Heart attacks and canker sores: why we need to take oral health seriously
Your microbiome begins in your mouth. Why don't we look there more often?
- Eighty percent of patients who've had heart attacks have gum disease, says Dr. Shahrzad Fattahi.
- Oral health is also implicated in forms of cancer, dementia, canker sores, and more.
- Fattahi says the future of medicine must also focus on saliva, as a whole new field of salivary diagnostics is emerging.
Over the summer, I was sitting in the dentist's chair, waiting for a cap to be placed over a cracked tooth. While dentist offices rarely inspire joy, I always enjoy visiting Shahzrad Fattahi. Leaving my doctors in New York City was one of the hardest aspects of moving. Thankfully, a mutual friend recommended me to Dr. Fattahi. I gladly travel the extra distance to get to her Playa Vista office—we sometimes forget how much a good doctor matters until we find one.
Part of the reason I enjoy our visits is that we end up spending half the time talking about a variety of topics related to health. On this occasion, I mention the microbiome; it's something I've been writing about lately. Dr. Fattahi mentions that the mouth has its own microbiome: Oral health affects a variety of autoimmune disorders, cancers, heart problems, and cognitive issues.
It makes sense. The entryway into our gut microbiome is the mouth. Yet I'd never made the connection about just how important food is from this particular perspective. Gut health begins with salivation. In fact, as you'll read below, saliva contains nearly as many molecules as blood, making chair-side salivary diagnostics an important part of the future of medicine.
During our wide-ranging discussion (much of which I couldn't fit into this article), we talk about why dental insurance is separate from medical insurance—one of those givens in America we rarely question—as well as the connection between gut and mouth health, how to promote good bacteria and reduce bad bacteria, why dentistry misses so much by focusing on cosmetics instead of functional health, how oral health affects your breathing, and the best way to help your child develop a strong, healthy jaw for life: breastfeeding.
One thing became clear while I talked to Dr. Fattahi: Holistic health needs to include oral health. Insurance companies need to figure that out, too.
Dr. Shahzrad Fattahi
Derek: In your office, you pointed out the connection between dental health and the microbiome, which is something I had never thought about.
Shahrzad: It's a great place to start, but maybe we can back up to how dental health affects your whole being and overall health. There is a missing link between what happens in the mouth and what happens in the rest of the body. With our distaste for dental checkups and focus on treatment versus prevention, we really fail to see how dental disease is a warning sign of so many other diseases. We should take a cue from our medical colleagues, who have made a shift toward more functional medicine and looking at root causes of diseases. When you come in for a dental visit now, we are only doing a cleaning, checking for cavities, recommending whitening, and sending you on your way.
We need to move toward functional dentistry. We have so much more information that we can pass on to our patients in terms of their overall health, like salivary testing for your pH levels and your airway assessment. We can do a simple chair-side salivary test to tell you if your bacterial levels are off.
In terms of your microbiome, we all hear so much about gut health, which is really your digestive system. Your gut is now responsible for 80 percent of your immune system and your gut starts in the mouth. If you think of the gut as a long tube, sort of like a conveyor belt, you put the food in your mouth first. Any diet that you follow—keto, paleo, vegan—you're actually first coating the food with your saliva. If there's an imbalance, you're passing that down into the ecosystem along the way. That's the main way swallowing bacteria is going to further affect your immune system downstream.
Derek: And you start salivating before you even begin eating. Sometimes a trigger, such as thinking about food, can make you salivate.
Shahrzad: Absolutely. The first part of your digestive system is the salivary enzymes that are exuded from your salivary glands. You activate your vagus nerve the first time you swallow, which activates the rest of your digestion. What's important to understand is that we're not saying "antibacterial." We are saying you should have a balance of bacteria. Imbalance causes the dysbiosis between the good and bad bacteria.
Interview with Dr. David Wong on Salivary Diagnostics
Derek: What causes bad bacteria in your mouth?
