166 - Oral health, best hygiene practices, & relationship between oral health and systemic disease

1. 0:00 – 0:10

   Intro

   1. PAPeter Attia0:00

      [upbeat music] Hey, everyone. Welcome to The Drive Podcast. I'm your host, Peter Attia. [upbeat music]

2. 0:10 – 12:53

   Anatomy of teeth and the purpose of the dental pulp—a highly vascularized and innervated region of the tooth;

   1. PAPeter Attia0:10

      Hey, Pat, thanks so much for, uh, sitting down with me today. I've been wanting to sit down with you for quite some time. Uh, and I know we've been-- We scheduled and rescheduled-

   2. PCDr. Patricia Corby0:19

      Mm-hmm

   3. PAPeter Attia0:19

      ... on several occasions, and between one thing or another, uh, it, it took a while, but I, I am pretty confident it's gonna be worth the wait. How are you?

   4. PCDr. Patricia Corby0:27

      I'm good. Thank you. I'm very happy to be here. That's something that I have a lot of pleasure talking about oral health with MDs. That's my life is trying to, to do this connection. So I'm very excited to be here. I'm, uh... It's gonna be interesting because I don't know in-- uh, I don't know much about what you do and, uh, and I think I can bring something new about, uh, dentistry and oral health and things, which is so important.

   5. PAPeter Attia0:55

      Yeah. Well, I think it is important, and that's certainly why I've wanted to talk about this for a while, and I've been trying to figure out, uh, who would be the right person to speak with, and you came very highly recommended, um, because I think it's actually a very underappreciated, uh, part of health. Um, I think it's easy to think of the mouth as this sort of thing, and we go to the dentist and, you know, hopefully we don't have cavities, and obviously we have a whole bunch of cosmetic concerns with the spacing of our teeth and the whiteness of our teeth, et cetera. But I'd like to sort of tie that all together. Um, but I wanna kinda start with a little bit of your background. So, uh, obviously you, you grew up in Brazil. I shouldn't say obviously, but I recognize your accent-

   6. PCDr. Patricia Corby1:33

      [laughs]

   7. PAPeter Attia1:33

      ... and I, uh, I know your, your, your history a little bit. Uh, when did you, when did you leave Brazil?

   8. PCDr. Patricia Corby1:38

      Well, so it was a long time, over 20 years ago. Um, so I, I had my dental, uh, degree in Brazil, and then I had my specialty in periodontics and implant dentistry, um, which is one of the fields that is more connected with systemic health. I always wanted that. Um, and then I went... I came to US mostly for personal reasons, uh, and I wanna... and, and my passion for research because I-- that's what I do my whole life. And I never went back because I got fascinated by the opportunities and, um, everything that I could have here that, unfortunately, we don't have the resources, uh, in Brazil to do. Um, and I'm still doing research up to today, [laughs] many years.

   9. PAPeter Attia2:32

      So, um, this is a bit off topic, but, uh, tomorrow is a very sad anniversary. Um, do, do you remember where you were 27 years ago tomorrow?

   10. PCDr. Patricia Corby2:44

       No. Remind me.

   11. PAPeter Attia2:46

       Sunday, May 1st, 1994, was the day Ayrton Senna died.

   12. PCDr. Patricia Corby2:54

       Oh, wow. I remember that day really clear.

   13. PAPeter Attia2:58

       Yeah.

   14. PCDr. Patricia Corby2:59

       Wow.

   15. PAPeter Attia2:59

       I, I... Where were you that morning? I, I... Were you like everybody watching the race on TV?

   16. PCDr. Patricia Corby3:04

       I, I... Yes. Yes. I was, I was still there in Brazil. Mm-hmm. Yeah.

   17. PAPeter Attia3:10

       Yeah. I, I've, um, I have so many, uh, Brazilian friends, and, and, and we're just fortunate. So many people in our life are Brazilian. Our nanny is Brazilian.

   18. PCDr. Patricia Corby3:20

       Mm-hmm.

   19. PAPeter Attia3:20

       And, uh, I've never met a person from Brazil who is-- who was, uh, you know anything over about four or five years old on that day, it's, it's etched in, in their minds forever.

   20. PCDr. Patricia Corby3:35

       Yeah. Well, yeah, he's a big legend, um, and I think in a time that make, made Brazil so visible for the world and all those things, so we, everybody was always very proud, mm, of him.

   21. PAPeter Attia3:50

       Yeah. Well, he's, uh-

   22. PCDr. Patricia Corby3:52

       Mm-hmm

   23. PAPeter Attia3:52

       ... he's my personal hero. Um, and so for you today, I wore-

   24. PCDr. Patricia Corby3:56

       [laughs] Wow

   25. PAPeter Attia3:56

       ... one of my Senna bracelets here.

   26. PCDr. Patricia Corby3:58

       [laughs]

   27. PAPeter Attia3:59

       Um, so let's start a little bit with tooth anatomy. Unfortunately, I have teeth that my wife refers to as Attia teeth, which she jokingly means, like, I just have genetically horrible teeth. Like, I always seem to be at the dentist for something. Something's always going wrong. So, um, uh, I, I'd like to think she's exaggerating a little bit, but, uh, you know, there was a period in my life, unfortunately, of maybe 10 years when I didn't go to the dentist once, and I think I'm s- I sort of ended up paying a bit of the price for that going on, which sounds like a stupid thing to say. Imagine somebody not going to the dentist for 10 years, but that's sort of what happened for m- largely much of my medical school and residency. I just never made the commitment to go. Still brushed my teeth and did all that stuff, but obviously wasn't getting regular checkups. And now that I find myself taking dental care so seriously, the first thing I realized is I had to understand the anatomy. You know, I had to understand what they meant by pulp and dentin and all of these things.

   28. PCDr. Patricia Corby5:12

       Mm-hmm.

   29. PAPeter Attia5:12

       But I think it might make sense to give people, um, a, a, a, a, a decent overview over the semantics of the tooth at the individual level and then sort of at the, the level of how all of the teeth fit into the mouth. Is that-- Can we start with something like that?

   30. PCDr. Patricia Corby5:29

       Yeah. Yeah. Yeah.
3. 12:53 – 17:18

   Types of teeth and the different purpose they serve;

   1. PCDr. Patricia Corby12:53

      Mm-hmm

   2. PAPeter Attia12:53

      ... so you, you've already started to talk a little bit about the pathology that can go wrong here. Before we do that, I wanna get a little bit more an understanding of the function. Um-

   3. PCDr. Patricia Corby13:04

      Mm

   4. PAPeter Attia13:04

      ... can, can you show me again that slide that has all of the teeth, and maybe explain-

   5. PCDr. Patricia Corby13:09

      Yeah, sure. Mm-hmm

   6. PAPeter Attia13:10

      ... how, how different teeth serve a different purpose in the mouth?

   7. PCDr. Patricia Corby13:15

      So technically you have the incisors. So you have four of them on your jaw, in each part of your jaw, in the maxilla and the mandible. Then you have the canines. There are another four. So the incisors is mostly in your mouth where you can cut your food-

   8. PAPeter Attia13:33

      Mm-hmm

   9. PCDr. Patricia Corby13:34

      ... in any animal. That's how you bite and how you separate pieces of food. And then you have the canine that is a very strong, that's the longer root that you have in your mouth that is to tear. So you can see, see animals when they are eating, uh, meat and all of that, that's... You tend to go to the side because it's a very strong, uh, anatomy that they have. And then you have four, we call premolars or bicuspids. So that's where you start to break down the element, the, the food that you eat to, to, to tear, tear them apart. And then the molars, they do the whole trituration. That, that's where you have to chew. And, and when I- I always talk about chewing is because the, the, you know, when the digest pro- process starts in the mouth. So it's very important that people chew their food and in contact with the saliva and all the nutrients that we have. But it's a completely different subject talking about saliva, but it's mainly to, to chew your food, to start the digestive product so then you can get most of the nutrients out of your food. Um-

   10. PAPeter Attia14:42

       Now looking at the lower part of this figure, [clears throat] um, it, it seems that the different teeth have different numbers of roots. Is that correct?

   11. PCDr. Patricia Corby14:52

       Yes, that's correct. Mm-hmm. So incisors and laterals and premolars, the one in front, they have single root. Then if you go to premolars, they will have two, and some prem- The molars itself, they might have three or four, depending on, uh, how big the tooth is. So it's, it's a much more complex because they are much more strong and they, they, they have to get much more pressure and, and to, to, to function, so they need to be- have much more, like, susta- sustainability so they can ch- you can chew and, and, and, and triturate our food.

   12. PAPeter Attia15:33

       I see. So that actually probably explains another reason why these things are innervated, which is to... If the, the harder they have to, um, oppose other teeth, right? So the molars would have the greatest opposition to another tooth, um, then they need greater sensory input to understand the relative spacing and force. Would that be part of the difference as well?

   13. PCDr. Patricia Corby16:02

       As well. It's, uh, uh, you think like in your mouth, it's like a bridge. It's has to be very well-balanced. The occlusion needs to be perfect because then you're gonna hurt all your ligaments and cause inflammation in your mouth. So it's a very elaborated system which all... A- and, and if you think about the occlusion, they connect. They have to be very perfect aligned so y- you, you don't have... If you start having issues like your teeth, they don't, don't have a perfect occlusion, you start losing your vertical occlusion, then you have a lot of other issues like, uh, pain on your face and headaches. There, there are many other, uh, issues that can happen if you don't have a, a, a good function in your mouth.

   14. PAPeter Attia16:48

       Okay. Um, by the way, I learned the hard way that I have four roots in my molars, not three, because-

   15. PCDr. Patricia Corby16:56

       Mm-hmm

   16. PAPeter Attia16:56

       ... the... I, I've had two root canals, and the first one, they missed one of the roots. They only went after three roots, and I-

   17. PCDr. Patricia Corby17:04

       Mm-hmm

   18. PAPeter Attia17:04

       ... still had endless persistent pain until they figured out I... And I went to finally then see an endodontist who realized I had a very hidden fourth root.

   19. PCDr. Patricia Corby17:13

       Oh. Mm-hmm.

   20. PAPeter Attia17:13

       Uh, but we'll, we'll get to root canals later, um, my least favorite procedure in the world.

4. 17:18 – 22:54

   Anatomy of the oral cavity, bacteria in the mouth, and what a healthy mouth looks like;

   1. PAPeter Attia17:18

      Um, so, so let's talk about what a healthy mouth looks like. Uh, you alluded to saliva. I, I, I assume that that plays a very important role in oral health, and I assume it does something beyond lubricating food. Does it, does it play another role?

