , it is not reversible . Once you've gotten to the bone loss stage , that's it . So strong association with thrombosis miscarriages and anti phosph li uh anti fos lipid syndrome . And so that's why if we can lower these risks and we can lower risks in general . Next slide , please . Ok . So perio and diabetes . So if you have type two , you increase perio by 34% you have severe pero it increases your risk for type 2 53% . There's your bidirectional relationship , your risk of type two increases proportionally with the increasing severity of periodontitis , right . And so again , looking at some of these common genes that are shared between dyslipidemia type two diabetes and perio you have a positive correlation with il 10 but negative correlation with Ifng . And so there is a strong connection . So you have to treat one to treat the other . Next slide , please . Ok . Talked a little bit about pregnancy gingivitis , the permeability , right . So when you're pregnant , more permeability , you also have more hormones because of that you have more susceptibility to pregnancy gingivitis . All right , we saw the first case of stillbirth due to oral bacteria . They actually did a uh autopsy of the fetus . Unfortunately , uh mom had pregnancy gingivitis was not doing the normal hygiene routine , not flossing was , you know , gingivitis , which not pregnant wasn't causing an issue necessarily that she knew of . But now that you have vascular permeability , extra hormones and you're growing a human inside of you . Um Mom had a respiratory infection , she had a weakened immune system and she was able to do it was transmitted from the mouth to the uterus . And so they isolated fusobacterium nuo atom from the placenta and the infant . And this is one of our key players in dental disease . So it is important that uh pregnant patients need to understand the importance of visiting the dentist , get your teeth cleaned once a trimester . So three times during the pregnancy and it is safe and encouraged to get dental x-rays while pregnant . I repeat it is safe . It is encouraged . Yes , of course . Anything cosmetic we put off until after the baby is born . But during the pregnancy , it is important that any sort of disease , um , is taken care of that abscess , just like in this case , it wasn't an abscess wasit that can go to the baby as well . And so , um , it's important just having periodontitis increases your odds of preterm birth , low birth weight by six . Next slide , please . All right . Um , so another poll coming up here , some of the , the things . So be totally honest . Right ? How many of you like ? Yeah , I totally floss and you're , you know , you're like , yeah , you've lost the day before . So you're thinking like they're not , they're , it's gonna look great news flash . We know the people who floss regularly and the people who floss like a day or two before to make it look like they've been flossing so good . Ok , I like it . I like it so very important to be honest . Just like I'm sure , you know , in medicine , it's important to be completely transparent with your providers . You do not wanna lie about symptoms or taking medications or not taking medications . Same thing . You don't wanna lie to us about flossing because if you swear up and doubt , yes , I am flossing . I am doing the things . Then we start to think you've got a systemic issue something is not right in there . And that's how a lot of the times dentists are the first ones to discover that a patient has diabetes because , um , they're doing everything right . They actually , we are flossing and brushing and yet they still have disease and it leads us to think what's going on in here . So , um , a lot of the times we will also discover or recommend a consult for an inflammatory disease , an autoimmune condition , rheumatoid arthritis , lupus something because the mouth is telling us that something here isn't right . And so that's why , uh , when I had my civilian practice again , I had a lot of geriatric uh patients in my population , but a lot of them were very frustrated and their physician included , they're like , I don't understand , I'm exercising , I change my diet . You know , I'm taking the Metformin , I'm doing all the things and I still can't get my HB A one C to go down . I see them and I go , of course , you have periodontal disease , your , your mouth , it's full of inflammation . No wonder your diabetes and your poor pancreas are working hard and no , you know , they're not gaining anything . And so as soon as I did , the deep cleaning treated their periodontal disease and got them on a regular schedule because now that they're perio patients , they have to be on cleanings for every 3 to 4 months for life because Perio is permanent . So you have to keep maintaining it or it can get worse . Ok . Good . So the majority , right ? So maybe , maybe after today that will change . So slide 30 . That is what a clean happy healthy mouth should look like . Next slide , please . All right . Um And so plaque , plaque is living soft bacteria starts forming as early as two hours after you brush and floss . Um It does initiate the inflammatory response but you can remove it by brushing and flossing . So that's the good news . Next slide , please . Then we're gonna talk about calculus and this is to show the the top is with the calculus . The bottom is the calculus has been removed . But all that stuff around the gums , the like lower necks of the teeth . That is bad . Next slide , please . And