Heart Attack? Stroke? The smoking gun might be your “smoking” gums.

Oral health has a bigger impact on your overall health than you likely suspect. Inflammation associated disease in the mouth can have a negative impact throughout your whole body and lead to some very serious conditions. Bacterial, viral and fungal pathogens contribute to arterial disease (50% of heart attacks and strokes!) metabolic disease (insulin resistance, prediabetes, Type 2 Diabetes), cancer, dementia, high risk pregnancy, and inflammatory arthritis.

One of the key players in this oral systemic connection are the bacteria that live in your mouth. There are both good and bad bacteria that inhabit the mouth, the “oral microbiome.” The goal is to maintain barriers to invasion locally (gingivitis and periodontitis) and systemically (arterial injury) reduce the population of the bad bacteria and create an environment to promote good bacteria.

While colonization may be difficult or impossible to eliminate, prevention of infection of gums and systemic invasion are the primary goals of an optimal oral hygiene routine. Brushing and flossing are the foundation of good oral hygiene, but may not be enough if bad bacteria have taken hold.

How are bad bacteria detected?

Visual inspection alone will not pick up the presence of high risk bacteria. Even if your gum tissues appear healthy, these bacteria may invade subtle pockets of inflammation or be opportunistic for a lapse in hygiene or the barrier to invasion associated with healthy gums. This can turn colonization into infection and inflammation in the gums, arteries and elsewhere.

More and more dentists and hygienists are highlighting the connection between the mouth and the rest of the body. If your dental care providers are on board with this focus, you are fortunate. If your dentist is unaware or uninterested in this connection, The CureCenter can recommend oral health providers who are on board for at least a second opinion and perhaps a transfer of care.

We use saliva testing to measure the amount of bad or pathogenic bacteria in the mouth. The results will motivate a plan (provided by a dental professional) to address the concern. The key is to reduce the level of bad bacteria that contribute to chronic disease and preserve barriers to invasiveness locally and systemically. For more detail, click SimplyPerio. In general, I classify Fn as “bad, Td and Tf as “worse” and Pg and Aa as “the worst” bacteria to be present in the mouth.

For more details go to https://simplytest.solutions/testing/saliva-perio-testing/

What should my dentist be looking for?

Dentists who are on the leading edge of oral care use cone beam/3D CT scans to look for presymptomatic abscesses and other issues that may be missed by routine examination and standard x-rays. These conditions don't always cause symptoms that would cause concern. This can be dangerous because the first noticeable symptom could be a heart attack or stroke. High risk oral pathogens can also contribute to poor control of diabetes and prediabetes.

We recommend cone beam CT, especially for our patients who have had prior events or elevated myeloperoxidase (MPO). Traditional x-rays will routinely miss abscesses that could be driving arterial inflammation and increase the likelihood of heart attack or stroke. For example, old root canals can be sites of chronic inflammation but detection may not be possible without use of the cone beam CT. 

At the CureCenter, we will work with your current dentist to gather this type of information if they show an interest. If not, we can recommend a dentist who we know is on board with this process.

What can I do to avoid oral health issues?

Choose a dental professional who understands concerns beyond your teeth. You can find this out by learning if your dentist has participated in continuing education about the oral systemic connection. Regularly visit this dental professional and make sure they provide an ongoing treatment plan for any issues. Follow their plan.

Get saliva testing at least once to discover any bad bacteria that may be present. We have seen patients that have no obvious issues or new cavities that have had significant levels of dangerous bacteria in spite of their current dental plan. Don’t let colonization with these bacteria become invasive infection in your gums or arteries.

Associations between high risk (red complex) oral bacteria and serious medical conditions and complications.

Follow a daily routine to maintain proper oral care and prevent bad bacteria from growing in your mouth. Daily brushing and flossing can be augmented with use of a waterpik and dental picks. Use a pH neutral mouth rinse twice daily to help promote healthy bacteria that protect teeth and gums. Brush your entire mouth, not just the teeth and gums, and always go to bed with a clean mouth.

During the day, choose 100% xylitol gum or mints and eat tooth protecting foods (low carb/high protein) at the end of meals or snacks.

Get regular cleanings and follow the advice of your dental professional. They are your best resource for learning to avoid oral systemic disease.

Ask your dentist about PerioProtect, a system that delivers an antibacterial solution to the areas below the gumline where brushing and mouthwashes/rinses won’t reach. If your current dentist does not offer Perioprotect, we are happy to suggest one who will.