   2. PCDr. Patricia Corby17:35

      It's ex- So the, the, the oral cavity is a very complex, uh, system. So if you think that you have teeth, uh, you have the gums, you have the gingivocavicular fluid that's, uh, open and allows the bacteria to go in and out. Uh, you have the tongue, which is a completely different texture and structure. You have the throat, which is entrance to your body. So all this whole complex system, they need to live in, in a very s- uh, uh, organized way. And on top of that, you have the saliva. Saliva is... A- again, we could have a completely other podcast just about saliva, but In the context where we ... They preserve health because we know today that, uh, people with dry mouth, if you have ... I treat patients with radiation. They're going through radiation oncology. We, we're gonna talk, we can talk about that later, but, uh, the moment, uh, you dry your mouth for any reason, systemic conditions, medication who causes dry mouth, there are many of them that causes, or, uh, toxicities through cancer care, radiation dries mouth, it's a completely shift of the oral microbiome in your mouth, uh, because, uh, sal- saliva protects. It's that biofluid that's constant washing and, and flushing your mouth and maintaining a very, uh, homeostasis on the microbiome as well. It, it prevents dysbioses on the, um, oral microbiome. So this whole complex needs to be balanced on every single aspect that we look. You need to have your teeth, you need to brush, you need to have a lot of saliva, and you need to eat well. So that's, it's a lot of, it's a combination of a lot of factors that makes people, uh, say you ha- to be in health when you look at oral health, but the primary is so simple. It's actually oral hygiene. Uh, if you brush your teeth, you're gonna, you're gonna be, technically, you, you preserve a little bit more of health than people who don't.

   3. PAPeter Attia19:44

      I want to go back to what you said about the, the, the, um, the dysbiosis and the microbiome of the mouth. So-

   4. PCDr. Patricia Corby19:50

      Mm-hmm

   5. PAPeter Attia19:51

      ... th- my recollection is that the mouth actually has a, a, a significant amount of anaerobic bacteria. Is that correct?

   6. PCDr. Patricia Corby19:58

      Well, they're both.

   7. PAPeter Attia19:59

      Okay.

   8. PCDr. Patricia Corby19:59

      You have aerobic, you have anaerobic, you have fa- facultative bacteria. They can play both roles-

   9. PAPeter Attia20:06

      Yeah

   10. PCDr. Patricia Corby20:06

       ... because it's so strong. They can change. Um, but we have over 700 different bacteria that lives in a perfect symbiotic, uh, uh, habitat in our, in a kingdom, right? We, we call that. Uh, and they can live really well with the host without causing disease if you can maintain the state of health because w- what we all... In the past, people think that the, what causes a disease, oral disease is the specific bacteria, but it's not true. Uh, we all have all those bacteria in your mouth. Uh, it's indigenous to you. It's not that it's from something external. You have that. It's a, uh, their normal habitat is your mouth, but for some reason, you don't, you stop brushing, or you start taking medication and your mouth becomes dry. You have a health condition that allows inflammation to, to be more prevalent in your mouth. All those things might change the oral cavity environment, and that allows some bad bacteria to grow and supersede the good ones, and then all ... That's what happens. It is the dysbiotic. Uh, so it's, we talk about two things, abundance, changes in abundance, and diversity, which is allowing bad bacterias to flourish and, and suppress the good ones that helps us preserving health. So that's mainly what's going on. Of course, there are the complex things.

   11. PAPeter Attia21:38

       So in, in an ideal state, directionally, what amount of bacteria are aerobic, anaerobic, and facultative? What's the approximate distribution in a-

   12. PCDr. Patricia Corby21:51

       Hm

   13. PAPeter Attia21:51

       ... in a, in a, in a relatively healthy mouth?

   14. PCDr. Patricia Corby21:54

       It's probably I- half and a half between aerobic, anaerobic, um, and another maybe 30 to 40% of them, they can play both roles. Um, but those, let's say, uh, a clear example, uh, and, uh, we can talk about that in a completely different section, but, like, even children, uh, when I did my studies with the twins and then we asked them to stop brushing for two weeks, all the periodontal pathogens, P. gingivalis, T. denticola, forsythus, that we only see in adults with periodontal disease, in two weeks they became abundant in their mouth. So they were there, that I couldn't see at baseline. The moment they stopped, uh, flossing, they became abundant. So they are there, but they will never cause disease unless you have a shift on the oral microbiome.

5. 22:54 – 32:45

   Pat’s study demonstrating the importance of flossing;

   1. PAPeter Attia22:55

      So, so let, let's talk about that study. So how old were these twins?

   2. PCDr. Patricia Corby22:59

      So let me go back. It was a long time ago. That's when I first started my research because I was highly interested in dental caries. Um, so they were between 12 and maybe 16 years old. I wanted to have adolescents because they have, that's the, where they don't like to brush, to floss. You know, it's a very hard t- uh, population to do that. So what we did, we got... So when you do studies, uh, I'm gonna talk a little bit about the twins, so you understand why we use the twins. So they are the perfect model to do clinical trials. That's my passion is clinical trials. Um, because they share, especially on that age, the same households, the same home. There is no confounders, right?

   3. PAPeter Attia23:48

      Right.

   4. PCDr. Patricia Corby23:48

      You don't need to adjust for age. They're identical twins. You don't even need to adjust for a gender because they share the same sex.

   5. PAPeter Attia23:56

      Right.

   6. PCDr. Patricia Corby23:56

      And they, they share 100% of their genes. So when you look at monozygotic and dizygotic twins, the monozygotic twins, they share 100% of their genes. It's almost the perf- perfect clones of each other.

   7. PAPeter Attia24:08

      Right. And to your point, a- as adolescents, they're still in the same house. It would be different if you did this-

   8. PCDr. Patricia Corby24:14

      Exactly. They-

   9. PAPeter Attia24:14

      ... with 30-year-old monozygotic twins 'cause at least there might be some environmental differences, right?

   10. PCDr. Patricia Corby24:20

       And the environment takes place and then a lot of the-

   11. PAPeter Attia24:23

       Yeah

   12. PCDr. Patricia Corby24:23

       ... you know epigenetics might change even mutate genes. So and then when you look at the dizygotic twins, they are 50/50. They share 50% of their genes. It's ex- same as two brothers.

   13. PAPeter Attia24:35

       Siblings, right

   14. PCDr. Patricia Corby24:35

       ... siblings. So y- there's two ways that you can do studies with twins. You either get the twin set and then you do treatment A and B to see response to treatment because they're very similar, or the way I like when you want to see traits and how a trait can modu- be modified by genetics or environmental factors, you get the same set of twin and you give the same drug, medication, or, or treatment. Because then when you look before and after, if you don't see ... If you see that they are identical twins, they behave in the same way, you're gonna say, "Well, genetic is modulating that trait." But then if you look at both of them and say they're all over the place, they behave in the same way as the identical and the fraternal twins, you say, "Well, here the environment is playing a big role because genetic is not holding anymore," right? Um, so when we did the this flossing in twins, that's how we did, uh, the study. We got, uh ... We wa- we didn't wanna give separate treatments for the twins because they're going to the same house. So the ... And, and I did very controlled. So for two weeks, um, we asked the twins to come every day to the center, and I'd have dental hygienists and my clinical people trained, and they do brushing or, and/or flossing because there are two groups. One group we wanted them just to brush. The other group we wanted them to brush and floss teeth. And then so the hygienists would floss and watch them doing. It was very supervised and controlled, and when they go home I asked them to do at night at home. But if you think about, that's a very hard clinical trial to do because we have to bring the kids every single day with their parents to the center so we could actually watch them doing the intervention. So when we finished the study, what happened is that, that we saw is that the, the children that stopped brushing their teeth, um, they ... We saw a gingival bleeding. Uh, not brushing, sorry. Both of them were brushing. The t- the children that did not floss, we saw elevated levels of gingival inflammation, which was represented by a, uh, gingival bleeding. We measured gingival bleeding. And what was most striking was all those periodontal bacteria, they, they just, uh, came in abundance in the mouth.

   15. PAPeter Attia27:15

       Whi- which ones in particular, um, over expressed in the non-flossing group?

   16. PCDr. Patricia Corby27:23

       It's the three big guys, uh, we call P. gingivalis, T. denticola, A. actinomycetemcomitans. It's very complicated names, but it's the top bacteria that causes periodontal disease and gingivitis we found in, in a very young population as well, in young kids.

   17. PAPeter Attia27:43

       Are those all, are those all facultative anaerobes or any of those-

   18. PCDr. Patricia Corby27:46

       Yeah, an, uh, anaerobic-

   19. PAPeter Attia27:48

       Yeah

   20. PCDr. Patricia Corby27:48

       ... species. But most of the bacteria ... So caries and periodontal disease are very similar in the way they behave and, and the risk factors, but they can be separated that caries is most aerobic species because they live in the presence of the oxygen. So they're free on the oxygen because of the oral cavity. Most bacteria that cause periodontal disease, they're anaerobic, or the faculty that they can bo- go up and they can hide again inside the gums. So they're anaerobic. That's why they love hiding in the periodontal pockets. It's the perfect reservoir for them to just grow and, and cause inflammation and, and tooth loss, which is the end.

   21. PAPeter Attia28:32

       And, and just to be clear, the periodontal pocket is inside the tooth and the gingival pocket is between the gum and the tooth?

   22. PCDr. Patricia Corby28:42

       It's all the same thing.

   23. PAPeter Attia28:45

       Okay.

   24. PCDr. Patricia Corby28:45

       So, so the way periodontal disease manifests is that first it starts with inflammation around, uh, the gums. So the, the way the periodontium works is that it's very s- it's sealed by the periodontal ligament attaches. If you are in health, your periodontal ligament is very healthy. It's like a muscle. Yeah. It's very tied to your tooth. If you stop brushing, which is a primary cause that, uh, your gums get inflamed, if you stop flossing or you relapse, you're gonna immediately ... If you floss, you're gonna see some bleeding. That's the initial stage of periodontal disease, but it's highly modifiable. If you have period- only gingivitis, you can revert to health.

   25. PAPeter Attia29:35

       Mm-hmm.

   26. PCDr. Patricia Corby29:36

       So if you keep going and you continue with the traits of the disease, the ligament is gonna get inflamed, and they're gonna deattach from the tooth. The bacteria is gonna come in, and then that whole process of inflammation, bacteria, and deterioration of the ligaments, that's why we form the pocket, and it, uh, uh, that cumulative like, uh, harm to the periodontium, it culminates in bone loss. So the initial, the acute periodontal disease you're gonna see someone is that they come to your office, you take radiographs, the gums are still somehow attached to the tooth, very inflamed, very ... It bleeds a lot. You touch, it bleeds. But if you go and look at the radiograph, you're gonna see a big gap. The bone is all gone And then that's the pocket. It's when the bone goes down, and then if you put a probe, you're gonna see three millimeters, five millimeters, seven millimeters. It keeps going down.

   27. PAPeter Attia30:40

       Now, how does that relate to the carry? Because the carry typically occurs on the, the sort of top surface of the tooth typically, correct? And everything you're describing is, is often actually below the g- the, the gum line, yes?

