I have had an epiphany. While I admit to recognizing that diet is important to health any many ways, I have been influenced by Dr. Dean Edell to resist dietary supplementation by pills. Dr. Edell is in a position to read more of the medical literature than any doctor who actually sees patients, so I credit him with being able to keep up with all the latest research. And he seems to be honest in his advice, so I tend to trust his advice to his listeners.

But now I think he is wrong about nutritional supplements, like vitamins. His reasoning is that he is healthy and personally doesn’t take supplements. It is likely that he is correct in assessing his own needs.

This week I attended a conference on the oral-systemic connection in Reno, where I shared the podium with Dr Lisa Marie Samaha, Dr, Lee Ostler, and Dr. Bill Domb, and Robert Maccario. Dr. Samaha presented case after case of people whose periodontal disease was helped greatly by nutritional supplementation. They still needed treatment to reach optimum periodontal health, but the improvement was unmistakable from the nutritional supplements.

I saw her present briefly last November, and we have started offering nutritional supplements to our periodontal patients. But I admit it was half hearted. I didn’t understand the mechanism of how supplements helped, and I wanted to be able to repeat Dr. Samaha’s success in our own office.

It was Dr. Ostler’s presentation that brought the epiphany. He explained the nature of a few genetic defects which make the body work harder to repair damage on a molecular level. I won’t try to explain, and I am not sure that I can. But suffice it to say that there may be about 20% of the population whose genetics interfere with the body’s defenses or repair mechanisms enough to affect there ability to defend themselves against the pathogens of periodontal disease. And if we can provide molecules to help them in the diet, their defenses or repair mechanisms can be more normal. I would speculate that Dr. Edell does not have any of these genetic anomalies, so he would be correct in saying that he does not need them.

The day of genetic medicine and dentistry is coming, and soon. Doctors will be able to look at the entire genome for known genetic polymorphisms and either repair them or provide the work-around to help people avoid getting sick. Right now the reams of data from the entire genome is overwhelming and expensive to acquire. But the days of computer interpretation of the data are here and soon the practice of medicine and dentistry will be vastly changed by the information from the genetic testing.

So my take on this new understanding, is that we must infer from unusual presentations of periodontal disease that nutritional supplementation is necessary or the person will not ever get healthy. And there is another bit of evidence that it is just not always the fault of the person that they are not healthy. We have placed too much blame on people for their dental diseases. Good oral hygiene certainly helps people prevent dental diseases. But for somebody who has been infected with aggressive pathogens, or is genetically missing the ability to effectively fight the pathogens, good oral hygiene is just not enough.

I have never felt so needed. Now be well.

Leading Cardilologist Comments on Gum Disease

If you are a cardiologist, a dentist, or even just any American over the age of 40, I recommend that you spend the fourteen minutes to hear the message above. Dr. Ridker, the director of the Center for Cardiolovascular Disease Prevention, Brigham and Women’s Hospital, was the keynote speaker at the American Academy of Periodontology this year.

Dr. Ridker is proposing double blind studies to prove that inflammation from periodontal disease is related to death by cardiovascular disease. In a previous blog, I proposed that we stop discussing the possible relationship between gum disease and heart attacks and admit that the bacteria from the gum disease are causing heart attacks. Dr. Ridker is recognizing that inflammation is a more important indicator of cardiovascular risk than high cholesterol, and proposing studies to prove just that.

I don’t know about you, but I don’t want to be part of the control group. The scientist in me wants the definitive proof, but the clinician in me already knows the likely outcome. We test the C reactive protein of our periodontal patients before we commence treatment. We see dramatic declines in the C reactive protein levels of the patients who get their periodontal disease under control. And as Dr. Ridker admits, your C reactive protein levels are a better indicator of heart attack risk than your cholesterol levels. Yet while most American adults know their blood cholesterol levels, almost none know their C reactive protein level.

Obstructive Sleep Apnea

It has been estimated that 17% of American adults have obstructive sleep apnea, with 85% being undiagnosed. OSA is the most common chronic disease in developed countries. The person who is suffering from sleep apnea, has brief periods of interrupted breathing during sleep. He is unaware that this is happening, but the quality of sleep suffers greatly.

The symptoms that most likely indicates risk for obstructive sleep apnea are snoring, fatigue, morning headaches, or daytime sleepiness. If you grind your teeth at night, your risk jumps to 80%. If you had four premolar teeth extracted for orthodontics, your risk is 80%.

Why should you be concerned? OSA is a cause of high blood pressure, which leads to risk of death by heart attack. Reggie White, a famous retired football player, died of a heart attack attributed to OSA in his sleep at age 43. OSA would be a much more common cause of death on death certificates, if it were not for the fact that it only causes the heart attack that causes death. Most autopsies list heart attack as the cause of death without commenting on the cause of the heart attack.

