How Oral Health Impacts Systemic Health?

We swallow 600 times a day, and yet most people are totally disconnected from the mouth being a part of the system of the body, and yet it's where our digestion begins. If our mouths are in bad shape, we're literally supplying our gut and the rest of our body with tons of potentially bad bacteria, infection, etc. So much so that these types of bacteria have shown up in arterial plaque, uh, inside the brains of Alzheimer's patients. The list goes on.

Today we're joined by two absolute experts in this field. Number one, uh, regular guy on the show, Craig Mullen, who's got more education than I can possibly cover. Uh, and then, uh, same thing for Dr. Bryan, who's an oral and maxillofacial surgeon, board-certified, and has been practicing for over 20 years in Oklahoma City, has an incredible CV. Thank you so much for joining us, Dr. Bryan, today so that we can really dig into this at a level that I don't think anyone else is talking about.

You know, this is going to be something — I, I just have to say, you know, after spending quite a bit of time in what we call long — you know, functional longevity, health span, cellular medicine, whatever you want to call it, uh, and, you know, really until talking with Craig about it, it, it really — I just haven't heard anybody really talking about this one key piece. I think it comes down to training and sort of how, uh, medicine looks at dentistry. I certainly came up on the medical side of things and then spent a lot of time working with oral and maxillofacial surgeons and learned quite a bit about what can happen when we let our dentist or our gums or whatever go, uh, south. So today is a great day to talk about this and what are the ramifications of having a quote-unquote unhealthy, uh, mouth and oral microbiome.

Craig, let's start with you just because you grew up with a father who was an oral and maxillofacial surgeon in practice for how many years?

40 years.

Yeah. A little over 40 years. So, this is something that you were aware of your entire life growing up.

Yes. Yeah. Absolutely. Uh, spent plenty of time in my dad's office. You know, he used to bring me in the room when he was doing extractions. I didn't get to go into the operating room with him to see the cool stuff that he did there, but I know, you know, the extent of it, roughly what he was doing. And, um, just had, as you mentioned, plenty of exposure to oral and maxillofacial surgery topics, dentistry topics growing up. Uh, and you know, this was a big win for me because I grew up, you know, I had braces twice. I was regularly going to the dentist. Oral health was a top priority, uh, in maintaining my own health as a, as a child and now as an adult. And so I do feel like I had a leg up in that situation. But it's certainly an interesting world.

And one of the, one of the things that sort of, you know, was indelibly imprinted on my, you know, my, my understanding of health is how closely oral health is really linked to overall systemic wellness. I mean, just as you mentioned, there's been this significant paucity of conversation around the, the oral microbiome, right? When we go to conferences, when we're doing these lectures and modules for functional cellular health trainings, um, it seems to start at the distal esophagus, right, and the, the gastrointestinal tract from there on, uh, and nobody really pays enough attention to what's happening inside the mouth, which is the direct upstream, uh, ecosystem that is ultimately going to influence everything else that's happening from that point forward. So it really is a critical topic, and it's great to have Dr. Bryan here today, who's, you know, has such a wealth of experience, and, um, I think it's going to be a great episode. We can dive into a number of topics.

Yeah, Rob. I mean, we've talked about it for I don't know how many years, right? I mean, this is something that's been going on where we've been talking about failed dentition. Uh, you can't chew your food properly. You can't, uh, can't digest it. That's probably maybe a place to start, and then we can get into all the other things that are the, maybe the lead-up to why you get there.

Yeah. You, you — the, the thing that you just mentioned really kind of hits the nail on the head, and that is the, the digestive system literally begins in the mouth. It is the first step in digesting food, and it, and it's not a small part of it either. In fact, uh, it, it's impossible to have the rest without it. Uh, it's a very dynamic environment. It is loaded with, uh, a micro population that's — blows the mind. Uh, and it's ever-changing. It's — changes based on, uh, many factors. It changes based on your habits. It changes based on your diet, changes based on, uh, your environment. Uh, and so it is truly, uh, a remarkable part of our systemic health that, as mentioned, gets ignored.

Yeah, it's — I think the, the age-old sort of, like, um, divide. There seems to be this notion of dentistry just being a separate, uh, thing from medicine, when in fact it really is. I think the beautiful thing about oral and maxillofacial surgeons is it that you guys are the bridge that brings those two together. And oftentimes people will look at an oral and maxillofacial surgeon, they say, "Well, they extract wisdom teeth and they place dental implants," but they fail to realize that, you know, you're also doing orthognathic surgery. And for those that don't know, orthognathic surgery is the movement of the jaws, the maxilla and the mandible, uh, for aesthetic reasons, also for airway management, which has now become such a hot topic. I mean, Craig, I mean, we now know that you can't actually really function at a high level if you have obstructive sleep apnea. Not only will it affect performance, but it could kill you.