Watch and share: Oral Systemic Podcast

What is visceral fat and how do I reduce it?

There are two types of fat that our body stores: subcutaneous fat and visceral fat.

Subcutaneous fat is stored just under the skin. We can feel it in our arms, legs, and hips. Think of it as the fat that you are able to pinch with your fingers.

Visceral fat, or visceral adipose tissue, is the fat that is stored inside the body cavity and wraps itself around and infiltrates our internal organs, such as the heart, liver, or intestines. This fat is metabolically active and functions as if you had another organ in your body which produces negative hormonal effects. We call it “angry” or “inflammatory” fat.

Why is visceral fat dangerous?

Visceral fat is also referred to as “active” or “inflammatory” fat because it produces substances that contribute to insulin resistance, leading to Type 2 Diabetes. Insulin resistance is the prediabetic state where your body is losing its ability to properly balance insulin and regulate blood glucose. 

Visceral fat secretes a protein called retinol-binding protein 4 (RBP4) that increases insulin resistance in the body. It also releases inflammatory substances called cytokines, which leads to chronic inflammation.

High levels of visceral fat are associated with increased risk for:

• Type 2 Diabetes

• Heart disease

• Breast cancer

• Colorectal cancer

• Alzheimer’s disease

• Nonalcoholic fatty liver disease (NAFLD)

It is very difficult to be healthy with high amounts of visceral fat. Lowering visceral fat eliminates a major driver of chronic diseases.

What are the sources of visceral fat?

The root causes of visceral fat are refined carbohydrates, processed foods, and artificial sweeteners ingested without periods of fasting. This type of diet is typical in Western cultures. In order to eliminate visceral fat, the secret is to minimize the five S’s: Sweets, Starch, Snacks, Seed oils, and Sitting.

How do you test for visceral fat?

There are many ways to estimate your visceral fat. MRI, DEXA, and CT scans are accurate but costly and inconvenient. A cheaper way to estimate visceral fat is to measure your waistline. A healthy waistline in women is typically 35” or lower, and 40” or lower for men. However, these measurements are prone to variability. They are inexpensive, but not precise.

At the CureCenter, we have a simple, non-invasive, and cost-effective way to measure and monitor visceral fat. We use the InBody 570 analyzer to obtain accurate body composition data on our patients repeatedly over time. This data allows us to monitor not only visceral fat, but percent body fat, skeletal muscle mass, and hydration levels. This information is crucial in monitoring the benefit of our treatment and demonstrating optimal results. The InBody data goes far beyond the scale and helps us provide motivation for ongoing lifestyle improvements.

Body composition tests using the InBody 570 only take a few minutes and are completely painless and non-invasive. The process is similar to stepping on a scale - only this machine measures much more than your average at-home device. If you have a pacemaker or defibrillator, or you are pregnant, we don’t use the InBody, even though the risk is not high.

How do I eliminate visceral fat?

• Reduce your sugar intake, especially sugary drinks, refined white carbohydrates, and processed foods.

• Avoid artificial sweeteners. They raise insulin in the same way as sugar, even though they are lower in calories. They also perpetuate cravings for real sugar by feeding your sweet tooth, like a “gateway” drug.

• Restrict eating to a window of time (ideally 6-8 hours) and devote time every day to fasting (drinking only water or non-sugary drinks). At least 16 hours of fasting, including sleep, is a goal we promote to our patients. We call it “window feeding.”

• Exercise as much as you can most days.

• Eat a low-glycemic diet. Low-glycemic foods consist of green vegetables, whole fruits (in moderation), beans, and lentils. 

• Get a good night’s sleep. Too little sleep or too much sleep on a regular basis can lead to more visceral fat storage.

• Manage stress. Mindfulness practices like prayer, meditation, or yoga can help manage your body’s stress response and lower cortisol levels.

• Limit alcohol. When your liver is processing alcohol, it is not processing fat.

• Quit smoking. Tobacco use can negatively affect your ability to deal with glucose and increase insulin resistance.

• Targeted supplements and medications can improve insulin sensitivity for some individuals with stubborn visceral fat.

What is Insulin Resistance? Can it be reversed?

