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1325 Dr. Gabriel Nussbaum on the Bacteria that Cause Periodontal Disease : Dentistry Uncensored with Howard Farran

1325 Dr. Gabriel Nussbaum on the Bacteria that Cause Periodontal Disease : Dentistry Uncensored with Howard Farran

1/3/2020 6:00:00 AM   |   Comments: 0   |   Views: 198
Dr. Nussbaum trained and was US board-certified in internal medicine after completing an MD/PhD at the Albert Einstein College of Medicine. He performed post-doctoral studies at the Weizmann Institute of Science, an internationally known research center in Israel. He continues to be actively involved in the investigation of inflammation and autoimmunity. In addition, Dr. Nussbaum has research experience with botanicals, specifically cannabis. Dr. Nussbaum has numerous publications in leading scientific journals.


VIDEO - DUwHF #1325 - Gabriel Nussbaum


AUDIO - DUwHF #1325 - Gabriel Nussbaum


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Howard: it's just an honor and a privilege to be in Jerusalem Israel with Dr Gabriel Nussbaum and you're a double doctor you're an MD and a PhD making a dental mouthwash for a periodontist who's a DMD I can't wait to hear about this entire journey totally what kind of MD and PHD and immunology yes so  from Albert Einstein College of Medicine in New York and

Dr Gabriel Nussbaum:  I trained in internal medicine and did a PhD in immunology and be selling new neurology at Einstein B cell immunology bodies and then in Israel I've been more focused my research was focused on the innate immune system so in 1999 there were receptors discovered that explained to us how the immune system the first rapid response of the immune system recognizes and responds to micro microbes like bacteria and viruses who was always known that the response was there but the receptors responsible for that response were not known and then in 1999 a major discovery was made of toll-like receptors which are a family of circus proteins responsible for recognizing and responding to the microbial world and in 2008 there was already a Nobel Prize given for that discovery so the toll-like receptors are very important for the how the immune system makes that initial recognition and response in the presence of microbes which is of course happening all the time in the oral cavity and it explains to us a lot about inflammation and what's driving inflammation it's this recognition and response and production of inflammatory mediators that's driving that inflammation and in the oral cavity it's happening all the time and disease 

Howard: it's um I mean for in 87 were you basically relatively the structure caucus mutants cause cavities a gingivalis cause periodontal disease and now I hear they're discovering a new species living in the mouth like every three months is that true so it is fascinating how much has been discovered since we all went to school and

Dr Gabriel Nussbaum:  everything I'm involved in are things that are weren't known when I was in school which is what makes it so exciting to be in in fields that require you to always be learning and always be updating yourself so yes absolutely a gingivalis can't be thought of as a direct cause of periodontal disease it's much much more complex than that and really it's about the host response I mean what's causing ultimately that tissue destruction is all of that inflammation that's there

Howard: I'm going to talk about some old wives tales I don't say a white yourselves that sounds sexist but it seems like the people who have a lot of gum disease don't have cavities and people who have a whole mouthful of counties don't have gum disease is that observation real or not really 

Dr Gabriel Nussbaum: well there's one way to look at that which is just about the clinical and you know I don't I'm not the right person to comment on how good the clinical evidence is for that but you would have to look at what is the real clinical evidence that supports that observation I've heard it also for many you have yeah I'm not know and then you could ask well why would that be and then of course what could explain that very nicely is the host response I mean the way we respond to these bacteria is what's driving periodontal disease and the same person who responds in a certain way and can control strep mutans may be responding too much and causing too much inflammation in response to all those microbes that are associated with periodontal disease so it makes a lot of sense so there's the one aspect of proving that kind of old Y husband tale is to look for the clinical evidence so the other is to look on a mechanistic level to understand what could explain such an observation 