Yeah, 100%. I mean, we've talked at length about the downstream negative, you know, ramifications of having OSA or other sleep apneas. And, uh, you know, when it comes to oral health, we, we know that one of the things, one of the dynamic things that can really influence and change the microbiome and put us at risk is, uh, open mouth breathing at nighttime. You know, um, xerostomia or dry mouth, uh, and there are a number of other considerations besides just sleep apnea that can contribute to that, but that's just one of the things that sort of starts to influence the microbiome in the mouth from an, from an early stage.

So yeah, absolutely. You know, obstructive sleep apnea is such an interesting topic. Also, again, one that gets ignored. If you think about an obstructive event or an apneic event, it's kind of like you're having a mini stress test. You're — and, and it's not one that got ordered either, and it's not one that's being monitored. And eventually, you're going to lose one of those stress tests. You're going to fail one at some point, and something catastrophic is going to occur. That's why people go to sleep and don't wake up. It isn't just because something strange happened during the night. You can trace it back, and you can find in many cases there's untreated obstructive sleep apnea, sleep disordered breathing that has resulted in one too many apneic events.

I was speaking with, uh, Dr. Keith Schneider, uh, who practices in Ohio. Uh, he was in on the Pathway to Peak Performance podcast, and he said he had a patient who was, um, uh, had stopped breathing 75 times per hour, which means that, you know, it's more than once a minute. Um, and then when she had the, um, the actual surgery, she showed up, she's like, "Oh, thank you so much. You know, I can s— I can smell, I can breathe." Uh, and you know, the patient looked oxygenated and completely — like, it's almost like immediately, you know, Rob, we've seen for years those orthognathic cases that you would do where you would see, like, oh wow, this person just looks like a totally different person. But now we're also starting to see, like, oh wow, these people look oxygenated. They look, like, different than they did before. Uh, it's a — certainly is a huge topic of health, and I love how it leads into this notion of dry mouth and what happens thereafter, after, and how that affects the microbiome.

One point I want to make: another Dr. Bryan, who's focused on, uh, nitric oxide, or nitric oxide, has talked a lot about how using mouthwash, uh, can be detrimental, uh, to the actual oral microbiome in such a way that it can increase blood pressure and also wipes out the nitrates that you need to create, uh, uh, nitric oxide in the system. So, you need that in your mouth to be able to do that. Um, I'm curious what your guys' thoughts are on that with regards to mouthwash. I don't use it. I did in the past. I never use it now. I never — I just make sure that I floss, I brush. Oh, and last thing, hygienist just told me the hot new thing is this super Waterpik. Uh, there's a lot of new data out on these Waterpiks that I've really taken to the next level to really clean out the mouth in a way that flossing just can't. Just the contact piece, yes, but the getting in there and really flushing in there is, is pretty powerful. So, we just covered — I just said, like, 10 different things, but I, I'd love to hear what you guys' thoughts are on that.

Yeah, you know, mouth rinse is an interesting topic. Um, lots of mistakes can easily be made by going to the, to the pharmacy and picking up a bottle of mouth rinse. They're getting better. They're getting better, but a lot of them still have some things in them that are really pretty bad for you. One of them being alcohol. Xerostomia, you mentioned earlier. Well, you know what? What, what better way to, to exacerbate your xerostomia than to flood your mouth with alcohol. Uh, you know, the other thing that it does is — we talked about the, the biome — wipes it out. You know, it, it instantly changes the pH of your mouth. It changes the content of your mouth. You know, all of that stuff is, is a, a tightly regulated system. And when you throw a variable into it that dramatically changes things in, in an instant, and then you do so repeatedly night after night after night, yeah, you're probably going to develop some chronic problems that are undesirable. Xerostomia and dental caries go hand in hand. And dental caries and gingivitis go hand in hand. And gingivitis and systemic inflammation go hand in hand. Uh, and the trickle-down effect gets started pretty quickly.

Absolutely. It's that whole idea of, you know, sterilization, right? Where we need these things. Um, you know, Dr., um, Keller, you know, had been on the podcast previously and, and was, uh, talking about the fact that her, her microbiome — she was more micro than, than herself, right? Uh, so we need these bugs, um, and we need them to be in relative balance, and, uh, the idea of just wiping out an entire population is, is sort of ludicrous, and, uh, unfortunately, you know, all too often that the access that people have to these things that can radically disrupt their, their oral health is, uh, a little bit too prevalent. Yeah. And, and again, that, that impact that it has on the nitric oxide pathway that you brought up, Jock, uh, directly pertains to vascular health and, and, uh, vascular tone, blood pressure.