   28. PCDr. Patricia Corby30:56

       Well, that's the next stage. So once the pocket gets influenced with chronic periodontitis, what happens is that the atrophy of the gums. So the gums, they're gonna recede, and they're gonna keep going down. So it's very typical that you look... If I know, I... If I look at someone, I know they have periodontal disease just by looking at their gums because you're gonna see the teeth, they become bigger, and then you're gonna see the gap, uh, that it gonna expose the root. So usually the root of your teeth, they're not mean- meant to be exposed because it... Once they expose, caries can, uh, the bacteria can colonize, and you can have root caries as well. So you can have the coronal caries, which is just on the crown of your tooth, but when the root get exposed due to periodontal disease, other forms of trauma, malocclusion, and things like that, then you can get caries to take over the root of your teeth as well.

   29. PAPeter Attia31:55

       So in children, um, the, the sort of typical caries that we see are on the occlusive surface, correct?

   30. PCDr. Patricia Corby32:06

       Mostly, but one of the most common, uh, caries we call child- early childhood caries, which is caused by baby bottle. Children that like breast... Not the breastfeeding, but the bottle overnight and many times a day, so it's mostly on the anterior teeth. Uh, I don't know if you had a chance to see, but the carry develops very rapid-
6. 32:45 – 42:27

   Detrimental effects of sugar and the importance of fluoride and oral hygiene;

   1. PCDr. Patricia Corby32:45

      worldwide, uh, due to that caries. Everybody has dental caries. Um-

   2. PAPeter Attia32:50

      W- why did you say it doesn't happen with breast milk?

   3. PCDr. Patricia Corby32:54

      Because the breast milk, we have studies showing that it causes much less decay than t- uh, formula because every formula has sugar.

   4. PAPeter Attia33:05

      So what is it about sugar? We w- we all grew up knowing that sugar was the worst thing for your teeth. Um-

   5. PCDr. Patricia Corby33:12

      Mm-hmm

   6. PAPeter Attia33:12

      ... I've never understood or heard a con- a, a, a, a, a c- I don't wanna say compelling reason that suggests I don't believe it. I do believe it empirically.

   7. PCDr. Patricia Corby33:21

      Mm-hmm.

   8. PAPeter Attia33:21

      But what is it about sugar? Is it the fructose? Is it the glucose? Is it the combination of them, um, that, that leads to an, a rapid overgrowth of the, uh, the carry-causing bacteria?

   9. PCDr. Patricia Corby33:36

      It's all of them. It's, uh [laughs] , fructose, sucrose, lactose, more complex starch food. Uh, they are even worse. Um, all the drinks today, they have added sugar. Um, you name it. Everything has sugar, right? But the m- the main mechanism is very simple actually, is that, um, the, the cariogenic bacteria, they love sugar. They metabolize the sugar. It's, uh, actually energy for them every time that they see it. So the, the way they... They have a very, uh... They have capability of attaching the tooth surface, all this bacteria. They, they... So they, they get together, and they stick to each other. They... And they have the ability to secrete that extra, uh, cellular matrix that is like a glue, and the, the... And we call biofilm, and that attach to the tooth. So every time that you put sugar, they take that sugar, they metabolize that sugar as energy source, and they multiply, and they, it, they grow with other food that we put it on, in the oral cavity as well. But what happens that when they mi- metabolize sugar, they secrete acids, and that acid is the one who destroy the enamel of your tooth. So that's the cycle.

   10. PAPeter Attia34:59

       So that, that, that suggests that they're metabolizing sugar anaerobically to produce lactate. If they're increasing the acidity of the environment, presumably hydrogen ion is coming out with lactate. They're doing this not in mitochondria. They're doing this outside of mitochondria. They're, they're, they're... Uh, this is almost like the Warburg effect, um, where whether oxygen is present or not, they always choose anaerobic metabolism. Do we, do we know if that's been looked at?

   11. PCDr. Patricia Corby35:32

       Probably yes, but I don't know su- Uh, I don't remember, uh, Peter.

   12. PAPeter Attia35:37

       A- and also you say sugar, but I just wanna be clear. Do, do these, do these bacteria have a preference for glucose over fructose? Um, obviously sucrose is both. It's an equal mix of them, but I wanna-

   13. PCDr. Patricia Corby35:50

       Yeah

   14. PAPeter Attia35:50

       ... I wanna get very specific on this point. Is fructose specifically harm- more harmful? Because if that's true, then sucrose would be more damaging than, say, starch, which would just be pure glucose.

   15. PCDr. Patricia Corby36:05

       I think the glucose, uh, is the worst, uh, especially, uh, when they do syrup, you know, when they, they intensify and do with higher concentrations of sugar, uh, o- on that. Uh, but technically all of them can be metabolized. Even the fructose from a- from fru- fruits and vegetable, th- they can metabolize that as well.

   16. PAPeter Attia36:35

       Do you have a sense of how our species survived before we brushed our teeth?

   17. PCDr. Patricia Corby36:43

       How they survived?

   18. PAPeter Attia36:44

       Yeah. I mean, when you think about it today, if you-

   19. PCDr. Patricia Corby36:48

       Mm-hmm

   20. PAPeter Attia36:48

       ... if, if, if, if after two weeks of twins not flossing their teeth, never mind not brushing, just two-

   21. PCDr. Patricia Corby36:56

       Mm-hmm

   22. PAPeter Attia36:56

       ... weeks of not flossing, you're able to induce significant periodontal disease where you actually had gingival disease that would induce bleeding in the gums. And now let's go back in time 300 years, which our species looked the exact same as we do 300 years ago.

   23. PCDr. Patricia Corby37:14

       Mm-hmm.

   24. PAPeter Attia37:14

       It's not like we're talking Neanderthals. But presumably-

   25. PCDr. Patricia Corby37:17

       Mm-hmm

   26. PAPeter Attia37:17

       ... 300 years ago, we didn't have toothbrushes and dental floss, did we? Like, do we know what oral care consisted of 300 or 400 years ago?

   27. PCDr. Patricia Corby37:26

       Um, well, we know that for 100 years ago, we see from research that people had periodontal disease, they had dental cares. This is not new, right? But, like, if I look at populations, uh, from developed country, for example, I go to Africa, and I do a lot of research there, um, they have, like some plants, they have like a stick that they use, and they clean their teeth with that tree... It's a tree that-

   28. PAPeter Attia37:58

       Yeah

   29. PCDr. Patricia Corby37:58

       ... they find. So I'm assuming that people just use different devices to clean their teeth because if you think about removal of plaque is mechanical detriment. Uh, you need to disrupt the biofilm. What we do with brushing, we're just trying to disrupt that matrix of the biofilm. But they form again. Uh, research shows that you clean, you can have the mouth with zero plaque, in two hours, you have them all, all formed again. They, they, they colonize back. Um, but we're trying to do with the brushing is just disrupting that we don't that let that accumulate and be like overwhelming in, in the oral cavity.

   30. PAPeter Attia38:42

       Yeah, I just... I, I, I mean, I, I would assume that the, [clears throat] that the food consumed somehow, even though obviously people hundreds of years ago still consumed glucose and fructose, m- maybe the form in which they consumed it was less concentrated and refined, which I suppose we know-
7. 42:27 – 53:05

   Oral health challenges for cancer patients and immunocompromised people;

   1. PAPeter Attia42:28

      Um, when you say brushing the tongue, is the purpose to remove bacteria, or-

   2. PCDr. Patricia Corby42:36

      Yeah

   3. PAPeter Attia42:37

      Okay. And what about the rest of the oral mucosa? Do you mean brushing the gums as well?

   4. PCDr. Patricia Corby42:43

      Well, [laughs] technically, um, the way ... That's not standard of care, right? So the way research has done and proved that you can maintain optimal, uh, oral health just by brushing your teeth, by flossing, uh, really well, and having good nutrition and all those things. Uh, of course, there are phases in your life, um, where, like in the specific case of my population, they're go- undergoing radiation oncology. They have a lot of ulcers in their mouth, and they can't s- drink, they can't eat, and/or they cannot brush their teeth because it's so painful because of all the ulcers. And then there, there is a whole just icky that occurs in the oral cavity because on top of this, it has radiation and a bunch of things. So on that specific population, they need a more intense oral care program where we clean the periodontium, we clean the teeth, and we decontaminating and brushing the oral mucosa. So it's, it, it depends. It depends on the risks. It depends on the population that you're treating. It depends on their ability to, to, to brush. Uh, e- e- every oral hygiene program I think needs to be personalized to the person, to the age, to the risks that they have, if they have dry mouth, if they have, have different diseases that affect the oral cavity. So it's a, it's a very uni- it's a holistic approach that not one regimen would fit all. Um...

   5. PAPeter Attia44:24

      Um, is the importance of flossing the, um, mechanical removal of food particles between the teeth, or is it the actual transient irritation of the gum that actually provides the benefit? Because, um, you can imagine a thought experiment where a person subsided on an all-liquid diet, so there would never be food particles that are between the teeth, but where they might still benefit from flossing or m- more directly, they might still experience a harm from not flossing. At least that's my hypothesis, which would suggest-

   6. PCDr. Patricia Corby45:03

      Mm-hmm

   7. PAPeter Attia45:03

      ... that the benefit of flossing is not just the actual removal of the gross large particle, but it's the transient irritation that's created at the gum surface. Uh, do, do you have a point of view on that?

   8. PCDr. Patricia Corby45:19

      Yeah. There have been research on that. Um, some people on the opposite direction that might, if you floss, for example, a mouth of someone who is immunocompromised, you might see nurses and doctors saying, "Don't floss."

   9. PAPeter Attia45:37

      Yeah. What about non-immunocompromised people?

   10. PCDr. Patricia Corby45:40

       I don't think there is any harm, uh, on, on flossing. It, it might give you more resistance to, to those constant exposure to bacteria, but mainly it's to clean that anaerobic bacteria that it's really hiding in between your teeth. So that's the mainly, uh, function of, of flossing. And the brushing, if you think about brushing, it also stimulates the gum. The gum is not different fr- from any other muscle or in your body because it needs to be really strong and attached around your teeth. So the brushing as well helps a lot with that dynamic constant, uh, because it massages your, your, your, all your gums, your periodontium. And, and I believe that is a good benefit as well.

   11. PAPeter Attia46:32

       Is there a benefit, um, or a, a, a rationale to flossing before brushing? Which for some reason is the way I've always done it. I don't know why.

   12. PCDr. Patricia Corby46:41

       Yes. I love that. Mm-hmm. Because, uh, that's usually how we recommend. Actually, it's, I ask them, "You brush, you floss, and you brush again [laughs] if you want to be perfect." Because when you brush, you remove all the biofilm of the bacteria on your surface of your teeth.

   13. PAPeter Attia47:01

       Mm-hmm.