why is it bad ? Because calculus is the living plaque , right ? That was alive and we could remove with loss in a toothbrush that was due to minerals in our saliva . Ok . That harden that plaque and make it calculus . It is hardened dead festering bacteria . And yes , it initiates an inflammatory response . Your immune system doesn't like this . Your immune system is is going oh my gosh , there's bacteria , right ? Like any other wound , your immune system is coming to the rescue with neutrophils and macrophages and all the things going . Let's get rid of this except in the mouth . We cannot self clean . So that calculus , unfortunately , no matter how much your body is throwing all these things at it , it's not gonna fix it . It sees it as a foreign invader and that's why it's chronically inflamed trying to fight it off . Um And so that is why gums bleed because just like a cut or a wound , the first reaction the body is gonna bleed to send the messengers in to try to fix it . But we can't , calculus does not come off a floss or a toothbrush , excuse me . And that's why it's important because that we're maintaining good hygiene because that mineralization of the plaque starts as early as 24 hours . So that's why we say you got to floss every day and floss correctly . The only way to get rid of the calculus is a professional cleaning . So that means that you're gonna continue with Anita of inflammation and infection until your next cleaning . Next slide , please . Um OK . So these uh next few slides . Um next slide , please . What procedure do you think we were doing here ? So you can see that in the lower mandibular area , there's quite a bit of blood pooling next slide , please . All right . And so what we were doing is a cleaning . We were not doing surgery . There was not a scalpel in sight . This was just a cleaning , but it shows you the amount exact . Yeah , it shows you the amount of bleeding just because there isn't good housekeeping in there . Patient is not taking care of their teeth . Um and it , and it's not even a deep cleaning . It's just a regular , I love the answers though . It's just a routine cleaning . Um , on somebody that had ginger VIIS but untreated . That's what it looks like . And so I show that picture because that is what came out of their gums , right ? I wasn't surgical , I wasn't cutting them . So it shows that that much inflammation and bleeding . If you saw it in any other part of your body , I think you would be horrified . So um so again , but we can fix it right next slide , please . OK . So some myths , right ? Some myths . OK . I have soft teeth . Now , that's not true . You have soft habits , right ? There's only a few uh you know , uh dental conditions where patients actually have soft teeth , right ? And their enamel is actually has enamel defects or dentin has defects is few and far between . I inherited bad teeth from my parents . No , you didn't . You inherited bad habits . That is the truth . Um Yes , there's a genetic component . I am a great example . Both my parents have a pretty awful teeth . However , I have great teeth . Why ? Because they grew up in countries where maybe den wasn't super enforced . Um But then when they moved to the States , they got on board um and they made sure to get me on board . So just because they had bad teeth does not mean I have to have bad teeth and I know , I'm just one sample , my small , small sample size , but I do see it pretty frequently . The baby took my calcium from my teeth while I was pregnant and that's why I have so many cavities . Um So in Sassone , I used to help teach the pregnancy course for all the , you know , up and coming mommies and I heard this so much . I don't know where it came from , but it is not true . I promise babies do not leach calcium from teeth . And the reason they get so many cavities is again the hormones , the circulatory , you know , permeability and poor habits , right ? Like if you're not flossing and brushing stellar , you know , prior to pregnancy , I don't think pregnancy is a time where you're gonna step it up either considering you're cooking a human in there , you're tired . So , again , habits prior are habits that are gonna stick . Um , the next one is we're all gonna lose our teeth and end up in dentures anyway . This couldn't be further from the truth . You know , it's almost like saying we're all gonna lose our arms and legs and end up with prosthetics anyway . Now we're not , you just have to take care of the teeth that you have . I don't eat candy . So I won't ever get cavities . A lot of patients tell me this and I have to remind them it's not just candy , it's carbohydrates . So anything that is bread , pasta , rice , cereal , fruit , oatmeal ok . Even , even healthy carbs are still in the end , right . Starts with amylase . They're still gonna be broken down into simple carbohydrates that the bacteria are gonna munch on the minute you start munching , they start munching . All right . And then fluoride in the water is poisoned . Now , fluoride was , you know , in 1945 we started adding in the water and it's been a game changer . You don't need fluoride as an adult . Now we've talked about that everybody benefits and baby teeth fall out . So just take them out if they get cavities . Nope , not at all . Uh baby teeth are important . They are placeholders . If you take them out too early and you do not put a space maintainer in , then it causes problems for the adult teeth to be able to um come out and then it's more expensive