Floss and Flip-Flops Episode 2


This month, the Sanders sisters turn their focus to heart health, the role clinicians have in prevention, and how the medical and dental professions can partner in prevention efforts.

Elizabeth Sanders, DPM 0:01
Hi, I'm Dr Elizabeth Sanders, a foot and ankle surgeon and assistant professor at Boston University Medical Center.

Katrina Sanders, RDH Hi, I'm Katrina Sanders, a registered dental hygienist, consultant, international speaker, and wine lover.

Katrina & Elizabeth Sanders 0:15
And we're sisters.

Elizabeth Sanders, DPM 0:17
I grew up looking up to my big sister Katrina

Katrina Sanders, RDH 0:20
And now I look up to my lady boss physician sister Elizabeth.

Elizabeth Sanders, DPM 0:23
Together, we are working to unite the dental and medical communities in unique and exciting ways.

Katrina Sanders, RDH 0:29
Welcome to Floss and Flip-Flops with the Sanders sisters, our monthly podcast...

Elizabeth Sanders, DPM 0:34
where we unpack all things health-related, from your mouth to your toes.

Katrina Sanders, RDH 0:38
So grab your flossy floss slide,

Elizabeth Sanders, DPM 0:40
And slide on some flippy floppies!

Katrina & Elizabeth Sanders 0:42
And let's get on with the show!

Katrina Sanders, RDH 0:51
Hello, and welcome back to another episode of Floss and Flip-Flops with your favorite ginger sisters, the amazing Dr Elizabeth Sanders and me Katrina Sanders, your favorite ginger RDH. Hey, Doc, how are you today?

Elizabeth Sanders, DPM 1:06
Oh, I'm so good. Um, this is my call week. So I've been you know, it's been kind of crazy, 'cause I'm a black cloud. But I had a full OR day and it's been really good.

Katrina Sanders, RDH 1:15
What does 'black cloud' mean?

Elizabeth Sanders, DPM 1:17
Oh, it means that whenever I'm on call, it seems like all the patients in the Boston area just know it and they come in with with what problems.

Katrina Sanders, RDH 1:28
When it rains it pours, right?

Elizabeth Sanders, DPM 1:29
But that's all right. That's all right. Yeah, living the dream here. Yeah. How about you, how's your day,

Katrina Sanders, RDH 1:35
I'm so good. I'm good. I'm just you know, here, you know, living the good life and spreading the good word about the world systemic link. So I'm super excited to chat with you today. And so today's podcast episode is really going to focus on cardiovascular disease, the role that we as clinicians have in supporting our patients in the provision of cardiovascular disease, and most specifically, how the medical and dental communities really have an opportunity to partner in their efforts. This, of course, is a cause that is very near and dear to our hearts as your 2 female co-hosts. Because we know that cardiovascular disease is the number 1 killer of women, it oftentimes is a silent killer. And we oftentimes see that the mortality affiliated with cardiovascular disease for a female population is oftentimes because women tend to do a very good job of ignoring some of the important signs or symptoms that they could be having a cardiovascular event. Whereas our male counterparts are far better about complaining if something's not feeling right, and then going and seeing a physician. So if you are a female out there listening, please, you know, take the time to not only think about how this would align with what your patient care modalities are, but also what this will mean for you. You know, there's incredible amounts of data out there that although we as providers know what those risk factors are, it doesn't mean that we're immune to it. So please make sure that you're screening for yourself and taking care of yourself—Maslow's Hierarchy of Needs. And, of course, our male listeners out there, we know that there absolutely is a risk for our male population. And we definitely want to make sure that you're all taking care of yourselves as well as being advocates in maintaining, managing, screening for cardiovascular disease. So with that, let's begin. And I want to kind of pose a question to you, Dr Sanders. When we talk about cardiovascular disease. What exactly does cardiovascular disease actually mean?