Shahrzad: Good and bad bacteria is divided into two groups: the slow eaters and the fast eaters. The fast eaters feed on simple carbohydrates like sugars. When we eat sugary, white flour foods, we send these back bacteria into a frenzy. Then they metabolize acids. The slow eaters are actually the ones that are designed to digest longer, more complex molecules. They feed more on fibrous fruits.
Derek: Good and bad in this sense are based on the foods you're eating. When you say slow, it's not necessarily the amount of times you chew, but the actual foods you're consuming?
Shahzrad: In part, yes, definitely the foods that you're consuming. Processed foods, white sugars, and grains tend to see the faster-metabolizing bacteria. The more fibrous foods tend to affect the more slow-growing bacteria. If you eat too much sugar, the fast-metabolizing strains multiply too rapidly and spew out too much acid. That starts a chain reaction that leaches too much calcium from the enamel. The fastest-growing bacteria grow at the expense of the slower-growing bacteria.
If you have an imbalance, for example, if you have a lot of stress, we know that cortisol tends to secrete from the fluid around your teeth. That leads to the growth of gingivalis, which is the main bug that causes all the problems that we are seeing with GI.
Derek: What is it psychologically that people don't like to or are afraid to go to the dentist?
Shahzrad: We have to talk about the fear and trauma around dentistry. I was a kid in the seventies. We didn't grow up in a very kind, nurturing environment. Usually they would kick your mother out, tell you to be quiet and just suck it up, and you would be sitting helpless on the chair. More than anything, I hear every day, "Doc, I don't want to be here. I'm so afraid." The dentist appointment is the last phone call anyone makes. You're not thinking of your dental appointment as part of your health.
Most of the calls I get are pain calls. You tend to only go when you're in pain. Organized dentistry is now making a more concerted effort to create nurturing environments.
A dentist treating a soldier, Trench Mortars School, Nervesa della Battaglia, World War I, Italy, 20th century.
Derek: How do we get people to understand that oral health affects overall health?
Shahzrad: We have so many studies linking all kinds of periodontal disease and gum disease. There are links between gum disease and heart disease. In fact, 80 percent—this is a staggering number—80 percent of patients who've had heart attacks have gum disease, yet there's no discussion between dentists and cardiologists. We now have evidence of Alzheimer's being linked to gum disease. We now show increments of the same bacterial colonies in the intestine of patients with HIV, colon cancer, GI, and pancreatic cancer. The science is there.
Derek: We're really just learning how important gut health is. You're adding another layer here. The "tongue microbiota" is a new term to me.
Shahzrad: Yes. And we need to have more of these discussions. We need to make a paradigm shift to thinking about oral health as valuable and a part of our overall health. As our food got softer and less nutrient-dense, not only did we stop eating less roughage, we stopped using the muscles of our faces. We also started to eat a more grain-based diet, which is lacking in fat-soluble vitamins like A, D, and K. We also see in our patients a higher incidence of canker sores. If you're low in Omega 3s, you may be having periodontitis.
Derek: Cooking, however, made foods more nutritionally bioavailable. Richard Wrangham wrote an excellent book on that topic. The trade-off, of course, was that our jaws got much weaker.
Shahzrad: It's like going to the gym and exercising your muscles. The more you exercise, the better muscle strength and overall bone bone density improves. It's the same with the jaw. You want to eat more fibrous foods, but also foods that are nutrient-dense, that have K2 and vitamin D.
Derek: I used to have regular outbreaks of four to six canker sores at a time. When I went from a longtime, grain-heavy vegetarian diet to eating meat again, my canker sores disappeared. I haven't had one in four years now; I know there is a link there. This is just one example of the importance of food and your mouth. Overall, what is the future of oral health?
Shahzrad: The field of salivary diagnostics has come so far. Saliva markers can be used to detect all kinds of diseases, oral cancer, breast cancer, all kinds of autoimmune diseases. Chair-side salivary testing, which we offer in our practice now, will be the new paradigm, not only in the dental field but in the whole medical field. Dr. David Wong at UCLA is doing some very exciting research. He published 165 million genetic sequences and found that saliva contains many of the same molecules contained in blood. In the future, if you're not looking at saliva, you're going to be missing indicators of disease.