and more traumatic later . So let's not take them out until they're ready . Next slide , please . Ok . So um looking at risk factors , right , just in general for dental disease , right ? Smoking , we can control that autoimmune disease . Uh we can't control it but we can mitigate certain medications like uh medications like phenytoin for seizures , um or verapamil like calcium channel blockers can cause gal overgrowth . So , you know , dental professionals can look and go , you know , maybe um have a conversation with your primary care physician to see if maybe there's a different medication that you can use that will not have those side effects , any medications that causes your Stoia . Right . Those are , you know , some others , even for shores , a lot of the times we prescribe PLO Carpine to help with the lack of saliva obesity . That's a controllable one stress . I know we're supposed to be able to control it , but some days are harder than others . Talked about genetics . And really it comes down to , you know , a bad diet with simple , mostly simple carbs , excuse me , poor oral hygiene , right ? But a lot of these are modifiable and they're in our control . So our patients , they can control it and they don't have to succumb to disease . Next slide , please . Right . So , um or oral hygiene protocol , right ? Important right after you're done eating or drinking , drink a rinse with water . Why ? Because it takes 30 minutes for an acid to neutralize . So if you brush immediately , you're scrubbing the acid that the bacteria just made because they're munching while you're munching and you're just scrubbing around your teeth , which is why my pregnant patients they tell them , sorry , I know the first thing you wanna do when you vomit is you wanna brush your but please don't do that , please rinse with water and alcohol free fluoride mouthwash . Wait 30 minutes and then brush because if not , you're brushing the um you know , acid all over the teeth , string floss once a day every 24 hours , right ? So the little floss picks , I'm so sorry . They don't work . Teeth have hips . They are around , they need a custom piece of string to go around and clean all the nooks and crannies . The little floss picks . It's a tight piece of floss and it just doesn't go down as far . So if you're gonna spend time flossing , use your string floss . Water flosses don't work . Water picks . It's an adjunct but it doesn't replace string floss . You need string floss and a toothbrush . Do I love Ma Sonicare ? Of course , I do . Is it necessary ? No , but you wanna make sure that I love the Sonicare . Get the cheap model , the $40 model . You don't need to get the one with the bells and whistles . But brush for two minutes . I love it because it has a timer at 30 seconds . It'll tell you to move to the next quadrant . You can spit out the toothpaste , important . Do not eat rinse or drink for at least 30 minutes . So if you're gonna use a mouth wash alcohol , fluy fluoride , it should be first and then you brush and then you floss . Why ? Because that fluoride that you just spit out some of it is still hanging out and you're gonna shove it in between the teeth . Fluoride is like lotion . You wouldn't put lotion on and then take a shower because now all the lotion went away . Same with fluoride . You wouldn't use fluoride toothpaste . And then once when you're done , all the fluoride just went down the sink . So we need it to hang out if you can't brush or floss , chew some sugar free gum that'll stimulate saliva . We love saliva . It has protective ig a components in there and that bacteria don't like and it gets bits and pieces of food out of the teeth . Tap water , impossible , bottled or filtered water doesn't have any fluoride . So love your tap water . Next slide , please . So , um you know , when we're looking at all this , an important one is dental clearance . So patients that are undergoing chemo radiation , all of that , it is advisable that they come and see their dentist prior . When possible . I understand that sometimes like a diagnosis um has been given , it's an advanced stage and it is what it is . But when possible , we want to come in and get rid of any infection and inflammation because we're a patient that's about to have their immune system wiped out . Probably not good to start with infection and inflammation , right . This allows us to educate patients regarding like what's happening , what's going to happen . All things are could possibly happen during their chemo uh radiation , we can talk about mitigation strategies . Um you know , and so bone marrow suppression , it's immuno compromise , poor wound healing . You know , you're gonna have higher risk for in infections like Canada and it's just gonna make existing conditions worse . So , head and neck radiation , ok , over a lifetime , if you've had more than 60 grays of a dose . It is a lifetime risk of osteon , neos of the jaw . Next slide , please . And so we , you know , again , I had a lot of civilian patients that were geriatric . So I did work as a team with the oncologist , the primary care , we worked together to manage these patients and it worked very well . Um So osteo uh across the jaw , higher risk and the mandible . Um and so if you add existing co morbidities like diabetes , excessive alcohol intake , poor hygiene , um poor fitting procedures , uh poor fitting dentures and invasive procedures , right ? We don't wanna be doing dental extractions or any kind of surgery , you know , during