[00:02] the simple act of getting you a deep cleaning done and having three months regular maintenance is can lower the requirement is can lower the requirement for diabetes medication by a whole pill.
[00:15] for diabetes medication by a whole pill. A whole dose reduction can happen if your mouth is healthy. So So a healthy mouth actually helps to reduce your need for diabetes medication as well. So this is integrated care. We work very very
[00:30] very closely with our endocrinologists. >> [music] chair of periodontics and oral medicine at the University of Michigan and
[00:43] globally recognized leading investigator on the oral systemic health access, who has authored over 100 scientific papers on oral microbial ecology and serves as a senior editor on the journal microbiome. So Dr. Kumar, welcome to
[00:57] >> Thank you. I'm so happy to be here with you today. >> Thank you. So Dr. Kumar, we tend I I think to think of the mouth as kind of a separate thing and we go to a dentist to get the dentist to get our
[01:11] teeth fixed, but it has a far larger influence on our overall systemic Could you talk about what does it provide when it's working well? I mean, how does it
[01:25] positively influence our systemic health? >> Yeah. Um Absolutely. >> [clears throat] >> Um you know, it's time to put the mouth
[01:38] back into the body. We've we've we've, you know, kind of taken the mouth out of the body and we've been treating it in isolation. And in doing so, we've really underestimated um the huge health benefits that a
[01:52] um the huge health benefits that a healthy mouth can offer um to us throughout life. And I'm going to start with the very simplest, the most obvious function, and that is your, um, emotional health. Nothing like a
[02:06] bright smile to brighten your day, or to see someone smile brightly back at you. So, part of that is, you know, your lip oral musculature, beautiful teeth, all of that. And that's the most obvious and the most clichéd, um, um, uh, use that,
[02:22] you know, the mouth has for you. But, apart from that, it affects human physiology, the functioning of your body in many ways. Um, [clears throat] and the first, the most simplest thing is, um, in helping it to chew food. So,
[02:36] [clears throat] Your teeth grind food into small, manageable bits, and digestion, actually 60% of digestion begins in the oral cavity. The mouth, glands, right? You have spit glands sitting up here, and you have one
[02:52] sitting right here. All of these pour saliva, or spit, into your mouth, and they contain a lot of enzymes that begin to break down complex carbohydrates, proteins. And, you know how they say chew your food 20 times before you
[03:05] swallow? That actually has value, not only in breaking food down, and in slowing down, and you know, being mindful and thoughtful about what you eat, but it's also very, very important to jump-start, um, your your digestion.
[03:20] But, here's an additional point, and and we we have recently discovered this, and we're beginning to uncover more of this. The bacteria that live in your mouth, you think of the bacteria that live in your mouth, the mouth is such a small
[03:35] organ, and the rest of your if your gut is all of the system, right? But, the number of bacteria that live in your mouth are actually equal to, if not more than the rest bacteria that live in the rest of your gut system. So, you have
[03:48] tons of bacteria that live in your mouth. And they live there with your permission, or without it, and they are actually friends with benefits. So, they break down they the food that's broken down is now further metabolized by
[04:03] bacteria into bioactives. So, your vitamins, your your um catalysts, your enzymes are released early on in your mouth itself. And you know, so the process of of getting the most benefits from your food begins in
[04:20] the mouth because you host this entire large community of bacteria that are metabolizing these products at rocket speed, if you will. So, by the time your mouth, you know, you swallow the food, a lot of its its benefits have been
[04:34] very very small story, and I'm sure you heard this many times before, but what you put in your mouth and how you process that in your mouth plays a very big role in how healthy your heart is. So, so the story is very simple.
[04:51] when you go to your cardiologist, what do they tell you? Oh, healthy diet, exercise, eat lots of green leafy vegetables, yeah? How many times have you heard this? The problem is this, your human DNA does not have the code
[05:05] the genetic code for enzymes that can There's this very important enzyme called nitrate reductase. Our human DNA doesn't code for it. Guess what codes for it? The bacterial genome. So, all
[05:20] actually break down these green leafy vegetables because they have nitrate reductase to release nitrous oxide, nitrates, that then concentrate in your spit glands, in your salivary glands, and in those glands they undergo further
[05:35] breakdown to release this gas called nitric oxide. Now, nitric oxide is a very powerful vasodilator, which means it opens up blood flows more smoothly from your heart to the rest of your arteries and
[05:49] in doing so the blood pressure the resistance to blood flow is lowered. So, green leafy vegetables plus a healthy oral microbiome are what are going to protect your heart and keep your heart healthy. So, there's lots of benefits.
