Welcome to Chasing Life. For years, you may have watched scary movies with dentists as the villains. Think "Marathon Man."

Is it safe?

Or "Charlie and the Chocolate Factory."

Let's see what the damage is, shall we?

Little Shop of Horrors.

You have a talent for causing things pain, so be a dentist.

Maybe because of these movies or not, we have a lot of dental anxiety. In fact, in the United States, nearly three quarters of the population have some degree of fear or anxiety about going to the dentist. That was according to a survey published in the Journal of the American Dental Association. But at the same time, people know that dental care is crucial to our overall health. Get this, the number one most common health condition in the world is not cancer. It's not diabetes. It's is not even heart disease. It is tooth decay. Among both kids and adults, untreated cavities tops the list. Now, the good news is that cavities are largely preventable.

The problem is, if I ask, you know, the next 100 people I'm going to meet today, how do you get cavities? They're all going to tell me, of course, if you don't brush your teeth and eat a lot of sugar, your mouth is more complex. It's an organ with multiple things that are functioning with a whole world of oral microbes.

'That's Dr. Kami Hoss. He is a dentist. He's an orthodontist specialist. He's also author of the book called "If Your Mouth Could Talk: An in-depth guide to oral health and its impact on your entire life." Today's discussion is gonna make you think differently about how you care for your teeth. We're gonna talk about Dr. Hoss' approach to oral health, what he recommends as the optimal routine to fight cavities, and to keep your entire mouth in tip-top shape. We're talking about in between the teeth. We're talkin' about your tongue. We're talkin' about you breath. We're also gonna dive into the fluoride debate. I'm Dr. Sanjay Gupta, CNN's chief medical correspondent. And this is Chasing Life. Ok, before we get started, I wanted to take a minute to explain how fluoride works. I think this is really important. Fluoride is a naturally occurring mineral that can help prevent tooth decay. Remember, prevent tooth decay. Here's how it works. When we eat foods, in particular sugary foods or highly refined carbohydrates, the bacteria living in our mouth that are already there get to work, breaking down that food. And in doing so, when the bacteria start doing their work, they are releasing acid. And that acid is what then corrodes the minerals that make up the outer layers of our teeth. That process is called demineralization, and that is the very start of tooth decay. Now, fluoride, if it's already on your teeth, can help prevent this loss and even restore some of the minerals broken down by the acid released by those bacteria. Keep that in mind. You got food. You got bacteria, it releases these acids, fluoride can help protect your teeth from those impacts and even restore some of the minerals. Okay, so keep this in mind during this conversation.

It's a pleasure to meet you. I've seen you obviously on TV a lot. So thanks so much for always been such a wonderful job.

Thank you, doctor. I appreciate that. I am curious just for yourself personally. What is your oral health care routine like?

In the morning, before breakfast, not after. I start with a very safe and effective mouthwash.

First thing in the morning you're saying.

'Yeah, before, breakfast, BB, and before bedtime, BB. Why? Because every time you eat or drink, the pH of the saliva drops and mouth becomes very acidic. And that's why you wanna avoid brushing your teeth at least for an hour after you eat or drink anything. So in the mornings before breakfast, you want to get up, use a very safe and healthy mouthwash that doesn't have artificial colors. It's not acidic. It doesn't have antimicrobial agent that kills 99% of your germs. So it alkalizes your mouth, it loosens the plaque, it freshens the mouth. The next thing after that is either you can floss in the morning or in the evening. And if you're going to take away one thing from this, remember to clean your tongue because they leave all these microbes that lead to bad breath. And so you want to clean your tongue with a tongue cleaner. You can clean your tongue with a toothbrush, which is very, very minimal cleaning, or you can use these U-shaped tongue cleaners, they're like metal ones, which are the next better version. Or the third one, which my favorite, is a specialized tongue cleaner that has a tongue brush on one side -- These longer brushes that go into the deep crevices of the tongue, and a scooper on the other side that you can get out, you know, microbes, the debris and the sulfur that causes bad breath.