Yep. All right. We've covered some of those, those topics, and now let's get into what kind of bacteria, negative bacteria, um, things that are deleterious downstream into the gut do we find coming from the mouth that are often not talked about. Rob, we'll go to you because I think, you know, you, you've got a huge background. Craig, I know you do as well, but let's, let's get into this, and let's really talk about what kind of bacteria can develop in the mouth at the first stage, which is healthy dentition. You know, we got to brush our teeth. We've got to make sure that we're doing everything to keep — I go to the hygienist four times a year. You know, I just come out of pocket and just do it because I believe that keeping my teeth clean is super important. Um, makes me a better patient, right? Um, but so we have a clean mouth. Then what happens when we start to get into things like you're talking about, caries — uh, for those that don't talk that language, those are cavities — or then periodontal disease, which is where you see red, inflamed gums. Uh, that's harboring a lot of bacteria we can lead to infection. And then, Rob, just take us through the whole kind of — what's the domino effect?

Yeah. So, you know, I — my experience over the years, there are kind of two, two kinds of patients. One kind of patient struggles with caries, cavities, uh, and then you'll have the other type of patient that really struggles with periodontal disease, periodontitis, gingivitis. And, and they're very distinct too. Typically you'll see someone who has significant periodontal disease, and notice, interestingly, they don't always have a lot of cavities, and vice versa: a lot of cavities but not a lot of periodontal disease, so not a lot of bone loss. The reason for that is the type of bacteria present in the mouth. Regarding dental caries, Strep mutans is the bad guy, and what we have to keep in mind is what we eat, they like to eat. So the more sugar you eat, uh, especially refined sugars, that gives Strep mutans a steady diet. That's why sipping on sodas and sipping on even healthy drinks like milk and, and some would argue about juices — but point being, a steady stream of carbohydrate-laden foods and/or drinks feeds the Strep mutans, and as they metabolize that sugar, the oral environment becomes more and more acidic. That acid works on the enamel of the teeth, uh, demineralizing that, and eventually that's how you end up with what we call a dental carie, uh, which can literally eat through the tooth and down to the nerve, which will then result in a toothache, an abscess, and that's when we see people in the emergency room.

I've seen people literally be, be placed into the intensive care unit on a breathing machine because of a single cavity. One cavity in one tooth results in, uh, you know, an airway compromise. Really depends on what kind of bug you have present. Once the Strep mutans and the acid eats down into the pulp of the tooth, then the floodgates are open. Everything that's now in your mouth gets in to your systemic vascular system, and, uh, you can get, uh, abscesses in the neck, which again causes airway compromise. So that's one issue, Strep mutans. Then you've got some other, uh, pretty bad players. P. gingivalis, uh, it's a Porphyromonas gingivalis. It's a gingivitis-type bacteria. You know, you're going to get bleeding gums, uh, immune dysregulation, things of that nature. Once you start getting gingivitis, that inflammation, once it's there for long enough, you start developing bone loss. That results in tooth mobility, which then results in more bacteria flooding into the what we call the crevicular space, or the space sort of between the, the, the gum and the tooth, so to speak. Another pathway for bacteria to get into the mouth. Uh, then you got Fusobacterium nucleatum, another periodontal-type bacteria. And, uh, you know, these all work together. You know, they, they, they like each other. Uh, one thing leads to another, and again, uh, you know, you can get significant systemic vascular inflammation from these bugs.

Definitely. It's interesting because, you know, both those, those latter two organisms that you talked about, they've been linked to some pretty serious disease processes. I mean, the P. gingivalis, we have associated, you know, more as a correlation than a direct causation in the research as of yet. Um, but there is certainly a signal there with regards to Alzheimer's dementia. We know that they're, um, releasing these proteases that, uh, can, you know, degrade, um, proteins, and we associate that potentially with disruption of the blood-brain barrier, which is a very necessary piece of the vasculature within the brain that protects the parenchymal tissue of the brain. And, uh, so P. gingivalis has been isolated in brain tissue, um, and has been associated with, uh, amyloid, uh, protein, uh, issues in the brain. You know, that's one of the hallmark biomarkers of Alzheimer's dementia. And then, um, you know, I think the whole association between, uh, the Fusobacterium nucleatum with, um, you know, colorectal cancer — this is a, an area of research that is certainly, you know, continuing to show more and more, uh, emerging data that, uh, there is an association there. It's not, you know, going to be the primary cause of somebody developing a colorectal cancer, but it has been isolated in tumors, um, and will influence tumor signaling, or has the potential to influence those things. So, um, you know, very, very fascinating stuff.

