The oral-systemic disease connection has long been established (recall older recommendations for prophylactic antibiotics before dental work in individuals with endocarditis or joint implants), but with the emerging data on the oral microbiome, new attention is being paid to oral health and the prevention of diseases ranging from cardiovascular to autoimmune and more. A transient bacteremia is the normal course after brushing, but when there is a breakdown in oral health and alterations to the oral microbiome, this transient bacteremia leads to chronic, systemic inflammation, contributing to the course of systemic disease. There is much we can do to support our patients in correcting this inflammation, not the least of which includes a healthy, sugar-free diet; regular cleanings and appropriate brushing techniques. Ideally, the dentist is a part of the functional medicine team.
Disordered sleep breathing is a wide-spread, underappreciated problem in children and adults. Once thought to be primarily stress or trauma related, bruxism is now understood to be evidence of disordered breathing (see reference link below). Additionally, a scalloped or fissured tongue (macroglossia) also contribute to disordered sleep breathing.
In this clinical pearl-packed podcast, Dr. Burhenne covers:
- Oral/systemic connection and what we can do
- Tracking CRP in oral and systemic inflammation
- Tending to our oral microbiome: Do’s and Don’ts
- Disordered sleep breathing: how to identify on physical exam
- Root canals and implants
Podcast sponsored by Designs For Health
Designs for Health is a professional brand, offered exclusively to health care professionals and their patients through referral. By providing comprehensive support through our extensive line of nutritional products, our research and education division, and our practice development services, we are able to maximize the potential for successful clinical health outcomes.
Podcast Series sponsored by Designs for Health
Kara Fitzgerald: Hi, everybody. Welcome to New Frontiers in Functional Medicine where I am bringing you the best minds in functional medicine and today is no exception. I’m really excited to be talking to Dr. Mark Burhenne. Mark is a family and sleep medicine dentist. He’s been in private practice for almost 30 years. He focuses on patient-centered and preventative dental healthcare. The day his wife was diagnosed with sleep apnea was the day he began learning everything he could about sleep medicine dentistry and sleep breathing. He’s author of The 8-Hour Sleep Paradox: How We Are Sleeping Our Way to Disease, Fatigue, and Unhappiness and the creator of askthedentist.com, which is dedicated to helping people understand oral health and the mouth-body connection for overall wellness. I do want to say his website is a treasure trove. It’s geared towards the lay audience, but there is much for us as clinicians to glean from the site. Mark, welcome to New Frontiers.
Mark Burhenne: Oh, Kara, thanks for having me. Thank you.
Kara Fitzgerald: Yeah, I’m really delighted to be talking to you. You are a key player in the functional medicine team and I think we will be embracing dentistry and the need for you as a pivotal player in our team as this research around the oral-systemic connection continues to bloom. Talk to me about the oral-systemic connection. What’s your take on it?
Mark Burhenne: I agree with you. It’s something that more collaboration needs to occur between dentistry and medicine. I think it’s beginning to happen, especially with this wave of information coming about the oral-systemic condition, the connection, I mean. On our website, we always refer to as what happens in the mouth happens in the body. That’s just a simple way to look at it, but it is so true and a little scary, but the more you know about it and the more you understand about it, there are things that can be done about it.
In simple words, it’s an infection. It’s an oral infection, so it’s an infection that starts in the mouth that can affect the rest of the body. For example, gum disease, which is the classic oral infection … There are other infections we’ll talk about, but periodontal disease is a big one. 70%, maybe 75% of the population in this country has it. It’s endemic. It can affect the course and even the pathogenesis of things like cardiovascular disease, pneumonia, diabetes, low birth weight, and early term pregnancy, those are 2 scary things, even inflammatory bowel disease, rheumatoid arthritis. There is a connection between what does go on in the mouth does happen in the body and it can linger. It can be transient, but it’s important to know why an infection in the mouth can have this effect as a practitioner, but also as a patient.
It’s caused by a bacteremia, bugs in the blood. Normally, blood is sterile, as we all know, but after a dental visit or even at your home with an infection in your mouth, your blood could be nonsterile, which, of course, leads to a vigorous immune response. Back to functional, you mentioned functional, I just think that’s so redundant because in healthcare, everything should be functional. We shouldn’t even have a label, but unfortunately, there is a division there.
In dental school, it’s pounded into our heads first of all prevention, prevention, prevention. I think we, as a profession, started out based as prevention, maybe more so than medicine, although that’s changing, but it was pounded into our head for legal reasons, malpractice reasons, that you had to premed and this was that oral-systemic connection. This is 30, 40 years ago. It’s long been known that if you don’t give a patient who has had infective endocarditis or a prosthetic heart valve, for example, that if you don’t give them some form of antibiotic before your dental visit, they could walk out of there and die 2 or 3 days later. Dentists have always known this, but it’s only been the last 10, 15 years where it’s just really bloomed and we’ve gotten more information. Of course, we don’t understand it all, but it’s important enough to discuss.
Kara Fitzgerald: Right, it’s fascinating. I’m remember when I was a kid, they thought that we had mitral valve prolapses, me and my siblings, and we were always treated with antibiotics for a period of time. Then imaging, I guess, became a little bit more refined and they said, “No, in fact, you don’t,” so no more antibiotic.