Okay, you got that? The mouthwash first, which isn't one of those mouthwashes that kill all the bacteria, but something that actually makes your mouth more basic or more alkaline. Then brush your tongue, and finally brush your teeth. Now with regard to flossing, Dr. Hoss says at least once a day, either in the morning or at night, your choice, but as for the nighttime routine, here's what he recommends.

In the evening before bedtime, you do everything you did in the morning, but backwards. You do the flossing first, if you haven't done in the early morning. Floss is such a critical thing. I know that's the one area that almost everybody lies about to their dentist about how much they floss, but truly we actually get most of the cavities between the teeth. So floss, it's super important. It causes bad breath if you don't, and use a good floss, you know, and wrap around your finger. If you can't do that, because that's the best way, then use a water flosser, and the next thing is those little floss picks. But the best thing is actually a floss picker. You can get the cleaner part of the floss in between the teeth. And the flosses I like to use actually have the toothpaste ingredients right infused in the floss. Because as I always say, you don's brush without toothpaste. What would you floss without toothpaste? Because that's actually where we get most of the cavities. You want to floss first? Then you want to brush your teeth, again, safe brush and toothpaste. And then the last thing you do at night is use the mouthwash and swish it around really vigorously and spit it out. Don't rinse anymore with water, so the mouthwash protects your teeth overnight.

Wow, okay, so thank you for that. How do you sort of determine the evidence that makes this the right routine? Is this based on your patience or, because it's a very specific routine, how do you arrive at that?

'Yeah. So the model of brush your teeth with fluoride, floss and see the dentist twice a year. This is the model that we've been following for 30 years. And what is the result? The number one disease is dental disease, cavities and gum disease. And so that model, we know it doesn't work. When I was in dental school like 30 years ago, the only discussion was fluoride versus non-fluoride, right? And what do we hear now? Fluoride versus non-floride. As if this one ingredient, it's either going to save the world or it's going cause havoc. You know, you're a physician, it would be as if in medicine, the only thing we talked about for 30 years was the benefits of broccoli, one thing. So by just putting fluoride in a toothbrush and brushing our teeth, it's just such a simple solution to a complex problem.

Yeah, look, I realize that we've probably been pretty reductionist about this sort of thing. We'll just stay on fluoride for a second. This idea that when you take in fluoride, when you ingest it through fluoridated water, for example, it's getting into your system, it's doing things to your teeth and to your bones. There's been this movement recently to try and reduce, if not eliminate fluoride in the water or stop adding it at least. Obviously some of it occurs naturally in water. If you look at the CDC's website, they say this is one of the greatest public health achievements of the 20th century. And then there's other people who say, look, hey, it's associated with neurodevelopmental disorders and other things. Where do you land on this?

By the way, all of those statements are true. And by the way, that CDC statement is from before the new environment is changed at CDC as you probably know. So fluoride works, it's not a controversial thing. We know that fluoride makes the teeth more acidic resistant. It does have one benefit and one downside.

Because of the acid you're saying?

That's right. The one benefit is it makes the teeth stronger especially against acidic erosion. Great. Why all the controversy with fluoride? Because it also has some side effects. If it's ingested too much in childhood, it can lead to things like fluorosis, which is a discoloration or deformation of enamel, or in very high doses and in serious side effects, it can actually cause neurotoxicity or other toxicity. So that's why there's a controversy. And that's my recommendation to people is only use fluoride when the benefit outweighs the risk. Like someone who's in braces, like teenagers, maybe an adult, and they're not brushing their teeth or whatever they're doing, they should be getting decalcifications, which are these white spots around the brackets within cavities. Well, then add fluoride to the regimen, because then the benefit of that outweighs the risks for that particular person. What are the situations that I wouldn't recommend fluoride? Well, on a baby or on a pregnant mother, because the risk doesn't outweigh it. There's other ingredients that we can use to help remineralize enamel and help having a better oral health without the potential risk of fluoride. So again, we've known about these advantages and disadvantages of fluorite for decades, but by obsessing over this one ingredient. It doesn't allow us to focus on the rest of the ingredients, on the rests of the mouth, on how the body works and how the mouth works. I don't think it's the only solution for all of the population.