[06:05] [clears throat] on the very very high level bits and pieces of this. So, um yeah, the mouth is key. It it provides a smile. It gives you function. It it lowers your blood pressure. But just by
[06:21] chewing food you start the breakdown which means you need less insulin to to, you know, process this and to take the sugar into your body. So, your glycemic index, if you're diabetic, it's even more important to have a full
[06:36] complement of teeth to have as many teeth as you have to be able to break your food down into smaller particles. So, all of these become important. In Institutes of Dental and Craniofacial Research, NIDCR, which is an institute
[06:50] in the NIH here in the United States, it states that you need to have at least 20 teeth to have optimal chewing function. And these 20 teeth have to meet each other in 10 opposing pairs. So, you need to have 10 pairs of teeth that meet each
[07:06] other in order to have optimal health. So, that's the number of teeth you need to have in your mouth. And that's just I'm just scratching that surface. You know, you have you have mucosa in your mouth. You have taste receptors in your
[07:20] so many other functions. Let's let's pause here and I'll I'll wait for you to pick up on this. >> Yeah, so one question. Is there any enzymes that are only present in your mouth? So, if you don't digest the food
[07:34] in your mouth, then it doesn't get digested anywhere? >> Um yes. So, there There enzymes called amylases. They're produced in the body, but salivary amylase, which breaks down, and I'm going to use just one. Um
[07:46] salivary amylase, which is which is really a strong enzyme to break down carbohydrates, you know, complex sugars, um that is is very powerful. So, chewing your food, releases the amylases, which start that that really jump-start that
[08:01] process because if you swallow food as a big whole, a big chunk, the amylases in your gut don't get to act on it as much as you have. The other enzyme that you have in your mouth, which is highly protective, it's not
[08:15] fraction is an enzyme called lactoferrin. lysozymes. So, there are several enzymes that are found in your saliva that are powerful um digestive and meta- metabolic um you know, food calorie
[08:29] burners, if you will. So, your calorie burn begins with your spit and then goes on to the rest of your body. >> Does the immune system The immune system famously uh is concentrated on the gut, right? We're
[08:44] there's a lot >> That's what the gut people say. Talk to the gut >> Yes. So, how about the oral cuz cuz in a bacteria, and there's more stuff going on in the mouth. So, how does the immune
[08:57] system work in the mouth? >> Yes. So, so >> You know, we talk about the mouth, but I'll tell you the real estate that's available in the mouth is the size of your palm.
[09:10] And all of it is highly vascular. It's It's embedded with blood vessels. So, there's a lot of traffic that goes on there. You know, there are immune cells, uh immune molecules, there are there are proteins that are constantly literally
[09:26] going through the space at rocket speed as fast fast as your heart can beat, for example. So, so we have a very large um real estate with a lot of blood vessels, which means a lot of immune cells are coming in and out and and they're
[09:41] happening. That's just immune cells. What people don't What's not commonly recognized is that the barrier membrane, our skin, the mucous mucous membrane, which lines our oral cavity, they they are lined by cells called keratinocytes.
[09:55] And one of the most powerful immune organs on a mammalian system is the organs on a mammalian system is the keratinocyte. So, the lining mucosa of for your your cheek, your lips, your gums, your tongue, your tonsils,
[10:09] everything, these are powerful immune mediators. And right in your tonsils, you have these concentration, like two big globs of of immune cells that are sitting there, they're known as lymphoid tissue, that are sitting there here,
[10:24] right here, just under your your your, you know, jawbone, you have that organ as well. So, there's a lot of immune action that happens. And and think about this. Why is this so important? This is evolutionarily programmed, right? The
[10:38] mouth is the gateway to the body. Everything and his brother passes to drink this glass of water, all the bacteria that are there in this water are passing through my mouth. And, you know, we need a system which would
[10:53] recognize these bacteria as foreign, but >> [clears throat] >> benevolent or benign, and have them just offer them safe passage, and recognize others that are actually infection
[11:08] causing, and it's like kill at sight. And and then, let others, you know, you hygienist, you get your teeth cleaned, you pretty much get a lot of the bacteria removed from your mouth. You need these bacteria to recolonize
[11:22] the same way as they were before you went to the dentist. And so, to recognize that some of these things, when they attempt to grow in your mouth, that they're actually your friends and to let them to grow. So, immune cells
[11:36] provide that kind of surveillance, protection, as well as tolerance, which is which is very underappreciated in in, you know, um host-microbial interactions. What we are we are healthy not because our immune system is
[11:49] constantly in attack mode, but because our immune system is highly tolerant. our immune system is highly tolerant. It's very zen at good times. So, that's that's very key. >> Does the Does saliva have like white
[12:02] >> Does the Does saliva have like white blood cells in it? I mean, so the the uh immune system is actually active inside the saliva or So, so uh and and again, you don't have to have immune cells are one thing and
[12:17] immune molecules are another and immune cells don't have to be at the site. So, immune The immune system works in multiple different ways. One of the most um rudimentary ways is that you have immune
[12:30] cells that can actually go in and engulf a pathogen. Like like an amoeba, right? It can just hold it, squeeze it, break it, and destroy it. That's that's one method. The other method is that an immune cell can toss out all of these
[12:43] proteins that can um destroy toxins. They can They can destroy They're called antimicrobial peptides. They They can just throw this entire cascade of of molecules at a bacterial community and
[12:58] destroy them. And the third mechanism is these immune cells can signal to other cells in the body. So, for example, the lining mucosa in your mouth, the the lining uh cells in your mouth, I told you they were keratinocytes, right?