   14. PCDr. Patricia Corby47:01

       And you need to rinse your mouth well to just get all, everything out, and then you floss. But imagine if you floss and then you're throwing all that bacteria back in the oral cavity, they might populate and recolonize again. So that's why I say you just brush, you floss. We either rinse your mouth really well after that, or you just quick brush again. That would be the, the most, uh, the way if you want to be obsessed. And then you need to brush your tongue because bacteria, even the ones that you're flossing and throwing out your mouth, they might just colonize the tongue as well. Some people have fissures on their tongue, and that allows them to get in. When, when we do studies and I c- I collect bacteria, for example, swabs from different parts of the mouth, every study that we do we collect that. Buccal left, buccal right, tongue, floor of mouth, throat. Every surface of your mouth you find different bacteria. So your tongue has a different colonization from your buccal, from, from the floor of mouth, from the throat. Throat we know, uh, colonized by bacteria and virus, the HPV virus. It's highly associated with oropharyngeal cancer. So all those variations, they, they, they do different things, right?

   15. PAPeter Attia48:30

       Um, but you don't recommend also brushing the buccal surfaces or other surfaces if they're also a great source of bacteria?

   16. PCDr. Patricia Corby48:39

       I don't think I can recommend because it's not a standard of care. So everything that you recommend, uh, for example, the trial that I'm doing right now, I'm implementing a oral care that doesn't exist. So no one tells people, uh, patients who are undergoing radiation treatment that they need to see a periodontist and do a periodontal treatment every week. That's how intense it is. They come, we do the whole debridement of the periodont, we clean the oral cavity, we clean the teeth. That doesn't exist, and if you ask a dentist, they're gonna say, "Ah, why I need to do that?" So ... And that type of procedure as well is not insured. So if you get a patient who you're doing, undergoing radiation treatment, they can get speech pathology. They go to see the oncologist. They go to see their nutrition. This is all part of the healthcare system, and this is all they can charge to the insurance or Medicaid, Medicare. Oral health is not part of that. So the ... And I want that to be part of, uh, a medically compromised patient, that the m- same way that they need to see a nutrition, they need to see a oral health specialist because that's gonna help them respond to the cancer treatment. They're not gonna have the burden of infection, inflammation in their mouth, and of course they're gonna perform better. They're gonna eat better because if they have ulcers, they're not gonna be able to eat. So there's a whole benefit around that, but there is no insurance would pay, and that is not a standard of care procedure. So I'm doing the research. I'm collecting all those biomarkers, and I want to prove the benefit of that. And once I prove the benefit of that, because now I did a clinical trial, I might be able to push and get other centers and other people to do it, and that might become a standard of care for this specific population.

   17. PAPeter Attia50:34

       Now, is there evidence that cancer patients, because of two things, they're immune compromised through treatment coupled with the increased susceptibility, um, and the loss of immune barrier in the mouth, are actually at greater risk of systemic infections that arise from the mouth?

   18. PCDr. Patricia Corby50:57

       Yes. Yes. There's a lot, uh, a lot of research on that, um, and that's what I believe as well, and when they're going ... On top of everything that is going on with them, they have horrible dry mouth. Week two of radiation, they cannot ... Two or three, they c- some patients cannot produce saliva anymore because the d- radiation damage the salivary glands, and that's changed the whole oral microbiome, allows opportunist meca- uh, organisms to prevail. So they have a lot of fungal infection because of the issues that they have with dry mouth, and that escalates a, a lot of local infection and inflammation burden on the oral cavity, and affects them systemically because I don't have data from the trial that I'm doing right now, but the reason was I'm doing is that on my small pilot that I did to lead to this large trial that I'm doing now, I saw that main inflammatory markers ... I, I look at saliva inflammatory markers and microbiome before they started the trial and, uh, three month after they completed the last dose of radiation. And then when I look at cytokines, I, I sampled several cytokines in saliva. Most of them, they're completely suppressed on, on the oral cavity. They're all cancer patients, but the, the group that I, I didn't do the periodontal disease, they all had even increased on those, but the ones that I did is very comprehensive. They're all gone, suppressed, on the negative. So it's clearly showing that that's something going on systemically on those patients that is just because I'm brushing their teeth. And, and, and the way my study started, that's why I always say that it makes me so happy when I'm discussing oral health with a MD like you, a smart that understands a lot about, about those things, is that

8. 53:05 – 1:02:45

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

   1. PCDr. Patricia Corby53:05

      I started my life when I was at NYU and I used to work with all the radiation oncology, all the surgeons that they were doing surgeries on the patients. So they diagnose the cancer, and because I was doing research, I would go to the OR, collect the samples, and take over those, the, the patients throughout the whole research when they're looking for oral cancers and all, all those things. And I start looking at those patients' mouth, and I said, "I can't believe that there is not a single doctor who is looking at their mouth." They have horrible oral hygiene. They got the cancer. They're depressed. They, uh, start radiation right after surgery, which they already can't brush their teeth because sometimes they, they lose the half of their jaw. They take their tongue. So they're highly debilitated, so they stop brushing, and they're going to radiation. When they get into radiation, then comes with Archie. The radiation also changing the microbiome, and they develop horrible ulcers in their mouth bec- and then they become immunocompromised. It's, so it's a whole cascade of things that happen in, in those patients. And then I started ... One of them, I came to the oral surgery and I said, "Do you mind if I start cleaning your patient's mouth?" And they said, "Why do you wanna clean?" And I said, "Well, I know he's gonna go into radiation. Let me do a dental cleaning. I can't look at anymore the way it is." They said, "Pat, do it, whatever you wanna do it." So I start doing my cleaning periodontal disease, and after I treat it, and they were going through radiation. Some of them, I'd say, "Well, I'm gonna clean your mouth twice a week." Radiation is usually six to eight weeks. So if I change, clean your mouth every two weeks, at least you're gonna get a baseline, middle of radiation, and end. And others will say, "Well, if he's not responding really well, I, I always just start trained say, what can I do to, to get a good oral health?" Others I start every week. And then after I treated like 10 patients, uh, I got a call in my office with the, he was the j- head, his name is Nico Sanfilippo. He was the ch- the head of the head and neck group. And he said, "Pat," I never had never talked to him, but he was the referrals from our patients because you have the cancer, you have the surgery or not, and then you, radiation oncologist like a refer. So you need to find a radiation oncologist that can see your patients. So he called me and say, "Pat, can you tell me what you're doing with my patients?" And I was like scared because I knew that wasn't like a perfect like standard of care. And then he said, "Well, I have maybe eight patients that you treated, and they don't develop mucosites. And they're sitting on my waiting area, and they're talking to each other, 'Well, I went to see Pat. Pat is doing that. Pat is doing that.'" And then he said, "Can you tell me what you're go- doing?" And I said, "Nick, you're gonna laugh, but I'm brushing their teeth." Of course it wasn't that brushing, but it's, it's oral hygiene. And he was the one say, "Pat, can we do a pilot? I'm fascinated by that." And then we did. We saw 16 patients. That's the pilot that I submitted, and then we got the grant. But that was how everything started, was him calling and saying, "What's going on?"

   2. PAPeter Attia56:38

      Now, the, how in depth was the oral care you delivered to these patients? Is it the type of thing that they could do for themselves if taught, or did it have to be done, uh, while they're sitting in a dental chair and by someone who was highly trained?

   3. PCDr. Patricia Corby56:55

      It's a combination. Actually, on the current trial, I'm trying both approaches. If I can just give a baseline cleaning, because if they have a lot of, if you, someone has a lot of plaque in the, for a long period of time, and you haven't brushed for six month, for example, the plaque becomes harder-

   4. PAPeter Attia57:17

      Yeah

   5. PCDr. Patricia Corby57:17

      ... and becomes calculus. No one can remove that unless we have a very specific ultrasound that vibrates, an instrumentation.

   6. PAPeter Attia57:25

      That's what we do every six months when we go-

   7. PCDr. Patricia Corby57:28

      Yeah

   8. PAPeter Attia57:28

      ... and get our dental cleaning.

   9. PCDr. Patricia Corby57:29

      They either scrape your teeth-

   10. PAPeter Attia57:31

       Yeah

   11. PCDr. Patricia Corby57:31

       ... with very sharp instruments, or they use the electronic one-

   12. PAPeter Attia57:35

       Yeah

   13. PCDr. Patricia Corby57:35

       ... to disrupt and get plaque. So at a minimum, you have to do once in a dental office.

   14. PAPeter Attia57:42

       Yep.

   15. PCDr. Patricia Corby57:42

       But in my trial, I'm doing both because I don't know which one is better. Nobody ever did before. So one group, I'm doing mechanical debridement as a periodontist. It's the same, even I go subgingival. I'm trying to flush every toxins that I have sitting on the oral mucosa, inside their gums, on the gums, on the tongue. I, I brush and floss. It's, there is not a single surface on the oral cavity that we don't clean.

   16. PAPeter Attia58:12

       How long does that take?

   17. PCDr. Patricia Corby58:14

       Takes one hour on the chair.

   18. PAPeter Attia58:16

       Okay.

   19. PCDr. Patricia Corby58:17

       The other group, we give them a dental hygienist come every week that she in, in, reinforce the importance of brushing, flossing, and she flosses the patient mouth, tell them how to proper do that. So it's just to blind the study. They both come to the clinic. They didn't have to come because it's just a brushing, but we wanna blind, so both groups come to the chair, and the hygienist does a light cleaning, flossing only, and, and brushing, or she does this holistic comprehensive approach that I put together. Um, so which is something that is striking going on right now on the, my patients in either group, they're not developing the disease.

   20. PAPeter Attia59:06

       Now, now how, just to make sure I understand, how many of these patients are patients with head and neck cancer where they're developing, um, the, the, they're either directly receiving radiation to the mouth or this area, which is resulting in the deterioration of the environment, versus patients with other cancers whose chemotherapies are rendering them-

   21. PCDr. Patricia Corby59:30

       Mm-hmm

   22. PAPeter Attia59:30

       ... uh, susceptible due to the mouth sores that are pretty common with chemotherapy coupled with, you know, the anticholinergics that can dry the mouth out?

   23. PCDr. Patricia Corby59:41

       Well, on my population, because I wanted to do a more controlled clinical trial, they all head and neck cancer.

   24. PAPeter Attia59:48

       Okay.

   25. PCDr. Patricia Corby59:48

       Uh, scheduled to undergo radiation. Uh, the head and neck cancer can be different areas-

   26. PAPeter Attia59:56

       Yeah

   27. PCDr. Patricia Corby59:56

       ... of the head and neck, but I have a very strict inclusion criteria that at a minimum 50 grays of radiation needs to be delivered to the oral cavities due to the cancer. Because I know that in this particular condition, 90% of them will develop mucosites.

   28. PAPeter Attia1:00:17

       And this is male and female?

