The Hidden Link: Bruxism’s Impact On Heart Health

Cheng Ruan, MD

It just came out. It’s on Amazon.

Joel Kahn, MD, FACC

That’s good because it’s a must-read. If you happen to be a healthcare professional and you’re tuning in to this great interview, you want to go over to physiciantransformationinstitute.com. It’s a great website, but you might want to join Dr. Ruan and the second annual retreat of the Physician Transformation Institute to discuss AI spirituality and simplification. You might want to find some strategies to avoid physician burnout, which is everywhere, even though we have an audience right at this moment that includes healthcare providers and others. Thanks so much for being here. You work hard. I work hard, but your message is important.

Cheng Ruan, MD

Thank you so much for having me on. I appreciate it.

Joel Kahn, MD, FACC

No problem. you want to teach us because that’s the essence of this. I’m a student too, about this skull-mouth-heart connection. I’ve never talked about that. jump right on in and just take us through this over the next little bit.

Cheng Ruan, MD

I’ll call you. Can I tell you the story of how I came into this not knowing another one I talked about? I learned it in medical school. I learned so much from dentists and orthodontists over the last couple of years that there’s been a lot of aha moments that come out. One of the things that we do at the Texas Center for Lifestyle Medicine here in Houston, Texas, is practice medicine based on a program-based approach. People are coming in for different programs, such as fibromyalgia, and PTSD: We now have one of the largest Ehlers-Danlos Programs in the country. it’s a program-based approach. One of the things that I’m a nerd at is that I’m a data miner and I do coding, which means I look for data that’s correlating diseases nicely and diagnostic codes with symptomology.

One of the things I discovered in 2018 is that a lot of people with arrhythmias have quite a ton of evidence of sleep apnea or sleep-related disorders. That’s not anything new. A 2021 circulation publication came out asking for cardiologists to think about sleep apnea, especially after the diagnosis age for ablation and heart failure rates. well, that’s nothing new. But what’s interesting about it is that our body is so amazing at compensating that a lot of the compensation mechanisms of sleep disorders, such as sleep apnea, are cardiovascular diseases or arrhythmias, such as fibrillation. Long story short, you have a hard time sleeping. You have a hard time getting air into your body in the evening; the heart rate increases and that can precipitate arrhythmias and all sorts of other things as well. That process starts with your canines. Let me kind of dissect it for a little bit.

Joel Kahn, MD, FACC

You’re saying canine-like teeth in your mouth. 

Cheng Ruan, MD

You have it; it’s not just in your canines. Canines are a huge part of it. You have these nerves that go to your teeth, and they come from a branch of the trigeminal nerve. The trigeminal nerve sits on the side of your face, like my hand right here. There are different branches. You have a maxillary branch and a mandibular branch, and they send smaller branches to the teeth. As it turns out, for the trigeminal nerve to function normally, it has to receive a signal back into this small little bundle of nerves right next to you, called a concerned ganglion, and to top it off, the signal comes when your teeth are shut together. What happens is that there are a lot of kids, especially those who have early tooth removal from their palates, and they can’t fully shut together. This is in dentistry; this is called dental occlusion syndrome. They’re either diagnosed with overbite, frostbite, etc., and their trigeminal nerve cannot receive the signal back to the hypothalamus to calm down. Therefore, it creates disruptions within the vagus nerve. The vagus nerve is a nerve that goes to the heart, slows down the heart rate, and then goes to the rest of the body.

A lot of these kids get diagnosed with ADD. ADHD, sometimes tics, sometimes bipolar disorder. But they all have the same similarity that they have some sort of narrow palate or some sort of sleep disorder breathing that’s creating this effect. As it turns out, that has a huge effect on the heart. We look at journals in oral maxillofacial surgery because sometimes there are motor vehicle accidents where they have maxillary mandibular fractures and they develop arrhythmias right afterward. They can’t calm down. They develop quote-unquote, mental health issues. But afterward, it’s like their body and the brain cannot calm down. Now we have, later on, multi-organ damage from that issue. That’s right there. We thought it was like PTSD, but there’s a reflex for the trigeminal cardiac reflex, the TCR. It has a huge implication for how we restore our autonomic nervous system.