[13:11] These keratinocytes, as soon as they sense a pathogen or or some kind of a sense a pathogen or or some kind of a foreign invasion, what they will do is are actually signaling molecules which say, "Hey, I'm doing my best, but now I
[13:25] need the troops to come out and help me. And so these bring in those white blood cells, neutrophils. They bring in other white blood cells, lymphocytes, macrophages. All of these to the site and concentrate them and then have them
[13:38] take action. And some of these cells, when they come, these big immune cells, the the the dedicated immune cells, when they come to that place, some of them know, kind of doing that work. And the others are just sitting there building
[13:53] They're like, "The next time I see you, I'm going to get you." today." So they're building memory. So this is called clonal memory. And all of this is how vaccines work. Because once you have
[14:07] those those clonal memory cells, they come in, they attack much faster, they need a smaller trigger to be woken up and to get into attack mode. So those things are all happening. So so immune the immune system, as you talk about it,
[14:20] operates through multiple different ways. So in saliva, you have a lot of immune molecules. Yes, you have immune cells, but the immune molecules in saliva are the ones that that actually have the bigger impact because they what
[14:34] molecules actually can cause the bacteria to form clumps. So, that into large things and then they get so heavy because these clumps are so large, you just end up swallowing them. So so it's it's very cool. It's very
[14:51] very cool what what your body can do, yeah. Yeah. >> So that's how it's meant to work, right? When it's working well. >> I I think especially as we get older,
[15:05] because partly because of probably the the immune system is is not as operational as it is when we're younger. But uh So what what are the kind of things that go wrong in terms of the the
[15:21] I guess the pathogens. Where do the pathogens come from? What are they? How do they have negative effects on our health? questions and I'm going to pick them at two different ways ways. We'll first
[15:35] do they come, and what what happens when things go wrong, and then we'll talk about the second thing as we grow older and our immune system is is getting less inflammaging, and we'll address that in a minute. Let's first talk about
[15:50] You're doing everything right. Why do you get gum disease? Right? Why do you have to see Kumar the periodontist, right? Um periodontist, right? Um and and um the simplest way. So, so the
[16:04] the bacteria that live in our mouths don't simply live in ones and twos. They form these integrated highly communicating communities, and we call these biofilms. They they hang out in these beautiful layers and thick
[16:17] structures on our teeth, on our gums. When you have a crown put on it, when the crown. When you get an implant, they grow in that implant space. They will colonize any space. So, they live there and they kind of live in harmony with
[16:32] system has learned to tolerate them. And there's a whole cool story about how the immune system learns to tolerate certain organisms and not. And we've done the more. We're just just getting ready to publish this paper. I'm going I'm
[16:46] calling it the I biome because it's, you know, how your microbiome gets personalized um in the first years of life, in the first year of life, actually. And what we're learning is, and I'm going to take this little side
[16:59] story. But what we're really learning is um um when a woman gets pregnant, um you know, she's releases a lot of estrogen. And the gum tissue has a lot of receptors for estrogen. You'd ask why,
[17:14] right? Why does gum need to have receptors for estrogen? But there you have it. You have a lot of receptors for estrogen, and when estrogen binds to the in your gum tissue to open up. So, there's some inflammation, which means
[17:27] bacteria can move from her mouth through her bloodstream. And we found that these bacteria actually travel through her bloodstream and settle on the maternal side of the placenta. So, you know the placenta has two sides, right? This is
[17:41] the maternal side and it's stuck to the woman's uterus, and this is the placenta forms the amniotic sac. Does that make sense? And between the maternal and the fetal side, you have blood vessels that crisscross each other, and they form the
[17:54] blood brain barrier. So, nothing crosses from the mother to the child. Bacteria bacteria are sitting on the maternal side, and on the fetal side are these fetal infantile immune cells that are looking to learn. And what they learn is
[18:09] that these bacteria sitting on the maternal sides are friends. And so, when the baby is born and the mother takes the binky out of her mouth bacteria get transferred from the mother to child, but the child's immune system
[18:23] doesn't reject it as foreign, it accepts it as a friend, right? Which is how the pioneer species in an infant's mouth get colonized from mother to child saliva transmission. And we now know that the mother's contribution is about 85% and
[18:38] the father and other, you know, intimate caregivers are about 15%. So, she is the largest, and almost a vertical transmission through immune education. within the first year of life, whatever bacteria get into your mouth, those are
[18:54] come back and come back every single time you clean your mouth teeth or or do something else to it. And everything else that your body, your immune system didn't get educated on in the first year of life will be rejected as a
[19:07] pass-through. And that is so key because this is the gateway to the body. And this has to have such an unshakeable juggernaut kind of a situation. So so it it is unchangeable very unchangeable. It's
[19:22] very stable, very robust. It's It's a great system in the mouth, right? And the baby bacteria that you get from your mother are truly your first mouth guards. They protect you in ways that are
[19:36] amazing. So now, what happens? Why do these mouth guards One, because your immune system recognizes them. And two, because these recognizes them. And two, because these bacteria are like good Airbnb guests.