Elizabeth Sanders, DPM 3:52
Yeah, absolutely. So you would think to yourself, cardiovascular disease, you would think, Oh, you know, certainly that's heart disease, you know, but really, it does encompass a large group of diseases that affects the heart, but also the blood vessels throughout your entire body. So we'll kind of go through kind of the basic things that are encompassed through cardiovascular disease. So of course, the most common being an abnormal heart rhythm or any type of arrhythmia, right, so any, any problem with your heart that's going to affect the blood flow throughout your entire body, any sort of heart valvular diseases such as problems with the hearts tightening the heart valve tightening or leaking. That can include narrowing of the blood vessels in your heart or even through to other organs or throughout your entire body. Specifically, you could think of with plaques, for example, or a narrowing of the blood vessels. That can also include heart failure or problems with the heart actual the pumping and the relaxing function of the heart which may lead to a fluid buildup. And that can certainly cause a Deema and swelling throughout the entire body as well as problems with breathing because you'll get fluid in your lungs. And that can lead to a shortness of breath. I can also include aortic disease, such as people with aortic aneurysms, it could include something that you were born with something you got genetically congenital heart disease as well. You also have to think about pericardial disease or the lining of your heart that there is a problem with that. So we like to keep that area so that your heart can actually pump correctly. And that can, there can be a problem with that and cause friction on the heart. And that can be part of it as well. We also think of cerebrovascular disease. So not let's not just think about the heart, let's think about what's going to your brain. So cerebrovascular disease or problems with the blood vessels that actually deliver the blood to your brain. Then we go into the things that I see on a daily basis, especially right now with my in house patients, peripheral arterial disease, or problems with the arteries to your extremities, or even, you know, to your abdominal organs. And that can cause for a lot of different problems including ischemia to your feet, and even to your hands as well. You also sink, I know you can think about your arteries, but also remember your veins. So especially people with varicose veins, hey, I'm one of them, I wear my compression socks every day because I know that I have this problem and I get a great deal of swelling, and I'm on my feet all day. But even so, I'm in if you're not staying hydrated, people are at risk of a deep vein thrombosis or basically a blockage in your veins. But I think I definitely see that on a daily basis. And I'm constantly writing prescriptions for compression socks because of it.

Katrina Sanders, RDH 6:51
You know, it's so crazy, like looking at all of these different types of diseases and conditions that you went over. And I know it's obvious, but when you think about cardiovascular disease, I think a lot of people immediately think about the heart muscle. And we forget that a lot of times when we're talking about diseases, a lot of times those diseases will manifest in peripheral arteries. This is where we will see things like you know, the dental professionals out there we will see broken blood vessels on the face, for example, great indicators that there might be some type of a cardiovascular issue underlying or you know, the things that you see in the feet, that it's like, okay, so I'm seeing this in an extremity. This is obviously a concern of something greater. But we understand that the blood vessels, they're really the superhighway, right for being able to transport oxygen, being able to transport our, you know, nutritional components, our inflammatory cytokine. I mean, it is everything. It's a superhighway for everything. So there's a disease process. It's not necessarily just the heart muscle itself. But it looks like it's also in the surrounding vascular system as well, both leaving and returning to the heart, which we can certainly see in other different types of modalities.

Elizabeth Sanders, DPM 8:13
That's a good point. It's almost like the heart is like the mothership of everything that we're talking about right now. Yeah. So, Katrina, I loved that you mentioned that this is a topic near and dear to our hearts, because it really, truly is. So a question to you. How common is heart disease? And why do you think it is important that we talk about this?

Katrina Sanders, RDH 8:35
I think it's important for us to consider this because first of all, cardiovascular disease is the leading cause of death, not just across the United States, but around the world. And I've got some interesting data here that I wanted to share. So first of all, about half of all adults in the United States have some form of cardiovascular disease. I'll say that again.

Elizabeth Sanders, DPM 8:57

Katrina Sanders, RDH 8:58
Half of all adults in the United States have some form of cardiovascular disease, one in three women die from complications of cardiovascular disease. And what's more, and I think this is like, just this is incredible statistic data. This actually comes to us from our wonderful friends at the BaleDoneen Method. There was a 2020 update from the American Heart Association that actually looked at not just cardiovascular disease, but cardiovascular events, and most specifically myocardial infarction. Get this, the heart attack has remained the number 1 killer since 1900. Every year, the number 1 killer is heart attack since 1900.