Insulin resistance occurs when the cells of the muscles, fat, and liver become insensitive or resistant to insulin. This causes the body to produce higher insulin levels in response to glucose intake to achieve the primary goal: Optimize blood glucose and its utilization as fuel. This state of hyperinsulinemia is highly inflammatory for your entire body, especially your arteries and nerves. Eventually insulin production fails and blood sugar levels begin to rise. It is at this point the patient is diagnosed with diabetes based on elevated blood glucose/”sugar”, the final stage of "diabesity."

However, even thin, lean people can be insulin resistant, especially if muscle mass is low (sarcopenia) relative to body fat, especially visceral fat. This is especially common for women after menopause.

Insulin resistance is so common that we should assume its presence till proven absent. Why is it so common to be called a “feature” rather than a “bug”? Why wouldn’t evolutionary pressures get rid of it? The answer: It is a benefit to the hunter gatherer lifestyle. It is not well suited for our current cultural habits of “grazing” constantly on sweets, starches and highly processed snacking. And, it doesn’t cause death prior to reproduction.

The answer: Eat like a hunter gatherer! Eat within a short time window (6 hours is ideal) and eat lots of vegetables, a little fruit (sugary!), meat/protein and good fat (olive, coconut or avocado oil, seeds, nuts).

What is Diabesity? 

Diabesity is the spectrum of adverse health effects of diabetes and obesity. It is the result of a modern environment of processed food loaded with sweets and starches consumed throughout the day. 

Before rising glucose levels are detected, the higher insulin levels (caused by insulin resistance) raise blood pressure and create inflammation that contributes to arterial injury. We call this injury and the resulting inflammation and scarring atherosclerosis. It can also lead to diabetes, dementia (Type 3 Diabetes?) erectile dysfunction, and depression. Risk of heart attack, stroke, and dementia also increase. 

We develop "tolerance" to the toxic effects of sweets and insulin. This leads us to crave more sweets, driving our insulin levels higher, and can lead to early death and disability if unrecognized and untreated.

Image Source: International Diabetes Center

This graph illustrates the relationship between insulin resistance, rising insulin levels, and blood glucose levels associated with the progression from insulin resistance (“pre” prediabetes, prediabetes to Type 2 Diabetes.  It should be labeled "The Natural History of "Diabesity."

What are some indicators of Insulin Resistance/Diabesity?

Some indicators of insulin resistance include (but are not limited to):

• Increased waist size

• Elevated visceral fat

• High blood pressure

• Elevated blood sugar

• High triglycerides

• Low HDL cholesterol (Metabolic syndrome)

• Small dense LDL predominance (Pattern B)

• Heart attack or stroke

• Gestational diabetes

• Polycystic Ovary Syndrome

• Erectile Dysfunction

• Ananthosis Nigricans

• Periodontal disease

How do we identify Insulin Resistance/Diabesity?

The gold standard identifier of insulin resistance includes a two hour oral glucose tolerance test with simultaneous insulin levels. During this test, your blood is drawn before and after drinking a sugary liquid to see how your body responds. Measuring against certain high benchmarks define diabetes and prediabetes. Normal glucose (blood sugar) levels should be below 125 after one hour of this test and 120 after two hours. 

Fasting glucose levels above 90 and HbA1c above 5.0 should raise concerns about insulin resistance until other measures are used to rule it out.

Other measures used to identify insulin resistance include: high triglycerides, low high-density lipoprotein (HDL), small and dense low-density lipoprotein (LDL), hypertension, non-alcoholic fatty liver disease (NAFLD), and “idiopathic” neuropathy. Insulin levels outside the context of response to standardized glucose intake or infusion are not helpful. Normal fasting insulin does not exclude insulin resistance or disprove and elevated levels tell us no more than other evidence already cited and generally availalable

At the CureCenter, we perform body composition analyses on all of our patients to help identify insulin resistance/diabesity. Elevated visceral fat (which correlates with percent body fat) can be detected in a few minutes, revealing some of the earliest evidence.

Visceral fat can be hard to identify without a body composition analysis, as one may appear “thin” on the outside, but still have high levels of visceral fat. These healthy looking individuals have low muscle mass, known as sarcopenia. This occurs especially in women after they experience menopause, especially if they avoid resistance exercises.

New options for continuous glucose monitoring, like Lingo and Stelo make continuous glucose monitoring available without a prescription at affordable pricing for the masses. Stelo is even available on Amazon. The feedback from seeing the actual real time impact of food choices and other behavior, make this perhaps the most powerful tool in our battle against cardiometabolic disease. It confirms diagnosis, but more importantly offers individualized feedback about foods that should be avoided and choices that are safer to guide choices.