Howard:so it's not really known yet well again 

Dr Gabriel Nussbaum:  I think what is known is that certain types of immune responses or what we call today host responses to the microbes in the oral cavity will make you more likely to develop periodontal disease certain types of host responses will make you more likely to develop caries and those are not the same it is very very different diseases the tooth this has uncontrolled diabetes are the host is a chain-smoker exactly we have a different so one is all of those environmental and systemic factors and then the other is also really on a very basic level when your immune system meets let's say four pramanas gingivalis what happens in that encounter if you are the type of person that responds very very strongly and produces a lot of inflammation well that could be a dense with the detriment rather than a benefit and if you're a hyper responder so this concept of producing too much inflammation in response to the same challenge we make you more susceptible to disease and periodontal disease whereas it may do different things and other conditions 

Howard: so you know I'm from North America I'm from Phoenix so now I'm on the other side of the world near the Fertile Crescent we we've been told that the streptococcus mutans jumped to humans from cats in the Fertile Crescent area about 15,000 years ago did you hear that believe that and the same with P morphus was that iam how did I get in that humans mouth it was that how long has that been was it was that a transfer from that they could go to sheep a chicken something something else the environmental the natural niche of Stremme youth ends

Dr Gabriel Nussbaum:  I do know that it's there's some fascinating studies coming out now tracing where did these microbes come from in the oral cavity so you know now we live in the age of what's called next-generation sequencing or deep sequencing where we can take an environmental and it can be from the human mouth it can be a soil sample whatever you want and actually do a deep dive into what are all of the microbes there and we can do it on environmental samples today but we can also actually do it in even archaeological sites so there's fascinating research tracing where did these bacteria come from and how long have they been associated with humans so not my field I've read some about it but it is interesting today that forth ramona's gingivalis for example as a an example bacteria of periodontal associated with periodontal disease that's a human pathogen so we don't see it in dogs or in mice or in other animals so it seems like it's co-evolved with us at least for a very long time it's been with the human mouth for a very long time which which also means that it's learned how to persist and live in this environmental niche because it's adapted to it 

Howard: another big question and this is kind of taboo talk about it but if you look at the other end of the human body STDs um you know they  know the other in the body you can pass bacteria and and all that so they always wonder okay well if I have gum disease and I'm kissing you um can I kiss you to gum disease and cavities and HPV and chemicals can i infect you with a kiss we know I you know you can infect someone else with sex yeah can you infect someone with a kiss at the other end

Dr Gabriel Nussbaum:  so I guess an important question here is which is an infectious disease versus just sharing microbes so now we talk about the microbiome which is the entirety of all of those microbes living at a certain site it could be a mucosal site it could be the mouth it could be the anus it could be the vagina could be anywhere but there's a community that lives there and there's one thing is to talk about the sharing of that community so we know those communities become pretty well established early on in life so that so the mother will transfer a lot of those from to the fetus or to the child when it becomes born and then over the first months two years of life there's some shifting in those communities until it's eventually stabilized then there's a separate question about pathogens when are those when and how are those shared some of those that sharing is very well known and yes you can certainly transfer some of the pathogenic organisms so you as you probably are very aware there's a shift for example in head and neck cancer and certainly in the United States to what's been a smoking associated to disease to now human papillomavirus associated disease so there's been a spreading and penetrance of certain types of human papilloma virus into the oral cavity and that it there is a causative factor in head and neck cancer it's mostly a different type a slightly different type of cancer it's a little bit more posterior so it's oropharyngeal cancer rather than the tongue tumors and the smokers but the question is where are those coming from well it turns out some of the oncogenic in other words cancer-causing subtypes of HPV are coming through oral sex so yeah there you have a very classic example of transferring a pathogen that then establishes  itself in the oral cavity and that's being transferred through an oral sex encounter and 

Howard: Michael Douglas was the first celebrity to admit that on t v-- and draw attention to it remember Farrah Fawcett yeah she died of anal cancer which is very very rare so the what you're doing here is um and a lot of people now we're talking about that the antibiotics are changing your microbiome and you see studies that arm identical twins one had antibiotics for an ear infection the other one didn't and now they're different maybe ones heavier or what have you what are your thoughts from what you learned everything about periodontal disease mouthwash and antibiotics