Joel Kahn, MD, FACC

I just want to interrupt you. You’re brilliant. I’m enjoying this. But the audience has heard about an oral health cardiac health connection, and they know that gingivitis or periodontal disease or perhaps silent infections under a root canal or a crown could drive inflammation. It’s associated with diabetes, erectile dysfunction, dementia, and disease when you don’t have excellent oral dental health, but you’re opening up a completely new pathway of trigeminal cardiac reflex.  You’re going to start telling us about grinding and bruxism as a trigger of cardiovascular disease which for most of us is a fascinating new topic. I just wanted to lay that out and make sure I got it right. As you’re listening to me learn.

Cheng Ruan, MD

Absolutely.

Joel Kahn, MD, FACC

Keep going, Professor.

Cheng Ruan, MD

Thank you. I can take it to the dentist who taught me this famous guy. By the name Dr. Felix Liao, he has a lot of books on Amazon and one of them is right here. It’s called Your Child Childhood Best Face: How to Nurture Top Health and Actual Glow. This is all about growing a child’s face when they’re younger. Now, why is this important? It’s because we humans have now been exposed to tons of processed and soft foods. The diet that we have now is complete and different than it was before. There’s not a whole lot of fiber intake in the standard American diet anymore. The actual chewing during early development is not necessarily there. Then there’s another issue. There’s a bigger issue: there’s a fear of choking hazards. The choking hazard has been well publicized over the last few decades. So the challenge of introducing a child to actual solid foods is not as robust earlier on. What happens is that there’s less challenge for the palate. The palate requires things like chewing and a challenge in fiber to expand before the human fuzes the bone later on in the teenage years. That plays a huge part in it. But you’re right, Dr. Kahn; you also have periodontal disease. You have other issues and oral microbiome issues in the mouth. Also, these are called cardiovascular diseases. But today I’m going to focus on the actual structure because this is pretty new to me. We think about it as we grow older, there are a lot of people who have had their wisdom teeth removed, but in reality, wisdom teeth removal means that the teeth don’t necessarily fit on the palate. There’s less real estate for the tooth to go into. When that wisdom tooth is removed, the palate remains narrow. The top arch and the top palate don’t necessarily come down because the mouth doesn’t widen. The palate remains like an arch right here. Guess what’s right above that? That’s your nasal septum. a lot of people have deviated septums. if chronic sinus issues are also related to arrhythmias and cardiovascular disease, your skull health is extraordinarily important for your cardiovascular health. Does that make sense?

Joel Kahn, MD, FACC

Fascinating. 

Cheng Ruan, MD

On top of that, what people are doing these days is, because of a lot of the standard American diet, because there’s less fiber even as adults, people are eating inflammatory diets rather than anti-inflammatory diets. So inflammation causes mucus to aggregate in the mountain to throw. People are sniffing all the time and clearing their throats all the time. and that creates these issues within the airway that can threaten the airway. People start snoring more. When you snore, that means there’s airway resistance that’s going on. As that occurs, the propensity for arrhythmias or abnormal heartbeats becomes much greater. Then inflammation comes out even more after that. We see in these patients that they have highly elevated markers of mild peroxidase, which is one of the markers of bloodwork for inflammation. We see elevated interleukin 6T and TNF alpha. These are all things we can look to in the bloodwork to see what’s going on. They also have elevated LP(a). I’ve heard you talk about that for quite a while, apolipoprotein B markers. a lot of these advanced lipid markers that we see in the bloodwork, a lot of times even when people change their diet, they may only get about halfway there.

The other half may be looking at what’s going on in the oral airway; do they have bite issues? Do they grind or clench their teeth? Because if we, as humans, clench our teeth, it is only to make room inside, to tend to open our airways, to get more air in. Some people are thinking, Well, maybe people are anxious here in their right. they’re anxious here. Then, are they clenching because of the anxiety? Well, let’s think about that. If someone is anxious and we grit our teeth, this activates the trigeminal part of that reflex to try to get the vagus nerve to calm down. That’s why when you’re overstimulated by something, you go into this protection mode, kind of holding your breath or grit your teeth and holding your breath. That’s part of us trying to calm down. Some people have molars or canines that don’t even touch because the palate is so narrow that no matter how much they grip it, they can’t calm down. They get diagnosed with mania, hypomania, bipolar disorder, anxiety, panic disorders, and, you name it, ADHD, which is a huge one as well. But these are the same people who develop arrhythmias and heart disease as well. We have to understand that our skull and our airway are huge components of attempting to reverse cardiovascular disease.

Joel Kahn, MD, FACC

Much conversation at this summit is about the importance of testing for sleep apnea, correcting sleep apnea, atrial fibrillation, hypertension, weight issues, and rest and all. We’ve talked about oral health, but now we’re talking about the structure of the jaw. Structure of the mouth. The teeth have been removed. Teeth are moving around. You’re talking;  let’s just focus on one more topic for now. But the grinding of the bruxism or not everybody uses B.R.U.X.I.S.M. How does that play into triggering that trigeminal cardiac reflex that may cause our blood pressure to drop, our heart rate to drop, or even our stomach function? How does that all play into grinding?

Cheng Ruan, MD

So the grinding mechanism. First of all, you can tell who grinds by looking at them. If you’re listening to this or watching this and you feel maybe that the back of your neck is developing a bit of a hump and that your neck is being pulled forward, you have a lot of muscular strain and straining your neck. You might be grinding a lot if you notice that your temples and around your eyes are starting to get a lot more strained. You may be grinding a lot, and what’s happening here is that your body’s accommodating. Grinding is nothing abnormal. Grinding is trying to compensate for a small airway. As you grind, you’re grinding your jaw forward to do what’s called a jaw thrust. As you get jaw thrust, you expand your airway, and the area in your neck where your trachea, which is your windpipe, is connected, is within its trying to enlarge. that’s why your neck has been forced forward over the last few years. These are people, typical people who grind. you, dentists or dentists, are so used to it now that I would tell people that they grind. But the people who grind, you can see grinding where on the teeth you can see that the roots of the teeth are buttressing out like this into the gums.  So many people have these issues that we see. What happens is part of the grinding is because the body is trying to restore equilibrium. What happens is during sleep let’s say if you have a restricted airway during sleep, you go grind to open your mouth to try to get more airways. But to do that, you can’t be in deep sleep because technically if you’re in deep sleep, your body’s paralyzed, and your brain paralyzes your body in deep sleep. You don’t  get into deep sleep. If you don’t get into a deep sleep, your body’s autonomic nervous system fight or flight versus rest and digest becomes very discombobulated.

What is happening here is grinding, which is an activated trigeminal nerve that was trying to calm the vagus nerve in her heart at the same time. We can only do so much. A lot of these root mechanisms right here is that the body’s trying to find it, like fit correctly. But because of malocclusion or not fitting correctly in the teeth, the body continues to try to do so. Instead of the teeth doing the job, the entire neck and fascia, which is the connective tissue covering the head and neck in the body and chest, starts going forward. Now, here’s the problem: When your neck starts going forward, it pulls on a diaphragm, and the diaphragm doesn’t fully pull down. So the diaphragm coming down is required for you to take a deep breath. Not only are you having these sleep apnea episodes, but you also can’t take a deep breath. Your production of this beautiful gas and nitric oxide has been significantly less over the years as well. It’s very much a physical structure that has a curtain and all sorts of winding mechanisms.

Joel Kahn, MD, FACC

You may know you grind; maybe your sleep partner notices your grind. Some people grind their teeth during the day. It’s not exclusive to the nighttime thing.

Cheng Ruan, MD

Some people grind their teeth during the day, and a lot of people listen to this and play, which kind of grits my teeth a little bit, and that comes from a sort of subconscious play on the brain, like triggering the muscles to clench down. Chances are, if you grind during the day, you probably grind more during the night than your body’s been trained to do.

Joel Kahn, MD, FACC

You’re certainly at your next dental exam. Whether you’re a hygienist or dentist, you probably want to ask the question: Are there any manifestations of bruxism or grinding, say, bruxism? It’s such a cool word.

Cheng Ruan, MD

It is a cool word.

Joel Kahn, MD, FACC

It is a cool word. Pursue that. Immediately I am thinking about patients of mine who are very frustrated wearing their Oura rings or Whoop bands,  Apple watches, and their HRV is never where they want it. They go through so many machinations to improve their HRV. But I’ve not been pursuing this possibility that a higher vagal tone or some other alteration of the TCR is part of it. Can you see altered HRV measurements from bruxism?

Cheng Ruan, MD

We do a lot of those measurements. We measure the autonomic nervous system. We measure patients’ blood pressure in different positions when they are lying down. We do brain-frequency activity. One of the things in which I specialize is looking at quantitative EEG so that I can see when there’s a temporal lead right here, triggering a brush. We work with a neurologist, a sleep neurologist, who looks at this at night to see how much you are grinding at night. At night, you can already see grinding probably drops from  120 down to 40. Just like that. Stop grinding. Goes back up again; the heart rate drops. This is the hyper-vagal tonality. The vagus nerve has been creating so much of the parasympathetic response that the heart slows down.

Sometimes that can trigger a pause or heart rate pause for more than five, six, or seven seconds. Some of those people who require pacemakers can see that as well. In some people, when their heart rate slows down, they come back up and develop atrial fibrillation, where the heart rate goes faster and the rhythm becomes abnormal. That’s all seen by our neurologist team here as well. So as we coordinate things together, one of the things that we make sure people do is see the actual airway dentist and their dentist is different than regular dentists. They’re trained in oral appliances, devices, and splints that can keep the teeth aligned. We redo their autonomic nervous system and all this stuff like that after they get their appliance done. If you see a dramatic improvement. What I didn’t expect to see is how much their mental health improves. A lot of depression, anxiety, and panic attacks seem to start disappearing. It’s interesting.

Joel Kahn, MD, FACC

I can’t help but do it when I learn something new. I go over to Pubmed and put in bruxism, TCR,  all kinds of warnings, reviews, articles, series, and the connection to cardiovascular disease, and the autonomic nervous system. So this expert on the mark teaches something new. We’re going to shut down this standard portion of the presentation, which has just been fascinating. I do want to confirm that I have just ordered; please don’t accuse me of being a multitasker. You’re wonderful book in paperback, The Doctors Guide to Thriving in Integrative Medicine: Secrets to Successful Business Without Burnout. What a wonderful goal! the fact you’re trying to do it in an insurance model to make it more widely available and cost-effective. Hats off to you for trying to remake the system into a better one, a more equitable one, and all the rest. But for those that are in the general audience, thank you so much. Please study a little bit about grinding. Ask your dentist, evaluate that, and for the rest of you and our premiums, stay on. We’re going to come right back with Dr. Ruan, and we’re going to dive just a little deeper. 

All right, everybody, welcome back. We get the opportunity to go a little deeper with our special guests, who’re just blowing us away with information we’ve never heard before. Now this isn’t the Guinness Book of World Records Summit, where we have to come up with new things. But, we learn a new field: oral health, oral cavity structure, the skull and jaw, and potentially various cardiovascular syndromes as important as atrial fibrillation. Let’s just say somebody has been having some arrhythmia issues and sleep issues, and they come in from their dentist, and they announce to the family, I’m a grinder, and I hear that from patients all the time. As a non-grinder myself, I don’t spend a lot of time on it, but what can be done? Give us a little rundown of your clinic. You have an amazing team, and what can be done?

Cheng Ruan, MD

That’s a good question. A lot of people grind their teeth, and if not, sometimes they’re clenched or, necessarily, grunt. But both are trying to actively do the same thing, which is sort of a common response. Here’s the question. If you grind, who else in your family also grinds? Who also snores? Who else in your family has sleep apnea? Chances are there’s a huge hereditary pattern to this. That’s the first question. If you have children, you better watch out and look at them to see if they grind as well, because that’s a huge deal. If you capture it in a pediatric population before the age of, let’s say, 15, or 16, it is much easier to deal with from a dentist’s point of view than adults. Now, the other thing to think about is that if you’re a grinder, your clencher is: do you also have next-string pain? Is your posture going forward like this, okay? One of the most commonplace knows that is your feet. Because what happens is that as your access goes forward like this, it’s like the Leaning Tower of Pisa.

As you lean forward, your feet have to accommodate. A lot of people develop this thing called plantar fasciitis because their postures are lurching forward and everything is tightening up. Your body has to restrict you from going forward by constricting the fascia, which is the connective tissue like a giant C-arm. It’s trying to hold your back there, and a little goes in the bottom, your feet up to your head. By the way, this is because my mother is an acupuncturist, so she does a lot of those releases for people when they have these airway issues. So that’s the other thing to figure out because it can cause pain. The entire fuel of fibromyalgia is people with sleep disorders and airway syndromes who have malocclusion issues. We just had our fibromyalgia conference for healthcare professionals a month ago. We want to relabel five miles in airway occlusion disorder with mouth fascia. So, if you have that, it’s important to talk to your doctor and your cardiologist, and I might need a sleep study, especially if you snore. Now, most people with sleep apnea do not snore, believe it or not. So if you do snore, that means you probably have sleep apnea. But try to get some sleep studying which is important because sleep is the most important lever you can pull to improve your cardiovascular health. So if you’re not getting adequate sleep, you can’t adequately rest up. That’s what happens when you grind or clench your teeth. The third thing is to think about this. Talk to your dentist. On some dentists’ websites, you’ll see they treat sleep disorders like sleep apnea and oral appliances. Those are the ones that have a lot of knowledge about this. There’s an association, AAPMD, the American Association of Physiologic Medical Medicine and Dentistry.

The AAPMD has an entire registry of airway-trained doctors who can do this. There’s a very large consortium in Houston called the Sleep Education Consortium for all doctors and dentists who work together to treat these things right. But these are the people that you want to talk to once again. That’s AAPMD. Then another thing that you want to think about is mental health. Do you have a family history of mental health issues? I see this a lot, especially in my family, in the history of bipolar disorder. I see that multiple generations have the same arch palate that’s right there—the same dental model occlusion. There are things that we do in our clinic to measure them and see if they can activate their bodies correctly. It’s a very simple thing. But we see this in multiple generations every single time. Our skull shape is inherited over time. Every generation gets a little bit worse. Skulls become more narrow. That’s a byproduct of the foods that we’ve been eating since our ancestors ate very different foods than we do right now.

Nobody had McDonald’s French fries a couple hundred years ago. It doesn’t exist. But it’s so important to consider that. The fifth and last thing I want you to consider is that if you’re one of those people who has done everything for their health, eating the right things, you’re eating a polyphenol-rich diet. You’re doing all the right things. Maybe you’ve done it by fasting and changing everything in your life. If you’re exercising you might find that cardiac inflammatory markers are still high. You’re still on steroids, and maybe a little high. Something is missing. Then you’re a grinder. Well, guess what? The bruxism, or grinding, is sort of the last frontier that you haven’t discovered. A lot of times, when that’s treated, those cardio markers improve pretty much within about a year, which is fascinating to see.

Joel Kahn, MD, FACC

Well, you have given us so much food for thought. Since your time of the oral passageway, it is the food entry. just fascinating. You’ve touched a lot of people with a plan to upgrade their health. That’s all we’re trying to do—upgrade your cardiovascular health. As a brain-mouth structure, the nerve, TCR, pattern is just another way to do it. People are frustrated. Why am I not getting healthier when I’m doing so much and ignoring this whole system that you’ve laid out so beautifully? I want to thank you so much for your time as your busy doctor, busy father, busy husband, and busy entrepreneur. We have learned a lot. Thank you so much. Hopefully, we will be able to repay the debt at some point and help your audience.

Cheng Ruan, MD

Thank you so much. Appreciate it.