   29. PCDr. Patricia Corby1:00:19

       Male, female, and we have RT only, and we have combined, uh, uh, treatment. RT plus chemo, 100% get mucosites. There's not a single patient. If you have a combined, uh, program, regime like that, it's very aggressive. They all ... And then on top of that, they get immune-compromised, so it is-

   30. PAPeter Attia1:00:41

       But these are mostly squamous cell, not lymphomas and head and neck lymphomas-
9. 1:02:45 – 1:18:15

   Periodontal disease: caries and root canals;

   1. PAPeter Attia1:02:47

      I wanna go deeper into this, but before we do, I wanna actually go back to some of the more mundane stuff, the, the, the, the real, uh, you know, the blocking and tackling of dentistry, and talk about, uh, caries again and w- what, like, what the stages of caries look like, when the tooth can be preserved, right? So, so when you're just replacing a little bit of enamel, and then what that next layer of damage looks like that ultimately leads to a root canal, presumably once the pulp is irreversibly damaged, and then ultimately-

   2. PCDr. Patricia Corby1:03:19

      Mm-hmm

   3. PAPeter Attia1:03:19

      ... when even that can't be reserved and a crown is no longer sufficient and you have to replace the whole tooth. Can you... Um, I know you have some nice figures on that. Can we, can we kind of go through those different stages of, of dental care? Because I think it is important to see these images. Uh, it certainly-

   4. PCDr. Patricia Corby1:03:36

      Mm-hmm

   5. PAPeter Attia1:03:36

      ... helps me understand what's going on.

   6. PCDr. Patricia Corby1:03:38

      So technically, the first initial stage of dental decay is the one that breaks through the enamel. So a very incipient decays, they haven't got to the second layer of the tooth. Um, and they're, those are the ones, some of them even like if the, we call white spot lesion, you start the decalcification.

   7. PAPeter Attia1:04:04

      Mm-hmm.

   8. PCDr. Patricia Corby1:04:04

      They can be reversed. If you have a child, you can have a very intense fluoride varnish application there. It would reverse. So most of those very incipient lesions we shouldn't be touching or treating.

   9. PAPeter Attia1:04:18

      And, and to be clear, um, is this the type of thing where the dentist will use a little probe and say, "It's a little bit soft there, but I, I think it's okay," or, "It's a shadow on the tooth," but they're confident that it's-

   10. PCDr. Patricia Corby1:04:32

       Yeah. There, there, there are, like, some controversy on that. Uh, in the past they would have that very pointy probe and they would poke and, and do inspection. Today most people, they would clean and they look with air, because you don't wanna break the enamel more, yeah, right? Because if the enamel is already with loss of minerals, you don't wanna be poking.

   11. PAPeter Attia1:04:56

       Okay.

   12. PCDr. Patricia Corby1:04:56

       So you need to be very careful when it's a very superficial caries like that because you might wanna restore in a different way.

   13. PAPeter Attia1:05:04

       But this is not painful. The enamel caries have n- have come nowhere near the pulp, so no one feels anything.

   14. PCDr. Patricia Corby1:05:11

       Yeah.

   15. PAPeter Attia1:05:11

       There's no cold insensitivity or heat insensitivity.

   16. PCDr. Patricia Corby1:05:14

       Very, very minimal. Most people, they n- they, they just don't even know-

   17. PAPeter Attia1:05:19

       Okay

   18. PCDr. Patricia Corby1:05:19

       ... it's there. Mm-hmm. And then when it gets close, the more it gets close to the pulp, because it has so many nerve, the more painful it's gonna be.

   19. PAPeter Attia1:05:28

       Okay.

   20. PCDr. Patricia Corby1:05:28

       The dentin now is very soft, so it's more like a sponge, that it's there with very rich and, and, and inside. So the moment it hits the dentin, it's painful. So that's when you're gonna start feeling like you get something cold and say, "Hmm, something's different in my tooth." Hot is more signs of inflammation. If you feel the hot, hot surfaces, things that you put in your mouth. Uh, or when it gets infected and the bacteria can come to that hole and start colonizing, then it starts the inflammation, and it's that pulsation that you feel, and the pain now doesn't stop.

   21. PAPeter Attia1:06:13

       And, and what is... When you, when you, before you get to full-blown pain, when you're just dealing with temperature insensitivity, is there anything that can be gleaned clinically between the, the cold versus the hot insensitivity versus both?

   22. PCDr. Patricia Corby1:06:30

       Yeah. Most, uh, if... I'm not an endodontist, an expert, but, um, most tests that they do, uh, to look for inflammation and infection, uh, when you have, like, more of that hot sensation that is painful, you know that you most likely might need to do the root canal because it's highly infected, inflamed. Uh, the cold, it's a little bit better. Um- Because it's not in more advanced, uh, stage. And then when you go... If the cra- the decay progresses, that's when you see on the- this other two, uh, figures is that it hits the pulp. The moment it hits the pulp, there is no way you can, uh, not do the root canal because now everything's already infected. And most root canals are done when the pulp, it's still alive. They just excise the pulp, uh, and, and clean and disinfect. So it's not from a dead tissue that has been there for a long time because it, it, it's, it's hard to keep up with the pain.

   23. PAPeter Attia1:07:41

       But just to be clear, the, the dentin carry can be fixed without a root canal?

   24. PCDr. Patricia Corby1:07:47

       Yes. Yes. Mm-hmm. If it is not as close to the pulp that it got to the point that it's infected and you c- it broke through, you, it's, you can restore.

   25. PAPeter Attia1:07:59

       So this is my, this is my, this is my own personal misery. The bo- both root canals I've had were from what I now believe were dentin carries.

   26. PCDr. Patricia Corby1:08:10

       Mm-hmm.

   27. PAPeter Attia1:08:11

       So they were, they were, um... The first one was actually a dentist that wanted to change an old filling that I had from when I was a child. So I had an old-

   28. PCDr. Patricia Corby1:08:19

       Mm-hmm

   29. PAPeter Attia1:08:19

       ... mercury filling from when I was-

   30. PCDr. Patricia Corby1:08:21

       Mm-hmm
10. 1:18:15 – 1:25:51

    The relationship between poor oral health and systemic health diseases;

    1. PAPeter Attia1:18:15

       so, um, let's, let's go back a bit to the kind of broader theme of these systemic diseases. Um, when you think about major chronic diseases, is it safe to say that the greatest causal relationship we have between poor oral health and poor systemic health would be with cardiovascular disease? Or do you think there are, uh... Or, and, and so I guess, first of all, how strong do you think that relationship is causally, and how does it compare to others?

    2. PCDr. Patricia Corby1:18:51

       There is a lot of research, uh, showing association. Uh, we don't know what comes first, so they show the relationship that's proven with periodontal disease and diabetes, periodontal disease and low birth weight, periodontal disease and heart. There is a hypothesis. Of course, it's all based on the insult of the bacteria causing inflammation and systemic health. We know that, um- Uh, and other things, Alzheimer's for example, amyloid in the brain, and, um, a few studies that we did, uh, showed, uh, markers as well. Periodontal disease and markers of Alzheimer's. So it's, they're all associations, but the only way you can say causality is if you do a clinical trial, right? You need to treat those patients and see changes on those markers, and then you say, "See, I changed their behavior. They're brushing their teeth, now look how better they became." So we need to do those things. We have a group of people that I work with, uh, from NYU, since I was at NYU. Molly DeLeon is his name, and Dr. Kamer. She's been for over 10 years trying to make the point. She has all those papers. She, she saw, for example, children with, um, [lip smack] that have motor skills or sh- I think she, her, her study was in, um, [microphone rustles] I just blanked here now the name of the disease, but we found in children, uh, that they have amyloid beta, amyloid in, in, in, in their brains accumulation because... And, and we know this population has very poor oral health. They have periodontitis and six years old, uh, it's Down syndrome. So the first study that she looked, it was Down syndrome. So we know because they have motor skills, they have cognition issues, and it's a very hard to brush.

    3. PAPeter Attia1:20:57

       S- so that's interesting. So c- because we, we know that children with Down syndrome are very susceptible to Alzheimer's disease and cardiovascular disease. In fact, um-

    4. PCDr. Patricia Corby1:21:08

       Mm-hmm

    5. PAPeter Attia1:21:08

       ... people with Down syndrome usually-

    6. PCDr. Patricia Corby1:21:09

       Yeah

    7. PAPeter Attia1:21:09

       ... do not live a normal lifespan, and they usually succumb to, uh, these chronic conditions much sooner, as, as early as in their 40s or 50s.

    8. PCDr. Patricia Corby1:21:20

       Mm-hmm.

    9. PAPeter Attia1:21:21

       Um, so you're saying that, um... Well, again, it's hard to know if the increase that she sees in amyloid is an independent process that's being driven by the chromosomal abnormalities that are found in, in, in Down syndrome-

    10. PCDr. Patricia Corby1:21:37

        Mm-hmm

    11. PAPeter Attia1:21:37

        ... versus related to the, uh, poor oral care, which could be true, true, and unrelated. It could be that they have poor oral care because they're, they don't have the life skills developed to-

    12. PCDr. Patricia Corby1:21:48

        Mm-hmm

    13. PAPeter Attia1:21:48

        ... to provide oral care. So an interesting experiment would be a longitud-

    14. PCDr. Patricia Corby1:21:51

        They don't, they don't brush.

    15. PAPeter Attia1:21:52

        Yes, a longitudinal study-

    16. PCDr. Patricia Corby1:21:54

        Mm-hmm

    17. PAPeter Attia1:21:55

        ... of two groups of, you know-

    18. PCDr. Patricia Corby1:21:56

        Yeah

    19. PAPeter Attia1:21:56

        ... peers with Down syndrome, one that are provided intensive support for oral care, and one that are, you know, uh, uh, sort of-

    20. PCDr. Patricia Corby1:22:04

        Exactly

    21. PAPeter Attia1:22:04

        ... standard of care.

    22. PCDr. Patricia Corby1:22:05

        Mm-hmm.

    23. PAPeter Attia1:22:06

        And, but again, those are very difficult studies to do because they're very time-consuming.

    24. PCDr. Patricia Corby1:22:10

        Well, uh, they are, but they're, it's all about prevention, right? H- how about if we intensify a very intense preventive approach so we don't let that child be with caries and periodontal disease and pain and inflammation and all of that. It's not only that disease, it's any people with disability. Um, so like we just opened at, uh, Penn right now because the dean's a visionary. He, he really, he's really focused on prevention. He opens a center for people with disabilities. So any person who has any, uh, motor skills or have any disease that impacts, uh, cognition, we're gonna create this program that we can do a lot of research. How is the best way of cleaning, toothpaste, toothbrushes? What can intensify this population? We, we through caregivers. It's a whole educational process because it's not them. We need to educate people who are taking care of those individuals to do a optimal oral hygiene. It's simple as that. Can we just brush, brush, brush, fluoride, intensify? Because you can prevent. All those things are highly preventable. But I was looking for, say, what are we gonna measure? There is no outcome assessment that you can use for this specific population because they're so neglected.

    25. PAPeter Attia1:23:41

        But, [clears throat] but going back to your earlier point, just to make sure I understood, did you say that if you took two groups of people, and one group received e- excellent oral care and the other group did not, and this is not in cancer patients.

    26. PCDr. Patricia Corby1:23:55

        Mm-hmm.

    27. PAPeter Attia1:23:55

        Let's just say, uh, patients who are not immunocompromised and whose oral mucosa is not compromised. So if this hasn't been done, consider it a thought experiment. One group receives best-in-class oral care, which I want to come back and define. The other group receives horrible oral care, or mediocre at best. Would you expect to see a difference in inflammatory markers, including cytokines and, uh, inflammatory cells, macrophage, monocyte-derived lineage cells, um, across those two groups?

    28. PCDr. Patricia Corby1:24:32

        Yeah. Mm-hmm.

    29. PAPeter Attia1:24:34

        Because if that's true, that alone could explain the increase in systemic disease. In other words, that could be a causal factor. Um-

    30. PCDr. Patricia Corby1:24:44

        Mm-hmm
11. 1:25:51 – 1:31:04

    Potential connection between oral hygiene and COVID-19;

    1. PCDr. Patricia Corby1:25:51

       Ever. So look what's going on with COVID. COVID is a infection disease. What is the transmission of COVID? Saliva. It's the mouth. Now, there are papers coming up, because, uh, the, the AC2 receptors, which is the COVID bind to enter the body, they are highly expressed in the oral cavity.

    2. PAPeter Attia1:26:12

       Mm-hmm.

    3. PCDr. Patricia Corby1:26:13

       Look at the literature. They're in the tongue, floor of mouth, gingivocervical floor. They're everywhere in your mouth. So a patient gets COVID. There are two things that I, I'm like very, like, surprised and saying, "Why people are not doing anything?" So people get COVID, they go to the hospital. The first thing that they do, they put them a mask. They never brush their teeth. They don't look if they have periodontal disease, how is the quality of the oral cavity. They put on the supine position because they need to free up the lungs, and that patient spend, what, a month, some people more than that, in a very critical condition. Do you think this is gonna lead to pulmonary infection? Of course it will, right? If someone has periodontal disease and already have a lot of bacteria in pockets, all the periodontal pocket is a perfect reservoir for the virus to thrive. And even like the new p- you know, if you saw, there is a publication that just came out, only hypothesis because nobody ever test it, that it might be, if you look at the characteristics, characteristics of COVID, the way it manifests, the upper respiratory tract in terms of secretion, how congested you have is very minimal. You might have a stuffed nose, but it's from the mouth, goes directly to the lungs. So there is a huge connection there. No one is doing anything to tell people, "Can you brush your teeth? Do a mouthwash. Clean your mouth. If you have COVID, you have to have a excellent..." In the hospitals, give the nurses, "You have to ask this patient to, to brush, to floss." No one is doing that. Look at the committee. So of course now science is going back because our new president, they have... They're very, they're fostering all those prevention masks and everything. Look at the committee that we have that w- has been putted to support COVID. Is there any one of them is a oral expert?

    4. PAPeter Attia1:28:19

       I'm guessing not.

    5. PCDr. Patricia Corby1:28:20

       A oral epidemiologist, an oral periodontist. Is anyone there? If there are anyone there that has the, understands a little bit about the mouth, if you connect the mouth with the body, I can guarantee that you can prevent. Look what's going on in Brazil, China. It's just ridiculous because there is no prevention. The only prevention is the mask, which we could do something better, right?

    6. PAPeter Attia1:28:47

       Um, some ar- uh, some argued that last year we saw a great increase in the rise of dental caries. Some suggest that it had to do with mask-wearing. Uh, to me it seems the most obvious explanation would be simply that people sought less dental care last year. Do you have a point of view on... Uh, first of all, is it true that dental caries went up last year?

    7. PCDr. Patricia Corby1:29:09

       Well, so what happened, it's, that we're still dealing with that, is that when COVID hit, dentists was considered, uh, not essential.

    8. PAPeter Attia1:29:23

       Mm-hmm.

    9. PCDr. Patricia Corby1:29:23

       So they shut down everything that wasn't essential, which healthcare and places that you can buy food and things like that. So dentists was left behind. So dental clinics, I know because I had to suspend my clinical trial for three or four month. I came back immediately the moment they allow me to open the clinic. But dental clinics, they were closed, completely closed for about almost a year. And on top of that, they suspended every single type of procedure that, that produces a aerosol, because they, they, they thought that was a, a infection-

    10. PAPeter Attia1:30:03

        Right

    11. PCDr. Patricia Corby1:30:03

        ... a way of infect people. So people couldn't go to the dentist. You saw horrible things on the internet. Uh, we ha- left our emergency clinic open only, and we saw really detrimental things because people couldn't get access to care. So combined with, of course, putting masks, and if you're wearing a mask at work a whole day, you forget to brush because you, you can't drink too much because you need to hide because you have to drink water or eat. So everything is detrimental. You mi- might breathe more through your mouth because the mask, people don't know how to breathe well through the mask, so it dries your mouth. You have dry mouth because you're breathing. So this combination of poor oral hygiene, you have dry mouth, you have a mask in, in your-

    12. PAPeter Attia1:30:54

        Mm-hmm.

    13. PCDr. Patricia Corby1:30:54

        So it's not the mask-

    14. PAPeter Attia1:30:55

        Yep

    15. PCDr. Patricia Corby1:30:56

        ... that is causing anything.

    16. PAPeter Attia1:30:58

        Yep.

    17. PCDr. Patricia Corby1:30:58

        But it's just a cumulative effect of everything that is going on, right?

    18. PAPeter Attia1:31:02

        Yeah. That, that makes a ton of sense.

12. 1:31:04 – 1:37:05

    Dry mouth leading to oral infections and ways to prevent it;

    1. PCDr. Patricia Corby1:31:04

       Mm-hmm.

    2. PAPeter Attia1:31:05

       Um, you mentioned thrush earlier, right? So oral candida. Um, and you mentioned it in the obvious context of people who are immune-compromised. But from time to time, I've seen people with a totally normal immune system develop oral thrush. Now, I will say there's one... There's usually something going on, like they're usually on an inhaled steroid for asthma or something like that, so maybe that's partially, uh, explaining it, but, but do you have any other explanations for how a person with a normal immune system could develop oral, uh, candida or thrush?

    3. PCDr. Patricia Corby1:31:41

       It's, it's highly associated with candida infection. Um, and it can be through... I think the primary reason is, uh, lack of saliva-

    4. PAPeter Attia1:31:53

       Mm

    5. PCDr. Patricia Corby1:31:53

       ... um, because your mouth is dry. So that's why MDs, they should look at their patients and how much c- how much medication they have if... and ask the question, "Do you have dry mouth?" They might have, you know, other complications that you don't even know why. Um, but primarily I, I would think it's, uh, poor oral hygiene, because if you have periodontal disease and poor oral hygiene, you're gonna allow th- those opportunistics, uh, uh, species to grow, and medication. Um, it, it's... It... They don't have a specific cause, but mainly I would say medication and poor oral health, uh, would allow virus to, to grow. We see it a lot in HIV-

    6. PAPeter Attia1:32:43

       You mean fungus

    7. PCDr. Patricia Corby1:32:44

       ... uh, fungal.

    8. PAPeter Attia1:32:45

       Yeah, yeah.

    9. PCDr. Patricia Corby1:32:46

       Yeah, fungal.

    10. PAPeter Attia1:32:47

        Um-

    11. PCDr. Patricia Corby1:32:47

        Yeah. Mm-hmm. I've said virus because virus and fungal, they, they work really well together, like people with HIV.

    12. PAPeter Attia1:32:55

        Yep.

    13. PCDr. Patricia Corby1:32:55

        They have episodes constant of, um, fungal infection in their mouth. Um, so.

    14. PAPeter Attia1:33:05

        So there are lots of reasons why people could have dry mouth. Uh, certainly the, one of the most popular classes of drugs that would do it are anticholinergics. Um-

    15. PCDr. Patricia Corby1:33:15

        Mm-hmm

    16. PAPeter Attia1:33:15

        ... it's also interesting, by the way, that there's some strong associations between anticholinergics and Alzheimer's disease. Uh, it hasn't been demonstrated whether that's causal, but if indeed anticholinergics, which lead to a very dry mouth, would increase the... or rather decrease the resistance of the bacteria in the mouth to the, um-

    17. PCDr. Patricia Corby1:33:39

        Mm-hmm

    18. PAPeter Attia1:33:39

        ... the systemic system and that could play a role.

    19. PCDr. Patricia Corby1:33:41

        Mm-hmm.

    20. PAPeter Attia1:33:41

        So it, it, it becomes very interesting. But for an individual who has dry mouth, is there a downside in using, you know, sugarless chewing gum or lozenges or, you know, sort of having something in the mouth to induce saliva? Uh, is, is there a downside to that? Is that considered-

    21. PCDr. Patricia Corby1:33:59

        No

    22. PAPeter Attia1:33:59

        ... one of the effective methods that someone can use to keep their mouth lubricated?

    23. PCDr. Patricia Corby1:34:05

        Yeah, yeah, I don't see any wrong, uh, doing that, but never use anything that it's sugar, uh, content, right? There are a lot of sugar substitutes that you can do, because you can stimulate the salivary glands and you constant moving your tongue and your mouth. And I always say hydration, it's extremely important as well. Uh, if you don't like to drink, just get a sip water all day long. You always washing the oral cavity, the gastrointestinal tract, because it's all one system. It starts in the mouth and go to, to, uh... The bacteria, they, they are all together. So always hydration and, and drinking water I think it's very important for oral health as well.

    24. PAPeter Attia1:34:53

        Now, have you looked into, um, xylitol specifically? I, I've seen some literature to suggest that xylitol may actually not only not be harmful, 'cause I think there are lots of things-

    25. PCDr. Patricia Corby1:35:05

        Mm-hmm

    26. PAPeter Attia1:35:05

        ... out there that are not harmful, um, you know, aspartame or any other things that might be thrown into gum-

    27. PCDr. Patricia Corby1:35:11

        Mm-hmm

    28. PAPeter Attia1:35:11

        ... that are sugar substitutes, but that xylitol specifically could be beneficial. And, and-

    29. PCDr. Patricia Corby1:35:16

        Mm-hmm

    30. PAPeter Attia1:35:16

        ... so I've always kind of... my practice has been to have some xylitol-based chewing gum that if I'm out and I eat, I can chew it for a while to-
13. 1:37:05 – 1:43:00

    What determines the appearance of teeth, methods of teeth whitening, and whether you should remove mercury fillings;

    1. PAPeter Attia1:37:05

       Um-

    2. PCDr. Patricia Corby1:37:05

       Mm-hmm.

    3. PAPeter Attia1:37:06

       Okay, let's talk about teeth whitening. Generally, the two things people notice about somebody's teeth when they smile is how straight are they and how white are they. Um-

    4. PCDr. Patricia Corby1:37:15

       Mm-hmm

    5. PAPeter Attia1:37:15

       ... so, so let's talk a little bit about the latter. Um, is there... I- is, is, is the color of a person's tooth genetically determined?