[19:50] They come in, they stay, they do their work, they don't throw a massive crazy party, they don't have temper tantrums, they don't develop toxins, and your immune system says, "Fine. Happy. Let's stay together, right?" And what allows
[20:04] them to stay in that kind of a zen low-key state is that they're able to use oxygen. They have ready access to oxygen, therefore their metabolic process known as oxidative phosphorylation. Do you How far back do
[20:19] cycle and oxidative phosphorylation from high school botany and biology? Yeah. >> And that's key. That's key to keeping our mouth healthy. Now, how do you cut off the oxygen to these bacteria? Very simply, when you stop brushing. Remember
[20:34] I told you they live in biofilms? And as a biofilm gets thicker, the bacteria on oxygen. And so, they're not going to die. when the Earth was cooling, long before humans showed up here, right? They
[20:51] switch their metabolic processes from oxygen using to what is known as fermentation. So they go through fermentative processes, which means that they use up a lot more energy. They're doing a lot of hard work now, no more
[21:03] smart work. They're doing hard work. And because of the hard work they do, they produce a lot of metabolic byproducts, toxins, their nutritional requirements get higher, right? It's It's literally like
[21:16] suddenly you started running your marathon, and you need to do that. So being asked to run a marathon without being given the tools to do it. And so So, now your immune system looks at them and says, "I don't know you.
[21:31] You are You are not a friend anymore." And the immune system goes completely nuts and throws out all of these molecules, protein molecules, which are supposed to protect us, they're known as cytokines and chemokines, and they're
[21:44] supposed to protect us, but the bacteria look at them and say, "Oh, small protein molecules, I can actually eat you, and I can become proteolytic." And so now bacteria having an extra food source, and your gums start bleeding, and the
[21:59] bacteria say, "Oh, I now have iron that I can use for respiration because you cut off my oxygen, but guess what? I have a process in my body where I can use iron to start breathing, and thank
[22:12] you for the free iron." And so now you have a community that shifts. So, it's not truly a pathogen that comes in from the outside, not like typhoid and something from the outside to destroy you. It's just a change in how these
[22:28] relative numbers of these organisms live and how their lifestyle changes. So, it's more a lifestyle change that causes gum disease, bleeding gums, gingivitis, all of those things, rather than actually a foreign pathogen that comes
[22:42] in and suddenly grows in your mouth. So, So, I want to set set the stage on that. The other way for this pathogen to to proliferate is remember the mouth is and what happens here can can can certainly and does impact, and our
[22:59] research has shown that some of the things that that can impact this change from healthy to disease, um we call it normal biosis to healthy living to crazy living um in the bacteria. Um two
[23:14] three things that we've seen but that we've studied and I've studied this for 20 25 years now are smoking, vaping, and antibiotic use. Also to diseases in your body like hyperglycemia, uncontrolled blood sugar,
[23:30] hyperglycemia, uncontrolled blood sugar, um rheumatoid arthritis, um obesity, all of these impact these bacteria in your mouth and start shifting them towards dysbiosis which then is this this high alert trigger for your immune
[23:43] this high alert trigger for your immune system to go completely crazy. >> The biofilm is forming on your teeth or on your gums or both? on your gums or both? >> Everywhere. Gums, teeth, lips, cheeks,
[23:55] >> Everywhere. Gums, teeth, lips, cheeks, um tongue, tonsils, under your gums. They live everywhere and these live in niches so they're very each niche is unique. What lives on your tongue is not is not exactly the same community that
[24:07] lives between your tooth and your gum. What lives on your tooth is not exactly the same community that lives under your gum. Each is a micro niche. >> Right. Does this kind of the build up happen with age or is this something I
[24:20] mean so if I'm 50 and I clean my teeth properly, is it the same as when I'm 20 and I clean my teeth properly or do I need to take further action? >> Um um
[24:34] long as you're doing an efficient job. What limitations would you have in your 50, 60, 70 versus when you were 20, right? Um one of the things that can happen is um as you grow older, the bone that
[24:47] about a tooth that's sitting up like this. The bone holds it like a sleeve, right? We call this a tooth socket. it. it like that and the gum comes in and covers that as a second sleeve. So, it's literally a set of nested sleeves, if
[25:01] you can think about it. So, what happens is through chewing, biting, um brushing, friction, some amount of that bone that holds the tooth can can naturally kind of come down, which means that now you might have bigger gaps between your
[25:16] tooth and your gums, and simple brushing might not be enough. The other thing that happens as people grow older, especially postmenopausal women, is that especially postmenopausal women, is that they start getting more dry mouth.
[25:30] And there are certain medications, um particularly antidepressants and so your blood pressure medication and depression depression medication, that can also cause dry mouth. So, when you have dry mouth, you know, you the the
[25:44] your saliva has in your mouth is definitely reduced, which means that you definitely reduced, which means that you develop plaque much more easily. So, so you might need additional tools to clean between your teeth to to, you know,
[25:57] clean hard-to-access surfaces. And for some people there's an additional layer of complexity in that their their motor function is somehow reduced, right? So, if you have arthritis, osteoarthritis I mean,
[26:12] you know, things that that can that can impair your motor function, then how you toothbrush can be different. So, which means that you might take um help from means that you might take um help from like a motorized toothbrush, um from
[26:26] from an electric flosser instead of your manual flosser. So, you might start switching things. You might use um um mouthwashes or mouth rinses or gels that are specifically designated to increase hydration within your mouth. So, yes,
[26:41] hydration within your mouth. So, yes, changes might be required to to how you um brush, floss, and perform your oral hygiene, but the bottom line of healthy mouths, clean mouth, clean teeth doesn't change.