Dr Gabriel Nussbaum: so antibiotics certainly have an effect on the microbiome in the oral cavity and throughout the body which is why when you take antibiotics you're certainly a higher risk or outgrowth of Candida species so people on antibiotics will get yeast infections women in the vagina but also in the oral cavity you can get outgrowth of candida species so that's good evidence for the fact that the there's a shift going on in the microbial species because of the antibiotics what's interesting is most of that is a transient effect in other words the microbiome the microbial communities we'll come back to what they were a certain time period after the use of antibiotics but there's no question I agree with you completely that antibiotics are having major impacts on our bodies and the environment as you probably know most antibiotic use is in farm animals so it's in the livestock right and that's getting into the environment so even in the soil etcetera oward: 

Howard: so chicken if I need animals that were you know ninety percent of antibiotics nine states going to livestock does that how does that affect the person does it affect the person eating the hamburger the chicken that's a good good question in the controversial question that

Dr Gabriel Nussbaum:  I don't think I have a very clear take on a good answer for that one okay making it interesting and is it's it's amazing how fast everything is changing

H yes but um i am i call my per industrial sensor not on one sorry about what any everybody agrees on but i like to hit the controversies i know a lot of dentist a lot of them are my drinking buddies bars that after every root canal they just get everyone 10 BK and vicodin well what would you say as an MD with the peach and immunology to my homies that after every root canal they just write pen BK 500 milligram 20 tabs what do you think of that I think

Dr Gabriel Nussbaum:  I think it's a good idea to reevaluate that crap yeah I actually was involved in a study from the School of Public Health that looked at antibiotic use by dentists how much of it was evidence-based and there isn't good evidence for that for those grits so I would recommend reevaluating the practice because as we're all aware there's a huge problem of antibiotic resistance among the bacteria that are that we're all exposed to so there are superbugs today mostly in the hospitalized patients but there are some reports even in the community of exposure to superbugs these are bacteria that have learned to be resistant to all that all known or many most known antibiotics and a lot of that is coming from the training they're undergoing by being exposed all the time and why they exposed all the time well we talked about the farming this was the livestock industry but it's also from overuse of antibiotics not just by dentists by physicians as well and then you see I think all physicians and I'm including dentists in that category should think carefully before putting a patient on antibiotics don't forget they've only been around for you know not that long and already about bugs are resistant and people were living pretty well before them but we don't probably need to be giving that much and then really weird because penicillin against bacteria and the solder is actually even discovered in a fungi yeah well obviously the antibiotics are actually being produced by other microorganisms to fight each other was a eukaryota or a prokaryote I think that's very interesting 

Howard: so tell us about your journey then I assume one day you were Billie's patient William William Z Levine but you call him Billy you know yeah yeah so you were a patient at Billy's periodontal practice how did you and I'm current honest thing Billy meet up and tell us about their journey how did that happen okay

Dr Gabriel Nussbaum:  so we actually it's a nice story we were both sitting together at a table at a fiftieth wedding anniversary of common  friends and struck up a conversation and he was telling me that he founded this company to look at controlling periodontal disease well gingivitis and periodontitis and he needed to understand the science better and I said well you know I can help you and that's where it was born it was born from that and how long was that that was in 2003 Wow I see you guys have been at this long time around for a while 

Howard: so were you saying about make sure because make sure is 2020 I think you'll be able to see more clearly with 20/20 vision right so you start in 2003 you're almost at 2007 teen years how does this company and what you're doing look 17 years later than 2000 degrees