Mark Burhenne: They’ve become a lot more selective as to who gets a premedication of antibiotic, which is nice. It used to be a real broad, global thing where if you had any chance of anything, you would get lots of antibiotics just for a dental visit.
Kara Fitzgerald: I have a couple of thoughts around this bacteremia. Clearly, it can be fatal in a vulnerable population as you’ve just articulated, but I also wonder if, on this continuum of a healthy individual, bacteremia is moved through. There’s no issue associated with it. They have a chance to allow their immune system to jump into action and do its job. I think that that’s probably we’ve evolved this way, so that can’t be a bad thing. I think it’s probably absolutely appropriate. It’s totally appropriate and that’s why we have an immune system. In some cases, such as the folks that you’ve mentioned, there is a big problem and I think that there’s certainly cases that aren’t at the level of endocarditis who experience a bacteremia for which it’s a problem, so can you talk to me about that?
Mark Burhenne: You’re right. It is a normal thing. Every time you fall and cut yourself, anytime you break the skin, there’s a potential for and likely a bacteremia. It’s transient. Transient refers to maybe 5 to 20 minutes and the immune system in the blood and, of course, in the body, responds to it quickly. The macrophages and all the little I call the Stormtroopers, they come out. They’re there. They’re waiting. They will take it down. The problem is … Again, this is rare. This is something that doesn’t happen all the time, although I hear it often. I hear about someone dying after a dental visit. You hear it every once in a while and you wonder. What was the predisposing condition of that patient? Were they sick? Were they immune-compromised? Did they have diabetes and they were fighting peripheral neuropathy where they had some dead tissue in their foot and the simple dental cleaning just made things worse?
For example, so if you come in for a tooth extraction, it’s 100% likely that you’ll have some gram negative bacteria anaerobes running around your bloodstream for 10, 15 minutes. It’s pretty sudden, which I find amazing that the minute you cause some insular injury in the mouth, it’s within a minute, I think they say it’s within 30 seconds, and that’s incredible. I’ll discuss later how that happens and how it doesn’t happen as often in a healthy mouth. There is a little communication there where if it’s broken down that there’s a little doorway that does open and I think it’s important that we all know when that door is open. If you come in for a cleaning, a scaling, most scalings do, root scalings occur below the gumline and that causes bacteremia. That’s about a 70% chance of having a bacteremia. This is why you’re walking out the door. This is actually why you’re sitting in the dental chair.
Here’s a big one. I was surprised to see the numbers so low and I’m sure you’ve read about how scary root canals are perceived by some as being a source for a chronic bacteremia or seeding infections in the body, but that’s only if there’s a 20% chance of a bacteremia.
Kara Fitzgerald: A 20% chance?
Mark Burhenne: I’ll talk more about root canals, but those bacteria could, essentially, be worse because they’re in a closed space. They’re definitely anaerobes. I also throw in tonsillectomies in there. There’s a 55% chance of that. I think it’s actually higher than that. A lot of kids come in with fevers after their tonsillectomies and they do just fine. Again, that’s not in the realm of dentistry, but I include that because it is the oropharynx. It’s part of the mouth. It’s the same set of bacteria. They change a little bit as you drop down into the esophagus and then, of course, the gut bacteria.
Actually, you had a guest on a few months ago that I interviewed and she’s wonderful. Her name is Cass. I think it’s Cass Dooley, but she mentioned that there was a crossover of the bacteria in the mouth, the normal bacteria, the healthy microbiome in the mouth, and that in the gut. There’s about a 45% crossover and so tonsillectomies certainly can be included in that. As dentists, we were taught just to … It gets discussed in dental school, but maybe an hour is spent on it and then it gets forgotten because we see a cavity and we just drill and fill it. We are perceived as being and sometimes we perceive ourselves as just being machinists. We’re woodshop experts of the teeth. We see a hole and we cut out the dry rot, so to speak, the decay, and we fill it.
I think it’s better and I think this is happening in dentistry, it’s beginning to happen, that these infections, actually, are quite serious that we have to look at a tooth infection as, essentially, a systemic infection. The studies show that kids, about 9 or 10% of the kids with cavities have bacteremias. They’re walking around with an infected blood supply because of the cavity.
Kara Fitzgerald: Thinking about this, the movement away from just local action, drill and fill, as you say, to really considering the body as a whole and the impact of dentistry on the entire being or just the impact of good oral care on the entire being, how has that shifted your practice? How do you approach the root canal patient today? Do you advise any self-care before or are you using … I’m sure that antibiotics are required in certain individuals. I’m not a dentist. This area is … I’m learning from you today, but as you’ve really expanded, how has that shifted you as a clinician?
Mark Burhenne: I think 2 things. There has been a shift and certainly looking at root causes and personal preventing them. Again, prevention is how dentists think. We’re trained that way. We were trained that way from day 1. We even give out nutritional advice. It’s something that was just in dental school 30 years ago. We were doing acupuncture. This is a dental school on the West Coast. For some reason, I just felt that we were a little ahead of medicine, where medicine was just prescribing, prescribing and cutting and suturing up.
On the other hand, though, over the last 30 years, there are a lot of things I’ve seen and have changed and modified as you refer to and that is how can we not even get there to needing a root canal. There have been some things that have really blown my mind. For example, in the course of my career, grinding, bruxism, nocturnal bruxing and grinding was really a thing. It was behavioral. It was stress. There was a stress component. There was an acausal mechanics component, if the bite was off, if a crown was put in too high or if there was crowding, malocclusions and that would cause grinding.