    6. PCDr. Patricia Corby1:37:26

       Yes, somehow yes. We can see that different races, they might have more white. But it, it's, uh, it's relative as well because, let's say, if this person with the darker skin, the teeth are gonna become much more whiter So it's almost blend with-

    7. PAPeter Attia1:37:43

       Yeah

    8. PCDr. Patricia Corby1:37:43

       ... someone who has a very white s- skin. Most of the changes on tooth color can either be done by some, um, genetic factors. There are people who might have a lot of very yellow, and that will never change, but since, uh, they're born. Or, uh, sometimes they are like, um, in s- few countries, they have fluoride f- fluor- in the water, so excess of fluoride might have some stains on your teeth. But mostly the color of the teeth is it's highly environmental, uh, determined, um, because, uh, we, we talk about my study with the twins, uh, where w- when we gave the same product for the two twins, they, they behaved completely different. So even they were identical 100% of their genes. If the kid who ha- ha- had like eat a lot of, drink a lot of tea, coffee, and things, they had, they had much more stain their teeth. And of course, the whitening wasn't as efficient of another one who had less. So the environment takes place, and it's, it's highly ch- You can modify just with those whitening products, brushing, and things like that.

    9. PAPeter Attia1:39:00

       Yeah, I, I have found that for me, the, the two worst actors by far in terms of darkening my teeth are, uh, black tea and red wine. They will, they will... I've, I've be- be... I don't... We're gonna talk about whitening in a second 'cause I wanna ask you about it. I don't whiten my teeth due to sheer laziness, but, um, so, so my approach has been to just try to minimize how dark they get by always rinsing my mouth out with water or [clears throat] chewing gum or something like that after I consume those things. Um, so, so-

    10. PCDr. Patricia Corby1:39:31

        Mm-hmm

    11. PAPeter Attia1:39:31

        ... is, is whitening a, a safe procedure? Is it, is it, um, [clicks tongue] you know, is it something that harms the tooth in an effort to produce this a- aesthetic? Does it, does it bleach the enamel away or do something that's dangerous?

    12. PCDr. Patricia Corby1:39:47

        Yeah, it's, it's bleach, right? And it's of course in excess, which most people do, uh, because they wanna always have white teeth. Wine, uh, it's, it's detrimental because somehow, uh, it has loss of minerals because of this. The product's very strong. Uh, also, if you al- allow to touch the gums, uh, it's very aggressive because you're bleaching, and it cannot be for prolonged time. So wh- what I tell people is that, uh, if you wanna do at home because it's less expensive... Ideally, you should do at the dentist. If you care about your teeth, do, do at the dentist. They're gonna protect your gum. They're not gonna apply the product if you have periodontal disease, if you have root caries, and all those things. They'll know exactly what is the population who can have that. But people just go and buy out of the counter, and they don't know what they're doing.

    13. PAPeter Attia1:40:40

        Hm.

    14. PCDr. Patricia Corby1:40:40

        Sometimes they place that, and they watch TV. They spend hours, or every time they have a party, "Oh, I want my teeth white," they put again, and then becomes that constant demineralization. Of course, you're gonna have susceptibility to decay. You're gonna harm your gums and things like that. So if you wanna do, talk to your dentist. Ask them, "Sh- Should I? Am I a candidate for that?" And do at the dent- Do at the correct timeline. Look at the prescription. Don't do cheap or products that are not FDA approved. So all those considerations, if you do the right way, i- it's okay. Um, it's just when they, uh, go outside, uh, to do things that they shouldn't. Mm-hmm.

    15. PAPeter Attia1:41:23

        B- but it still seems that prevention is, is worth a lot here. If you minimize the things that make your... that really discolor your teeth, it would at least reduce-

    16. PCDr. Patricia Corby1:41:32

        Mm-hmm

    17. PAPeter Attia1:41:32

        ... the need to, to-

    18. PCDr. Patricia Corby1:41:32

        Exactly. Mm-hmm

    19. PAPeter Attia1:41:33

        ... to, to use other things. Um, I, I alluded to it earlier that one of my most miserable dent- Not one of, my hands down most miserable dental experience of my life went as follows: mercury filling placed when I was, whatever, 10.

    20. PCDr. Patricia Corby1:41:51

        Mm-hmm.

    21. PAPeter Attia1:41:52

        30 years later, someone comes along and says, "You really oughta have that removed because you, your insurance company will now cover the replacement of these, and you can have something white instead of something silver." Um, and that damaged the dentin and/or pulp enough that I needed a root canal. That root canal, I eventually... They... That's the one where they missed the root. I got to... Had to go back and back and back and back, and ultimately led to, uh, an injury that required the tooth coming out. Okay, let's go back to the jugular question. Should we remove mercury fillings?

    22. PCDr. Patricia Corby1:42:28

        No, if they're highly functioning, there is no decay under. There are several statements and research that has been done, and that's the minimal... They, they're afraid about the, the mercury-

    23. PAPeter Attia1:42:42

        Yes

    24. PCDr. Patricia Corby1:42:42

        ... that gets in the... It, it's proven that there is no harm, uh, with that. So if e- if it's working fine, if it's functioning and it doesn't affect the appearance, the aesthetics of your tooth, just leave it there. Uh, I don't think you should.

14. 1:43:00 – 1:50:37

    Importance of fluoride for preventing tooth decay, and dental care for children;

    1. PAPeter Attia1:43:01

       Okay. You also talked about fluoride earlier. Um, this might sound like a s- naive question, but does all toothpaste have fluoride in it?

    2. PCDr. Patricia Corby1:43:11

       No. Um, you have to look for, and not all of them have the correct amount. You want a, like, 1,000 PPM to 1,500 PPM-

    3. PAPeter Attia1:43:25

       Okay

    4. PCDr. Patricia Corby1:43:26

       ... of fluor. Um, so that's very important. So you have to... And e- the ADA, the American Dental Association, if you go to their website, they have all the toothpaste that they endorsed Not for political reasons or anything because as we've done research and we know they work, they have the correct amount of fluoride that prevents decay. So you just need to get from a, a good source, and it's extremely important to have fluoride in any toothpaste. Usually chi- children before one year, uh, they, they recommend not to put it on because they swallow all the time. But as long as they have the first tooth in their mouth, you can start putting very small amounts and start the, the regimen to, to brush so the child gets used to. Uh, but other than that, everybody should w- uh, use fluoride.

    5. PAPeter Attia1:44:19

       And is there fluoride at all in any small amount in drinking water?

    6. PCDr. Patricia Corby1:44:24

       It depends. Uh, I know that US is very particular with, uh, fluoride in many regions. Uh, people don't like to have. Um, most countries the drinking water is fluoridated, um, but there are additional sources of fluoride that pediatrician they can give you like drops that you... Even when you're breastfeeding, you can just put drops on the child. Um, and/or varnish, which I, I think is extremely, extremely preventive for children. It's so simple. It's like a varnish that you paint in their teeth every six month. And, uh, guess what? They will develop decay because it's, it's just protecting more and more.

    7. PAPeter Attia1:45:14

       So I do that myself also.

    8. PCDr. Patricia Corby1:45:16

       Yes, for any-

    9. PAPeter Attia1:45:17

       I have discovered that, um, I have one area in my mouth where my gum has receded just a little bit, and as opposed to putting a filling there, I just use every three to six months-

    10. PCDr. Patricia Corby1:45:30

        Mm

    11. PAPeter Attia1:45:30

        ... a little bit of what you said, like sort of a fluoride varnish.

    12. PCDr. Patricia Corby1:45:33

        Yeah, varnish

    13. PAPeter Attia1:45:34

        And it, it reduces any sensitivity, and my goal is obviously just to, you know, prevent any decay there.

    14. PCDr. Patricia Corby1:45:40

        Mm-hmm. Yeah, the fluoride varnish, uh, if someone is highly susceptible to decay, we have a, a... It's a prescription base. You have to ask your doctor who... Your dentist to... They call... It's a... One of the ones that we have in the market is Prevident. I give to my cancer patients. But they're highly concentrated fluoride, and we r- we recommend that they use once every night, and for people who are high risk, uh, of caries, which is people undergoing radiation. And then you do a regular oral hygiene with the regular fluoride toothpaste, you floss and everything, and then you put that toothpaste, um, on a toothbrush, and then you rin- you brush, and you don't rinse with water.

    15. PAPeter Attia1:46:27

        Right.

    16. PCDr. Patricia Corby1:46:28

        You want the product to just... to treat the cavities and everything, uh, overnight, right? So that's very efficient as well. Um, and mainly, and, uh, and it's a very fun story if you ask my son because I have two kids and none of them have never had decay. [laughs]

    17. PAPeter Attia1:46:46

        How old are they?

    18. PCDr. Patricia Corby1:46:48

        Uh, today they are, oh, 30, 34. [laughs]

    19. PAPeter Attia1:46:54

        Mm.

    20. PCDr. Patricia Corby1:46:54

        So, but they never had decay. But if you think Francis, which my youngest, uh, he... Because I would tell the stories about, uh, microbial that they're gonna eat your teeth. If you have food, they're gonna eat the food. They're gonna just go down and make holes in your teeth. So I would tell them those stories overnight. And how many times that kid in the middle of the night you'd... 'Cause he would fall asleep, and I'll put him on like three years old in the bed, and I would watch him in the middle of the night rush the bathroom and brush their teeth [laughs] because they're afraid. I always told them because the most important time of the day is actually the night brush. And never give your child baby bottles and things overnight-

    21. PAPeter Attia1:47:40

        Right

    22. PCDr. Patricia Corby1:47:40

        ... because when you're sleeping, you have a suppressed your saliva production, and that's the perfect environment to the bacteria to grow. That's why child have baby bottle decay because when they're sleeping and they put the bottle in their mouth-

    23. PAPeter Attia1:47:57

        Yeah

    24. PCDr. Patricia Corby1:47:57

        ... the milk concentrates all on the anterior teeth, and they get severe decay. So brushing before you go to bed and you floss, you, you're likelihood that you're having a optimal, optimal oral hygiene is really high and you're gonna prevent, right? It's a very important brushing time.

    25. PAPeter Attia1:48:16

        What, what are, what are the implications of children having caries in their baby teeth? I mean, for example, I, I assume we would never do a root canal in a child. You just yank the tooth out 'cause you know that the adult tooth is coming right behind it. Um, do, do-

    26. PCDr. Patricia Corby1:48:31

        Mm

    27. PAPeter Attia1:48:31

        ... do, do people put fillings into children's teeth?

    28. PCDr. Patricia Corby1:48:35

        It's, it's, uh, highly complicated to treat those kids, um, first because you traumatize them. Uh, you cannot do local anesthesia. They will never come back to the dentist if you treat... to try to do that in a regular way because they don't understand. They, they're very young. It's one to three years old that those type of decay appear. So they do in the hospital under sedation. The teeth that they can treat, they treat. They will extract the ones that causing a lot of pain.

    29. PAPeter Attia1:49:08

        Mm.

    30. PCDr. Patricia Corby1:49:08

        Some of them just treat the pulp, put some medication there, m- and wait until the tooth exfoliates just to preserve function because otherwise they're not gonna be able to chew. So every case they need to approach, there is another type of fluoride as well, um, but in, in... It's a highly concentrated that they put with a metal, uh, together, but the teeth becomes black. I don't... That's another resource that they have because they cannot open, put a hole, and restorations because a child would never allow that, us to do.
15. 1:50:37 – 1:59:44

    Useful dental products: floss, electrics toothbrushes, and more;

    1. PAPeter Attia1:50:38

       There's a, an entire cottage industry of products out there, like oil for pulling through the teeth and tongue scraping things. Are, are you aware of any research that supports the use of such devices? You've obviously talked about brushing the tongue, but any research-

    2. PCDr. Patricia Corby1:50:56

       Mm-hmm

    3. PAPeter Attia1:50:56

       ... that suggests scraping the tongue is efficacious? Or I don't even understand what oil pulling is, although I've seen the oils and, uh-

    4. PCDr. Patricia Corby1:51:05

       Mm-hmm

    5. PAPeter Attia1:51:05

       ... I don't, I don't think I fully understand what the claim is about why oil pulling is beneficial. Are you aware?

    6. PCDr. Patricia Corby1:51:11

       Oh, no. H- honestly, I've seen, uh, I have no idea. There is no clinical or research evidence that shows that it's good or bad. Uh, I've seen a few studies on the tongue scraping, which is similar with whatever the brush is doing, but I really like much better the brush because I ask the patients to put a little bit of toothpaste, because toothpaste is also anti-ba- bacteria, and then you just brush. It doesn't harm the cells or anything, you just brushing the surface. Um, if I had to choose between the toothbrush brushing the tongue with tongue scraping, I would say just brush. Um, it's simple and easy.

    7. PAPeter Attia1:51:59

       Okay. Is there a difference between the, the types of dental flosses out there? So the two most common that I see... Actually, let's say three. One is, like, kind of the ribbon. You know, it's like a very soft-

    8. PCDr. Patricia Corby1:52:11

       Mm-hmm

    9. PAPeter Attia1:52:11

       ... almost looks like a GORE-TEX like ribbon.

    10. PCDr. Patricia Corby1:52:14

        Mm-hmm.

    11. PAPeter Attia1:52:15

        Um, the other is, like, kind of like a f- a, a, you know, a, a rope, a miniature rope, and then the third one would be, like, kind of a miniature rope that's coated in wax. Um-

    12. PCDr. Patricia Corby1:52:25

        Mm-hmm

    13. PAPeter Attia1:52:25

        ... are they all basically the same and you just pick the one that is the most comfortable to you? Or do you, do you have a preference for which type of floss a person uses?

    14. PCDr. Patricia Corby1:52:35

        Well, what I tell my patients, I have like 10 different ones, and what I tell them, "Which one you're more comfortable using?" It's a mechanical, the brightening, it's disruption of the biofilm and taking the food away from in between your teeth. So there are people who have perfect teeth, very close together. They might need to use the one that has the wax because they're gonna go in and out very quick, and you don't wanna, uh, harm your gums-

    15. PAPeter Attia1:53:03

        Yeah

    16. PCDr. Patricia Corby1:53:03

        ... trying to pull in something very strong and then it's gonna cut your gum.

    17. PAPeter Attia1:53:08

        Yeah.

    18. PCDr. Patricia Corby1:53:08

        Has to be done very carefully. There are people who have prosthetics or big holes. There are like little brushes that they can put inside. Um, there are people who have, like, teeth that are connected to each other and they have another type of device that they can go inside the bridge and clean. Uh, it doesn't really matter. You just need to clean. And you can clean... Most people don't floss.

    19. PAPeter Attia1:53:35

        Really?

    20. PCDr. Patricia Corby1:53:35

        Most people don't.

    21. PAPeter Attia1:53:36

        What do... What does the literature suggest? What percentage of the US adult population does floss once a day?

    22. PCDr. Patricia Corby1:53:44

        Ah. If I s- if I tell something I might not be right, but I know by the whole population that I treated, it's like half of the people floss. Or they floss twice a week, or something gets stuck, they go and floss.

    23. PAPeter Attia1:54:02

        Mm.

    24. PCDr. Patricia Corby1:54:02

        But if you ask people, "Do you floss every day?" Most people don't floss every day. And a- another consideration is that floss costs money, right? So you keep... need to keep buying all those supplies, and you might not have... The fund might be used for different things. So, but if you think about flossing and brushing, I still think that floss is even more important than brushing.

    25. PAPeter Attia1:54:36

        Wow.

    26. PCDr. Patricia Corby1:54:37

        Because it, it's, it's, all the research that I did, people can stop brushing and you recover health easily. People stop flossing, it's the gingivitis, inflammation comes so quick because the plaque that is in between your teeth, you can never change or clean if you don't have a device. The plaque that is on in your top of the surface of your teeth, you eating, you get an apple, things that have fibers, you somehow, you just clean, you drink water. It, it, the saliva is constant cleaning your mouth. The flossing is where the... One thing is the bad bacteria because they lo- love, it's the anaerobic bacteria that causes most of the systemic health, such cardiovascular disease, diabetes. They're all anaerobic, and they are the ones that are hiding there. They hide in the tongue. They hide in between your teeth. They can hide back in your throat as well because they, they like those niches that, uh, the oxygen don't go.

    27. PAPeter Attia1:55:44

        Is a waterpik an additional benefit to flossing? Is it at all a substitute? I mean, obviously, um, there are some cases where it's very valuable, kids that have braces, things like that. Um, but how do, how do you incorporate the waterpik into your oral care regimen?

    28. PCDr. Patricia Corby1:56:03

        I, I like it, but I would say it's only if you're not able to use the traditional. The brushing is the best because the water is more, more... If you brush, then do the Waterpik. Don't do just the Waterpik without brushing, because the Waterpik is that flushing of all the toxins that are in between your teeth and between your gums and all of that. But you cannot do just Waterpik. It's a benefit, but don't do alone.

    29. PAPeter Attia1:56:36

        Any harm or benefit to using toothpicks? This is just a, a personal obsession of mine. I love toothpicks.

    30. PCDr. Patricia Corby1:56:42

        [laughs]
16. 1:59:44 – 2:13:57

    Ideal oral care regimens;

    1. PAPeter Attia1:59:44

       So let's now talk about the ideal reasonable regimen of oral care. Um, let's start with what I do and use me as an example of how I could do it better.

    2. PCDr. Patricia Corby1:59:57

       Mm-hmm.

    3. PAPeter Attia1:59:57

       Um, when I wake up in the morning, I do nothing. And the reason is I don't usually eat in the morning, but I drink coffee. So I don't know why. For some reason I think it's a waste of time to brush my teeth first thing in the morning 'cause all I'm gonna go to do is drink coffee. So let's say I get up and I drink my coffee... Oh, by the way, I used to scrape my tongue. I have one of those tongue scrapers. I used to do that. And then my wife got so mad at me 'cause she said, "That's so disgusting. It makes me sick. Get rid of that stupid tongue scraping piece of expletive."

    4. PCDr. Patricia Corby2:00:27

       [laughs]

    5. PAPeter Attia2:00:29

       So I still have it, don't tell her, but I don't use it anymore.

    6. PCDr. Patricia Corby2:00:33

       [laughs]

    7. PAPeter Attia2:00:34

       So I go and I drink my coffee and I kind of do all my... I usually exercise in the morning, and I usually don't eat my first thing until maybe 11:00 in the morning. At that point, I then go and I get my Oral-B toothbrush and I brush my teeth. And as you probably know, the Oral-B toothbrush has, like, this little 30-second timer that it does. It allows you to go two minutes. So I'm very, very robotic about this. I... 30 seconds on the top, 30 seconds on the top, 30 seconds on the bottom inside, 30 seconds on the bottom. And then I'm done. And then I don't do anything again except use my toothpick all day until dinner. After dinner, I then floss and I s- I, I like the... I like both. I like any floss actually. I just love flossing. So I'll use the little ropey floss and I'll use the tape floss, whatever I've got. And then I do the same thing with the Oral-B toothbrush. By the way, I'm using a xylitol-based toothpaste for what it's worth, if that matters. Um, and that's it. That's-

    8. PCDr. Patricia Corby2:01:34

       It has fluoride.

    9. PAPeter Attia2:01:35

       It has fluoride.

    10. PCDr. Patricia Corby2:01:36

        Yeah.

    11. PAPeter Attia2:01:36

        That's, that's my only oral care regimen.

    12. PCDr. Patricia Corby2:01:39

        Mm-hmm.

    13. PAPeter Attia2:01:39

        I don't use mouthwash. I don't use a Waterpik. Um, I used to, but then I gave it to my daughter 'cause she got braces. I figured she needed it more than I do. Um, that's all I'm doing. So wh- what, what, what sh- what could I do to be... Am I getting 80% of the benefit, uh, a person can have? Am I at 60% benefit? What should I... What else should I be doing?

    14. PCDr. Patricia Corby2:02:02

        Uh, so one little adjustment. So usually bacteria, the biofilm, it takes like Overnight, that's where you have the most suspicious bacteria, they start grow in your mouth.

    15. PAPeter Attia2:02:17

        Okay

    16. PCDr. Patricia Corby2:02:17

        With all those reasons that I said, your mouth is closed, no oxygen, um, reduced saliva flow, salivary flow is almost zero because you're sleeping-

    17. PAPeter Attia2:02:28

        Right

    18. PCDr. Patricia Corby2:02:28

        ... and things like, so people, when you wake up, you feel, if you stop and thinking, you're gonna see, yes, my mouth is dry. If you cross your tongue on the surface of your teeth, you're gonna feel the biofilm. That's the only th- that biofilm is invisible to your eyes, but you can feel with your tongue. It, that's the morning that you're gonna see.

    19. PAPeter Attia2:02:50

        Okay.

    20. PCDr. Patricia Corby2:02:51

        So there's nothing wrong of you. I do that as well. I like to take my coffee in my bed. I just read a little bit, and I take my coffee without brushing. I love that.

    21. PAPeter Attia2:03:00

        Brazilian coffee, I hope.

    22. PCDr. Patricia Corby2:03:03

        Exactly.

    23. PAPeter Attia2:03:04

        Okay.

    24. PCDr. Patricia Corby2:03:04

        Espresso.

    25. PAPeter Attia2:03:04

        Yes.

    26. PCDr. Patricia Corby2:03:05

        [laughs] Espresso. So, um, so then you get out of the bed and you brush your teeth. You have to wash out from your night.

    27. PAPeter Attia2:03:17

        Okay, so what, so the, uh, the change you're suggesting is before I g- begin my day, do a f- do a first brush. So I'm gonna be now brushing my teeth three times a day. I'm gonna do-

    28. PCDr. Patricia Corby2:03:29

        Exactly

    29. PAPeter Attia2:03:29

        ... the first the morning-

    30. PCDr. Patricia Corby2:03:30

        That's the ideal. [laughs]

Episode duration: 2:14:01