OSA also upsets the leptin cycle which causes your body to think it is hungry when it is not. The result is obesity. The weight gain that results then makes the OSA worse, which makes the weight gain worse.


OSA is a cause of ADHD, ADD, depression and sexual dysfunction. OSA is a major cause of heartburn and gastric reflux.

Why is a dentist interested in OSA? We see people every day with symptoms of OSA. Our office has a simple screening device which you wear at home for one night. When you return the device, we get a computer printout of how many times you have had episodes of obstructive breathing problems. If your problems are severe, we make a referral to a sleep disorders doctor. But if your problems are mild or moderate, you can be successfully treated with an oral appliance which holds your chin forward when you sleep (mandibular advancement device). I wear one of these appliances every night, and I have lost 25 pounds since I started. My blood pressure has dropped to normal, without pills that have side effects.

US Health Care Debate MIsses the Point

There is little argument that the US health care model needs to be changed. But up to this moment, the arguments going on in congress make me think we are missing the boat entirely. What they are debating is changing how health care will be paid for, and how health care will be distributed. What we need is a fundamental redesign of our health care model, starting with the first day of medical school.

Considering how many years of their young lives they give up, in my opinion, physicians are some of the most under-compensated people in our society, right along with teachers. It takes until the early to mid thirties before a physician finally gets into practice. In the mean time, most of their college classmates have been out earning a living for a decade, investing in their retirement, buying houses, having nice vacations, while the medical residents are subsisting at near minimum wage, barely making ends meet.

And some of their years of training are brutal. During my one year of internship, I had two surgical interns as roommates. They would typically sneak moments of sleep in the hospital for two full days, before coming home for a good night’s sleep (maybe six hours) on the third night.

When I was in college in the 1970’s, the best and brightest of the college students were pre-med. There was a promise of a good income to all who could beat out the fierce competition to get into medical school (less than one in ten would succeed), and put in all the hard years of work to become a trained physician. But for decades now, the insurance companies have been dictating compensation to the doctors, who almost all have to sign on or go out of business. Become a member of their panel of doctors, and they will send you plenty of insured patients, but the doctor will work for what the insurance company determines is fair. The result has been a steady drop in the relative incomes of the very people whom we trust to keep us healthy.

But even worse, is the way that doctors are compensated in our current economy. Doctors are paid for doing procedures. Pap smears, X-rays, tonsillectomies, vaccinations, exams, crowns, root canals. It is way more lucrative to treat a heart attack victim than it is to prevent the heart attack. And that is just wrong.

But insurance companies are only one of the major forces that are influencing our health care system. Let us not forget the influence of the drug companies. The drug companies hit the jackpot when they create a drug to handle the symptoms of a chronic disease that is affecting millions of people. It is way more lucrative to manage the symptoms than it is to cure the disease. When you are cured, you no longer have a need for their drugs.

Could Diabetes be Caused by Periodontal Pathogens

We know that diabetes is multi-factorial. We have known since at least the 1970’s that diabetes and gum disease are related. We see more gum disease in diabetics and more diabetes in people with gum disease. A diabetic has a poorer healing response, so it would seem to follow that people with diabetes would defend themselves against gum disease wounds with less success than a non-diabetic. And dentists have been comfortable enough in that belief to treat diabetics more aggressively when the signs of gum disease appear.

But isn’t it possible that the insulin insufficiency diabetes, (the pancreas does not produce enough insulin), is being CAUSED by the same pathogens that might be causing pancreatic cancer, perhaps a less virulent strain? Remember the spirochetes that Dr. Nordquist implicated in coronary artery disease? Isn't it possible that another species of spirochetes could be attacking the pancreas? Shouldn't we be treating periodontal disease as if we could prevent chronic diseases of the rest of the body? It would seem to me that we should.

Gregory L Sawyer DDS

Oral/Systemic Connection

There are two books that have made significant impact in my thinking process about the connection between gum disease and other systemic diseases. In Plague Time, the author, Paul Ewald postulates that the majority of chronic diseases that plague mankind are really chronic transmissible infections. We all know acute transmissible infections, the cold and flu being the most common. They attack us shortly after we have been exposed, and generally run their courses in a matter of a week or so. But chronic transmissible infections are different. These infections can wait for years or even decades to attack us, and all the while we can be spreading them without knowing we are infected. Dr. Ewald gives multiple examples in his book, but the one that jumped out at me was a cancer pathogen in Japan that is spread from mother to daughter in breast milk that does not manifest until the fifth or sixth decade of life, by which time the daughter has already passed the pathogen to the grand-daughter.

What is difficult for us to imagine, is that there are chronic diseases such as cancers that have a pathogen as the cause because we don’t know or can’t find what the actual pathogen is. The invention of the microscope allowed mankind to look at one celled animals first the first time, but their existence had already been postulated if not yet well understood by the infectious disease specialists at the time.

Wouldn’t a transmissible pathogen explain the breast cancer cluster in Marin County of California? Researchers have looked at the air, the water, the high power lines and who knows what else in Marin without an explanation of the breast cancer cluster there.

Wouldn’t a sexually transmitted pathogen explain the fact that a man’s risk for prostate cancer is exactly in line with the number of sex partners? The fact that we don’t know what that pathogen is does not diminish the likelihood of its existence.

What does all of this discussion have to do with our oral health? Well, I asked Dr. Ewald if he thought that the route of entry to the body of some of these pathogens might be through the bleeding gums. He told me that he thought it was not only possible but likely.

Which brings me to the other book that has had a major effect on my thinking. Stealth Killer, by WIlliam Nordquist. Dr. Nordquist is also a dentist, who had noticed the presence of spirochetal bacteria in the biofilms of the plaques of gum disease. These spirochetes worry me, because they are related to the bacteria that cause Syphilis and Lyme disease, which are truly dread diseases with no known cure if they aren’t defeated soon after infection. They worried Dr. Nordquist even more (and sooner), so he began studying them.

When a mature spirochete is attacked by antibiotics, it rolls its body up into a little ball that resembles a spore. The spores are impervious to any known attack that we can mount against them, and they can live for decades in the tissue of the body waiting for a signal to attack the host. Dr. Nordquist identified that presence of these spores in the bacterial plaques that had occluded the coronary arteries of recent heart attack victims. How did those spores get there? Since the exact same spores can be found in the plaques around the teeth under the gums, it would certainly follow that these are getting access to the bloodstream via the bleeding gums. The bacteria can be as small as 1 micron, and the red blood cells that we are seeing are between 70-100 microns in size. Isn’t it likely that these bacteria are getting access back through the damaged blood vessel wall in the gums and attacking the blood vessel walls around the heart? And when we use an antibiotic, these spores defend themselves from the attack by rolling up into the defensive spores that we see in the coronary arteries of recent heart attack victims and the gums of periodontal patients.

I am tired of the hedging of all the doctors that are saying that gum disease MAY be related to other diseases such as coronary artery disease. Isn’t it time that we stop the hedging and say that the bacteria from bleeding gums create the bacterial plaques that CAUSE heart attacks? The evidence here is nearly as strong as the evidence that HIV causes AIDS, and we can’t prove that either. Why can’t we prove HIV causes AIDS? Do you want to volunteer for the study to be inoculated with HIV and wait to see if you develop AIDS? Me neither.

And what about pancreatic cancer? What is the cause? We will admit that it MAY be related to gum disease again. What about Alzheimer’s disease? Renal (kidney) Insufficiency? Preterm births? Ischemic stroke? What else?

Gregory L Sawyer DDS

Risk Assesment cont.

I have seen older people who have started taking medicines for chronic illnesses that dry up the protective saliva. This has become so common that it has been called, MIX, for medicine induced xerostomia (dryness of the mouth.) When you eat, your mouth becomes acidic (low pH) as the beginning of the digestive process. The saliva buffers the pH of the mouth, so that in a normal mouth, the pH returns to normal within about a half hour of a meal. But in a person with a dry mouth, it can take hours. Indeed for the person with a dry mouth, the mouth can live in a highly acid environment from breakfast until hours after bedtime, because by time the limited saliva has had a chance to buffer the mouth from the last meal, the person has eaten again.

Type of bacteria and saliva amount (and pH) are predictors of risk for cavities. It is possible for dentists to evaluate you for that risk by testing the saliva. And it is possible to treat the saliva of those people determined to be at risk for cavities to reduce the risk, before the damage is done to the teeth. This is done with a series of mouth rinses that over a period of time lower the acidity of the saliva.

Risk for gum disease can likewise be assessed by determining the bacterial make up of the fluid next to the teeth at the deepest invaginations of the gums. The unhealthy bacteria, are anaerobes, or bacteria that prefer an environment that is without oxygen. The bacteria can be observed and generally identified as unhealthy with the use of a microscope. The exact make up of the gum disease-causing bacteria and the approximate numbers can be determined by a test called DNA-PCR, (DNA-polymerase chain reaction)

The presence of the unhealthy bacteria can be determined before the damage has started from the inflammatory process that results from gum disease. And science is finding that the damage to the body goes well beyond the teeth and gums.