Elizabeth Sanders, DPM 9:48
Like 1900s was like we were kids!

Katrina Sanders, RDH 9:50
Well, I wasn't a kid and it was just barely a twinkle in anybody's eye in the 1900s, right? But the idea of being this is like frickin Oregon Trail. Old times, right when everybody's like getting cholera and like their oxygen or, you know, dying in the river or whatever, since the 1900s. The number 1 killer has been a heart attack. There's one exception to that—that year was 1918. Well, of course, what happened in 1918?

Elizabeth Sanders, DPM 10:16
The Spanish Flu.

Katrina Sanders, RDH 10:16
The Spanish Flu, that's right. That was our very first influence of the H1N1 genome. So yes, in 1918, we did see that there was a pivot in the main cause of death. But I mean, I really aside from 1918, it's incredible to think that people have died from this acute, you know, episode affiliated with a chronic disease. Someone has a cardiovascular event, a heart attack, every 40 seconds, someone dies from a heart attack every minute. So by the end of this episode, we will have probably lost what 30 or 40 people due to, you know, complications of cardiovascular disease.

Elizabeth Sanders, DPM 11:00
It's too many.

Katrina Sanders, RDH 11:00
The average age for heart attacks, quite honestly, for men, it's 65 years of age, which is amazing, because that's retirement age. It's I mean, it's incredible. For women to around 72 years. But really, it's just amazing to see, in 2020, about 650,000 Americans died from cardiovascular disease versus 400,000. Americans dying of COVID-19 in 2020. So just some interesting data there that really just helps to kind of color the picture I would say about the disease process about how, how prevalent it is. And I guess, also the incidence of it. I mean, gosh, we're seeing cardiovascular disease just so deeply widespread. And I think that's why this conversation is just so imperative for us to have.

Elizabeth Sanders, DPM 11:58
Absolutely. So Katrina, what are the disease risk factors of cardiovascular disease? Because that data is very startling and very scary. So what are the risk factors that we should be concerned about what we should be looking for?

Katrina Sanders, RDH 12:15
Yeah, so oh, my gosh, there are a bunch. So let's first start by looking at the patient's health history. So, here are some according to the BaleDoneen Method these would be considered red flags: chronic kidney disease, gall stones, kidney stones. This could also for example, be things like asthma, migraines, HIV, Hodgkin's lymphoma, kidney disease, thyroid abnormalities, erectile dysfunction. Patients that have that are on medications, particularly those who are on proton pump inhibitors have high concentrations of the bacteria, Helicobacter pylori, which we of course, oftentimes see with our patients who have GI issues, patients that have blood type B, or AB. In addition, we also see that lifestyle choices—long working hours, caring for a loved one, frequently dining out, divorce—divorce, but particularly for women, it's the first divorce. For men, the data that comes to us is that it had to take the second divorce before they were at an elevated risk. I don't know what that's all about, right? But divorce is a big one. Even looking at things like tobacco status. We understand that tobacco use can absolutely be a complication. I don't know if I mentioned diabetes, but we know that diabetes, particularly gestational diabetes. And of course, then you've got your typical components, things like patients that come in with high blood pressure, patients that already have high cholesterol, patients who have a family history of cardiovascular disease, high alcohol consumption—although there is some data that indicates in moderation, particularly the polyphenols that come from red wine, cheers to our red wine drinkers.

Elizabeth Sanders, DPM 14:21
Thank you for saying that.

Katrina Sanders, RDH 14:22
There you go. That is an important component and does provide some protective element to it.

Elizabeth Sanders, DPM 14:27
Thank you, Wine-genist.