Actually, that’s beginning to shift. Maybe not concrete yet, but we’re beginning to think and see, and I certainly believe it, and that is that bruxism is a sign that that patient is struggling for air at night. When I look at teeth damage now, I look at it in a very functional, systemic way. It’s like okay, you’re pounding that tooth and I need to fix it and crown it and protect it, but what caused it? What was the root cause of that? Oh, my goodness. You have a small airway and from being a child to an adult who’ve been grinding their teeth away and, of course, the teeth can’t tolerate that. They crack. They break. They fall out. Yeah, I think I have changed in my approach because things and the more information we get, it’s great, so there are some big concepts in dentistry and I think things are changing.
Kara Fitzgerald: You might be looking at the patient with bruxism as potentially having sleep apnea or some sort of a nocturnal hypoxia. You would work them up …
Mark Burhenne: Sleep disorder breathing.
Kara Fitzgerald: Sleep disorder breathing?
Mark Burhenne: Sleep disorder breathing, yeah.
Kara Fitzgerald: Okay and so you’d be working them up for that and looking carefully. Would you recommend that to us that we refer to either a dentist specializing in sleep medicine or go for a sleep study or something in our patients with bruxism?
Mark Burhenne: Yeah. Dentists cannot diagnose sleep apnea. We can only screen for it. That’s one of the big cruxes in my book is why should you be listening to a dentist about sleep and that is that we can pick it out sooner than a physician can. Most people don’t come in and say, “Listen. You know what? I’m tired in the afternoon. I’m kind of drowsy, asleep at the steering wheel and I think I have a small airway. I think I need to get that checked.” They don’t know that. They can’t vocalize that. It’s a difficult thing, even though it’s out there in the media and all that. We just think we’re getting older and we’re slowing down and that we’re stressed.
A dentist can sit a patient down. Of course, we see our patients lying down. We throw a lot of water in their mouth and do things in there and that’s hard for them. If they’re a nose breather, for example, they can do pretty well. If they’re a mouth breather and they can’t breath through their nose and we’re working in their mouth, we can pick up on that. Mouth breathing, that’s an indication of poor development as far as the airway goes. We can see things like a fissured tongue, a scalloped tongue. We can see the attrition, lingual erosions. That’s where the teeth, on the upper teeth, on the linguals on the inside of the teeth are literally being etched away by acid. There’s a big correlation between GERD and sleep apnea, so in a matter of minutes, even seconds, I pretty much made a decision on whether this patient should go get a sleep study.
Yes, you can refer to a dentist. You would probably have to go to an organization like the aadsm.org and then refer off of that list because they’re trained to do that. Not every dentist is. I think that will change, but certainly, send them to your primary care physician after viewing all that. I would sit down with your local dentist that is trained in this, go through a few slides. It’s not difficult to pass this knowledge on. It’s all visual and I’m sure you’re already seeing it. You can see a retrognathic patient, that’s a classic patient with a very receded chin.
You probably know this, Kara. You go to a cocktail party and you’re analyzing everyone in that room. I look at facial expressions, the amount of wear and tear on the teeth. Within a few seconds of conversing with someone, I pretty much know if they’re a grinder or not. Then I wonder what’s going on there? What’s the root cause of that? Anyway, it’s an exciting time to be a dentist because we have a lot to share, but again, it’s the collaboration between the dental and medical worlds that’s important.
Kara Fitzgerald: I’ve got a bunch of questions. Thanks for all of that, many pearls in that. Just to circle back, you see bruxism and obviously, you see this various signs. Protracted bruxism leads to damage and possibly requiring root canal and then we’re back to the bacteremia and inflammation. Is that …
Mark Burhenne: Right.
Kara Fitzgerald: Okay. I got it and so why the bruxism. Is stress a big component of bruxism? Do you think that disordered breathing would be higher up on your differential?
Mark Burhenne: It would be higher up. I think the paradigm is shifting. There’s a study out of Quebec, Levine, I forget the other 2 doctors, and that is suggesting, it hasn’t crossed over completely saying it is absolutely the cause, but they’re recommending, and they’re doing further research, of course, that bruxism should be looked at as when you see bruxism, you should consider a small airway. To me, it makes sense. I have treated over 1000 people with oral appliances or referring them out for CPAPs and I see them every 6 months, every 3 months, probably more often than a physician does. I’m convinced that … I have maybe 2 or 3 patients that I just got it wrong that they were severe bruxers and the sleep study came back negative. I suspect that perhaps the sleep study wasn’t completely accurate, but we’re going with it for now. That’s a high batting average.
To me, it is concrete that if it’s accurate enough to know that if you see bruxism and it’s nocturnal bruxism, then you do need to consider a small airway. I see it in kids all the time, their weird sleeping positions and grinding. Kids aren’t really stressed. They have short term stress. I’m talking about like a 4-year-old and you look at their baby teeth and they’re ground flat and you’re wondering why are they doing that? There’s no reason they should do that. That’s why when this study came out I was relieved. I knew there was something more to grinding. It’s wonderful because now we can treat it early. We know that bruxism is not a normal thing. I would say most dentists, and less so today, they wouldn’t even mention bruxism. I think bruxism is a huge, huge thing and should be treated as such.
Kara Fitzgerald: Yes, I’m with you. We see it in practice all of the time and I have to confess that I more often than not consider the stress component, so I appreciate this remarkable pearl.
Mark Burhenne: You probably see a lot of TMJ and TMD and that’s always been very difficult to deal with, but the source could be years and years and years of these parafunctional grinding movements at night that are designed to help open the airway.
Kara Fitzgerald: Yes, absolutely, so with TMJ, would you say that that’s most commonly caused by bruxism, that’s often my conclusion, or not?
Mark Burhenne: Yeah, I do, although there’s some other factors. The big one is trauma. Has there ever been any trauma, facial trauma, car accidents, falling, bicycle accidents, a blow to the face, that kind of thing, so there’s usually a history of some kind of trauma, but, of course, bruxism is trauma. It’s long term trauma. It’s self-inflicted.
Kara Fitzgerald: That’s very useful. I just wanted to let you know, folks, the website that Mark mentioned, aadsm.org, I’ll make sure that it’s on the podcast page so you can access that. That’s dentists trained in sleep medicine, correct?
Mark Burhenne: Yes.
Kara Fitzgerald: Okay, so you can look for referrals there for your patients. Just a very valuable pearl. Okay, so you threw out a couple other things that I just got flagged on immediately and need to circle back to just for a couple of comments from you. You mentioned the fissured tongue. You mentioned scalloped tongue, evidence of GERD. When you see a fissured tongue, what are you thinking about?
Mark Burhenne: A fissure is that long line down the middle dorsal side and it means that the tongue is too large for its space. It’s folding over on itself. When you swallow and assuming that the patient is swallowing correctly, it’s being forced up into the palate area or, if the patient’s a tongue thruster, being forced forward. That tongue keeps getting folded over. Then, of course, the scalloping occurs on the edges of the tongue. See these little scalloped ridges. I, of course, see lots of tongues, but just looking at the tongue, doing a Mallampati evaluation or Friedman Scale. Those are how the ENTs look at the airway. Just have them open and if the tongue hides the tonsils and the uvula and is up against the soft palate, and that’s in a nonrelaxed state, think about what that would be in a relaxed state when the patient’s in deep sleep or trying to get to deep sleep and there’s paralysis of the muscles. That all just congeals together. The tongue rolls up into a little ball, like a little golf ball, and sits on top of that little airway and plugs it.
Kara Fitzgerald: Oh, those are great, great pearls. I see scalloping and fissuring, especially scalloping, in my patients all the time because I do check the tongue and gums and so forth. In my world, as an in-the-trenches, functional medicine clinician, when I see evidence of tongue enlargement, hyperglossia, I think about digestion absorption …
Mark Burhenne: Yup, nutritional, yup.
Kara Fitzgerald: … small intestinal bacterial overgrowth, and on down the line. Food sensitivities seem to result in scalloping and so forth. There’s quite a bit on it, so I work from that perspective, but thinking about the impact on breathing and on particularly disordered breathing at night is just a extremely useful pearl. Undoubtedly, fatigue is a complaint of these patients because it’s a complaint of almost all of my patients and so that would be a piece of the puzzle. Very good.
Mark Burhenne: What’s interesting is that physicians, they call the mouth, where the teeth are and the tongue, they call it the little black box. I get that reference. I hear that all the time and I stopped laughing because it’s pretty serious and someone like you that’s looking in the mouth, that’s important. Everyone should look at the mouth, but physicians literally look past it.
I ski with a ENT and last weekend, he was referring to oh, the teeth, the black box, yeah. I have no idea what that’s all about. That’s where the collaboration is very important. A lot goes on in the mouth and as you just said, you can tell a lot about just by looking at someone’s mouth, their smile, their muscles of facial expression, the bleeding gums. There’s just so much wealth of information. We’re trained to be diagnosticians, right? That is our main goal is to find out, get quickly to the root cause and that certainly can help. It’s such a quick and easy … It just adds so much to the equation.
Kara Fitzgerald: Yeah, absolutely and I appreciate your vantage point on getting to root cause. It’s useful for me. Okay. Obviously, we’re going to save a lot of teeth this way if we go there, but any comments around root canal in the individual who does require one?
Mark Burhenne: Yeah, that’s a good question. You asked that before and I didn’t answer it. Here’s my take on root canals. It’s a bread and butter thing for dentists. We’ve long been doing root canals, even back in Egyptian times. Mummification of the tooth with gold coins. It has an amazing history and, of course, it’s refined since then. Here’s my take on root canals. Maybe I should back up a little bit and describe the mechanism of how the bacteria in the mouth get into the body. There’s this thing called the biological width. In other words, there are very few areas in the body where something comes right through the skin or the seal of the mucosa and the teeth are one of them. The body has to keep that area very safe from infection because bacteria can enter through that, so the teeth are popping out through the gums. How do you keep that sealed?
Of course, the mouth is a crazy place. All this stuff’s coming in. You’re breathing in air and eating things and you’re taking in a lot of bacteria in your food, most of it hopefully good. That’s where the microbiome is fed, right, through the mouth. When that breaks down and that breaks down, that little attachment, that little, fibrous, it’s like a girdle around the base of the tooth. Where you see your gum and just below that there’s a little bit of a pocket and below that, there’s this little, tight girdle of fibers and we call that the biological width.