[26:56] So, if we were to think about uh specific diseases, I mean, I'm thinking particularly like cardiovascular is one of the core ones. So, how So,
[27:09] part of it, I think, is that the if you don't have the right microbiome, you then you won't get the the the nitric oxide, and so your uh arteries become stiffer. But, are there other ways in which the
[27:27] the changed microbiome can have a negative impact directly on the >> Sure. And and I I mean, some of the work we have done in our lab, but but a lot of the work has been done in many other
[27:39] researchers um all across Europe and America and Brazil and other places. Um and and the the evidence came out like this. The first thing they saw was that people who are having heart attacks, cardiovascular
[27:54] um were more likely to have gum disease than people who are not. Or people and conversely, people who had gum disease were more likely to get um atherosclerosis, thickening of the arteries, than people who did not.
[28:07] where they went to these, you know, these blocks, these arterial blocks where that's atherosclerosis, and they actually um took a sample of it, and they they looked to see if there are bacteria present, and if so, what type
[28:21] able to find that the bacteria that live on these atherosclerotic plaques, the heart blockages, the valve blockages that you have, they actually are oral bacteria. They are of oral origin. So, bacteria move from the mouth, and
[28:35] Bacteria move from your mouth in your bloodstream. Let's get that very real. It happens when you're chewing, it happens when you're brushing your teeth, it happens to all of us. The thing is, we have such highly competent immune
[28:49] systems that look in and say, "Oh, you're in the wrong place. Sorry, buddy. You know, light lights out." And and it gets the thing off, right? So, so that's normal function. So, I don't want people to get all crazy and say, "Oh, I got a
[29:03] joint replacement and now I need to take antibiotics to kill the bacteria." You These bacteria You can't take an antibiotic. You can't wake up every day sense? You really can't start the day with antibiotic and continue with an
[29:17] antibiotic before I chew an apple, an antibiotic before I brush my teeth. That's not how that works. You have a very competent immune system that very competent immune system that handles the small loads of um bacteria
[29:29] keeping your mouth healthy is one way of bloodstream. One, keeping the bacteria load low in your mouth means less number of bacteria that go down there. Does that So, that's the second line of
[29:42] evidence that came up. The third line of evidence that came up. And to me, the evidence, and I'm going to spend just a second talking about this simply because it's my work and I'm more intimately um um you know, um knowledgeable about it.
[29:58] We looked at um three groups of pregnant women. We looked at women who delivered full-term, you know, full birth weight, normal birth weight babies. We looked at women who delivered preterm. And we looked at women who delivered preterm
[30:13] looked at women who delivered preterm but also had preeclampsia. Okay. Right. So, what did we do? As the baby was being born, we walked into that space and we said, "Here, spit in this
[30:26] cup. Here, I'm going to take samples of of bacteria that live in Oh, they love us. They These women just want to get pregnant just so we can go back and do this." No. It was It was It was but, you know, in the in the spirit of science
[30:39] and research, they were they were amazing and they consented to do this. So, we collected samples of bacteria that live under the gum line, spit, um blood serum, and the maternal side of the placenta.
[30:52] dissected it, took out the maternal side, and did that. And we said first thing, are there bacteria found in the maternal side of the placenta? And we find that found that all women, one who the healthy
[31:05] ones, the preterm, the preterm with preeclampsia, all women had bacteria on not just these full bacteria and communities that are, you know, it's wall. It could be the nucleus. It could be, you know, the nucleic acid, no
[31:21] nucleus in bacteria. Could be nucleic acid, the fragments of bacteria that live there. But what these fragments do is that they trigger receptors on the placenta. These are recognition receptors on the placenta. So, the
[31:35] placenta has all of these recogni- receptors that can recognize bacteria. They're called TLRs, toll-like receptors, and we have about 10 of those in our human systems, and they recognize them. And what we found, this was the
[31:48] coolest thing, the women with preeclampsia, which is like, you know, high blood pressure before you deliver, right? So, that's preeclampsia. right? So, that's preeclampsia. They had a particular type of TLR, it's
[32:00] They had a particular type of TLR, it's called TLR7 and TLR9, that was so high called TLR7 and TLR9, that was so high signaling.
