Ask Me Anything (AMA): Oral Health, Healthspan, and Longevity with Dr. Gil Blander and Ashley Reaver, MS, RD, CSSD

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Did you know that your oral health has a profound impact on healthspan and longevity?

Do you want to learn about the connections between oral health, healthspan, and longevity and what you can do to improve your oral health to help you live longer and add more healthy years to your life?

This episode of Longevity by Design is an Ask Me Anything (AMA) between Dr. Gil Blander and Ashley Reaver, MS, RD, CSSD, where they dive into the often-overlooked importance of oral health for healthspan and longevity. They gathered and answered questions asked by the Longevity by Design audience, with the scientific evidence indicating that oral health is not just about a nice smile, but also has a startling link with healthspan and longevity.

Dr. Gil Blander and Ashley Reaver begin by defining what oral health and oral frailty are. They discuss that good oral health is an essential aspect of overall health and well-being, whereas poor oral health can lead to various dental and health problems. They then answer questions on the oral microbiome and what you should know about it. They also answer questions on how oral health is connected to the health of the rest of the body, healthspan, and longevity–with an emphasis on mortality, Alzheimer’s disease, cardiovascular disease, and diabetes.

Importantly, Dr. Blander and Ashley answer questions backed by science on what you can do to improve your oral health. They conclude by addressing questions on the influence of nutrition on oral health and the not-so-obvious but intriguing link between oral health and physical fitness and function.

Episode highlights

• Introduction: 00:00-01:44
• What is the reason for choosing the topic of oral health, healthspan, and longevity: 01:44-03:11
• What is oral health: 03:12-04:23
• How is oral health connected to healthspan and longevity: 04:24-09:01
• What is oral frailty: 09:02-10:04
• What is the oral microbiome and what is known about the oral microbiome: 10:05-14:59
• What is the relationship between oral health and cognitive health: 15:00-19:36
• What is the relationship between oral health and cardiovascular diseases: 19:37-23:43
• What is the relationship between oral health and diabetes: 23:44-28:01
• Preventing versus treating diseases: 28:02-30:54
• How to improve oral health: 30:55-31:42
  • When should I brush my teeth in the morning, before or after breakfast: 31:43-33:51
  • How long should I brush my teeth? How do I know if I am brushing them correctly and for the right amount of time: 33:52-35:38
  • Should I use toothpaste with fluoride in it: 35:38-36:15
  • How often should I floss? What is a water flosser, and is it beneficial: 36:16-38:15
  • Should I use a mouthwash: 38:15-42:27
• What is the influence of nutrition on oral health: 42:28-48:35
• Is there a connection between oral health and physical fitness and physical function: 48:36-51:14
• Summary: 51:15-55:42

What is oral health?

Oral health refers to the condition of your mouth, including your teeth, gums, and related structures. Oral health is not only about preventing cavities but also about promoting healthy gums, fresh breath, maintaining moisture from saliva production and proper usage of teeth. In 2016, the FDI World Dental Federation approved a new, multifaceted definition of oral health: 
“the ability to speak, smile, smell, taste, touch, chew, swallow, and convey a range of emotions through facial expressions with confidence and without pain, discomfort, and disease of the craniofacial complex.” [1]

How is oral health connected to the health of the rest of the body, healthspan, and longevity?

The definition by the World Dental Federation noted that oral health is an essential aspect of overall health and well-being, whereas poor oral health can lead to various problems, including:

• cavities 
• gum disease 
• loss of teeth 
• and bad breath 

Poor oral health is also linked to more than 50 systemic health conditions–including: 

• Alzheimer’s disease, 
• Cardiovascular disease 
• Diabetes 
• Respiratory issues

The link between oral and systemic conditions can be microbial, inflammatory, or a combination of both. 

Poor oral health is not only associated with decreased healthspan, but also decreased lifespan. There are numerous scientific studies showing that those with fewer teeth are at an increased risk of death. 

• For example, in a study with a 4-year follow-up period with 85,161 Japanese people, females with ≥20 teeth had a 30% lower mortality risk than did females who had no teeth, and males with ≥20 teeth had a 42% lower mortality risk than did males who had no teeth [2]. Similar findings have been observed in US, Danish, and other Japanese populations [3].
• In a 15-year-long study including 500 participants in the US, compared to those with ≥20 teeth, the mortality risks for those with 1–19 teeth was 2.1 times greater, and 1.76 times greater for those with no teeth [4]. Again, similar findings have been observed in other studies carried out in countries including others in the US, Japan, China, Sweden, and the UK [3].

Oral frailty: Recently, oral frailty has become one of the most important issues regarding dental and oral health. “Oral frailty” is a new concept that was introduced in Japan in 2013 in relation to oral function. 

As of 2020, oral frailty is defined by the Japan Dental Association as follows: a series of phenomena and processes that lead to changes in various oral conditions (number of teeth, oral hygiene, oral functions, etc.) associated with aging, and accompanied by decreased interest in oral health, reduced physical and mental reserve capacity, and an increase in oral frailty leading to eating dysfunction; the overall effect is decreased physical and cognitive function [3].

What is the oral microbiome, and what should you know about the oral microbiome?

The oral microbiome refers to the complex and diverse community of microorganisms that inhabit the oral cavity, including the mouth and throat. The oral microbiome consists of bacteria, viruses, fungi, and other microbes that form a dynamic and balanced ecosystem. The oral microbiome seemingly plays a crucial role in maintaining oral health and has implications for overall well-being [5, 6].

If you’ve never considered your mouth’s microbiome, all you have to do is run your tongue over your teeth in the morning. That slimy feeling on your teeth is a film formed by the bacteria in your mouth. 

Some key points about the oral microbiome [5,6]:

• Diversity: The oral cavity has more than 700 microbial species. The diversity of these microorganisms contributes to the stability and resilience of the oral microbiome.
• Balance: A healthy oral microbiome is characterized by a balanced and harmonious relationship among different microbial species. Disruptions in this balance can lead to oral health issues, such as cavities, gum disease, and bad breath. This is pretty new research, and just like the gut microbiome, there isn’t enough concrete evidence on specific strains or treatments to change the microbiome. But, just like your gut, it is best to encourage diversity and not one or a few types of bacteria becoming the overwhelming majority. 
• Functions: The oral microbiome performs important functions, including helping with digestion since it can contribute to the gut microbiome and our microbe's ability to help digest fibers, defend against pathogens, and contribute to the development of the immune system. Some bacteria in the oral cavity are beneficial and aid in maintaining oral health.
• Influence on health: The oral microbiome is being increasingly recognized for its impact on overall health. Imbalances in the oral microbiome may be indicative of overall oral health which has been linked to various systemic conditions, including Alzheimer’s disease, cardiovascular diseases, diabetes, and respiratory infections.
• Oral hygiene and Diet: Obviously, practices such as regular brushing and flossing, especially before bed, are your best bet for maintaining good oral health.  Diet can also play an important role. Most importantly, monitoring the intake of simple sugars may have the biggest impact, which we know is also important for avoiding cavities. If you notice gum bleeding, you should see your dentist as soon as possible. Going to the dentist regularly, once or twice per year, is also important.

Research on the oral microbiome is at a very nascent stage, and researchers are continuing to investigate how it is linked to various health conditions. At this time, we really just know the microbiome exists and is important, but the use of probiotic mouthwash, toothpaste, chewing gum, or tablets is currently not well supported. Maybe in the future, as new research emerges and our understanding of the oral microbiome improves.

What is the relationship between oral health and cognitive health?

There is a bi-directional relationship between oral health and cognitive health. However, the exact mechanisms are not fully understood.

Poor oral health, specifically periodontal disease is linked to up to a staggering 2-fold increase in the risk of developing dementia and a 1.5-fold increase in the risk of developing Alzheimer’s. 

In the other direction, dementia and Alzheimer’s can increase the risk of poor oral health and periodontal diseases [7].

Some key points regarding the relationship between oral health and cognitive health [7]:

• Inflammation: Chronic inflammation has been identified as a common factor in both oral health conditions, particularly gum disease, and cognitive decline. Inflammation in the body, including the mouth, may contribute to systemic inflammation, which is associated with cognitive issues.
• Periodontal disease and cognitive decline: Some studies have found associations between periodontal (gum) disease and cognitive decline. Chronic gum inflammation may release inflammatory molecules that could reach the brain and contribute to neurodegenerative processes.
• Bacterial impact:  There is some evidence that oral bacteria and their byproducts may potentially enter the bloodstream and reach the brain, impacting cognitive function. While the exact mechanisms are not fully understood, there is ongoing research exploring the potential pathways through which oral bacteria may affect the brain.
• Shared risk factors: Certain risk factors, such as age, diabetes, and cardiovascular diseases, are associated with both poor oral health and cognitive decline. Shared risk factors suggest a potential commonality in the underlying processes contributing to both conditions.
• Tooth loss and cognitive function: Some studies have suggested a correlation between tooth loss and cognitive decline. The number of natural teeth remaining in older age has been associated with cognitive function. A dose-response meta-analysis, including 34,074 participants, showed that those with greater tooth loss were at an increased risk of cognitive decline and dementia [8].

What is the relationship between oral health and cardiovascular disease?

The scientific evidence indicates an association between oral health and cardiovascular disease. However, a direct cause-and-effect relationship has not been fully established. The connection between oral health and cardiovascular disease primarily revolves around inflammation and oral bacteria entering the bloodstream [9, 10].

Some key points regarding the relationship between oral health and cardiovascular disease [9, 10]:

• Inflammation: Periodontal (gum) disease is a chronic inflammatory condition caused by the accumulation of bacteria in dental plaque. The inflammation associated with gum disease has been linked to systemic inflammation, which is also a factor in the development of cardiovascular disease.
• Bacteria: Oral bacteria can enter the bloodstream through the gums when they have cracks and bleed, especially in individuals with gum disease or during activities like brushing and flossing. Once in the bloodstream, these bacteria can act like other bacteria, causing an immune response from white blood cells. Elevated levels of white blood cells may contribute to the formation of plaque in the arterial walls. Monocytes, a type of white blood cell, invade the cell wall, forming foam cells that contribute to the formation of plaques in blood vessels, potentially increasing the risk of developing cardiovascular disease.
• Atherosclerosis: Atherosclerosis is a condition characterized by the buildup of plaques in the arteries. Atherosclerosis is a key factor in cardiovascular diseases like coronary artery disease. Importantly, inflammation is a key piece of the atherosclerotic process, along with LDL-cholesterol. Poor gum health can cause the systemic inflammation that fuels the development of these plaques. 
• Endothelial dysfunction: Oral bacteria may impact the function of the endothelium, the inner lining of blood vessels. Endothelial dysfunction is associated with impaired blood vessel function and is considered an early step in the development of cardiovascular disease.
• Shared risk factors: While not a direct link, oral health, and cardiovascular disease share common risk factors such as smoking, diabetes, and poor dietary habits. Addressing these risk factors can have positive effects on both oral health and cardiovascular health. It is also important to state that social, economic, and lifestyle factors like lack of access to healthcare, healthy foods, and leisure time for activity are influential and need to be addressed.

What is the relationship between oral health and diabetes?

The relationship between oral health and diabetes is bidirectional, meaning each condition can influence the other. People with diabetes may be more prone to certain oral health issues, and conversely, poor oral health can potentially impact diabetes management by resulting in increased blood glucose and HbA1c [10, 11]. 

Some key points regarding the relationship between oral health and diabetes [10, 11]:

• Gum disease and diabetes: There is a strong connection between diabetes and gum disease (periodontitis). Individuals with diabetes are at an increased risk of developing gum disease, and untreated gum disease can make it more challenging to manage blood sugar levels.
• Inflammation: Both diabetes and gum disease involve inflammation. Chronic inflammation in the body can affect the development and progression of diabetes. In turn, diabetes can contribute to an exaggerated inflammatory response, potentially worsening gum disease.
• Blood sugar control: Poorly controlled diabetes can lead to high blood sugar levels, which can promote bacterial growth in the mouth and increase the risk of gum disease and cavities. Conversely, treating and managing gum disease may contribute to better blood sugar control in individuals with diabetes.
• Oral infections: Diabetes can reduce the body's ability to fight infections, including those in the mouth. This makes individuals with diabetes more susceptible to oral infections, including gum infections.
• Dry mouth: Diabetes and some diabetes medications can contribute to dry mouth. Reduced saliva flow can increase the risk of cavities and other oral health issues because saliva helps neutralize acids, wash away food particles, and prevent the overgrowth of harmful bacteria.
• Shared risk factors: Diabetes and poor oral health share common risk factors, including smoking, poor diet, and lack of regular dental care. Addressing these shared risk factors can have positive effects on both diabetes management and oral health.

It's crucial for individuals with diabetes to be proactive in managing their oral health and working closely with both their dentist and healthcare provider. Maintaining good oral hygiene practices, managing blood sugar levels, and seeking prompt treatment for any oral health issues are essential components of overall diabetes care. Conversely, taking steps to control diabetes can positively impact oral health outcomes. The interdisciplinary approach involving dental, medical, and nutrition professionals is important for comprehensive care in individuals with diabetes.

Key things to do to improve oral health

Maintaining good oral health or improving oral health involves a combination of regular oral hygiene practices such as brushing your teeth twice a day in the morning and at night, daily flossing, a healthy diet, and routine dental check-ups. 

Some key factors and answers based on the most up-to-date scientific evidence and expert recommendations to commonly asked questions are addressed below:

When should I brush in the morning, before or after breakfast?

The optimal time to brush your teeth—before or after breakfast—can depend on various factors and personal preferences. When you should brush your teeth depends on your morning routine and whether or not you eat breakfast or what you eat or drink. 

Breakfast staples like orange juice and coffee are notoriously acidic. Brushing your teeth right after eating or drinking acidic foods can cause damage to your tooth enamel. The American Dental Association recommends waiting at least 60 minutes after eating or drinking acidic foods before brushing your teeth.

If you don’t have time to wait, it might be best to brush your teeth before eating in the morning. For those who don’t drink coffee, tea, or orange juice or eat other acidic foods, brushing after breakfast can help remove food particles and plaque buildup while freshening your breath.

How long should I brush my teeth? How do I know I am brushing correctly and for the right amount of time? 

The American Dental Association (ADA) recommends brushing your teeth twice a day for 2 minutes each time. When you brush, make sure to brush all surfaces of your teeth—the front, back, top, bottom, and chewing surfaces. It is recommended to brush gently in short strokes, aiming the bristles at a 45-degree angle to your gums, while avoiding sawing motions. Using a timer or playing a song that is 2 minutes long can help you brush for the full recommended time. Another great option is an electronic smart toothbrush that includes a built-in timer.

Smart toothbrushes are electric toothbrushes that use the latest technology to provide personalized guidance and feedback for developing better brushing habits and oral care. The connectivity and tracking features help you improve and maintain proper brushing technique.

Some key features of smart toothbrushes:

• Bluetooth connectivity: Smart toothbrushes can connect via Bluetooth to a mobile app to track brushing data over time.
• Pressure sensors: Sensors detect if too much pressure is being applied while brushing and alert the user, helping protect enamel.
• Timers: Built-in timers ensure brushing for the dentist-recommended 2 minutes, alerting you when to switch areas.
• Brushing modes: Brushing modes like massage, whitening, and sensitive care are programmed to optimize brushing for different needs.
• Location tracking: Sensors and timers track where in the mouth you are brushing to ensure you hit all areas.
• Personalized guidance: Some brushes provide personalized brushing programs and instructions based on your habits.
• Gum health monitoring: Advanced brushes use technology to monitor gum health and inflammation.
• Progress reports: App connectivity allows the brush to provide progress reports on improving technique.
• Brush head replacement reminders: Smart brushes remind you when it's time to replace the brush head.
  
  

Should I use toothpaste with fluoride in it?

Yes, it is recommended to use fluoride toothpaste. Fluoride is what protects teeth from tooth decay that leads to cavities. Using a toothpaste with fluoride in it helps prevent decay by strengthening the tooth’s hard outer surface, called enamel.

How often should I floss?

It is recommended to floss once a day. Cleaning between teeth helps to remove food and plaque, which is also part of a good oral hygiene routine. If plaque is not removed, some of it can harden below the gum line and irritate the gums. The gums become red and swollen and may bleed easily. These are signs of gingivitis. Gingivitis caused by plaque buildup is a mild form of gum disease, and you can usually reverse it with daily brushing and flossing.

If plaque stays on your teeth for too long, it can harden. This hardened plaque is called tartar. The only way to remove tartar is to have your teeth cleaned by a dentist or dental hygienist. If the tartar is not removed, the gingivitis can worsen and lead to more severe gum (periodontal) disease. In advanced stages, gum disease causes sore, bleeding gums; painful chewing problems; and even tooth loss. 

What is a water flosser, and is it beneficial?

A water flosser is an electronic device that uses a stream of pressurized water to clean between teeth and along the gumline.

• Benefits:
  • Effective cleaning: Provides a gentle and effective way to remove debris and plaque.
  • User-friendly: Easy to use, especially for those with braces, dental work, or sensitive gums.
  • Adjustable pressure: Allows for customization of water pressure.

Should I use mouthwash (mouthrinse)?

This question is a difficult one to answer. While not a replacement for daily brushing and flossing, the use of mouthwash may be a helpful addition to the daily oral hygiene routine for some people.  

Broadly speaking, there are two types of mouthwash: cosmetic and therapeutic. Cosmetic mouthwashes may temporarily control bad breath and leave behind a pleasant taste but have no chemical or biological application beyond their temporary benefit. For example, if a product doesn’t kill bacteria associated with bad breath, then its benefit is considered to be solely cosmetic. Therapeutic mouthwashes, by contrast, have active ingredients intended to help control or reduce conditions like bad breath, gingivitis, plaque, and tooth decay.

The traditional viewpoint is that therapeutic mouthwashes are beneficial for oral health due to their anti-microbial and anti-bacterial properties. 

For a long time, up until more recent years, evidence and expert opinion supported the idea that removing pathogenic species from the oral cavity with antiseptic mouthwashes should be good for oral health. However, it is now understood that the oral microbiome exists as a complex and diverse community of bacteria, fungi, archaea, protozoae, and viruses involved in oral health and disease. Despite this, most studies of the oral microbiome refer to bacteria; the antibacterial effect of mouthwashes on the oral microbiome can be positive or negative, depending on whether there is a “good” shift towards oral “health,” or “bad” shift towards “disease,” depending on the presence and amounts of “good” or “bad” species [12].

Using mouthwash in moderation, such as once per day, is likely okay. If using a mouthwash, timing is an important point to consider. It is generally recommended to use mouthwash after brushing because it is likely more beneficial for your oral health. The anti-bacterial and anti-microbial properties of mouthwashes can be diminished if you brush your teeth right after. Using a mouthwash immediately after brushing your teeth is also generally not recommended, but it is recommended to use a mouthwash thirty minutes after brushing your teeth. This allows enough time for the fluoride in your toothpaste to protect your teeth, and the mouthwash can further protect your teeth from any harmful bacteria or plaque buildup.

What is the influence of nutrition on oral health? 

Nutrition plays a crucial role in maintaining good oral health. The food and beverages you consume can have a significant impact on the health of your teeth, gums, and overall oral cavity. 

Some ways in which nutrition influences oral health [13]:

• Tooth decay and cavities: Consuming sugary and starchy foods provides a food source for bacteria in the mouth. These bacteria produce acids that can lead to tooth decay and the formation of cavities. Limiting the intake of sugary snacks and beverages helps reduce the risk of tooth decay.
• Gum health: Adequate nutrition, including a balanced diet rich in vitamins and minerals, is essential for maintaining healthy gums. Vitamin C, in particular, is important for gum health, as it is required for the formation of collagen, a protein found in very high amounts in the gum tissue. You have likely heard of scurvy, a condition caused by inadequate vitamin C intake that results in bleeding gums. Scurvy is not commonly seen in people nowadays due to factors such as easier access to foods and beverages containing vitamin C, fortification of foods and beverages with vitamin C, and supplemental forms of vitamin C being commonly taken by people. However, although uncommon, scurvy is still seen today in people who do not eat enough fruits and vegetables and have low vitamin C intakes or low blood concentrations of vitamin C for a period of 2 to 3 months. The recommended intake of vitamin C is 75 mg for women and 90 mg per day for men.
• Calcium and phosphorus: Calcium and phosphorus are vital minerals for maintaining strong tooth enamel. Dairy products, leafy green vegetables, and nuts are good sources of these minerals. Including them in your diet supports the strength and mineralization of your teeth. Certain diets, like a raw vegan diet, may lead to loss of calcium from the teeth, causing them to weaken and become susceptible to cavities.
• Hydration: Drinking water is essential for oral health. It helps in saliva production, which is crucial for neutralizing acids, washing away food particles, and maintaining a moist environment in the mouth. Adequate saliva flow is important for preventing dry mouth, which can contribute to tooth decay.
• Acidic foods and beverages: Acidic foods and drinks, such as citrus fruits and sodas, can contribute to enamel erosion. Consuming them in moderation and rinsing your mouth with water afterward can help minimize their impact on tooth health.
• Vitamin D: Vitamin D is important for calcium absorption, and it plays a role in maintaining bone density, including the bones that support the teeth. Sun exposure and certain foods like fatty fish and fortified dairy products are sources of vitamin D.
• Balanced diet: Overall, a balanced and varied diet that includes a mix of fruits, vegetables, whole grains, lean proteins, and dairy products supports not only oral health but also general well-being. Nutrient-rich foods contribute to overall health, which is reflected in the condition of your teeth and gums.

Maintaining good oral hygiene practices, such as regular brushing and flossing, along with a nutritious diet, can significantly contribute to optimal oral health throughout life. It is important to note that poor nutrition can compromise the body's ability to resist infections, including those in the oral cavity, so a healthy diet benefits oral and systemic health [13].

Is there a link between oral health and physical fitness? 

While the connection between oral health and physical fitness may not be immediately obvious, there are several ways in which the two are interconnected [14, 15, 16]:

• Nutrient absorption: Good oral health is important for proper nutrient absorption. Oral health issues, such as gum disease or tooth decay, may affect the ability to chew some foods and eat a balanced diet. This, in turn, can impact the body's ability to obtain essential nutrients needed for physical fitness and overall health.
• Inflammation and systemic health: Oral health conditions, particularly gum disease, have been linked to systemic inflammation. Chronic inflammation in the body can negatively impact physical fitness and athletic performance. It may contribute to fatigue, slower recovery times, and decreased endurance.
• Respiratory health: Oral health is connected to respiratory health. Poor oral hygiene and conditions like gum disease can lead to the growth of harmful bacteria in the mouth, which may be inhaled into the lungs. This can potentially affect respiratory function, which is crucial for physical fitness, especially in activities that involve cardiovascular endurance.

Additionally, a systematic review reported that poor dental or oral health negatively influenced physical fitness, balance, and cardiorespiratory function [14].

Also, a cohort study with approximately 2,000 older adults in Japan found that people with oral frailty were at higher risk of physical frailty, sarcopenia, severe conditions requiring nursing care, and death [15].

Similar Longevity By Design episodes we think you would love: 

• Ask Me Anything: Lowering Cholesterol and Optimizing VO2max with Dr. Gil Blander and Ashley Reaver 
• The Latest Updates in Longevity Research with Dr. Eric Verdin
• Why Lifestyle is the Key to Longevity With Dr. David Katz

References:

1. https://pubmed.ncbi.nlm.nih.gov/27885673/

2. https://pubmed.ncbi.nlm.nih.gov/28605598/

3. https://pubmed.ncbi.nlm.nih.gov/32307825/

4. https://pubmed.ncbi.nlm.nih.gov/18693229/

5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6503789/

6. https://pubmed.ncbi.nlm.nih.gov/37700024/

7. https://pubmed.ncbi.nlm.nih.gov/37089515/

8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8479246/

9. https://pubmed.ncbi.nlm.nih.gov/28281612/

10. https://pubmed.ncbi.nlm.nih.gov/35187824/

11. https://pubmed.ncbi.nlm.nih.gov/34211029/

12. https://pubmed.ncbi.nlm.nih.gov/37867065/

13. https://pubmed.ncbi.nlm.nih.gov/23601893/

14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7182722/

15. https://pubmed.ncbi.nlm.nih.gov/29161342/

16. https://pubmed.ncbi.nlm.nih.gov/36356627/

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