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This spring, a U.S. and Chinese team announced that it had successfully grown, for the first time, embryos that included both human and monkey cells.
In the novel, technicians in charge of the hatcheries manipulate the nutrients they give the fetuses to make the newborns fit the desires of society. Two recent scientific developments suggest that Huxley's imagined world of functionally manufactured people is no longer far-fetched.
On March 17, 2021, an Israeli team announced that it had grown mouse embryos for 11 days – about half of the gestation period – in artificial wombs that were essentially bottles. Until this experiment, no one had grown a mammal embryo outside a womb this far into pregnancy. Then, on April 15, 2021, a U.S. and Chinese team announced that it had successfully grown, for the first time, embryos that included both human and monkey cells in plates to a stage where organs began to form.
As both a philosopher and a biologist I cannot help but ask how far researchers should take this work. While creating chimeras – the name for creatures that are a mix of organisms – might seem like the more ethically fraught of these two advances, ethicists think the medical benefits far outweigh the ethical risks. However, ectogenesis could have far-reaching impacts on individuals and society, and the prospect of babies grown in a lab has not been put under nearly the same scrutiny as chimeras.
Mouse embryos were grown in an artificial womb for 11 days, and organs had begun to develop.
Growing in an artificial womb
When in vitro fertilization first emerged in the late 1970s, the press called IVF embryos “test-tube babies," though they are nothing of the sort. These embryos are implanted into the uterus within a day or two after doctors fertilize an egg in a petri dish.
Before the Israeli experiment, researchers had not been able to grow mouse embryos outside the womb for more than four days – providing the embryos with enough oxygen had been too hard. The team spent seven years creating a system of slowly spinning glass bottles and controlled atmospheric pressure that simulates the placenta and provides oxygen.
This development is a major step toward ectogenesis, and scientists expect that it will be possible to extend mouse development further, possibly to full term outside the womb. This will likely require new techniques, but at this point it is a problem of scale – being able to accommodate a larger fetus. This appears to be a simpler challenge to overcome than figuring out something totally new like supporting organ formation.
The Israeli team plans to deploy its techniques on human embryos. Since mice and humans have similar developmental processes, it is likely that the team will succeed in growing human embryos in artificial wombs.
To do so, though, members of the team need permission from their ethics board.
CRISPR – a technology that can cut and paste genes – already allows scientists to manipulate an embryo's genes after fertilization. Once fetuses can be grown outside the womb, as in Huxley's world, researchers will also be able to modify their growing environments to further influence what physical and behavioral qualities these parentless babies exhibit. Science still has a way to go before fetus development and births outside of a uterus become a reality, but researchers are getting closer. The question now is how far humanity should go down this path.
Chimeras evoke images of mythological creatures of multiple species – like this 15th-century drawing of a griffin – but the medical reality is much more sober. (Martin Schongauer/WikimediaCommons)
Human–monkey hybrids might seem to be a much scarier prospect than babies born from artificial wombs. But in fact, the recent research is more a step toward an important medical development than an ethical minefield.
If scientists can grow human cells in monkeys or other animals, it should be possible to grow human organs too. This would solve the problem of organ shortages around the world for people needing transplants.
But keeping human cells alive in the embryos of other animals for any length of time has proved to be extremely difficult. In the human-monkey chimera experiment, a team of researchers implanted 25 human stem cells into embryos of crab-eating macaques – a type of monkey. The researchers then grew these embryos for 20 days in petri dishes.
After 15 days, the human stem cells had disappeared from most of the embryos. But at the end of the 20-day experiment, three embryos still contained human cells that had grown as part of the region of the embryo where they were embedded. For scientists, the challenge now is to figure out how to maintain human cells in chimeric embryos for longer.
Regulating these technologies
Some ethicists have begun to worry that researchers are rushing into a future of chimeras without adequate preparation. Their main concern is the ethical status of chimeras that contain human and nonhuman cells – especially if the human cells integrate into sensitive regions such as a monkey's brain. What rights would such creatures have?