Yeah, the famous adage in medicine is the dose makes the poison.

A hundred percent.

You know, I just want to be careful because I think this idea that sometimes the benefits are underplayed and the harms are overplayed, I think is important as well. Certainly choice is important here, but the idea that in normal concentrations it can be beneficial for a baseline of oral health I think it's something you agree with.

But it does come with some risks. So as a society, we have to decide if this is something that we wanna do it as a general.

Even at normal concentrations, you're talking about risks?

'Yeah, I mean, so you're 100% right. Obviously, the dose has a lot to do. It's like vitamin D. At the right dose is an incredible bright vitamin, but at high doses could be toxic. It works, it's cheap. In fact, in Canada, in one of the provinces, they removed fluoride from the water and they saw an uptick in the amount of cavities, so they brought it back. So I know it works. Again, I'm not really, you know, crazy against fluoride, so I don't do really anything. I just don't put fluoride on top of it in my toothpaste and mouthwash because I don't need it because with all the other ways that I'm preventing cavities and having healthy oral health, same thing with my own family and same thing, with thousands of my patients. By the way, in my offices, in some patients we use fluoride and some patients we don't use fluorides. In some patients, we use hydroxyapatite. Sometimes we don't. Again, it depends on the patient and I think in our society, we just got to customize things a little bit more. I always give this example. Let's imagine a family comes in my practice or in your practice and they have a pregnant mother, the dad has gum disease, they have one-year-old with no cavities, a 10-year old with a ton of cavities a teen in braces and a grandma with some lost teeth and some bone loss. They have different needs. And so that's what I try to teach even the dental profession that make sure that we learn more about just fluoride. We learn about how the microbes work. Like according to CDC, up to 74 to 75% of pregnant women get gingivitis. For hormonal changes, the changes in the diet, et cetera. 75%. And that inflammation, the gum disease can impact the health of pregnancy. You know, it can increase the risk of many complications like preeclampsia, diabetes, et cetera. It can impact a timing of birth. And so, if my, my own wife was pregnant, I wouldn't recommend fluoride for her because it's unnecessary risk. So I would recommend nanohydroxyapatite because nanohydroxylapatite as an ingredient just, you know what it is. This ingredient has been around for decades. Unfortunately in US, FDA has only so far approved fluoride or anti-cavity, but in many countries has really been approved for that purpose. But I can just tell you what science says and what it does. Basically, it's a biomimetic version of your own enamel, say calcium phosphate. NASA invented it decades ago, early 1970s, in the micro size and then in the 1980s, the nano size. So it remineralizes enamel, it buffers enamel against acidic attacks, that's why you want to brush your teeth before eating, not afterwards. It reduces plaque as effectively as some of the most potent antimicrobial agents, but the way it works, it doesn't decimate the oral microbes, it also naturally whitens teeth and it naturally reduces sensitivity because it's literally liquid enamel. But, for someone who's got braces and they're not brushing their teeth and they've starting to get this decalcification out of their teeth, I would then add fluoride to nano hydroxyapatite. Should you see how if we customize products and the ingredients, we can get better results at the same time, mitigate risks.

'Okay let me pop in again here for a second because there's obviously a lot of nuance in what we're talking about. So let me just re-emphasize a few of the points. Here in the United States most communities have fluoridated water. So truth is you're probably going to be getting fluoride from your drinking water. And yes, there's been some recent debate whether we should move away from that. But the American Dental Association does continue to support this practice, the practice of fluoridating water and also the use of fluoride toothpaste for most people. And that goes for pregnant women as well. Both the ADA and the American College of Obstetricians consider fluoride safe for pregnant woman. And they recommend that pregnant women continue to use fluoride toothpaste. I just wanna make that point very clear here so there's no confusion. But the nuance comes down to the fact that we are able to get fluoride protection from different sources. So yes, like Hoss said, dental care can be individualized. But you have to remember at the same time, not everyone's gonna have access to good dental care. With that in mind, let's get back to the conversation.