Yeah. So Craig, you know, one thing I wanted to talk to you about now is, okay, we get these things down into the gut, we have those kind of potential — well, we know that there's some definite effects, right? And then there's potential effects. None of them are good. When you see a patient in your clinic, given your background, how are you handling it? Are you doing, like, a workup, like, "Let me see what's in your mouth. When was the last time you saw your dentist?" That sort of thing.

I think it's, it's an critical area to investigate. Um, one of the things that I like to emphasize, or that I would like to emphasize, is that, you know, just because you're swallowing these things doesn't necessarily mean that they're going to cause a problem, right? You, you sort of need an environment, an ecosystem that is primed for more problems to develop, right? So if somebody is already struggling with dysbiosis of the gastrointestinal tract and they have symptoms of leaky gut, you know, this is going to be an area that's much more amenable to bacteria that are going to translocate down into the stomach and beyond, right? So that's of critical concern. And, but when somebody comes in, um, especially if they're complaining of any sort of chronic ailment with rel— uh, related to the mouth, it's worthy to investigate these things. It's look — worthy to look at their systemic wellness, right? Do they have diabetes? Are they somebody who already has a history, history of some vascular disease, cardiovascular risk factors? Are they a smoker? Um, you know, are they dealing with mouth breathing, chronic mouth breathing, right? Uh, looking at all those factors and then asking them the important questions of, okay, well, you know, when you brush your teeth — are you brushing your teeth? Are you brushing your teeth twice a day? Are you trying to do interdental cleaning at least once daily with floss or a Waterpik? Um, if they're not, then we're encouraging these behaviors, right? We're looking for these patients to undergo annual screenings with their dentist. Um, encouraging patients to, when they, uh, are with their dentist or oral surgeon, you know, asking the question, do I have periodontal disease? If so, how deep are the periodontal pockets? You know, what, what's going on? That's, that's relevant information that the patient should be aware of and will help engage their provider.

So, um, but you know, the standard questions, going back to whether you, uh, are having some bleeding gums, right? What, what's the appearance of your gums on a regular basis? Do they look inflamed? Are they, uh, you know, red, uh, swollen, puffy, purple? Are you starting to have some erosion of the gum line? Um, you know, are your teeth tender to brush? Does it — is it uncomfortable for you when you chew certain foods, right? Uh, so asking those questions, and of course doing an oral, um, you know, exam, and if the patient does have any sort of risk factors that are identified or any concerning findings on the exam, certainly we're going to punt over to a dentist or oral and maxillofacial surgeon depending upon what the issues that are uncovered are. Um, but yeah, absolutely, that's — got to get them over.

Yeah, you bring up a good point with the gingivitis, uh, periodontitis. And, you know, another factor that we're really struggling with now, uh, with sort of this, uh, obesity problem that we have, uh, type 2 diabetes. Uh, type 2 diabetes, gingivitis, periodontitis — one feeds into the other. Uh, you know, if you have gingivitis and periodontitis, you're going to have more trouble with your control of, uh, diabetes, and if you have diabetes, you're more likely to have gingivitis and periodontitis. Now, the distinction between gingivitis and periodontitis, of course, is gingivitis in and of itself is reversible. You know, it's just inflammation. Uh, when that inflammation becomes chronic and you start developing bone loss, that's when you're getting into the, the realm of periodontitis. Uh, and now we're looking at a more significant problem that requires, uh, a more aggressive treatment in, in that patient.

Are you seeing that these people, once, you know, they're adequately treated for whatever systemic dysfunction that they have, whether it's, you know, hyper— chronic hyperglycemia, they, uh, are able to reverse that trend and get back into sort of a metabolic homeostasis, that you have slowing of their disease process in the mouth?

Absolutely. Yeah. I, I think, you know, one, one thing to keep in mind is when you have periodontitis and bone loss, that doesn't mean you're, you're done. Uh, you can get that under control and get the tissues healthy and, and maybe even save all of your teeth that are affected, assuming that there's enough bone, uh, that they're not loose. So this idea that, well, once you get periodontitis, you know, you have to go the new treatment option out, All-on-X — uh, you know, a lot of, uh — not to muddy the water here on this topic, but, you know, a lot of offices will see a patient with, uh, and they'll literally say if they have five or more teeth that are impacted, they're going to take them all out. Well, that, that's not necessary, and that's overt treatment. That's one of the big problems I see, is overtreating patients with periodontal disease by simply saying, "Well, we're just going to take all of your teeth out and give you dental implants." Well, you haven't changed your habits. You haven't changed whether or not you're a diabetic. You're just taking the teeth out and placing something else in that can get infected. So, it's very important that when you see these patients, not only do you, do you work on getting, uh, you know, their metabolic problems under control, but their oral health has to be addressed. You can't just take the teeth out and put implants in and expect, uh, no further problems, because they, they will succumb to the same.

Do you see, um — I mean, in practice, somebody who shows up and, and they don't really present with any oral complaints, um, on exam, what sort of things would either clue you into, okay, there's some underlying manifestations of disease here, uh, that are evident to you on the exam? Or, you know, what might, might patients not readily note at home when they're doing their routine oral care that would sort of be, like, a "hey, this is a red flag, you know, we need to look more into this, maybe I need to get back in with my dentist" sort of thing?

Yeah, you know, I, I think you bring up a really good point, because just like hypertension, uh, and other diseases, diabetes being one of them, of course, uh, periodontal disease can be somewhat silent because it is slow and insidious. So, uh, one of the things that people notice about gingivitis is their gums bleed. You know, they'll come in and they'll say, "You know, I was brushing my teeth the other day and my gums started bleeding." Typically, when I, when I hear people say that, this is someone who routinely takes care of their teeth. So, they're brushing, they're flossing, they're doing all the right things, but maybe, for example, they get, you know, a piece of popcorn kernel stuck in a, in an area. Now, they're going to have an acute flare-up. So, you'll have a very localized gingivitis, and they'll bring it up to you. They'll say — they'll, they may even make an appointment to come and see you just for that because they think, "Hey, something's wrong." Well, people who have chronic gingivitis and maybe even periodontitis, they're not engaging in those regular dental visits, usually. And so, and they're also probably not engaging in routine oral health care. So, they're not going to notice the fact that if they were brushing their teeth, their gums would be bleeding. So, a good test for people to say, "Hey, you know what? Am I, am I having periodontal disease?" Brush your teeth and see, do they bleed? And if you see your gums bleeding, uh, you know, just kind of generally speaking, that's a good clue that it's time to get yourself into the dental office.

Jock brought up really great point earlier. Again, we're almost talking about it as if it's a separate issue than systemic health. Uh, going to the dentist and getting cleanings. It's very, very important. You can catch so many things. You know, twice a year — that number was just something that kind of got made up. It's a great number. I mean, I think it's the minimum. It'd be nice if you could get in, you know, three times, four times a year. Uh, patients often cite the cost of the visit as being a barrier. Uh, I, you know, I, I find that really hard to believe given some of the lifestyle choices that we make in this country. I see people lined up at Starbucks to pay, you know, $50, $75 a gallon if you do the math for coffee, uh, or Frappuccinos or whatever that is, and they can't spend $200 four times a year or two times a year to get a dental checkup and a cleaning. And if you think about what that's actually going to do, it's going to save you so much money, but more importantly, it's going to protect your health. Uh, you know, this, this inflammation that is unchecked, it results in so many disastrous things. You know, I just saw a guy yesterday, in fact, uh, fitness person, very much into health, but not into oral health. So, that one thing that someone is not doing, uh, that's going to cost this person their teeth, all of them, most likely. It's a big price to pay. I think I'll probably feel pretty good about paying $200 two or three times a year to go see your dentist.

Another thing that we see, sleep disordered breathing. I brought that up earlier. I just saw a lady, uh, an hour ago, and she said, "I woke up in the middle of the night and I have a terrible, terrible toothache." Um, "Actually, Dr., Dr. Bryan, I think that it's the implant that you put in last week. I think the implant you put in is failing. It's, it's hurting badly." So, I look in her mouth, tap on the implant. Not a problem. Take a new X-ray. Everything looks great. So, I tap on the tooth in front of it, and she says, "Oh, that's it. That's the pain I'm having." Uh, and you know, I look on her X-ray. She has some bone loss around the root already. The tooth is moving. And what she's doing is she's grinding her teeth at night. She has sleep disordered breathing. She may even have sleep apnea that's un— undiagnosed and untreated. Uh, sleep apnea, sleep disordered breathing, and bruxism: best friends. Also gas— gastroesophageal reflux disease, another major problem. But, uh, grinding your teeth — people who snore tend to grind their teeth — can result in absolute devastation of the oral cavity.

What's the best solution for that these days for, for bruxism?