[32:12] the 7 to 9 ratio is what drives, controls your blood pressure. So, women with preeclampsia had this huge. Now, this is a cross-section huge. Now, this is a cross-section study, so take it as you may. But But
[32:25] there's something to say that, you know, bacteria can translocate from a woman's mouth through her bloodstream to her placenta, where it triggers these placenta, where it triggers these receptors to go completely crazy and to
[32:37] up her blood pressure so she has preeclampsia. So So there's something in that story, but that's the circulatory system that's not directly the heart. There are other lines of beautiful evidence which showed that um
[32:51] you had gum disease, if you had periodontitis and deep pockets and bone loss and things between your gums, when you got that disease treated, the um risk of getting heart attacks on or admissions
[33:07] uh hospital admissions due to cardiovascular um accidents was much So So there are several lines of evidence that point to um gum disease
[33:19] being somehow um a comorbidity, a contributor, an aggravator of things that are happening in your in your heart, right? It's not And And then of course we have to always take into consideration um
[33:34] people who get heart attacks and people who have gum disease have several confounding variables, same things. They many of them are smokers, many of them are overweight, many of them have hyperlipidemia, which is, you know,
[33:46] metabolic syndrome, many of them are also diabetic. So these two have the also diabetic. So these two have the potential to affect both diseases. So So you know, that is there, but adjusting for all of that there is still a strong
[33:58] enough signal to say you know, healthy mouth is healthy heart. >> Right. Do Do we know what the mechanism >> Right. Do Do we know what the mechanism is? Do we know why the unhealthy oral
[34:11] microbiome is causing difficulties for the heart? studied. One of them, like I said, are bacteria, right? So you have bacteria So the the bacteria that can translocate and live on your heart, and once they
[34:26] get to these arteries, they trigger what are known as foam cells. So your your response you you know, there's a you have bacteria that goes and sits in your blood vessel and it's you know if you if you have How is that? There. If you have
[34:39] a blood vessel that's like that and the bacteria sitting here, so immediately your immune cells come in and they try to get that out of the system, which means now they are creating this this layer of cells that are protecting and
[34:51] they're known as foam cells. These foam cells together with The foam cells start collecting cholesterol and other things, you know, fat molecules in the body and together they can cause thrombi and they can leave this, right?
[35:05] >> Yeah. >> So so um that is that is is one mechanism. The other mechanism is that in your own mouth, bacteria passively pass through. It's
[35:20] it's reacting and throwing all of these inflammatory products out and some of those inflammatory products leak back from the blood vessels and get into the systemic circulation and you can have that. You can have these inflammatory
[35:32] that. You can have these inflammatory products directly have a cascade of them flowing through your blood vessels that can cause inflammation and therefore, you know, increase your risk for for heart disease, valve disease. The third
[35:46] mechanism is what is known as molecular mimicry, that some of the proteins that bacteria release, some of the um proteins that are you know bacterial cell wall can be recognized by our immune cells as
[36:00] host cells. You know, the the the the protein chemistry is so similar that our body recognizes these as that and so it responds to that as a self antigen. So
[36:12] studied and it's multifactorial. There's no one single thing that you hang your you can hang your hat on. There are so many different mechanisms. >> So one of the things you have looked at as well is how
[36:26] uh like diabetes or other diseases can affect the mouth. So, you have like this loop where and maybe I I I think it's like a positive feedback loop. So, so the the the systemic health affects
[36:40] systemic health. So, could you talk about what you've seen there and what what is the impact of like diabetes or rheumatoid arthritis? >> Sure. And and you know, the mechanisms are are parallel. They're not exactly
[36:55] the same, but I'll tell you in a very very view from Mount Everest kind of a big picture view, right? So, what basically happens is um again, it all comes back to your mouth having receptors for for um
[37:09] hormones that it doesn't have to, I think, but evolutionarily when you think about it, um um Okay, let's talk about what diabetes does to your body first. Just just quick
[37:21] physiology, right? So, when you get What What is diabetes? It is It is resistance to insulin. So, basically, what is insulin? Insulin is a transporter. It's a sugar transporter. So, what it
[37:34] does is when you have insulin, sugar can move from outside the cell to inside the cell where it can be used to doing uh for for cellular functions, right? But when your cell develops resistance to insulin, sugar cannot pass. And so,
[37:49] sugar literally sits on the outside of that cell like a coating like almost like a crackle layer like a caramel layer, right? So, like a toffee. It sits on top of it. And your body is not going to let that sugar molecule just sit
[38:01] around the cell. What it does it it immediately takes that sugar and it adds other proteins, glyco proteins to it. So, it creates this complex molecule
[38:13] which now becomes this and it it's not just it's not just carbohydrate, it's also protein. So, it creates this un indestructible chunk of a molecule which is known as an advanced glycation end product AGE.
[38:28] Advanced glycation end products are very, very important because that's how old. Remember I was going to talk about immunosenescence and I said inflammaging and as you grow older, so this is artificial aging.
[38:41] Uh normal times advanced advanced glycation end products or AGE truly allow your body to recognize as you age and remove aging cells and replace them with new ones. So it's a very important physiologic mechanism. But if AGE is
[38:54] produced in such large numbers, they trigger receptors on your cells which are known as receptors for advanced glycation end products or RAGE. So now you have an AGE-RAGE interaction and the interaction between AGEs and RAGEs
[39:11] can create inflammation. Can create lots of different things. If it happens in a blood vessel, if the cells, you know, endothelial cells or blood vessel cells have these AGE-RAGE interactions, then it causes shrinking of the blood vessel.