'If something that's almost entirely preventable is the most prevalent disease on the planet among adults and kids, maybe we should reconsider what we've been telling people, right? Millions of people brush their teeth still and floss their teeth and go to the dentist and they still get cavities -- with fluoride, by the way. So we know that one ingredient can't solve everything. So let's broaden our knowledge about the mouth because again, remember your mouth is not just enamel. Fluoride works on enamel, right? That's all it does. It just makes the teeth a little bit more acidic resistant. What about the oral microbiome? What about nutrients that the teeth need to strengthen itself from inside, like vitamin D, vitamin K2, like calcium? What about prebiotics to help the oral microbiome? What about alkaline pH of the toothpaste and mouthwash? Let's stop arguing over one ingredient. If you want to use it in circumstances that are necessary with the known benefits and risks, I'm all for it. Again, as I said, I recommend it to many patients, but for people that don't need it, why take the risk when there are all these other alternatives to have a really healthy mouth.

OK, how you doing? Lots of new information there to absorb, but when we come back, we're going to learn about something really specific. Bad breath. Where does that really come from? And also teeth whitening: How to do it safely.

There was a study, I think, that came out on flossing a few years ago. And it caused quite a bit of a stir in the dental community. And I don't want to oversimplify, but basically, it was really questioning the benefits of flossing at that point, saying if you look at the data, maybe it didn't hold up in terms of actually reducing cavities and improving oral health. Do you remember that? What did you think of that?

'What did you think of that? I remember that. Most of us who've been practicing for 30 years or plus, we know that floss works. But not every floss works, some of the most common cavities happen between the teeth. It's called interproximal spaces. The floss I use not only expands between the tooth, but has all of our key toothpaste ingredients in the floss. The reason it expands because it removes 40% more plaque. So I try to avoid flosses that have PTFE, which is a forever chemical, or petroleum-base waxes. Like microcrystalline wax.

Huh, interesting.

These are forever chemicals that stay in your body, stay in the environment.

Yeah, and you talked about a very specific sequence of events, using the mouthwash, doing the tongue cleaning, doing the flossing, doing the brushing of the teeth. Do you have any sense, Doctor, what percentage of the country is doing this in a proper way?

Very small percent. Let me ask you a question that may really shock you. How much or how many hours of dental education do you think in dental school or hygiene school we get on toothpaste, mouthwash, toothbrushes, flosses? Basically the prevention, the oral care products.

Very little is my guess.

That's right. Zero. I went to UCLA dental school, not a bad school, probably one of the top schools in the country. And we had one hour on oral care products. All I remember they said, use something with fluoride. That was it. So I think it's shocking. So we've taken the responsibility to educate our company, me along with my colleagues. We now teach at almost all the major dental conferences. We provide CE courses online. We provide educational content, webinars, live courses, recorded courses, and we go to now dental school. So to answer your question, because we're not educating dental school and because we are not educating our hygiene school, of course, not a lot of people are following the way they should be doing their oral care. And the result is a disaster. So since nobody else is doing this, we've taken the responsibility to actually go out there and not only teach the public, but also teach the profession as well.

Yeah, and I wanna make clear again for people who may be listening, I mean, this is what you do for a living. You oversee many practices. So as a result of that, my guess is, doctor, you can collect a lot of data. That's right. Because this is one of those things where, again, like with the floss, does it work, doesn't it work? How long should you floss? How long you brush? All that. You've been collecting this data.

Over 30 years.

Over 30 years. And the book is called, If Your Mouth Could Talk. That's why you decided to write the book, my guess is.