It has a certain width that it depends. It can be 3 millimeters in some areas and in anterior areas, it can be a little thinner, but that width, the minute it’s violated, you have this oral-systemic connection. That’s where the bacteria get to. The bacteria in the pockets are more anaerobic because they’re not seeing a lot of oxygen and so they’re perhaps a little bit more virulent. Then that breaks apart. Then, of course, teeth are one of the few nonshedding parts of the body and they collect just layers and layers of bacteria and that’s the biofilm. That’s plaque and the pellicle and all that.
Then comes the root canal, right, so the tooth becomes infected. It dies and it needs to have its tissue removed on the inside because it’s feeding, already. A infected tooth that needs a root canal is causing a bacteremia. It’s spilling all the toxins out of the tip of the root and the bone and the blood vessels are taking that as a complete [onsault 00:27:02]. Of course, that’s seeding the whole body for an infection. Many people die because of abscesses back when we first started recording these things in the 18th Century.
Then the dentist comes along and he has a solution. He’s going to clean out, he’s going to bore a little hole in the top of the tooth and go inside and clean that infection out, completely remove it and seal it. The problem is and inside that tooth at that point in time, a lot of anaerobes. It’s almost 100% anaerobes. The problem is is to get every single bug when you disinfect the root canal, you can’t sterilize it, do you? The answer is no, so what happens to those bacteria? My take on root canals is … I have one in my mouth and I’m watching it very carefully and I was very upset that I needed it and have it.
On the other hand, I think a well done root canal can serve a function. The minute it goes south, though, I think you have to cut to the chase and remove the tooth. How do you ascertain that? You can talk to your dentist. You can look at it radiographically, although I don’t like taking a lot of x-rays, but here’s a little tip. If you tap on that tooth with the back end of a fork and you tap on all the teeth in that quadrant and that tooth is a little bit tender, I would say that’s a failed root canal. That should not be and I know a lot of patients that live with that. They’re like, “Oh, my tooth’s a little tender.” That could mean that you need a re-treat on the root canal. The root canal’s not doing well. We use terms like the root canal is leaking. It’s failing, that kind of thing.
I’m not crazy about root canals, but I have a lot of patients that have them. They do well. The ones that don’t, we go right to the next thing and that’s the implant. Unfortunately, the implant violates the biological width because there’s no connection. That little girdle of tissue that seals off the oral space from the systemic space, it can’t grow around the collar of the implant. It’s titanium. Titanium integrates very well with bone, but it doesn’t integrate at all with the tissue, so by definition, an implant violates the biological width and causes a bacteremia in a way.
I see a lot of that. I see a lot of implants with little pus coming out of, just very low grade purulence coming out of the sulcus or pocket. It’s always there. It’s there every 3 months, every 6 months. What do you do about that? It’s a tricky thing. We need our teeth. Without teeth, we don’t digest food properly. We live a lower quality of life and we don’t live as long, so it’s always a compromise. I’m not crazy about root canals, but I work with them. I do do them. I have an endodontist that I think does a great job, but the minute something goes wrong, it’s time to bail. You can’t let it sit in there. It’s going to cause a long-term, chronic bacteremia and that’s not a good thing.
Kara Fitzgerald: Right. Got it. Okay. All right. Then I see why clearly emphasis is on preventative and I appreciate how dentists have been educated in that way. Can you talk a little bit about that, what an ideal preventative protocol would be for you?
Mark Burhenne: Yes, just stop eating food, right? The real thing is to start eating the right foods. We don’t really brush and floss our teeth. If we ate raw broccoli and nuts and seeds then we probably would never really need to worry about oral hygiene. That goes back to our ancestors. Yes, they had chewing sticks and maybe they adorned their teeth and did things. We didn’t see much bruxism in our ancestors. What does that say about the airway? I don’t know. Here the diet that we have, this Western diet … It’s not even a Western diet. It’s a global diet since we’ve been growing things and modifying things and genetically modifying things. We’re getting allergies from our food. We’re reacting to it. We’re getting long-term inflammatory effects from it and that happens in the mouth too.
Sugar is a big deal. Sugar, refined sugar, has been wonderful for the profession of dentistry. It’s given us a lot of work to do, but cavities are pretty much all diet. You could, by eating the right diet, never need to break a tooth or fall on a tooth or if you’re bruxing, that kind of thing, but the infections in the mouth, prevention really is key. Of course it’s good knowing that we do cheat on our diets once in a while too, floss and brush. Perfect good oral hygiene at home is a good thing. It doesn’t do any damage, although when you brush your teeth, by the way, you do create a bacteremia, a transient bacteremia.
In a healthy mouth that’s not an issue, as we discussed, but if you have gum disease and you’re aggressive brusher, that could be a problem, especially if you have heart disease. Typically, people with gum disease have diabetes and then, of course, another oral-systemic connection, which is a reverse kind of thing, someone who has diabetes and gum disease, the gum disease makes it more difficult for that patient to regulate their blood sugar levels because that little feedback loop that occurs.
Yeah, the best thing to do it’s diet, bone broth, eating meats and vegetables. I would stay away from fruit. They do have sugar in them. Certainly juices, but if you eat like our ancestors did, typically you’ll be fine. You may even develop properly. As you’re a young kid, you’ll have a wider arch. You may have a better airway. You may be able to breathe through your nose better. These are these little epigenetic things that occur over time. When we stop breast feeding, we go to this formula and the formula causes us to not to be able to breathe through our nose because we’re allergic to it. Then we become mouth breathers and then our whole oropharynx and palates and arch widths and all that changes. We grow up with a crazy airway and mouth with crowded teeth.
Kara Fitzgerald: Oh, isn’t that incredible? Geez.
Mark Burhenne: Yeah, so it’s prevention. You’re right. It’s education and that’s what we’re here for. Doctors are educators. The name comes from the Latin root of the verb to teach. We need to teach and we’re not. We’re fixing. We’re applying meds, prescribing meds, and we’re treating symptoms. I know you’ve heard all this before, Kara, but it’s the same in dentistry. Even though we’re very preventative-based, we’re still just putting Band-Aids on and waiting. Dentists, I think, need to talk more about diet. It’s really one of the greatest contributors to problems in the mouth.
Kara Fitzgerald: Yeah, I hear you. Gosh, you’ve said so much in that last comment, connecting the dots, even epigenetically, so multigenerational, just the bad diet and the influence on systemic health, of course, but then the oral health and moving into sleep apnea and the other things. Thank you, that’s absolutely brilliant. Okay, so I want to move over and talk about the oral microbiome. Lots of research coming out on that. What is your take on it, big picture, and how do you talk to patients about it? Do you recommend intervention specifically for the oral microbiome, oral probiotics? What do you …
Mark Burhenne: Yes, definitely. It’s very exciting. You’re right. I love all this new information that’s coming out. I think it’s dead on. Unfortunately, the oral microbiome is being pushed aside. Not pushed aside, but not talked about as much and that’s what I like to talk about a lot. The oral microbiome and the gut microbiome are linked together. Again, as we spoke earlier, I had a wonderful interview Cass Nelson-Dooley, who you know well and have interviewed. She has really educated me in many areas and again, she’s not a dentist. It’s wonderful. There’s so much information out there and we can learn so much. That’s on the website. That’s one of our most popular and it is technical. Unfortunately, for our lay readers, it was a little difficult, but nonetheless fascinating.
The oral microbiome influences the gut and it’s connected to it. I think of it as the seeding station for the oral microbiome gut. Sorry, for the gut microbiome. Of course, we swallow foods. We can swallow probiotics. Fermented products, of course, are high in probiotics and even prebiotics and that’s important. The mouth, in that sense, is the gateway, but also it’s the colonization. It’s the colony of bugs that’s in the mouth that literally is connected to the gut microbiome.
For example, here we are. Obviously, we’re trying to cultivate good gut microbiome. We don’t send chemicals down there and we’re against antibiotics that, of course, would just wreak havoc down there, so what are we doing to our mouths? We are basically blasting it with mouthwashes that have triclosan, pesticides, antibacterial soaps, alcohol, ethanol, all these things that are basically killing and proudly state that. Oh, Listerine, we have a 20 minute kill rate. We kill everything in the mouth for 20 minutes. Of course, it’s impossible to kill everything, but there is a kill rate.
It does only happen for about 20 minutes, but then on the back end of that, we’re creating this massive regrowth, which isn’t necessarily a good thing because how does everything grow back? What’s the ratio of the good to bad bugs? It’s usually worse after you’ve done this massive kill. We can see that in the gut microbiome with antibiotics. It upsets the whole ratio and population. We’ve been doing that for decades to our mouth and no one’s raising the alarm on that.
It can also be toothpaste. There’s triclosan in toothpaste. There’s sodium lauryl sulfate. There are all these agents that don’t need to be there that are touted to be there to help us and they’re not. It’s the opposite, so what do you do? The best thing you can do, of course, is to culture. You have to feed and protect and nourish what’s in your mouth. You can do that. On our website, we recommend a lozenge. I’ve long been looking for this product. It’s wonderful. It’s a lozenge that you dissolve in your mouth and it’s loaded with probiotics. That would be a good thing. You could eat the right foods, back to the right foods. That’s number one, right, the right diet. You stay away from all these chemicals. Mechanically cleaning your teeth is fine. That’s with floss and a toothbrush, as long as it’s not a worn toothbrush and the technique is done and it’s not overdone. A lot of people overbrush and that’s in this country for the people that do brush. Then a lot of us don’t brush enough, so it’s back to diet.
The big threats to the oral microbiome are the high-sugar diets because that cultures a whole different … Essentially, you’re taking strep mutans and you’re feeding it and you’re making it the dominant bug in the mouth. I would almost call that a mismatch disease, where the diet essentially has changed our whole … We didn’t evolve on that diet, so now we have this diet that feeds all the wrong bacteria and we have this whole different colony of bacteria in our mouth. Of course, it’s causing cavities and gum diseases and a host of other thing, candidiasis and low pH levels. If we think of it as being something connected to downstream, then maybe we’ll give it a little bit more credit. I think we think as patients, but also as doctors, it just goes past the mouth. Don’t worry about it. It’s what happens down below that’s important. There is that 45% overlap of bugs between the mouth and the gut. I don’t know. Is that a lot or is that too little? I think it’s a connection.
Kara Fitzgerald: A big connection.