[39:24] If it happens in an immune cell, it causes immune cell to dysfunction. If it happens in your gum tissue and your gum tissue has receptors, you know, a lot of receptors for AGE. So the AGE-RAGE interactions can happen in
[39:38] your gum tissue. So all of these create this inflammatory pro-inflammatory And not only that, this whole interaction can also affect your flossing, you're doing everything right, but your blood sugar levels are through
[39:53] the roof and those changes themselves can change your microbiome, the healthy bacteria that live in your mouth from a normal biosis to a dysbiotic microbiome. Well, guess what? Now you have a second layer, second reason for your inflam-
[40:07] for your immune cells to go completely crazy. They're already triggered because your blood sugar and the AGE-RAGE interactions are causing a hyperinflammatory situation. Now you have a dysbiotic situation, and so the
[40:19] inflammation just gets compounded. And then it all spills over from the mouth and gets back into your body. So, now you have more insulin resistance, which then causes more oral inflammation. And and so so that the
[40:33] process is such it enters this vicious cycle. And the simplest we found that the simplest way and and remember I said remember how I said your bacteria and conversations with each other and the immune system actually tolerates the
[40:48] bacteria. Now, your immune system becomes hypotolerant. It's ready to kick out anything and everyone. Everyone's a spy, everyone's an enemy, everyone's got to go. So, so it becomes that kind of a situation. So, your immune system
[41:01] situation. So, your immune system suddenly becomes highly immuno um in less immuno-tolerant, let's say. It loses its ability to tolerate any sort of an insult. So, with all of these things together, the connections, the
[41:13] bacteria and immune systems break down. And the first thing we found molecularly is to re-establish those communications for your immune system to take control of the bacteria again and say yes, you can live here or no, you cannot live
[41:27] here, keep moving on. And the simplest way we found of doing that is actually way we found of doing that is actually to go through and perform oral um periodontal therapy. We call the scaling and root planing, people call it deep
[41:39] cleaning, and and whatever it takes to bring your gum tissue back to health and to reset your microbiome and literally, you know how your computer fails, you press the reboot button and you hold it down? Exactly, reboot the communications
[41:54] between your immune cells and the bacteria together, and that we found is hugely helpful. And there's actually studies which show that the simple act of um getting you a deep cleaning done and having 3-month regular maintenances
[42:09] can lower the requirement for diabetes medication by a whole pill. A whole dose reduction can happen if your mouth is healthy. So, so a healthy
[42:22] mouth actually helps to reduce your need for diabetes medication as well. So, very very closely with our endocrinologists to to do this. And and and rheumatoid arthritis does the same thing. So, the
[42:38] creates oral dysbiosis even when your gums are healthy. The dysbiosis causes your gums to go completely crazy and now you have poor gum health and people with gum disease have higher um they're called DAS 28 scores, you know,
[42:52] they're called DAS 28 scores, you know, the the um tender joints, the the all of those scores. They're it's ESR, which is, you know, CRP C-reactive proteins. These are proteins in your body that are markers of inflammation. They all go up.
[43:04] And we found that by cleaning people's teeth and keeping them on 3-month recalls and but regularly cleaning their teeth, you can actually reduce the DAS 28 scores in people with rheumatoid arthritis. And we're medicated. Of
[43:18] course, that that is its own story. But, body. And I always tell my patients, you know, what happens in the mouth doesn't The mouth is not Vegas. What happens in the mouth doesn't stay in the mouth. So,
[43:31] the sooner we recognize that and the sooner we act upon that recognition, the the better we're going to be. >> So, for people who have reasonably okay
[43:43] um oral health, at least they they they they don't have having a problem. So, what are the practical things that we can do? What are the things to look out for?
[43:56] And, you know, like some of the things I particularly have. So, you you mentioned cleaning and flossing. I mean, anything special on those that is there things that people
[44:10] those that is there things that people frequently do incorrectly? Yes, they don't floss. >> They don't floss. [laughter] That's true. Yes. >> It's It's you know, and I when I say
[44:24] floss, you know, you don't have to use a string floss. There are so many alternatives, and I hate to say floss because we use the floss as a very generic term. But, um you need to clean between your teeth.
[44:37] Anything that you can get in there that allows you to clean. Sometimes for some people, it's a little little Christmas tree brush. For some people, it's a floss. For some people, it's a Waterpik, you know, the the little power um force
[44:50] water forcers that get there. For some people, it's an air flosser. So, so find the tool that works and really work between your teeth, but because that is accumulate the most and those are the hardest to reach.
[45:05] And and yes, eat eat eat eat eating processed foods causes more sticky biofilm. So, so it's a very holistic kind of a thing, but in home care nothing beats brushing and flossing.