However, there seems to be an emerging consensus that the potential medical benefits justify a step-by-step extension of this research. Many ethicists are urging public discussion of appropriate regulation to determine how close to viability these embryos should be grown. One proposed solution is to limit growth of these embryos to the first trimester of pregnancy. Given that researchers don't plan to grow these embryos beyond the stage when they can harvest rudimentary organs, I don't believe chimeras are ethically problematic compared with the true test–tube babies of Huxley's world.
Few ethicists have broached the problems posed by the ability to use ectogenesis to engineer human beings to fit societal desires. Researchers have yet to conduct experiments on human ectogenesis, and for now, scientists lack the techniques to bring the embryos to full term. However, without regulation, I believe researchers are likely to try these techniques on human embryos – just as the now-infamous He Jiankui used CRISPR to edit human babies without properly assessing safety and desirability. Technologically, it is a matter of time before mammal embryos can be brought to term outside the body.
While people may be uncomfortable with ectogenesis today, this discomfort could pass into familiarity as happened with IVF. But scientists and regulators would do well to reflect on the wisdom of permitting a process that could allow someone to engineer human beings without parents. As critics have warned in the context of CRISPR-based genetic enhancement, pressure to change future generations to meet societal desires will be unavoidable and dangerous, regardless of whether that pressure comes from an authoritative state or cultural expectations. In Huxley's imagination, hatcheries run by the state grew a large numbers of identical individuals as needed. That would be a very different world from today.
Sahotra Sarkar, Professor of Philosophy and Integrative Biology, The University of Texas at Austin College of Liberal Arts
Scientists should be cautious when expressing an opinion based on little more than speculation.
- In October 2017, a strange celestial object was detected, soon to be declared our first recognized interstellar visitor.
- The press exploded when a leading Harvard astronomer suggested the object to have been engineered by an alien civilization.
- This is an extraordinary conclusion that was based on a faulty line of scientific reasoning. Ruling out competing hypotheses doesn't make your hypothesis right.
Sometimes, when you are looking for something ordinary, you find the unexpected. This is definitely the case with the strange 'Oumuamua, which made international headlines as a potential interstellar visitor. Its true identity remained obscure for a while, as scientists proposed different explanations for its puzzling behavior. This is the usual scientific approach of testing hypotheses to make sense of a new discovery.
What captured the popular imagination was the claim that the object was no piece of rock or comet, but an alien artifact, designed by a superior intelligence.
Do you remember the black monolith tumbling through space in the classic Stanley Kubrick movie 2001: A Space Odyssey? The one that "inspired" our ape-like ancestors to develop technology and followed humanity and its development since then? What made this claim amazing is that it wasn't coming from the usual UFO enthusiasts but from a respected astrophysicist from Harvard University, Avi Loeb, and his collaborator Shmuel Bialy. Does their claim really hold water? Were we really visited by an alien artifact? How would we know?
A mystery at 200,000 miles per hour
Before we dive into the controversy, let's examine some history. 'Oumuamua was discovered accidentally by Canadian astronomer Robert Weryk while he was routinely reviewing images captured by the telescope Pan-STARRS1 (Panoramic Survey and Rapid Response System 1), situated atop the ten-thousand-foot Haleakala volcanic peak on the Hawaiian island of Maui. The telescope scans the skies in search of near-Earth objects, mostly asteroids and possibly comets that come close to Earth. The idea is to monitor the solar system to learn more about such objects and their orbits and, of course, to sound the alarm in case of a potential collision course with Earth. Contrary to the objects Weryk was used to seeing, mostly moving at about 40,000 miles per hour, this one was moving almost five times as fast — nearly 200,000 miles per hour, definitely an anomaly.