Katrina Sanders, RDH 14:29
Cheers to that, right? High sodium, sugar or fat concentrations within our diet. And then there are some other things like certain careers where you're more prone, like police officers, firefighters—particularly firefighters, there's a lot of data out about their exposure to smoke and things like that, what that does for their risk. Preeclampsia during pregnancy is a big component. When we talk specifically about our female patients, the red flags that we look at are things like history of breast cancer, PCOS, bulimia, gestational diabetes, several miscarriages or history of miscarriages, early menopause, or women who are entering menopause. From a clinical standpoint, a few things that we can look at, there's a manifestation called Frank's Sign, it's a crease in the ear—so, ear creases could be an indicator that the individual has an elevated risk for cardiovascular disease. Baldness, xanthelasmas or fatty deposits that you can oftentimes see in the eyes. Clinicians out there, Fordyce's granules, or fatty deposits underneath that oral tissue. So ask your patient if they have had their cholesterol checked, you know, and then also, we understand that patients that have various autoimmune conditions could absolutely be at elevated risk for cardiovascular disease. So a few things to notate. And it's really important for us to consider this. There is some incredible data out there, really looking at the components around not just cardiovascular disease, but what our responsibilities are in cardiovascular disease. And so, you know, I'm just speaking very specifically to the dental community. You know, those are, those are my peeps, so shout out to the dental community.

Elizabeth Sanders, DPM 16:26

Katrina Sanders, RDH 16:27
With them listening right now. But it's important for us to take a look at cardiovascular disease, particularly for the work that we do, because we do understand, for example, that patients oftentimes present into our chairs far more routinely than they do seeing even their primary care physician. In fact, a current data indicates right now that about 27 million people visit a dentist but not a physician each year.

Elizabeth Sanders, DPM 16:52
Mmhmm, I'm one of them.

Katrina Sanders, RDH 16:54
There you go. Yes, go to the dentist, darn it! Data indicates right now that an estimated $100 million could be saved each year. If the dental provider was involved in things, medical screenings, like screening for diabetes, high blood pressure and high cholesterol, these were able to be conducted in dental practices. So, you know, it's really important for us to identify what these risk factors are, and what they mean for us in in really being able to move forward in serving and supporting our patients. So here's my question to you, Dr Sanders. How is cardiovascular disease diagnosed? You know, if we see a patient who's got a risk factor, how, how would we go about diagnosing that and subsequently, how is it treated?

Elizabeth Sanders, DPM 17:38
Sure. And again, we talked about so many different things that was such a big list of different types of risk factors that can lead to cardiovascular disease. And remember, we're talking about a very big system, but specifically how to diagnose and treat heart disease. Of course, bloodwork may be necessary. For example, if we're gonna evaluate your cholesterol, there are certain proteins or certain inflammatory markers, certain cardiac markers that may be elevated. So the primary care physician may want to order something like that. Your primary care physician may want to order an electrocardiogram or an EKG, which is essentially a some something to record the electrical activity of your heart, they may want to perform an echocardiogram, which is an echo. And it uses sound waves to create an image of your heartbeat, as well as the blood flow coming in and out of your heart. They may want to do ambulatory monitoring to track your heart rhythm and your heart rates throughout the day. And it's usually outpatient monitoring that you do just during the day you would go in and they would monitor you. Certainly, they may want to order a chest x-ray, or if indicated a CAT scan or an MRI to evaluate how your heart is working. A stress test is a great way to evaluate how your heart works under stress. And they do it in certain ways where they'll put you on a treadmill and they'll monitor your heart. Or sometimes people can't necessarily do that. So they may just give you a medication to basically stress out your heart and to see how it responds. In more severe cases, sometimes a cardiologist may have to perform a cardiac catheterization, where they use a catheter to actually measure the pressure and the blood flow in your heart. So from a podiatry standpoint, and I'll tell you when I know that a patient has a cardiovascular problem. Certainly, they'll come to me with a great deal of swelling in their legs and sometimes they come with so much swelling in their legs and they've never had any cardiovascular workup. I've had so many scenarios where they just think, 'I don't know I have a foot problem. So I'm going to make an appointment with a podiatrist,' and they end up with me. And of course, they haven't seen PCP or they haven't seen any other specialty in years. Because they just think, oh, I'll just, you know, nip it in the bud with one simple thing. And I do have to reach out to you, as you know, a dental professional, that there are so many people who, oh, you know, I just got to get my teeth cleaning. Why? Because I want my teeth to be nice and white. And I don't want to have bad breath. So you know, but I don't really need to go see my PCP. But I do need to go to my dentist to make sure my teeth are nice and sparkly white. And here, they come to you, you know, asking for your help. And you're the ones who sometimes need to have an eye out for it. You know, I'm one of those who's going from one job to another job. And I'm I know, there are a lot of people in United States who are doing that. And we're going from, you know, not having a health insurance plan to now having a health insurance plan, you don't have a PCP, but I'm going to go to the dentist, right? Sure. So I think it's very important that you as dental professionals are aware of these things.