Well, actually, I'll tell you a story about how I, why I decided to write the book. I'm a dentist. I'm an orthodontist. My wife is a pediatric dentist. We run this huge group dental practice with all the specialists. I've gone to one of the best schools in the country. And before my son was born, when patients would ask Dr. Hoss, what toothpaste you were coming? I would say anything with fluoride, because that's what I was taught. And so when my own son was one, I went to my wife and I'm like, what toothpaste should we give Aiden? And my wife said, I don't know. Because now it was our own child that was on the line. So that was the beginning of me. I actually panicked. I'm like, I don't understand. I know all these areas about sleep and breastfeeding and all these other things, but the area that I'm supposed to be the expert in, none of us know what to give my own child. And so I ended up reading over 600 research articles and books over the next few years. And that's really what led me to write my book, because once I had the knowledge, I figured, oh my God, really. We need to spread this information about why oral health is important, how it's connected to pregnancy, to childhood, to airway, to sleep, to mental health, to systemic health longevity. And then once I did that, the first question out of everybody when they would read my book, what toothpaste do you recommend, Dr. Hoss? And I would say, well, it really depends on your situation, how old are you, what are your risk factors.

'And so if people are listening, and you might have a pregnant woman, you may have an older person, a younger person who are all listening, the idea of customization of their oral care routine is something that you talk a lot about in this book. I mean, it's probably, there may be too many details to get into in one podcast, but I think the point that you're making is that it's not a one-size-fits-all approach.

Hundred percent. Again, the problem is, if I ask, you know, the next 100 people I'm going to meet see today, how do you get cavities? They're all going to tell me if you don't brush your teeth enough and eat a lot of sugar, because that's the message we've been given. But if cavities were this simple, then cavities wouldn't be the number one disease in the world. It's not that simple. It is more complex. Your mouth is more complex. It's an organ with multiple things that are functioning, with a whole world of oral microbes with saliva, with soft tissues, with gingival tissues. With the bones, especially in children, that the mouth is growing, we have the airway, we have tongue, and so we need to broaden our approach about oral health, and people like me, dentists, and like you, physicians, we need join forces. Even from educational thing, it's absolutely nuts that dental schools have been separate than medical schools. It's probably one of the reasons why oral disease is the number one disease in the world. So maybe we should have a different approach. We need to customize them for different ages and stages and preferences and risk factors. And hopefully we can get the results that we haven't been able to achieve in the last decade.

What are the other consequences of poor oral health? Like my dad had a cardiac procedure recently. The doctor I think very appropriately asked about oral health during that. Concerned about potential infections and the impact that might have on the cardiac procedure. So we're talking about mouth affecting heart. But it goes way deeper than that, doesn't it?

It goes way deeper. For some reason, and probably the disconnection between medicine and dentistry, people forget that the mouth is not a separate entity. It's the opening to your body. So if you have microbes in your mouth, if you toxins that those microbes produce, if you inflammatory cells, because of the reaction to the unhealthy imbalance or microbes that have you in the mouth. If you have oxidative stress molecules, All of these things, when you have bleeding gums, which is a very common sign of gum disease, all of those molecules and the chemicals and the microbes and the toxins, they can't get into the blood vessels. They can only damage the blood vessels, but like you mentioned, they can travel to the heart and cause infections or inflammation. They can go to the brain, they go to joints, they could go to an unborn baby and cause complications. Because blood goes everywhere, right? So that's one of the ways how oral health impacts every part of your body. There's other ways, during COVID, for example, we knew that people with gum disease had a high risk of complications from COVID because the oral cavity, the surfaces of the mouth are contiguous with those of the trachea and the lower airway. So we've always known that oral health can impact respiratory health, like you can aspirate oral microbes, et cetera. I've seen studies that show that in nursing homes, if the residents clean their tongue with a tongue cleaner, it reduces pneumonia.

And just by cleaning the tongue?

Just by cleaning the tongue, because they're not going to aspirate their microbes into the lungs as often. There's also of course, your mouth is the opening to the GI tract. So there's the mouth, we all need to remember is not just connected to our body. It is the body. It's the opening to it. It is one of the most important organs in your body, right? The airway. I think there's a mistake. A lot of people think your mouth just teeth, but the lower third of your face is the lower jaw. Middle third of face is your maxilla. The nasal bones are part of the maxilla, the lower parts of your eye bones are part of maxilla. The way you breathe, the tongue posture impacts your speech, the taste, everything. I mean, so the way you look, like these are all impacted by the growth and development of your mouth. So that's why we gotta take oral health a lot more seriously. The good news is, it's so much easier to, I think, fix oral health, which impacts all of these areas of our mouth, systemic health, mental health, personal successes, professional successes, our dating life. How much money we make. By the way, all of these are impacted by oral health. So why don't we at least have an open mind to look at alternative new ways of taking care of oral health?

Finally, just breath, bad breath. A lot of people come to you, I'm sure, talking about that, complaining about that. Is that coming from the mouth? Is it coming from lower down in the airways?

It can be caused by many things like your throat, the food you ate, but primarily it comes from your mouth. And it's not primarily from your teeth, it's primarily from you tongue. So that's one, clean your tongue. And it should be part of your routine, just like at least once a day you should be cleaning your tongue or maybe twice a day. So that is one thing. Teeth are also critical. And one of the areas that is also extremely common to have bad breath is between your teeth. If you have gum disease, just like that's what happens when you have gum disease you get inflammation, you get swelling, food gets stuck. And so flossing, I gotta tell you, after 30 years of doing this, when I talk to someone, I can just being in the distance of talking, I can smell if there are types of person that flosses their teeth or not.

Huh. Interesting.

Yeah, so because it really, really impacts bad breath. So, majority of the bad breath is from the mouth and these are the areas that you can do to really help it mitigate it.

Do you want to say a couple sentences on teeth whitening?

'Absolutely. I live in California. Everybody's obsessed with white teeth, right? So I want white teeth too. And so there are a couple of ways that you can whiten your teeth. One is through chemicals, like through bleaches basically, right, hydrogen peroxide is it really whitens it, but it also causes sensitivity. So you have to make sure that you use the right concentration. Don't overuse it because then you're going to literally damage your teeth over time. Your teeth are going to actually look more dull. You're going to cause permanent damage to your teeth, so that's with hydrogen peroxide. Do you know an ingredient that can naturally whiten your teeth but at the same time reduce sensitivity and at the time re-mineralize enamel, buffer enamel and reduce plaque? Nanohydroxyapatite. If I wasn't married, I would marry nanohydroxyapatite just because it has so many benefits. And so my wife, I hope she doesn't listen to this podcast. So, nanohydroxyapatite, it naturally whitens your teeth. Because it's like liquid enamel and makes it shiny, and smooth, and white. At the same time, it reduces sensitivity. So it works the opposite of bleach. Bleach whitens your teeth more, it bleaches your teeth. But over time, you can damage your teeth, so maybe once in a while you can bleach your teeth but your daily uses, if you wanna have white teeth, if you're a coffee drinker like I am, if you are a tea drinker, which I also am, you want nanohydroxyapatite, ideally with vitamin D3 and K2 in your toothpaste and mouthwash and floss. It naturally whitens it so that you can see why I'm obsessed in a way with this one ingredient.

'Well, I wish you and nano-hydroxyapatite a long and successful life together. Thank you. We, we're not, we don't endorse any products on this podcast, but the products that you're talking about, are they readily available? Can you find these toothpastes that have fluoride and nanohydroxyapatite and some vitamin D and K2 and all that, do they exist?

Yes, of course there are other oral care product companies that also have Nanohydroxyapatite. It's an upcoming ingredient and I think a dozen brands have it.

Doctor, what a fascinating discussion. I gotta be honest, I read the books, I knew that it was gonna be interesting, but you're a fascinating guy and you've been at this for a long time. You literally married another dentist. So this is your life. So I really appreciate you sharing your wisdom with us.

Thank you, that's very kind of you to say it. Thank you very much, have a wonderful day.

That was my conversation with Dr. Kami Hoss, orthodontic specialist, founder of an oral care company called SuperMouth, and author of the book "If Your Mouth Could Talk." If you'd like to read his dental recommendations more closely, please make sure to check out our show notes. Thanks so much for listening.