Well, if it's derived from sleep disordered breathing, you've got to treat that. So, you're looking at either an oral appliance, or you're looking at weight loss, or you're looking at a CPAP machine, or you're looking at bimaxillary advancement. Gold standard, of course, is weight loss. Uh, that's difficult for a lot of people. CPAP machines, often people are non-compliant with those. Oral appliances, uh, a lot of people don't even know about those. They can be non-compliant with those as well. Uh, bi— advancement is a great option. Uh, I don't know that I would consider it the gold standard because it's not recognized as such. But if you want to open someone's airway up, advance their maxilla and their mandible. I can open it up 10 millimeters in 3 hours. Uh, and that person can be laying on their back in the hospital bed breathing without a CPAP machine. I've seen it. I've walked into a room where a gentleman is laying on his back with obstructive sleep apnea diagnosis, who uses a CPAP machine, and his family is literally standing at bedside amazed at the fact that this gentleman is now breathing two hours after he's out of the operating room with no appliance, no breathing machine. It's amazing.

That's awesome.

But yeah, that sleep disordered breathing, sleep studies, uh, they're, they're underutilized. And I'll tell you another problem with sleep studies. Uh, I think people are getting better about them, but a lot of, uh, physicians, first of all, are very reluctant to order them on people that are not obese. I don't understand why, because we all know now that upper airway resistance syndrome is a problem in the fit young female population in particular. But you'll get a sleep study, and it's almost as if you get a red light or a green light. Yes, you have sleep apnea, or no, you don't. We're pretending as though there's no gradient there. Well, we know there's prehypertension. We know there's pre-diabetes. And now we know there's upper airway resistance syndrome, which I consider pre-obstructive sleep apnea. So the problem with the sleep study is it doesn't always give us the — it gives us the answer we want. Our interpretation of it, though, is frequently wrong, because a patient will come and say, "You know what? I had a sleep study. They said everything's fine." Well, what does that mean? Is everything really fine? Because you just told me you're snoring, and if you're snoring, everything's not fine. And if you don't believe me, sit in a chair and do absolutely nothing. Don't even move. But snore. Just snore. You'll be gasping for air. Try to do a workout routine, but snore. Not possible. So now tell me that snoring is not a problem. It's pathological.

Absolutely. Yeah. And it's important, too, that the distinction between these at-home tests that are available for consumers versus getting a test in, in the lab. You know, um, obstructive sleep apneas can be well identified, I think, on some of the at-home tests, but there are other causes of sleep apneas. A central sleep apnea really needs a good study in a facility, in a lab, to identify that, the presence of that. So, you know, patients should be aware of that as well. I just — I think it's remarkable, you know, we're having this discussion, but just thinking back on my own history of, like, going to the primary care, right? I, I, I don't think, unless I was being evaluated for some sort of, uh, throat infection, I don't think any primary care is ever, like, "Hey, let me look into your mouth and see what's going on in there." Um, it's — and I know that that's true across the board, really, for, for a lot of different, uh, primary care practices out there. So yeah, that's kind of why this conversation is quite interesting for me in particular.

Jock mentioned it earlier. It's kind of like you have the teeth and the dentists, and you have the body and the physicians, but the physician thinks that the body starts, and somewhere in the pharynx, maybe. And the dentist, they're, they're done at the tooth level. So that's where we come into play. You know, we're looking at the tongue, we're looking at the pharynx, we're looking at the palate, we're looking at the floor of the mouth, salivary glands, the ears, the eyes, the nose, the throat. Uh, you know, and not only are we in regards to the oral cavity, but oral and maxillofacial surgery in general dabbles in both worlds, which is why most of us end up becoming oral surgeons, because we start out liking dentistry and then we see this entire — almost like in a new universe exists out there where no one is. And it's very interesting for us because now we get outside of the tooth level and sort of into the systemic level, particularly when we start learning about anesthesia. That's one of our first exposures. Uh, you know, I remember in 2002, June of 2002, I was at Ohio State doing fillings. July of 2002, I'm at OU Health Sciences Center in Oklahoma City doing a general anesthetic in the operating room for who knows what procedure all day long for several months. You know, then several months later, I'm rotating on the internal medicine department. And you know, when you're a resident in oral and maxillofacial surgery, they treat you like an internal medicine resident, or they treat you like an anesthesia resident. Uh, and so you — the learning curve is very steep, but it's an adventure that — it's like none other. It, it — the four years in my residency were some of the greatest times of my life. I thoroughly enjoyed it. I thought it was so remarkable. Uh, I have fond memories of it, and I, I treasure it. And I think it's great, and, and it's, it's what I revel in every single day that I come to my office: the unknown.

Absolutely. It's super cool, too, because it's one of those fields, uh, for practitioners and, and doctors where there's so much gratification, because the, the community and, and the volume of patients that are treated by, by you and other similar practitioners, they're so — they're just so incredibly grateful, you know. And, uh, that was one of the things that stood out to me with my dad's practice. He saw, I don't know, like, 30,000 or some patients over his career. It was a, a huge number, and, uh, he passed away in, in 2024, and it's remarkable to still be in the area and inevitably run into people who had some sort of work done by him, and they're just always so grateful. You know, the, the impact that people can — that a, that a provider, clinician, can make in somebody's mouth, helping them with their oral health, you know, inevitably helping them with their overall wellness, uh, through those interventions is just profound. And so I, I think it's one of the most gratifying areas of medicine, probably, for you guys.

All right. I want to make a case going back to the hygiene side of things. Uh, which is, it's more than just getting your teeth cleaned, um, and making sure that you're maintaining a, uh, a healthy mouth. Uh, also includes being screened for oral cancer. And we know the five-year survivability rate on oral cancer is about 85% if detected early. Uh, and it is aggressive. Um, the numbers on it are not so great if it goes past that, and it kind of drops off rather rapidly, right? Uh, Dr. Bryan, we get into people who are late-stage oral cancer, and it's like, you know, you could be losing the top portion of your palate. Uh, you could be losing ma— mandible. You — I mean, the list goes on. It gets to that point, it becomes quite destructive, and, and treatment for it is, is, well, very aggressive.

Yeah. Seen those cases where people are plating jaws, and, you know, I mean, it's, it's not, uh, it's not something to fool around with. And I think, you know, as we start to move into this day and age where people are looking at health care differently — we know that we live in a sick care model that doesn't reward people for staying well. Like, if you had car insurance and you're driving well, you don't get speeding tickets, you don't hit anybody, your rates go down. But in healthcare, we just pay the same as everybody else regardless of what we do. We're three guys that spend a lot of time — we're in the dawn patrol, you know, we're in the gym super early in the morning before our days start to make sure we stay healthy, and yet we pay the same amount as everybody else. I think we're moving to a point in time where people are like, "Hey, I've had enough of this. I, I want to be — I want to be proactive. I don't want to accept what's going to be told to me as the norm. I want to do everything I can to make sure I maintain health span, the highest quality of life." Somebody said something the other day. I was — just thought it was so great. Someone had stopped her in the gym and said, "You're just so jacked. You're amazing. I just — oh my gosh, I just want to look like you." And she said, "That's great. That's not why I'm here. That's not what I'm doing. I'm doing this because I want to make sure that when I'm 80 years old that I can get up, stand up, move around, be healthy." We know the majority of health care costs exist today in the system in the end stage of life. So we spend all this money keeping people alive who are really already just past that point. And really, if you think about it, if we were to focus on preventative medicine and really getting dialed in on what we need to be healthy, uh, the world could change in such a positive way. So it's an exciting time. And I think what's really neat here today, we're making a connection that's long overdue. I have yet to hear this talked about. Craig, I'm curious, at conferences that you've been to — you've been to more than I have, I would imagine. At conferences that you've been to, h— have you, have you heard this?

No. No. Yeah. This is, this is really, uh, a new area that, that we're venturing into, uh, in this field, I think. I mean, it — obviously oral health is well explored, right, but it just has not been a topic that's, that's readily explored in, in these conferences in cellular medicine and health span optimization and whatnot, and it really needs to be, um, for all the reasons that we've just uncovered. And I do want to go back to one of the things you mentioned about oropharyngeal cancers. I mean, how de— you know, we see the devastating consequences of these. When I was working in the hospital, you know, the people that had these, uh, just explosions of tumor growth, um, that were ultimately, you know, was ultimately going to cost them their life. It, it's so terrible, and such a painful, painful way for someone to, to pass or meet their demise. And, um, you know, one of the things that I do recommend to patients is the Gardasil vaccine, right? Um, oropharyngeal cancer being linked to, uh, certain strains of HPV, human papillomavirus. Well, what can we do? What has been shown to be so effective in, uh, preventing some of these devastating cancers is the Gardasil vaccine, which, you know, anybody over the age of 15 can get a three-dose. Uh, takes less than 6 months to get all, all three, uh, the vaccines, um, and very protective. So, uh, something for, for people to be aware of. You can start vaccinating your, your teenager at a, at a, you know, young age and, and have them really be quite protected. And, you know, uh, again, we, we talk about preventive care, oral cancer screenings, so easy to do.