Katrina Sanders, RDH 21:05
So I actually want to kick that door open really fast here. Because a lot of dental professionals who are listening probably feel this same layer of concern or questioning and that is, oftentimes, we will identify a patient, for example, who has high blood pressure, this seems to be in just in my experience, the most common patient comes in and they're BP is like way off the charts, definitely stage 2, almost a hypertensive crisis. And we take this very seriously, particularly for those of us who are routinely and it should be standard of care now if I don't believe it is, but it should be standard of care to take BP on all patients all the time. But, you know, we'll see a patient with high blood pressure, extremely high and we tell the patient I'm this is not right. I'm very concerned, we do the thing, we say the thing, right. And we do get patients who are a bit laissez-faire about it every once in a while, yeah, we'll get a patient who's like, 'Wait, really, you know, and that's it's always kind of nice to have a patient that I don't know, actually cares and is concerned about their cardiovascular health'. But some of the challenges that we do see is that sometimes our patients have been told by a primary care physician, either that blood pressure is normal for you. Or maybe your blood pressure's high, just because you're at the dentist, and so you're nervous or you're scared, or you're stressed out, even though by the way, their pulse rate is stable. And it's just their BP that's high.

Elizabeth Sanders, DPM 22:29
Yeah, it's just used as an excuse. 'I just don't like the dentist.'

Katrina Sanders, RDH 22:32
Exactly. So they use that quote, unquote, "white coat syndrome." Or, and this is the hardest part for us, we get patients that we do say, 'Hey, I'm concerned, you need to have this looked at,' they go to a primary care physician. Many of us even write down the blood pressure, or like on our, you know, office business card, and we send the patient with it, 'tell your physician, this was my BP at my dentist appointment. And let them know, this is what we saw.' And the patient, you know, then we follow up with them, they'll come back in for another appointment or whatever. And they're like, 'oh, yeah, my doctor said it wasn't a big deal.' So help me understand, what's going on there. Like what's really happening? What can we do to be better advocates? What's happening?

Elizabeth Sanders, DPM 23:16
Yeah. And it's really hard to say, you know, I'm, I think, I think you as a dental professional and me, I'm also a specialist, we just really have to have a better eye out for them. And it's hard to say that because you don't have much time, right? I think you guys are given like an hour to clean your patient's teeth. And I'm given like seven minutes per patient. And here you're not given this time. And I think you're right, we need to step back and go back towards what is the standard of care and look at the blood pressure. Like even if they're taking it, are we really looking at it? Yeah, it's, it really is a problem. And I think it's something that we need to look at as a whole in our professions.

Katrina Sanders, RDH 24:06
Yeah, absolutely. So one of the things that we do look at in our professions, we do see things symptomatically in our patients things like you know, heart palpitations, or we've been screened for things like heart murmur, which back in the day we used to premedicate our patients for certain patients that have like chest pain or even neck or back pain or pain through their mandible that's a nice indicator that the patient could be having a cardiovascular event, heartburn or indigestion, sweating, dizziness, or oftentimes syncope, shortness or difficulty in breathing, generalized exhaustion or inability to tolerate you know, cardiovascular exercise or even swelling in the lower extremities. So we will see symptoms of these things. What are some of the things that I as a preventive specialist can do to counsel my patient in how to prevent cardio vascular disease,