Intrigued, astronomers tracked the visitor while it was visible, concluding that it indeed must have come from outside our solar system, the first recognized interstellar visitor. Contrary to most known asteroids that move in elliptical orbits around the sun, 'Oumuamua had a bizarre path, mostly straight. Also, its brightness varied by a factor of ten as it tumbled across space, a very unusual property that could be caused either by an elongated cigar shape or by it being flat, like a CD, one side with a different reflectivity than the other. The object, 1I/2017 U1, became popularly known as 'Oumuamua, from the Hawaiian for "scout."
In their paper, Loeb and Bialy argue that the only way the object could be accelerated to the speeds observed was if it were extremely thin and very large, like a sail. They estimated that its thickness had to be between 0.3 to 0.9 millimeters, which is extremely thin. After confirming that such an object is robust enough to withstand the hardships of interstellar travel (e.g., collision with gas particles and dust grains, tensile stresses, rotation, and tidal forces), Loeb and Bialy conclude that it couldn't possibly be a solar system object like an asteroid or comet. Being thus of interstellar origin, the question is whether it is a natural or artificial object. This is where the paper ventures into interesting but far-fetched speculation.
I'm not saying it was aliens, but it was aliens
First, the authors consider that it might be garbage "floating in interstellar space as debris from advanced technological equipment," ejected from its own stellar system due to its non-functionality; essentially, alien space junk. Then, they suggest that a "more exotic scenario is that 'Oumuamua may be a fully operational probe sent intentionally to Earth vicinity by an alien civilization," [italicized as in the original] concluding that a "survey for lightsails as technosignatures in the solar system is warranted, irrespective of whether 'Oumuamua is one of them."
You can shoot down as many hypotheses as you want to vindicate yours, but this doesn't prove yours is the right one.
I have known Avi Loeb for decades and consider him a serious and extremely talented astrophysicist. His 2018 paper includes a suggestive interpretation of strange data that obviously sparks the popular imagination. Theoretical physicists routinely suggest the existence of traversable wormholes, multiverses, and parallel quantum universes. Not surprisingly, Loeb was highly in demand by the press to fill in the details of his idea. A book followed, Extraterrestrial: The First Sign of Intelligent Life Beyond Earth, and its description tells all: "There was only one conceivable explanation: the object was a piece of advanced technology created by a distant alien civilization."
This is where most of the scientific establishment began to cringe. One thing is to discuss the properties of a strange natural phenomenon and rule out more prosaic hypotheses while suggesting a daring one. Another is to declare to the public that the only conceivable explanation is one that is also speculative. An outsider will conclude that a reliable scientist has confirmed not only the existence of extraterrestrial life but of intelligent and technologically sophisticated extraterrestrial life with an interest in our solar system. I wonder if Loeb considered the impact of his words and how they reflect on the scientific community as a whole.
This is why aliens won't talk to us
Earlier this year, in a live public lecture hosted by the Catholic University of Chile, Avi Loeb locked horns with Jill Tarter, the scientist that is perhaps most identifiable as someone who spent her career looking for signs of extraterrestrial intelligence. (Coincidentally, I was the speaker that followed Loeb the next week in the same seminar series and was cautioned — along with the other panelists — to behave myself to avoid another showdown. I smiled, knowing that my topic was pretty tame in comparison. I mean, how can the limits of human knowledge compare with alien surveillance?)
The Loeb-Tarter exchange was awful and, it being a public debate, was picked up by the press. Academics can be rough like anyone else. But the issue goes deeper.
What scientists say matters. When should a scientist make public declarations about a cutting-edge topic with absolute certainty? I'd say never. There is no clear-cut certainty in cutting-edge science. There are hypotheses that should be tested more until there is community consensus. Even then, consensus is not guaranteed proof. The history of science is full of examples where leading scientists were convinced of something, only to be proven wrong later.
The epistemological mistake Loeb committed was to make an assertion that publicly amounted to certainty by using a process of elimination of other competing hypotheses. You can shoot down as many hypotheses as you want to vindicate yours, but this doesn't prove yours is the right one. It only means that the other hypotheses are wrong. I do, however, agree with Loeb when he says that 'Oumuamua should be the trigger for an increase in funding for the search for technosignatures, a way of detecting intelligent extraterrestrial life.