How do we reverse Insulin Resistance/Diabesity?

Dietary Changes: First, cut out sweets, starches, and snacks from your diet. Excess sugar in your daily diet is stored as fat, worsening insulin resistance. Avoid sugar, artificial sweeteners (they raise insulin and enhance cravings), processed foods, and bread, pasta, potatoes, and rice. These all raise insulin levels (even in the absence of high amounts of calories) and perpetuate cravings for sweets. These cravings are a form of addiction, much like addictions to drugs and alcohol.

In order to effectively reverse insulin resistance/diabesity, be sure to eat more vegetables, protein, and good fats (from sources such as olive oil, coconut oil, nuts, seeds, and fish). 

Although fruit contains important vitamins, eat it in moderation. Fruit is higher in sugar (especially if dried or juiced) than vegetables. Eat whole fruit in limited amounts to ensure healthy glucose levels. Berries are the best. Apples, pears and other fibrous foods slow glucose absorption. Bananas and grapes are like candy bars and M&Ms!

Exercise: Get off the couch. A sedentary lifestyle is a recipe for all types of chronic disease. While nearly all types of physical activity can be beneficial, we recommend high intensity interval training and a focus on building muscle through resistance training in addition to aerobic/cardio exercise.

Restricted Feeding/Fasting: At the CureCenter, we see the best results in individuals who restrict their good food intake to an 6-8 hour window each day. In the other 16 hours of the day, drink only water or unsweetened beverages.

For additional information about healthy fasting, we recommend resources created by Dr. Jason Fung, including his books, “The Obesity Code,” and “The Diabetes Code,”  blog (The Fasting Method), and YouTube channel.

Proper Amounts of Sleep: Poor amount and quality of sleep has been linked to higher levels of insulin resistance. Be sure to get proper amounts of sleep each night. More is generally better. Very few of us get enough sleep. It is rare to get too much sleep in the absence of sleep apnea.

Manage Stress: High levels of stress and associated high cortisol have also been linked to insulin resistance. Although it’s not always easy, try to find ways to relieve stress to reduce cortisol levels, which raise glucose and insulin. Exercise is a proven and healthy way to reduce stress. So get off the couch and go outdoors or to the gym. Mindfulness practices such as meditation, prayer, or yoga can also help to manage stress.

Measure Your Results: When you first start on your journey to reverse resistance to insulin, it’s best to measure your results every 1-2 weeks by taking a body composition test (these can be done at the CureCenter office). When you’ve met your goal, continue to test every 1-2 months to ensure you are staying on track. Staying accountable is key. Seeing improvement perpetuates the process.

Wear and pay attention to the results of a continuous glucose monitor for at least 2 weeks to identify threats and avoid them. For those who need the extra discipline and monitoring, doing so more often can help resist the influence of our pervasive and powerful harmful processed food culture.

We call it M&M’s (the healthy kind): Measure, Motivate, and Maintain Momentum.

Supplements and Medication (if goals not achieved by lifestyle changes alone ): Sometimes, insulin resistance is so stubborn that a healthy diet and exercise do not achieve the reduction in fat that one may expect. This can be due to an incomplete commitment to carbohydrate restriction or insufficient patience. We cannot out-prescribe a bad diet. However, sometimes a little help is needed. At the CureCenter, we will prescribe medications and/or supplements that best suit your needs and lifestyle. Supplements that are most helpful include Bergamot BPF, Vitamin D3/K2, cinnamon, ALA and others.

I’m often asked about metformin. Metformin reduces glucose primarily by reducing release of glucose from liver stores of glycogen, but it is also considered a mild insulin sensitizer. There is a lot of interest in it as an antiaging and anticancer treatment. Its impact on cardiovascular outcomes is not as impressive as pioglitazone, a thiazolidinedione medication.

Pioglitazone improves insulin sensitivity. It is generic and has been around for a long time. It suffers from a bad reputation for fluid retention because its use was delayed till patients with Type 2 Diabetes had failed 1st line drugs that increased the risk of heart damage from prior heart attacks. But when used in the prediabetes stage, before the damage to the heart, it is generally well tolerated and dramatically reduces the risk of heart attack (>70% reduction) while lowering insulin levels. See Figure 3: