**EP253: Interview with Doctor Patrick Oxborough—Discussing Heart Health & Oral Health** **Dr. Warwick Bishop:** I believe we can prevent heart attacks. We can put in place strategies to reduce risk. We can literally plan to change your future. Welcome. My name is Dr. Warwick Bishop, and I'm a cardiologist, an author, a keynote speaker, and CEO of the Healthy Heart Network. I'm all about trying to help people live as well as possible for as long as possible, and that includes heart attacks, which impact Australia enormously. We're talking about a heart attack almost every 10 minutes and over 20 people per day dying from a heart attack in Australia. That's on a backdrop of over 9 million people globally being impacted. The sad truth is many of these could have been averted if only we knew what to do. Well, this podcast is all about that—weight, blood pressure, cholesterol, general health, and driving health literacy. I'm on a mission to help not just prevent heart attacks, but improve general health on a global scale. If you enjoy this podcast, I would be honored if you could give it a five-star review and share it with your family and friends. It may even lead to saving someone you love. My name is Dr. Warwick Bishop, and welcome to my podcast and videocast station. And today, I have the pleasure to share a conversation with Patrick Oxborough, a doctor, a dentist, and in fact, my own dentist. I know he has an interest in teeth preventative strategies. Welcome, Patrick. **Dr. Patrick Oxborough:** Thank you very much, Warwick. **Dr. Warwick Bishop:** Look, Patrick, over the years, and I'll let everyone know that my teeth are in excellent condition, thanks to your input. Over the years, we've talked about the importance of heart disease and how that can tie into oral hygiene, teeth health, and so forth. Would you like to speak to that for a moment for me, Patrick? **Dr. Patrick Oxborough:** Yeah, look, 100%. I think sometimes people tend to forget that just because we're working on teeth, teeth are connected to the rest of our body. I mean, the teeth have supporting tissues; we call that the periodontium. That's the gums that hold our teeth in, and that's all connected to our body. In general terms, I think we can talk generally and specifically about how teeth have an effect on the rest of the body. I mean, in general terms, it's quite common that my patients sometimes will see me more often than they will see their own doctors. And so we generally have an opportunity to assess other medical conditions or sometimes diagnose medical conditions just by looking at their mouth or looking at things. For example, I'll give you an example: bruxism, which is tooth grinding. Patients who are grinding their teeth often have issues with sleep apnea, and we know that sleep apnea sometimes has an influence in terms of another medical condition, which you know a lot about—hypertension. So that's just a general example. In specific terms, and probably the most widely investigated when we look at teeth and gums in relation to the rest of the body, we talk about gum diseases, or we call them periodontal diseases. There's a lot of emerging evidence to show that patients who have more severe types of gum disease often have an association with other cardiovascular diseases, for example, things like heart attacks, hypertension, strokes, and things like that. So, yeah, as dentists, we have an opportunity many, many times during the day to help patients with their medical health. **Dr. Warwick Bishop:** So from my perspective as a cardiologist, there's a couple of areas that I'm particularly interested in. Obviously, one of them is when the bugs or the bacteria that are in the mouth actually get into the bloodstream and can sit on the valves. And that's called bacterial endocarditis, which means inflammation of the heart or infection of the heart. Now, do you see people who would be at risk of bugs literally sneaking into the bloodstream through those inflamed and diseased gums? **Dr. Patrick Oxborough:** Yeah, we do. And so again, there are different types of gum diseases. I mean, anybody who doesn't brush their teeth properly for 10 days will develop gingivitis, which means their gums are irritated. When the gums are irritated, yes, you can shed bacteria very easily into your bloodstream. Even just eating and brushing your teeth will do it. And again, the more severe types of gum diseases can lead to more toxic showers of these bacteria into our bloodstream, which can lead to other conditions. Bacterial endocarditis is a very obvious association between bugs that we literally identify on the valves of the heart that we know come from the mouth. And for those listening, the risk of that gets greater based on your gum disease, but also on any irregularity of the heart valve. So if you've got a sticky valve for whatever reason, and as Patrick says, you get a shower of bugs through the bloodstream, then that shower of bugs is more likely to stick on a valve that's damaged for some reason or another. So there's a very obvious link between a direct infection getting into the bloodstream. But what about the concepts around inflammation? You said there's more evidence around that. Tell me a bit about that, Patrick. **Dr. Patrick Oxborough:** There's been a lot of research for a long time to try and elucidate exactly what the relationship is between these more severe types of gum disease, so we call it again periodontitis. Periodontitis means that the gums are so badly damaged that you're actually losing the attachment of your teeth to your bones and your gum. The various forms of periodontitis are caused by very toxic species of bacteria. The disease progresses because there's basically an inflammatory storm, a fight that goes on between the gums and these bacteria. And in the watershed of that, in the collateral damage, there's tissue loss. These bacteria then have been shown to turn up in, this is your main area, the atherosclerotic plaques. And so you can demonstrate these bacteria. It has been shown that these bacteria turn up in these plaques within the blood vessels. What isn't clear is exactly what the mechanisms are and how they cause damage or how they promote damage. I guess the one description that I've read that's been given is the bacteria are the irritant and cause and drive the gum disease. They're probably helping to drive the inflammation that's causing these atherosclerotic plaques to develop and then potentially lead to heart attacks or major cardiac events in some individuals. So in my practice, just leading on from that, if I'm treating—and it's one of my special interests—the treatment of periodontitis, I get very concerned when I'm seeing patients who have got severe periodontal diseases. I look very carefully at their medical history, things like that. Have they been to their doctor recently? Have they had their blood sugar checked? Are they under the care of a cardiologist? Have they got risk in terms of hypertension in the background? And sometimes for some of those individuals, if I'm looking at them, if they've got more severe disease, I'm certainly going to push them to maybe get more tests done, perhaps with a cardiologist, because I'd have concerns about them. Certainly in my own experience, I have one particular patient who comes to mind who had recurrent atrial fibrillation, which is that irregular beat of the heart where the top chambers lose their synchronicity. I'd been looking after her for a good number of years, and we'd been adjusting drugs, etc., and she kept coming back with issues until one day she literally came back and said, "Well, I think I'm fixed, Doc," and it's because I had my gums fixed. Up until that point, unbeknownst to me, she'd had severe periodontal disease and inflammation, and she'd had that all cleaned up. Almost overnight, her atrial fibrillation went away. **Dr. Warwick Bishop:** Now, do you have any stories similar to that that you can relate? Because it was a great... **Dr. Patrick Oxborough:** I haven't been lucky enough to have any sort of really nice cause-and-effect ones like that. I kind of had a little bit more probably on the negative side of things, where I'd been treating somebody for periodontitis, and he'd had it for some years. Unfortunately, shortly after that, and probably not immediately, within a few months, he actually did have a major cardiac event and ended up having stents and all that sort of thing. So again, it speaks to the fact that there's no direct evidence showing that if we treat periodontitis, you're automatically going to get these magic results. But the way I think about it is if you're treating these gum diseases, you're certainly, I think, taking away a big chunk of risk. And I think that going forward from here, because it's such a keen area of research, we're going to find that we're going to get more protocols hopefully in place. But my view about the whole thing is that it kind of works both ways. So, I mean, yeah, if you guys are treating patients who have got these conditions, yeah, it's good to check off and say, "Well, are your gums okay?" Because we know there's a major, very direct association between those two conditions. In fact, if we're looking to replace someone's valves, part of our workup is to make sure their teeth are in good condition. There are times where we actually undertake a full tooth extraction with dentures put in place to reduce the risk of a new valve being seeded or infected by those bad gums. So it's really important in that particular space. **Dr. Warwick Bishop:** What I was going to ask you, and you may not bow down to this, and it's a little bit again on those edges of where we're observing things, but outside of the heart, do you see other conditions within the body affected by gum disease? I mean, things like arthritis, for example, or multiple sclerosis. The reason I'm asking is many of the people listening to this will have heard lots of information about the gut microbiome and changes in the gut microbiome potentially having an impact on those sort of other global inflammatory type or immune type conditions. Do you see, we've spoken mainly about the heart, but do you see that with other systems, Patrick? **Dr. Patrick Oxborough:** Yeah, well, again, like if we just come across to say, another well-researched area is actually with diabetes. We know that there's this very direct relationship between diabetes and heart diseases again. For example, if somebody's presenting with severe gum disease, that's one of the first things we'll look at. We know that if we treat their gum disease, their diabetes—particularly not so much your diabetes type 1, but your type 2, I guess we call that mature onset diabetes—many patients, if you treat their gum disease, their control will improve. Equally, if their diabetes control is not good, then it goes back the other way. So it kind of works in both directions. I'd say there's probably less concrete evidence in terms of, you know, if we treat gum diseases, do we get better results or do we have magic results for things like multiple sclerosis? There's not a lot of strong evidence for that. But again, these are emerging fields. I think that as our understanding of those diseases improves and our understanding of the inflammatory process, which underpins all of this—I mean, most of these chronic diseases that we all suffer from are inflammatory diseases, and periodontal diseases are inflammatory diseases—then we'll have a better understanding of the relationships between these things. **Dr. Warwick Bishop:** In simple terms, Patrick, when you're treating this periodontal disease, what are your strategies? Is there a diet base? Does exercise help? Do you get people to floss or brush, and do you use antibiotics? What sort of is your approach there? **Dr. Patrick Oxborough:** All right. The mainstay of periodontal therapy is to remove the bacterial irritants from around the tooth so that they're not then directly driving the inflammatory process. That's what we call scaling and replaning. Excuse me. The mainstay of treatment is always to debride or clean the teeth and remove those toxins. Then subsequently, I mean, there are a number of other things we would then also do. For example, we would look at and make sure our patients have got proper blood sugar control. Is that an issue? And manage that. Smoking, obviously, smoking is a massive driver for periodontal disease. That's another thing you'd look at. There's weak evidence for dietary changes. The long-chain fatty acids have been shown to have a positive effect of reducing periodontal inflammation, but that's kind of about it. **Dr. Warwick Bishop:** Sorry, Patrick, presumably sugary drinks are a no-no? **Dr. Patrick Oxborough:** Sugary drinks are something we tend to get worried about when we're treating tooth decay. Yeah, it's kind of like a different axis. They're very different axes, those two things. So the periodontal diseases indirectly, we look at how sugary drinks affect that. Well, I would say again with blood sugar control, but then you've got confounding factors with the treatment of periodontitis in terms of things like obesity. So patients who are obese or overweight tend not to respond so well to periodontal treatment. And then again, you see the same issue with other chronic diseases. So weight control would be a huge one. So, yeah, again, there's a broad spectrum of things. There are, again, coming through looking at therapies, there's a cohort of patients that their inflammatory response in terms of their body's response to the periodontal bug pathogens—the bugs that are living around the teeth driving disease—they sometimes don't respond to the scaling and replaning, and you can improve their healing response by using antibiotics. So one antibiotic that's been well, there's two, there's three different ones. There's kind of the nuclear bomb effect, which is an antibiotic therapy that's still commonly used, and that's a combination of two different antibiotics. That tends to be a very heavy hit for the patient because it pretty much kills nearly everything in their body, and it's not something that I would favor. We use another antibiotic therapy, which is more, it is an antibiotic, but it has more of an anti-inflammatory effect. This is an antibiotic that's been used for many years in different parts of medicine, but that one's much more targeted, and it seems to downregulate or reduce that inflammatory response locally in the gum tissues. You often find you get much, much better healing responses. But again, as clinicians, we don't want to throw antibiotics around willy-nilly, and what we tend to do is use the mainstays, re-evaluate, and look at what the patient's response is, and then if needed, sometimes bring in an adjunctive or an extra therapy. **Dr. Warwick Bishop:** Are things like flossing and particular brushing techniques important as well, Patrick? **Dr. Patrick Oxborough:** Yeah, they're essential. I say this time and again to my patient groups. It's so obvious, even patients who have got the more severe types of gum diseases, once you treat them and you get them better, you keep them better by getting their cleaning routines 100% effective. What we're looking for is when we talk about how good is their cleaning routine, we can kind of score it. We like to see them operating at a 90% plus efficiency. They get, every time they go into the bathroom every day, they get 90% of the plaque off. If they do that, you see the difference immediately. It's very different from those patients who never achieve those sorts of levels of care. It's not easy to do, and it's something we have to work really hard with our patients to achieve, but it's very satisfying when you see it. So my own, I confess to this at the beginning, you are actually my dentist, and I don't think I'm the perfect patient, but I try pretty hard. I try and floss twice a week, and I try and use that sort of narrow head brush twice a week, and I use an electric toothbrush. For those listening, I actually go and see Patrick every six months just to make sure everything's on track because I just want to look after my teeth and know some of the knock-on effects. For anyone listening, Patrick, is there anything you would suggest to them different to that or over and above that that you think they should be aware of and mindful of in terms of their own teeth and oral hygiene? **Dr. Patrick Oxborough:** I think one thing I'll say about that is, you know, the whole, you know, do you go to the dentist every six months thing? What I like to do with my patients—my patients are all private patients; they're all paid to come and see me, and nobody else is paying for it except them. I like them to get value out of what they're doing. What I like to do with my patients is assess their risk. So I have patients that come and see me at different intervals, for example. So somebody like yourself, who's got probably moderate to low risk, I'm happy with you coming every six months because also that's what you want to do, and I kind of work with that. I have other patients who, seriously, if I don't see them from one 12-month period to the next because of their risk, I don't get too worried about it. Equally, I have patients who, if I don't see them every six weeks, they really don't do well. My intervals in terms of how often I see somebody would vary between six weeks and probably 12 months. That's tailor-made to the individual. You know, the whole six months you go to the dentist every six months, it came out of a toothpaste commercial from the 1950s. I'm not joking. Look, sometimes it works, okay? I mean, there's good evidence to show that if somebody's got severe periodontitis and you scale their teeth every three months, you're going to get better control of their condition than if you don't do that. That's got to do with how the bacteria carry on their activities. So what I'm saying is that I think it's important for everybody to have contact with the dentist and to then have their risk assessments done, as we all do as medical professionals. We always run risk assessments for each of our patients and then treat them accordingly. **Dr. Warwick Bishop:** Well, look, I think that's fantastic advice. I'm going to wrap it up there. For anyone listening who's in the Hobart area and is interested in knowing where Patrick practices, he's out of Battery Point Dental Practice; it's easy to find there. Look, I really appreciate sharing this with you, Patrick, because every time we catch up, we talk about hearts and teeth. I think this is a great opportunity for people to have a listen and, you know, really get that we don't deal with organs in isolation. We deal with a whole person, and everything's connected. I think you've really articulated that beautifully for us today. Thank you again for sharing. **Dr. Patrick Oxborough:** Thanks very much, Warwick. **Dr. Warwick Bishop:** For those listening, if you have any queries or questions, drop me a note at info@drwarwickbishop.online. Otherwise, thank you for listening, and go and brush your teeth and floss regularly. Be in close contact with your dentist. I'm going to hope you live as well as possible for as long as possible. Take care and bye for now. Did you know that coronary artery disease kills one in four people? So most of us are likely to carry some risk or know someone who does. If you're interested in finding out more about how to evaluate that risk, check out www.virtualheartcheck.com.au. It'll give you information about risk and what else can be done to be even more precise.