Boosting Diabetes Control Through Oral Care

Yin Hsu, DMD, MPH, MAGD, LLSR

Hi, how are you? Good morning, everyone. My name is Yin Hsu. Yes, Dr. Hsu said. I have been a very long-time patient of Dr. Hsu’s, so I have had my whole career going up with Dr. Hsu as well. 

I got my first dental education in Taiwan. I immigrated to this country pretty much ever after my graduate education. I renewed and updated my dental license here and studied a little about public health. Then I start practicing and teaching part-time at Tufts Dental School in Boston. My main concerns and interests start with restoration, how to rehab the patient, and technology with all its advancements. We get a lot of fantastic replacements for the damage. But again, after you keep doing those mechanics and we see patients regularly, and then you realize that some of the condition isn’t just a replacement, We have to get down to the root cause and then, of course, to dental speaking. There are two major conditions. One is dental caries, and one is gum disease. That’s why people are concerned. Then especially on the gum disease front perspective, because at least 50% of our population visits the dentist regularly. 

I think by having been doing this for more than 25 years—almost 30 years—you can see the progression of a patient’s condition. Plus, just like anything else, it goes up and down. It has seasonal well, things he has patients, personal life change things a lot to do with patients lifestyle. Then and then we found out that the most prevalent disease in humankind is gum disease. Pretty much, we’re thinking that more than probably a third of the American population suffers from so-called gum disease, but there are precursors for that, which as gingivitis, which is much more prevalent. Then, when you have that low-grade inflammation in or on the gums, if you stretch your gum tissue flat, that’s close to the size of your palm. If you think about that, if you wash your hands, your palms start to bleed. I think that’s shocking. But that’s what happens every day in the dose—a little minor inflammation. That recent study even tells us, especially for the A1C high patients, that if we simply do what we call deep scaling root cleaning or phase one gum therapy, we can drop at least 1% in terms of A1C without taking any order medical treatment.

William Hsu, MD

Dr. Hsu was so helpful in the opening for us and for a lot of our listeners that they may not even be aware of this link between oral health and systemic health. Maybe we start with that. Why do people with diabetes have to worry about their gums? Are they at a higher risk of developing oral health challenges?

Yin Hsu, DMD, MPH, MAGD, LLSR

Yes, absolutely. If you have low-grade inflammation in the gums, we know for sure that it is going to increase C-reactive protein. Also, you can think about that a little bit more. I mean, simply look at our gum tissue, our semi-permeable membrane. It’s the first contact with the environment. Then if we have a lot of inflammation that will increase the permeability of that membrane and a lot of just a leaky gut, I think the leaky gut starts with the mouth and then you are more prone to the exposure and then more inflammation, and those inflammations, as far as I understand, go through your mouth probably every 20 minutes you think about to keep on being all those inflammatory cells all over the body.

William Hsu, MD

Very interesting. You’ve mentioned that the oral cavity is the beginning of the GI tract. The leaky gut starts with the mouth, and that’s an interesting concept. Now, you mentioned CRP earlier. Just for our listener’s sake, that’s an inflammatory marker. You’re saying that because there is leakage between or there is a transfer of this inflammation in the mouth, it gets transferred into the system. If you don’t take care of your mouth, the inflammation of the mouth may go into the body. Is that what you’re saying?

Yin Hsu, DMD, MPH, MAGD, LLSR

Yes, absolutely. Then there is evidence showing that proper oral hygiene maintenance daily can have good preventative effects on cardiovascular disease. Today we even talk about potential Alzheimer’s. Of course, we just mentioned A1C. I think they’re all in the same pot. I think there are so many factors. I think I think that basically, since we have the systems set up in this country wonderfully, everybody should utilize their access to their dentists, at least get their gums checked, and then, including something very important, always ask the dentist. What do my periodontal pockets look like? How many of the areas of my gums are bleeding? Those are the indications. In general, we don’t want pockets more than five millimeters deep. Then in general, we don’t want 30% and above of your gum area that’s bleeding on touching or probing by the dentist. That’s, in general, what we consider to be a healthy status.

William Hsu, MD

This is interesting. What we’re seeing is that there is a convergence of healthcare providers, including dentists, participating in whole-body health. Now dentists are not only caring for people’s mouths, but there is a relationship to systemic health. This is astounding. Dr. Hsu, I have always known you to be a pioneer. I have known you to be an innovator in your own space. But your other dental colleagues aware of this systemic oral relationship, or this is something that people need to seek out a specific dentist for?

Yin Hsu, DMD, MPH, MAGD, LLSR

I think in general, I mean, all my dental colleagues are well aware of this general condition. Still, there is some breed of dentists like myself, who probably spend a little bit more time in terms of patients’ general condition, including their mental condition, including, I think most importantly, their diet condition, because I’m myself an older generation. I mean, when we were in Taiwan receiving dental education, this very important part was about diet counseling and diet analysis. When I first came to this country, I went back to school, updating my degree. That was in the early 1990s. I think we have a full semester of nutrition. But today I think they decreased down to maybe just a few hours.

William Hsu, MD

Unfortunately, that’s about it.

Yin Hsu, DMD, MPH, MAGD, LLSR

I think we’re.

William Hsu, MD

I saw that. We’re seeing that in medical school as well. This is a bad trend.

Yin Hsu, DMD, MPH, MAGD, LLSR

Yes. I think because we are so busy with those mechanical things, we know we can do a lot with the disease population, but then we are treating the disease instead of treating the health concern.

William Hsu, MD

Is there a category of dentists? I mean, how would you describe yourself as a dentist at all, not only focusing on the mechanical solutions but also addressing the systemic health and nutrition aspects? Is there a category where maybe there isn’t?

Yin Hsu, DMD, MPH, MAGD, LLSR

There isn’t. But I hope there is something called integrative dentistry. But I already heard that coming up, just the integrative medicine. We should not only know our stuff, but we should also be more concerned and learn about other fields of medicine and their contributions. Then, my main goal is to see my patient healthy. I think that’s the most fulfilling part of my career, but there’s not so much in how many holes can I drill with this patient. I was always my patient there. Let’s watch these holes to see if we can maintain them. Then not get bigger and does not need a root canal eventually. I think that’s just my calling as well.

William Hsu, MD

Yes, that’s such a refreshing thought here. Let’s come back to the relationship between diabetes and periodontal disease. You mentioned earlier that it’s truly a bidirectional relationship. It’s so people with diabetes have a higher risk of developing periodontal disease, and on the other hand, a higher or more severe periodontal disease would elevate a patient’s blood glucose. Is that a fair statement? Can you maybe address that a little bit about why there is such a connection there? Why do people with diabetes have a higher periodontal disease?

Yin Hsu, DMD, MPH, MAGD, LLSR

You have more inflammatory components in your system. Also, I have to include myself as a long-term diabetic patient. I know that sometimes our food choices not only affect A1C or metabolism but also our oral flora, which is the bacteria in the mouth. On top of that, if you have the initiation of the inflammation, the gums start to get swollen, and then the pocket gets deeper, and then you become more, anaerobic bacteria in the mouth. We do think that that has something to do with the shifting of the whole microbiome in the digestive system. But I think the rest of us know about that. Then what we want to do in the mouth is, I wish that we could take out a whole cardiovascular system and then do a cleaning, but one day we can do that, but at least we can clean our teeth.

William Hsu, MD

That’s so true. Yes.

Yin Hsu, DMD, MPH, MAGD, LLSR

Then maybe helps our body a little bit and then I think a lot of diabetic patients are probably frustrated with their whole mental health as well; sometimes they’re just not eating correctly, and then the dry mouth and dehydration of the dry mouth also facilitate good gum inflammation, especially today. On top of that, we have a lot of upper airway restrictions because of the environmental allergy. Those all contribute to dry mouth. Dry mouth also facilitates gingival inflammation. You become a malicious cycle and then or much.

William Hsu, MD

Yes.

Yin Hsu, DMD, MPH, MAGD, LLSR

We have to break it.

William Hsu, MD

Yes. For sure. Let’s get down to the basics. Okay. He is among our listeners. Many people live with type 2 diabetes. How often should they see their dentist? By the way, there are studies in the U.S. that say people see their dentist more often than they see their doctor. Inside, you’ve become the primary healthcare provider for many people. How often should they go, and what do they do when they go see you?

Yin Hsu, DMD, MPH, MAGD, LLSR

In general, I mean, most of the people who have dental benefits or insurance benefits have said, Well, you call the insurance company every six months. But actually, that’s not evidence-based. We don’t know for sure. Very interestingly, in a quote-defined study probably in the early 2000s, they found out that the A1C had nine and 10 patients for decades, and then the endocrinologist did everything, including their medicine, whatever they did, they couldn’t lower it. If they suffer from gum problems, simply go through a deep scaling cycle, what we call phase one periodontal therapy. They can drop their A1C by 1%. That lasts about three months. which that study pointed out that the frequency should be three months for high-risk patients, especially diabetic patients. They should have that unless they are so well maintained. As I said, do your bleeding areas last more than 30%? Their dental pockets are less than four millimeters. Then those people we consider are just as healthy as the general public. They should go every six months. That’s fine.

William Hsu, MD

Is there any insurance that covers more than twice a dental cleaning?

Yin Hsu, DMD, MPH, MAGD, LLSR

Yes. Any insurance will cover you three times. I think that coming out of the consumer, I would highly recommend that the consumer asks for it. But in general, if these are the patients, I hate to use the word qualified because insurance should not dictate what I mean by medical behavior. But if we think that a patient is at high risk, for example, if they are periodontitis patients, usually insurance will cover them every three months. After each area goes by, if you do deep scaling, then they will cover every three months, which is evidence-based.

William Hsu, MD

Now that you have a term, deep scaling is very scary. What does that involve?

Yin Hsu, DMD, MPH, MAGD, LLSR

What happened is that, if we just cleaned our teeth, everybody would have that experience. Sometimes you may be a little sensitive, but usually in those areas, you have some gum recession. Then so what I’m talking about, is if your measurement, the pockets are more than four actually hygiene, it has a hard time going deeper than four without hurting you. That’s why we want to give a little bit of local anesthesia, and usually, we do half the mouths at a time, so that’s why we use the term deep scaling. 

I agree we should change that verbiage because it is not very welcoming. then, in the dental term, we call that phase one therapy periodontal. I think every member of the general public should always ask their dentist, How is my pocket today? How do I see my bleeding condition? I usually tell a patient not a thing about their tie control or how well they brush their teeth. Then, I  go through what they eat because sugar is probably one of the things that you can do for hygiene is fluoride treatment, but the most effective way of preventing dental caries is sugar restriction. Today, if you tell the patient, don’t take candy, is so old. I think that’s why I’m so in love with this FMD and this fasting, mimicking diet concept. I think those are very good treatments, not only for general health, and that’s the most effective way to reduce dental caries.

William Hsu, MD

You’re saying you’re talking about an innovative nutritional approach, and you mentioned the fasting-mimicking diet. Maybe we go there for a few minutes. Tell us a little bit about fasting and mimicking diets. It seems like a little bit of a contradictory array of fasting, and then there is a diet in there.

Yin Hsu, DMD, MPH, MAGD, LLSR

What happened is this: let’s just talk about sugar and calories. I think we are more effective. I mean, what is damaging is not how much sugar you take at a time, but how frequently you do. 

William Hsu, MD

That’s an Interesting concept.

Yin Hsu, DMD, MPH, MAGD, LLSR

Yes, of course, if you take too much sugar, we talk about simple sugar that is bad for your metabolism and the loading of the system. But it just gives you an example. I think it was 1940–47, to be exact. The diet counseling is a very important and intricate part of dental education. Something happened in 1945: the great discovery of fluoride. I think it’s the discovery of insulin in terms of a century. They changed the behavior of the dentists. No longer, we’re telling the patient not to take candy; would you say fluoride? I think fluoride at best reduces dental carries by about 50%, but sugar restriction can be as effective as 80 to 90% of a carries reduction. FMD, it’s very hard to tell a patient not to have candy; almost every patient won’t take that. That’s an old record. I heard that before. If you look at today’s diet, I think the most convincing to me is FMD, because FMD doesn’t have any sugar in it. It also gives your body a chance to loosen up the inflammation. I think that because of the restriction and selection of the food during that time of a fasting week, you improve your gum health. Although that’s anecdotally true for people, when people are doing that thing, they take care of their general health, including their oral health as well.

William Hsu, MD

Yes, it’s very interesting because intermittent fasting is now all the rage. There’s been huge popular popularity. It’s estimated that more than 10% of Americans are fasting. This fasting-mimicking diet. It’s quite a fascinating innovation, essentially in nutrition: precision nutrition that gives you the benefits of a five-day fast. You’re not fasting; you’re fasting, and you’re getting the benefits of fasting while probably getting some nutrients. In this whole area of fasting, I think there’s a study by Dr. Hsu that I know of that looks at the effect of fasting-mimicking diets on periodontal disease that’s being carried out at the moment. Now it looks like the fields of dentistry and medicine are coming together even closer because the mouth is part of the body. I think our society and/or our medical discipline split the tube. There should be. I mean, there is a connection in the end. 

Let’s summarize a little bit about our discussion so far: there is a bidirectional relationship between periodontal disease and type 2 diabetes. People with type 2 diabetes have higher rates of periodontal disease, and people with periodontal disease happen to have to have a higher A1C blood sugar. This relationship must be broken. I say, Dr. Hsu, you mention that thing that dentists do more often for surveillance, for dental cleaning; if necessary, deep cleaning or deep scaling, as you call it, would be important. I’d like to finish off by focusing on nutrition, which is a very important thing. Nutrition has the benefit of improving metabolic health while also improving periodontal disease. But dentists are busy. How do you impart that education in your practice, especially on nutrition, fasting, etc.? When do you have the time to talk to patients about it in oral practice?

Yin Hsu, DMD, MPH, MAGD, LLSR

Usually, I have a lot of references on my bookshelf, so that’s a first introduction to my practice. Second, I am just yourself. Every time I went to see you, we came up with an action plan, and I am sure that most dentists give patients an action plan too. But in my action plan, I also include nutrition because,  as you probably know more than I do, a lot of people are taking SSRIs, taking all kinds of medications, and a lot of times they just need to reset their nutrition. They may be helping their sleep or their general health. Then, especially, I think I learned from you last time in your summit that, on average, the insulin resistance problem is longer than 15 years before your metabolism starts to show symptoms. I think the dentist can play a big role in that when we see a lot of uncontrolled gingival inflammation that you can’t explain. Maybe we have to think about that. Is there some component of the insulin resistance in it that contributes? I think it’s all about prevention, and then, so that’s just, I think that’s what I think, yes, that’s important.

William Hsu, MD

Dr. Hsu, our listeners who are living with diabetes, what advice would you give him or her when our listener goes to the dentist? What should the listener do? Why should the listener inquire?

Yin Hsu, DMD, MPH, MAGD, LLSR

Yes, definitely. They want to know how much inflammation I have in my mouth. As I said, there are two very simple things we call bleeding when probing, and you shouldn’t be bloody. You wash your hands, session with me, bloody wash. We do a dental cleaning. Cleaning that shouldn’t be bloody either. How much is that? You need to ask the dentist or hygienist. Second, we should ask again. You want to ask about the charting of the periodontal pockets. I believe that 100% of dentists should provide that information. Look at your pockets. You can look at those red numbers. In those red numbers, you should see more than four, which is millimeters. then you should ask, and then what can you do about that? 

Then if people have those too, you want to see if you can qualify four times or three times and you’re cleaning, starting with two would suggest that tradition, insurance coverage, and I think that’s the basic thing that we should do. Then if your dentist happened to be into nutrition, which I know plenty of them were, they should talk about that because it’s in our blood. We need to talk about nutrition. We just don’t know what to do with it. I think today we have the technology of the FMD. Like this summit is about. I think we should use it. Then in my practice, and then the moment that I talk about autophagy, to talk about renewal, because gum is a part of the skin, it’s a good in. I’m pretty sure it’s going to go for the gums, and that could.

William Hsu, MD

Point.

Yin Hsu, DMD, MPH, MAGD, LLSR

Then maybe people don’t see their gums. You said that as part of the skin. They want to look younger on the outside and younger inside as well. I think many of our friends were interested in doing the same thing.

William Hsu, MD

What an interesting concept. Yes.

Yin Hsu, DMD, MPH, MAGD, LLSR

Every dentist who tried to do it and did it was the whole office staff. That’s what we are doing.

William Hsu, MD

That is fantastic. 

Yin Hsu, DMD, MPH, MAGD, LLSR

The staff are losing weight; they’re looking better. Everybody says, What’s the secret? There you go.

William Hsu, MD

That’s amazing. Dr. Hsu, what an inspirational and helpful discussion we’ve had. So hopeful and very practical. Our listeners, if when you go to see your dentist, you haven’t made sure you go, and as these critical questions. Dr. Hsu, if our listeners want to look up your information and look up the type of practice that you have, and by the way, where are you at anyway?

Yin Hsu, DMD, MPH, MAGD, LLSR

At present, my practice is in Boston, looking at the Boston Commons, and then my office is Suffolk Dental Group, which is located in Suffolk County. We do have SuffolkDental.com as a website, or people can contact me with my email, which is my name. [email protected], and then you probably can. We are adopting a new system on the website that I can’t have a direct conversation with people.

William Hsu, MD

While you make yourselves so accessible. Thank you, Dr. Hsu; you are one of a kind. Our listeners, thank you. This will conclude today’s episode, Reversing Your Type 2 Diabetes Summit. 2.0. Thank you.

Yin Hsu, DMD, MPH, MAGD, LLSR

Thank you. Happy fasting.