[45:20] >> Mhm, right. Yeah, I was going to ask about diet. Is there anything in diet, I mean, obviously processed foods and candies, but is there anything that's
[45:32] specifically good or anything that's specifically bad in terms of diet for for for the microbiome or yeah, for the for the microbiome I'm thinking. >> Um
[45:45] Yes, I mean, think about it. It's friction, right? Anything you eat that can create friction will will keep that biofilm. You know, I tell my my some of said that the important thing about maintaining good oral health is being a
[45:59] good gum gardener. Think of your mouth as a lawn. Don't overwater it. Don't underwater it. Mow it so it has access to oxygen. >> And make sure the dandelions and this are taken care of, right? So So be a
[46:15] good gum gardener. And And part of that is, you know, if you have to mow your lawn, think about friction. Anything toothbrush works by friction to remove the biofilm. Foods that are less
[46:28] processed, foods that create friction can can be hugely helpful. So mechanical forces, those kinds of foods. Staying hydrated. Staying I cannot overemphasize the importance of staying hydrated. Nothing works if your
[46:45] mouth is dry as sandpaper. So So staying hydrated and that prevents you from getting cavities, from from your mucus, you know, our mouth the the lining of our mouth is also lined by mucus. And mucus won't form if your if your
[47:02] mouth is very dry. So the mucus offers a huge amount of protection, as much as the lining cells, the keratinocytes do. The mucus itself offers a huge amount of protection. And to to realize the full potential of those protections, um you
[47:18] do want to um stay hydrated. So And so that means less alcohol-containing things, even mouthwashes, less amount of effervescent things, things that can reduce
[47:33] your your ability to stay hydrated. And as you saliva provides something very important, which is a buffering capacity. It's perfectly balanced pH. can change the pH and you want to make
[47:46] sure that that, you know, it's able to be that kind of a perfect buffering be that kind of a perfect buffering agent for you. What's a tongue tongue scrapers? Are tongue scrapers good or bad?
[48:05] There are two camps, the scrapers and the not scrapers, right? So so And and the evidence is definitely present to for on both sides. There is risk. There's no um known risk to that um that would can
[48:22] outweigh any potential benefits. So if you're on the fence about it, do it. >> Okay. So So you did mention alcohol in mouthwashes uh in terms of dehydration. But it also uh can have strong antimicrobial effects.
[48:39] So you know, I understand that it's too strong. So it to use mouthwash or not? you, Richard? Just And the answer was, please don't use a
[48:53] mouthwash because you want to be a good gum gardener and keep that healthy microbiome going. I say there's only one reason to your mouth use a mouthwash and that's if you're going on a date. >> Okay.
[49:06] Sleep disorders. So especially I'm thinking about sleep apnea or or opening your mouth at night. What effect does that have and what should we do about it? >> Well, we've shown a lot of all many many
[49:19] many years ago. There's lots of studies which show that dry mouths mouth breathing can actually um dry your mouth so much that your gums get inflamed. So we've known that for years and years and years and years and years.
[49:32] Now what we're trying to understand is what these these sleep apnea devices do to you because you know, um um and and how they can change are they mouth? Um so we're studying that and I honestly
[49:47] have not pursued that field long enough to to know much more about it, but I do know there's a lot of work going on. >> Right. So, anyway, we don't want to mouth breathe even when we sleep, or especially when
[50:01] we're asleep. Cuz we're probably snoring, and it's >> Yeah. >> Yeah. Okay. In terms of like looking after your oral health, is there anything that I we haven't covered that
[50:14] you think would be important? >> Um no. Recognizing that's, you know, oral health is integral. Oral health is health. You you cannot have a healthy body when
[50:28] you know, you you don't have optimal oral health. I think that is very very central to that. And I think the other important um aspect of this is is that um things will
[50:41] change in your mouth. Oral physiology changes as you grow older. And and we do have to compensate for some of it. It's you know, you know, when you can't put on your tie your shoelaces anymore and things, you
[50:54] we do get annoyed. We're like, I could do this. 10 years ago I could do this. Why can't I do it now? Um yes, but being in denial about it is not helpful. Recognizing that oral physiology will change, and the change
[51:08] is much more marked in postmenopausal women and in pregnant women. Um but it's also present in men, not to diminish or take away from from, you know, changes that can happen in male um oral physiology. These are all there.
[51:23] And remember the mouth is the gateway to the body. And and, you know, it is it is the body. And and, you know, it is it is um structured for a specific way in a specific way for certain functions that it gives to us, and it's highly
[51:38] protective, and and it hosts a very very healthy um friendly community of bacteria that actually offer us a lot of benefits. So, actually offer us a lot of benefits. So, the less we do to destroy it,
[51:52] the the better your oral health is going to be. >> Excellent. Thank you. Yes, I think people really need to understand the the interconnectedness and how having bad oral health or suboptimal
[52:07] oral health can have such a knock-on effect on your overall health. Dr. Kumar, if people want to follow your work, where should they go? Where can they go? >> Um just Google me. I There aren't many
[52:23] Premila Kumars who work on oral microbiomes, so that's there, but we also have our our website at the university which which um showcases a bibliography of my work. So, I have my faculty page. It's It's umich.edu
[52:36] dent.umich.edu and so dentistry I have I'm at the School of Dentistry at the University of Michigan, so the website is dent.umich.edu and and there's a page about faculty
[52:50] page where where my work is is present. My bibliography is present and open for all to read. And I believe that science need to be democratic, so I publish all of my work open access. Um yes, it's a lot more work and it's a
[53:04] Um yes, it's a lot more work and it's a lot more expensive, but if if science knowledge is should be accessible to everyone, and so I I I my articles should be available for everyone to read.
[53:19] >> Excellent. Thank you. Yes, open access is so important. I certainly. Uh thank you very much. I will find that and put the link into the description. So, Dr. Kumar, thank you so much for
[53:33] >> You're welcome. I'm so glad we got to chat about this. chat about this. >> Yeah.