or after . We want to get it done first because that is a lifetime risk where we take teeth out and the jaw doesn't heal . And now we have patients in external fixation devices and it isn't that fun salivary glands , unfortunately , even uh doses as low as 2050 grays can occur . And so your salivary glands are wiped out . So that's your Stoia risk of carries and trismus , meaning they , they permanently cannot open their mouth as wide as they used to . So after head and neck radiation , we definitely see a high risk of prog rapidly progressing carries next side , please . So , uh we're on slide 42 and so it used to be called Bispo related osteoporosis . Now , it's medication related osteoporosis of the jaw , higher risk . Um you know , uh for life . Uh we see higher in like IV , like ZTA , but patients have been taking it long term . Um It is something important to disclose the dentist because we are not gonna want to take out teeth . If we know that a patient has been on that , we're going to want to probably refer to an old surgeon who is going to have access to things like hyperbaric uh treatment and all that in the event that you know , we do end up with the osteon neos and it varies , right ? Patients that are taking a ras or a as right , anywhere from 0 to 18% . But still it is such a devastating disease that it's no percent really is what we want to see . So uh 40% of cases of ie are mostly we think caused by oral bacteria . And so if you look at valve replacements , right , your post uh transcatheter aortic valve replacement , have a higher risk slightly than your surgical prosthetic valve replacements . Next slide , please . So um we know we can't always do clearance , but it's important . Some of these are the mitigation strategies that we will discuss with patients , the dryness , some of the palliative things they can do soft toothbrush , they have to have super great oral hygiene prior and during and so it's not something that , you know , again , you know , during cancer therapy is not when you want to start , you know , introducing flossing and you know , give yourself a transient bacteria , right ? So all of that has to happen before next slide please . But these are just some of the things that we offer . So I showed this because I'm gonna go into my Peto part . But breast milk has carbs formula has carbs , they both have carbs . So at the end of the day , what that means is these are cavities in a bottle . Yes , we have to feed the kiddos the the formula or the breast milk . But the point being is that please do not put the kiddos to bed with a bottle of any of this because that is what causes baby bottle rot . Um It is true unfortunately and um a lot of uh childhood carries are specifically for this next slide , please . So we're gonna be on slide 45 . Um So what we want is start the good habits early . All right , start it early . So later it's not a fight . If you've been doing it since they were born , they don't know any better and it's just what we do , right ? So start wiping the gums with gauze . After feedings , it gets them accustomed to things being in their mouth that way when the toothbrush comes . It's not so scary . As soon as the first tooth pops up , it is time to use fluoride . A smear of toothpaste is totally safe . The ad a recently changed their stance on it . We need fluoride . So no more of this kitty toothpaste with no fluoride . If they swallow a little smear and there's a picture at the top to show you the smear and the difference between A P sized . Please ensure that as soon as that first tooth comes up , we're brushing with toothpaste , that little smear . Yes , they're gonna swallow it and it is totally fine . Um , it is worse that they do not use fluoride and you're having to take your kid to the or and get teeth extracted right night time . That's prime time for cavities , please . You gotta brush your kids' teeth after the the last feeding . I know night feeding . Sorry . But it is just letting them drown in formula or milk . Any of that is just a recipe for cavities . So nothing in a baby bottle that is not water , milk or formula , please . No soda or fruit juice . All right . Once they have most of the baby teeth use the floss sticks . Then when they have adult teeth switch over string floss because the contacts between the teeth will get tighter . And kiddos about 12 , they gotta be supervised or brushing . If not , they're just gonna run it under the faucet . You wanna make sure that they're taking an active participation in this and make sure that the younger ones aren't swallowing gobs of toothpaste , keep it out of their reach . And of course , if you're living in an area without fluoride in the water , you want to consider a daily supplement and your pediatrician can prescribe that next slide , please . Um So hold off . You know , it is kind of some of the last things , but please do not introduce the sweets as long as possible . Right . I had a Corman in Japan . She was awesome . Her four year old had never had a piece of candy or a cake or a cookie . I loved her for that . She was like , I know I can't keep him from it forever . But the longer I hold off , I'm like , you are brilliant and she is right . And the studies show that . So , you know what the mom eats while pregnant is important while they're nursing and what the kiddo eats at an early age . So the more variety of flavors that you expose them to the better , the more variety later , ok . We have more evidence that if you introduce solid