Mark Burhenne: Mouth breathing can affect the oral microbiome. We evolved to breathe through our nose most of the time, especially at night and walking, maybe not while exercising. The nose, as you know, humidifies the air. It warms the air and it also increases the nitric oxide content. There are oral bacteria … When I say oral bacteria, that’s the bacteria that are in the nose, the nose airway, oropharynx, and in the mouth. We can’t make our own nitric oxide, but the bacteria in our mouth can. They contribute to about 25% of the nitric oxide production in our body.
Of course, nitric oxide is like crack for us. It’s the best thing for us. Crack’s a bad analogy, but you know what I mean. I was about to say like candy, but that’s also a bad analogy. It’s great. It helps our blood vessels, the tone of our blood vessels and the wall of the blood vessel. It’s important, so if we’re mouth breathing, we’re not getting the nitric oxide and we’re drying out the mouth, which changes the whole environment, the pH, and then the wrong bugs start growing. I’m a big proponent of mouth taping, a big supporter of mouth taping.
Kara Fitzgerald: What is that?
Mark Burhenne: That’s where you have to use the right tape. You can buy special tape for it. It’s a breathing method and I mention it in my book. I’ve tried it. I’ve had patients try it. If you can wake up in the morning with the tape over your mouth still after you’ve taped it closed, then you’re a great nose breather. That’s a great diagnostic tool. If you rip that tape off, you fold the edge of the tape over a little bit so that in the middle of the night you can grab it and pull it off, that means you’re a mouth breather and that your oral microbiome and your incidence of cavities and gum disease is just going to go up, not to mention what’s happening downstream. I think the take home message for oral microbiome is that if you don’t nourish it, if you keep killing it off and putting it down with all these chemicals that we have on our shelves here at the stores in the oral hygiene section, then the oral-systemic connection will be less of an issue for you and that’s a good thing. It keeps the mouth working as it was designed.
Kara Fitzgerald: Yes, wonderful. Thank you so much for that. I just want to circle back because you’ve said a lot. Strep mutans you brought up and I do want to just point out to folks that strep mutans is not only linked to dental caries, but also Sjogren and some other autoimmune diseases including rheumatoid arthritis, so there is, without question, a strong oral-gut connection. I think the 45% overlap is significant, but beyond that, these organisms are talking to each other, talking to the entire body all of the time and either stoking inflammation or quenching inflammation. Thank you for that. I just wanted to go back to brushing and flossing, which you support, gentle brushing and appropriate flossing. On your site, do you have some information about that if people want to access it or anything on how often we should be brushing and the products we should be using, so those details can be accessed?
Mark Burhenne: Definitely. We also have YouTube videos. There’s a video of me brushing and how not to brush. Yes, absolutely, and that’s important. Then we reply to things like there was a study out of England that said flossing was actually not good for you and things like that, so no, I’m sure to tell you we still have to floss.
Kara Fitzgerald: It feels good to me, but I can absolutely tell that I’m liberating bacteria when I do that. You’ve been looking at CRP and the mouth, the oropharynx influence on CRP elevation, which, of course, is indicative of systemic inflammation. Can you talk a little bit about what brought you to that connection, what you’ve seen, and what you’re doing in your practice around CRP?
Mark Burhenne: Definitely, definitely, yes. That’s a good question. Again, it has to do with collaboration between dental and the medical world. For example, just pure gum disease, periodontitis. Essentially, we know that it stimulates the liver to produce the C-reactive protein, which then we know can damage blood vessels over time. The studies all indicate that connection, so they show that patients with severe gum disease do have elevated CRP levels. I started noticing that in a way that indirectly, for example, all my patients with severe gum disease were having stents done, for example. They had high blood pressure. A lot of these people are very thin. I practice in the Silicon Valley and these are very entrepreneurial, high stress, no sleep kind of people.
Of course, there are other factors at play, but it was clear to me, especially in the South Asian population. There’s a book on that specifically referring to the South Asian males that are thin and tall that come from India to the Silicon Valley and start having problems. I’ve literally had to chase down some of these men. I don’t know why they’re always men, but they are, typically, and call them and say, “Listen, what I see in your mouth indicates to me that you are headed for heart disease.” In fact, this has happened where either they died. This is someone who has not had a cleaning in 6 to 8 years. They have severe gum disease. Then some we’ve been able to literally save where we brought them in and they had their stents, but now they’re getting their quadrants root cleaning and they’re getting gum disease treated. It’s a scary connection.
Again, I came about it in the clinical way seeing this correlation and then met a doctor, actually, at our Palo Alto medical clinic here that wrote that book, which is a great book. I recommend it for anyone. You don’t have to be South Asian. We started talking. We did a TEDx talk together. We were connected, actually, by one of my patients. It was fascinating and that’s where I came up with this idea of writing or creating this form. Again, it’s the collaboration between medicine and dentists. He was treating a lot of his patients and a lot of cardiologists that I work with are treating their patients. One of the ways they will observe improvement clinically is by observing their CRP.
What if the CRP is elevated because of the gum disease and they’re unaware of that? This form solves that issue. The cardiologist would automatically say, “Okay, we need to clear you in terms of the oral health. Bring this form to your dentist. The dentist will fill it out and assess the likelihood of CRP contribution via anything in the mouth.” Then that can get addressed, so that’s been wonderful. Has this form been taken up by the medical community? Not really. A lot of people are. A lot of physicians that I work with and healthcare practitioners that I work with are using it. Again, that’s how I came about it, through that connection, through, literally, South Asian males.
Kara Fitzgerald: Observing it over and over again.
Mark Burhenne: Yeah, right, right. Why not have a dentist ask for a CRP while we’re treating gum disease? That’s another thing that should be done. It’s a great test. It’s inexpensive. I think CRP is very important. Essentially, it’s a great indicator or it should show to everyone that how important oral health is because it’s a big factor in the systemic production of CRP, so it’s a perfect example of how the mouth contributes to systemic inflammation.
Kara Fitzgerald: You know what? Conversely, if you’ve got a patient with a good low CRP, you can probably infer that oral health is likewise relatively dialed in. Would you say that?
Mark Burhenne: Yeah, definitely.
Kara Fitzgerald: Oh, that’s really another useful pearl. This is something I’ve seen in my practice. In fact, just recently, a patient with chronically elevated CRP, it’s been around 6 for some time before she came to see me and so we were working on all the functional approaches that I do here and she did have severe periodontitis. She had laser surgery and really almost immediately, her CRP dropped and it’s currently 1.7, so we’re in the right direction. It was 6 originally and really refractory 6, so I did my end of the work and she got good dental care and she’s doing quite well.
Mark Burhenne: Great to here. That’s, again, team approach important.
Kara Fitzgerald: Yeah, I know and I think that you’ve made a strong argument for it and I can see the areas that I have blinders on or I just haven’t considered that you’ve enlightened me on today. As we head into the homestretch here, Mark, anything else you want to add about how we might, as functional medicine docs, connect with you or any other words of wisdom to send us off with?
Mark Burhenne: Yeah, there’s so much to say. First of all, any of your listeners and readers, by all means, give them my email address. It’s on the website. Happy to talk to them about any of this. If they want, they can send me … I can give them a little, quick protocol on how to take a intraoral photo. There’s so much that can be weaned from that. They can send me photos. I can get them in the right direction very quickly, within just matter of minutes. I’m happy to do that. I’m just happy here to be able to talk about how important what happens in the mouth happens in the body and just to keep reinforcing that.
I think maybe one thing that would be important and that is I was reinforced … When a patient comes in, I’m always asking, “When was your last physical?” I’m trying to cross over a little bit. I won’t do any diagnosing because that’s out of my realm, but I’m trying to reinforce the other healthcare aspects and visits with my patients, so if they haven’t had a physical, I will sit down with them and tell them why that’s important or why that’s a bad thing and how it can contribute to their poor oral health, but certainly their whole body.
Again, you know what I’m talking about. We all do. I’m looking at the whole body. I’m a dentist and, of course, they come in for me to look at their teeth, but again, if I see something wrong, I will point it out and say, “Listen, go get a sleep study. You’ve got diabetes and your blood sugar levels aren’t great and you’re telling me that your toes are numb.” I have a list of names that I give out. There’s no reason why we can’t branch out and overlap with the other specialties and keep reinforcing. Again, it’s all about treating the person as a whole being, a whole organism.
I think that’s so important and that’s what I love about your show. That’s what I love about what’s happening on the internet. Patients are looking elsewhere. They are fed up with the old medical system in general. We still need it. If we get into a car accident, we need them. They do patch us up and fix us up. They’re great at that, the new robot surgical devices and all that. It’s fantastic what we can do once we do get heart disease how we can stay alive for another 20, 30 years.
I think people are getting it. They are looking to the web. They’re looking to our websites and they’re asking us in the chair, in the clinics, there must be something more to this. How can I improve the quality of my life? How can I square my life curve without having to deal with side effects of pharmaceuticals and getting into trouble? I just think that as a healthcare practitioner, even though I’m just really a specialist, when that patient comes in, I try and look at him and say, “Listen, we’re doing teeth here, but I’ve noticed these things. Please go see this person and this person.” I think that’s really a metaphor for the oral-systemic connection. I’m looking at the mouth, but I’m also looking at the body.
Kara Fitzgerald: Thank you. Thanks for that. Okay, so folks, askthedentist.com is Dr. Burhenne’s site and The 8-Hour Sleep Paradox is his book. We’ll provide you links to these resources. Again, Mark, thank you so much for joining me today.
Mark Burhenne: Oh, it was a pleasure. Thank you for having me.
Mark Burhenne, DDS is a family and sleep medicine dentist who has been in private practice nearly thirty years, focusing on patient-centered and preventative dental healthcare. The day his wife was diagnosed with sleep apnea was the day he began learning everything he could about sleep medicine dentistry and sleep breathing. He is the author of The 8-Hour Sleep Paradox: How We Are Sleeping Our Way to Disease, Fatigue, and Unhappiness and the creator of AsktheDentist.com, which is dedicated to helping people understand oral health and the mouth-body connection for overall wellness.
- The 8-Hour Sleep Paradox: amzn.to/1RLFWeq
- Contact Mark directly at firstname.lastname@example.org or @askthedentist on Twitter
- The American Academy of Dental Sleep Medicine: www.AADSM.org
- CRP and Oral Health
- Research papers recommended by Dr. Burhenne:
- Easy Oral Hygiene Tips for in Between Meals
- The Oral Microbiome with Cass Nelson Dooley, MS