Elizabeth Sanders, DPM 25:01
I think the big thing we can really talk about if we have time to is a change of lifestyle. Certainly, you want to talk to your patient about a diet with less sodium and less saturated fat in their diet, you want to talk to them about increasing their aerobic activities. If they do smoke, if they're a smoker, you want to tell them to quit smoking. You know, something that's easy to say, but it's harder to actually do, you need to tell them to try to reduce stress in their life. You know, unfortunately, stress and especially being in the United States, where we work, work, work, work, work. And then like you said, at 65, now you're a male at retirement age. But we need to have that, you know, work-life balance and reduce stress. Managing underlying conditions like your diabetes, your hypertension, your hyperlipidemia is very important. Sometimes people do need to be placed on certain medications. And this will depend on what kind of cardiovascular disease you have. In some cases, once diagnosed, patients may require surgery like a stent or balloon angioplasty and they're in their heart or what I see all the time are stents or balloon angioplasties in your legs, because remember, this is a continuing system. So if you're not necessarily getting the blood flow back up to your heart, or to your feet, you're affecting the whole system. Sometimes people do need cardiac rehab, like monitoring exercise programs. And then sometimes people do need some active surveillance over time including careful monitoring.

Katrina Sanders, RDH 26:44
Yeah. You know, it's it really is amazing. Where lifestyle has, you know, where lifestyle pours into it, and you're absolutely right. We've glamorized the concept around...we I think we've lost the glamorization of tobacco use. Remember when it was like a little Virginia Slims? Oh, you know, you..

Elizabeth Sanders, DPM 27:04
And that's what we grew up because they didn't know about it. And it's unreal, yeah.

Katrina Sanders, RDH 27:09
Exactly. We didn't understand that. And now it's like, okay, so our generation we understand that like, smoking is bad. We get that but now we've glamorized stress, we've glamorized not getting appropriate sleep, full night's sleep, you know, we've glamorized to this, like work, work, work, work, work all the time. And those things, you know, there's we're starting to see a rise in Millennials having cardiovascular health issues. Now, you know, and oftentimes, although you're doing all the right things, and exercising and eating well, it's like that stress is an important component that we forget about. So definitely make sure that you're taking care of yourself. Stress stinks.

Elizabeth Sanders, DPM 27:49
I like that. Very good point. So Katrina, um, I've been getting a lot of articles on some really interesting topics on the role of periodontal disease and heart disease, which is something I know you are, are very fond of, and I've been getting articles into my emails, and I love reading them. So tell us a little bit about the role of periodontal disease and heart disease.

Katrina Sanders, RDH 28:18
Oh, my gosh, so I mean, this is like a little bit, I was just gonna say, this is like a four hour lecture. You know, I'm so excited because I know that we don't just have our dental colleagues listening to this, we have our medical colleagues listening to this as well. And so this is a really key component. In fact, we mentioned this on our first episode, but, you know, we've done some serving of how, you know, medical providers when they are treating patients who have diseases that have an internet dependent link to oral disease, like are you asking the patient have when's the last time that you saw your dental provider, when is the last time that you had a dental, you know, treatment or dental screening. So these are important components for us to look at. You know, there are two major components for us to be concerned about when it comes to periodontal disease and cardiovascular disease. And those two are number one bacteremia. So what happens when bacteria and or their byproducts enter the bloodstream and circulate through the body? And number two is systemic inflammation that begins from a local acquisition. So just a nice over the balcony. Look, when we talk about bacteremia we talk about bacteria. This goes back to something that you mentioned earlier, Dr. E, and that is, you know, when we look at patients that have peripheral disease, this is oftentimes due to clogs or clots and the microvasculature. Our friends at Bell donate have some amazing research that actually talk about the fact that when you have a cardiovascular workup done the average person, typically they're looking at your major arteries, your vena cava, your aorta, I mean they're looking at your carotid like the big ones, but the vascular majority of the time, when we see a cardiovascular event occur, it's because that clog or clot happened in a peripheral artery way far away a teeny, tiny little microvasculature issue. And that was the straw so to speak, that broke the camel's back. When we talk about bacteria, we talk about Bacteria entering the bloodstream and circulating through the body. We talk about the fatty concentration of these plaques, we talk about plaque in the mouth. That is essentially what we're seeing in our cardiovascular in our vascular systems, you know, in the lining of our cardiovascular systems, so bacteria play a role in this bacteria, you know, we know have the ability to create byproducts and the bacteria byproducts can also elicit cardiovascular disease. The other layer to that is the inflammatory component, the host response that when we have bacteria present, we know that our mast cells are like going crazy, releasing heparin and histamine. We know that our white blood cells are going nuts with releasing inflammatory cytokines, we know that our liver is going nuts, releasing C reactive proteins. And so the challenge being we know that periodontal disease is the second most frequent modifiable inflammatory condition across the United States. And so with the prevalence being 47.2% of adults between the ages of 30 and 79, who have oral inflammation in their mouth right now, this is where we're starting to see that creates that systemic dumping, I mean, just constantly have inflammatory mediators. So that is a long story for the little bugs in your mouth are going to cause additional problems. And the fact that your mouth has inflamed means that the rest of your body is inflamed. And so we understand that role. We see data about oral inflammation like ginger, Vitus, or periodontitis. But we also see data around patients who have endodontic disease. So patients who have had failed teeth, or infections in their teeth, where they needed to have root canals, or maybe those root canals got infected, and the patient needed to have their teeth removed. So we're seeing a lot of data there. And, you know, I, I'd love for there to be a day at some point in our careers, when we do see our medical colleagues, you know, beginning to screen for some of these things, because we do know and there are incredible amounts of data out there indicating that if a patient has inflammation or infection in their mouth, and they treat that inflammation, or they treat that infection, that long term, we're going to see the patient systemically being far more resilient to their disease process. So I implore you to consider to our medical colleagues out there. You know, people in the dental field, we want to be a partner with you, we want to be advocates for our patients, we want to be able to serve them in the disease processes they're experiencing. So let us know how we can partner with you. With that, though,

Elizabeth Sanders, DPM 33:04
That was so great. And I just think about, I just think about how you know, the mouth is the portal to so much stuff. And for some reason, as you were talking, I was thinking about the time that you told me you diagnosed someone as possibly being pregnant, you were doing a just a routine dental exam, like, obviously evaluating for cancer and whatnot, and then you're gonna clean her teeth. And then you're like, 'is there a chance you might be pregnant?' And I just thought that was so amazing. There's so much you can tell just by looking at people's mouths. Oh, my gosh, I have so much respect for your profession. Yeah,

Katrina Sanders, RDH 33:45
Thank you! The cellular turnover in the oral cavity allows us to oftentimes see, you know, issues systemically, or nutritional disease, which stay tuned, we're going to talk about that next month. But we can see a lot of those changes in the oral cavity first before the patient might even experience symptoms because of how fast those cells turn over. So we are happy to be partners, we're happy to be advocates. And it truly is a wonderful opportunity to work alongside you and to work alongside physicians like you who very deeply believe in what we're doing in the dental profession and want to support us. So thank you for joining me today, Dr E. And thank you to our amazing listeners for joining us today for cardiovascular health month. As we took the time to brush up on information about cardiovascular disease. Stay tuned next month as we talk about Nutrition Month.

Elizabeth Sanders, DPM 34:43
We promise to keep you on your toes!

Katrina Sanders, RDH 34:49
Thank you for joining us for another monthly episode of Floss and Flip-Flops with the Sanders sisters.

Elizabeth Sanders, DPM 34:55
Thank you for being part of the change we need to see in the medical and dental professions.

Katrina Sanders, RDH 35:01
Join us next month for another sister-to-sister chat about other unique, interesting, and perhaps provocative and disruptive health topics.

Elizabeth Sanders, DPM 35:10
Don't forget to like and subscribe, and maybe even leave a fabulous review!

Katrina Sanders, RDH 35:15
And we'll catch you next month for another episode of Floss Flip-Flops with the Sanders sisters.


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  2. Rana, JS, et al. (2020). Changes in Mortality in Top 10 Causes of Death from 2011 to 2018. Journal of General Internal Medicine. Published online July 23, 2021. Doi: 10.1007/s11606-020-06070-z
  3. Virani, SS, Alonso A, Benjamin EJ, et al. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation. 2020;141(9):e139-e596. doi:10.1161/CIR.0000000000000757.
  4. Witers D, Agrawal S. Unhealthy US workers’ absenteeism costs $153 billion. Gallup. October 17, 2011. Accessed February 6, 2014. https://news.gallup.com/poll/150026/unhealthy-workers-absenteeism-costs-153-billion.aspx
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