Problem with oral cancer is when it starts, it's not painful. You could have a lesion. Uh, you know, we're talking about things that don't belong in the mouth, and, and we talk to hygienists about this at, at CE courses, and, and by the way, the dental hygienists are fantastic. They are — they really are the guardians of the oral cavity. Dentists are great, you know, but the dentist is focused on teeth. The hygienist, they're looking at soft tissues, lateral tongue, floor of the mouth, pharynx, uh, uvula. You know, they're looking at the tonsillar pillars, buccal mucosa. Those are important areas to look at, because if you see something that doesn't belong, you've got to look into it. We have a — actually, we have in our office now, in our practice, uh, something that, uh, is very interesting, and that is we have an entire system that's designated for rapid diagn— rapid diagnosis, really, is what we call it. And so we have a form the dentist can fill it out, uh, wherein they describe the lesion, send us photographs — they can send them via email — and when we receive those, I will stop in the middle of my day and I will look at the photographs. I'll read — I'll do the read-up on it, and we'll get that — if it's warranted, we'll get the patient in for a biopsy without them having to come in for a consultation first. So we, we get rid of the, the lengthy — you know, it could be weeks sometimes. Well, you know, if I've already looked at the photographs and the dentist has given me a good write-up on it, we'll get them in right away and get a biopsy that same day, get it sent off, and get a diagnosis rapidly. You know, rapid diagnosis, early diagnosis, so important. Uh, and like I said, these are dental hygienists that are catching most of these things because they're looking. Uh, and you know, if you, if you don't go to the dentist, imagine how many times do, do you really look at the roof of your mouth? How many times do you examine your lateral tongue? Never. So if no one does that for years and years, you could have a tumor that's quite sizable by the time you yourself notice it as a patient, and then it's just off to the races.

Uh, I remember with Chris Daniel — uh, shout out to Dr. Daniel — I had a, uh, bump. Yeah, I don't know what it was. It was some sort of bump in the roof of my mouth. I'm like, "This is not right." So, I go to see him. He does the examination. He's like, "Ah, I don't think that's anything. We're going to — we'll take a look at that again in a month." Um, and it was, like, some sort of, like, you know, I ate something or had done something. But, you know, that notion of what you're doing, I really want to congratulate you, because that makes a huge difference when you're in that particular scenario. We can say, "Oh gosh, you've got plenty of time." But do you really? I mean, that's why you're doing it. It's because the — every day matters.

Every day matters. And you know, in, in the mind of a patient, if they have something somewhere that they know doesn't belong, it's cancer to them until someone tells them that it's not. So, the more nights you have to go to sleep knowing that something's there and you don't know what it is, but you have an appointment in two weeks to find out — golly, it's a lot.

Craig, how much cortisol are we releasing when we're in those days? A lot of cortisol, right?

Yeah, I'm sure. I'm sure tons. You know, I, I think that — and even beyond, outside of the scope of cancer, right? The, the oral cavity being the window to overall health. I mean, there's so many lesions that can present that can be, uh, a clue to something else that may be going on. I mean, you know, there are lesions that are characteristic in HIV, AIDS. There are, uh, you know, the presence of aphthous ulcers in conjunction with other systemic manifestations may lead somebody to investigate something like Crohn's disease. You can look for micronutrient deficiencies sometimes based on the appearance of the tongue. I mean, it's remarkable how much information you could get from a good oral exam.

Yes, absolutely. You know, a lot of rheumatological-type diseases can be, can be diagnosed through an oral cavity exam.

Well, today we took a deep dive into all of the different, um, aspects, I think, at 30,000 feet down into, like, I don't know, 10,000 feet, and I think we go a little bit lower in the future and talk about some more, more stuff. So, Dr. Bryan, I want to thank you so much for making yourself available today. Um, and yeah, it was great to have you on the show. We'll circle back, and hopefully we can continue to get this discussion and make more and more providers aware. I think what, what we're after here is unity. Let's bring everybody together. Uh, get everybody understanding that this is not a separate piece of the body. It's the beginning of where it all starts to happen. And, uh, and certainly, you know, I mean, we could — same thing, same thing could be said about what we put on our skin and what we breathe in and all that good stuff, but gosh, you know, uh, that mouth is a massive component. So, all right, guys, before we wrap up, any final thoughts? Anything that you want the world to know, uh, a key takeaway before we, uh, before we sign off?

Yeah, I think it's just like everything else: prevention, prevention, prevention, maintenance. Sometimes we worry more about what we put in our car than what we put in our mouth, and it certainly should be the — quite the opposite.

Agreed. All right. Well, it's another great episode of Cell to Systems. Uh, join us next week. We've got another barn burner of an episode coming up. We want to thank you guys. Always remember, please like, share, and subscribe. And on this particular episode, there are some key pieces that, if you listened closely, you'll know you need to share this with friends and family members. This is information that isn't really talked about all that frequently, and yet it just must be disseminated. We've got to get it out to everyone if they want to live a healthy life. So, thank you guys both, and we'll see you in the future.