foods by four months , it makes them less picky , right ? And so they're willing to eat more fruits and vegetables and they're more receptive to different food tastes and textures between four and nine months . So let's not start with the apple sauce and , and the pear puree babies are gonna love that . Start with the spinach , start with the peas and the carrots and the things that they probably aren't gonna love so much . But if that's what you start with , you know , again , the sweet stuff is easy . So introduce the not so sweet stuff to begin with and they will love that for life , right ? Also decreases the risk of allergy incidents and does not increase the risk of obesity . Next slide , please . Ok . All right . So more dental humor , uh you know , uh we grind our teeth , right ? So no grinding uh next slide , please . And so takeaways oral health , dental health , they're together overall health , right ? Dental conditions have local and systemic effects . We have inflammation , we have to work together to manage health and disease prevention , prevention , prevention . Uh consider a dental clearance when possible . Right ? Prior to some of these treatments , every patient interaction is an opportunity to reinforce good habits . If you start oral hygiene , good oral hygiene from the womb increases the likelihood of strong habits for life and patient education and awareness are vital to improving these outcomes and reduce the need for interventions . Next slide , please . I think we're done . Yeah . Thank you so much . I will take questions of course . Um But if there's any that you want to email me , there's my email , please do . Thanks so much , Commander Aye for that fabulous presentation . I'm excited that we got to hear such wonderful information . Um I would say um Commander Aye if you are able to , I would invite you to turn on your video camera just for this last portion of uh the Q and A . So maybe we can answer a couple of questions and if for our audience , if you haven't already done , so please go ahead and put your questions into the chat box . Do have a couple of questions that came through . Um , the first was if you had a reference for recommendations related to dental cleanings for pregnancy during all the trimesters , I don't know if that's something we could maybe put into the chat . I can , uh , I can do that . So what I'll do is if I don't get to all the questions I can answer them in the chat later because I don't think we'll get to all of them . I wasn't expecting this many . This is fabulous , but I'll put something in there for , for pregnancy gradations . Yep . Perfect . There was one more question about if it matters as far as the time of day , when to floss , morning versus night or midday , it's whenever the patient is gonna do it commit . I am a person that in the morning I am , I'm not trying to have a spa day . I'm trying to get out the door . I am sleeping as long as I can . And so I floss at night because that is what works for me . A lot of patients . I tell them floss at lunch because in the morning , you're in a hurry to get out the door at night , you might be tired and you want to skip it . So it's really whatever you like string floss , any string floss is gonna work . So I the brand doesn't matter . Wax on wax . Cinnamon have at it , but it just needs to be string floss and used correctly . Perfect . Thank you so much . And then maybe one more question real quick . They're asking for Children that have yellow teeth . Is there um a you know , potential causes for that for staining ? So it uh yes , it depends , right ? Um Just in general , is it more yellow , is it more brown ? Is it like a stripe across the teeth ? Because that tends us to think um that we're looking at antibiotic induced staining um from tetracyclines that were used either in the womb or in early childhood . So as the teeth are developing and if you see like a brown yellow line going across the teeth , sorry , that indicates to us that um you know , we've got some antibiotic use , it is not unhealthy , it's just , you know , it's just a cosmetic defect but those can be some causes . Now , some Children as adults , we just have naturally yellow teeth like teeth come in all shades , right ? And so not everybody you know , is going to have sparkly white teeth . A lot of people do bleach , ok ? And bleach is safe as long as it's uh prescribed bleach and not toothpaste , that's whitening , whitening , toothpaste is awful . All it does is scrub off your enamel which over the years you're gonna end up with less enamel dentin , which is the sensitive part of the teeth and yellow . So you end up with more yellow , more sensitivity and you didn't whiten anything . So , whitening treatments itself is fine , which is usually like a carbonite peroxide crest whitening strips . But if teeth are naturally yellow and you try to bleach them and they don't bleach , then it's just kind of how the enamel is . So , and we don't recommend bleaching in Children , obviously . So I point that out . Excellent . Well , thank you so much . I think that's the end of our time for this session . But I did just want to recap to say that we heard some great information about preventing , um , dental caries and periodontal disease and your presentation especially resonated with me because of the lifestyle medicine overlap . So we appreciate that . And certainly she'll continue to try to answer the questions that were in the chat , um , via the chat throughout the next presentation .