Dr Gabriel Nussbaum:  so I'll tell you a little bit about the  background of the company and  in the exciting products we've developed and future directions so the idea really was to take a different look at periodontal disease not as an infectious disease but as a disease that is an outcome of the host response to microbes and if that's what's driving the disease the host response then maybe the way to treat it would be to try and control the host response so there's this really fascinating phenomenon that we all know as clinicians that you've got a plenty of bacteria in your mouth and that's being cleaned with the scaling and root planning but you've got plenty of host response so the reason you have those back there your mouth is not because your immune system doesn't know how to respond to them they're actually your immune systems responding very well there's plenty of inflammation there's a whole wall of neutrophils there's T cells these cells if you look at histology you'll find a very very diverse and robust immune response to the microbes so why do the microbes not going away well it turns out that the microbes associated with gingival inflammation and very thoughtful disease actually benefit from those from that host response they're living off the response we think of it as a host response they think of it as nutrients food source etcetera so one of the fascinating things about if we come back to port from oysters develops but it's true of a lot of those bacteria is that they do not use sugar as a nutrient source there are what's called a Sakura lytic they do not use glucose sugar what they do use is proteins so they're all had very very powerful proteases enzymes that break down proteins so what  is inflammation well I'm saying that that you can just look at it as then loving inflammation so they are lovers of inflammation because inflammation provides proteins it's a very protein rich environment and nowadays information provide protein because a lot of those hosts response factors are proteins so we think of the cytokines tumor necrosis factor-alpha TNF alpha interleukin 1 data we think of them as very powerful activators of the immune system makes the cells kill bacteria better that's what it's supposed to do but what are they they're proteins and actually it's been shown in very nice studies that the protease is those enzymes from the bacteria like pork from one instrument about us break down the side of minds and you 

Howard: so what are sources for what I'm here he says we should eat more candy because P gingivalis only wants protein 

Dr Gabriel Nussbaum: yeah well they would get more caries what I'm saying is that the bacteria actually does a great term in the literature now they're in flannel filling lovers of inflammation so really if we want to control the bacteria we need to control the inflammation which is really why if you keep if you maintain a healthy environment you know healthy gums it's more it's less likely that the bacterial plant will outgrow again will grow in because in order for it to grow it needs the hygiene 

Howard: to go down so that is you know I don't want to embarrass him bear things but I have a patient who's a hygienist who's one of my mentors and role models and his old annoying she has had the most perfect home care around the clock her whole life she doesn't have system and she doesn't have a baby sure she's doing everything right and she's so motivated and she's had such horrible results and she's lost teeth and she's crying so when someone says something you were simply say well you you just don't brush and floss come on come on man that's too over simplistic because we've all had patients that have tried harder than anyone and then another thing we see is we see again people who try real hard coming in every three months from gum disease and then you got Billy Bob use hasn't trained at all and he doesn't have young disease something's not adding up

Dr Gabriel Nussbaum:  I agree with you a hundred percent I think there's a big problem in oversimplifying periodontal disease the oversimplification starts with calling it by one name okay so you know there's many many forms and many differences and varied on the disease and Billy Bob is not the same as very Dalton disease and Karen and not the same as periodontal disease in John etc etc there are many variants of the process they can cause ultimately the same clinical outcomes may be of bone loss and tooth loss etc you know it was eventually down the road if you have enough disease you will activate the osteoclasts they will absorb bone and you will get those teeth will start to come out but  that doesn't mean the way you've got there is gonna be the same so I think there is a variant where yes you know poor hygiene is contributing to the process but there is a variant for sure where you got pristine hygiene and you're still getting it and why could that be well there's many possibilities one of which is the host factors in that individual that individual is producing something that's driving the disease you know because the disease ultimately is a combination of the microbes the factors that activate the  osteoclasts with the outcome of bone resorption you know receding gums received and bone resorbed loose teeth etc so I'm not trying to over simplify I'm just trying to point out that in the in the common variant of periodontal disease where you have poor hygiene that's a factor in the driving of the of the disease you would want to control the  inflammation reduce the inflammation in order to better control the bacteria so you're actually trying it's counterintuitive especially for me coming from medicine you know usually you think well one second I'm gonna make the person if I'm gonna shut off the inflammatory response well they'll be more susceptible to the bacteria here is really the opposite I can shut off some of the inflammation to make them less susceptible to the bacteria and that was where even our company was born it was born of that idea can we control the inflammation in order to have better clinical outcomes and we're just I assume coming from me so I assume comes from the Hebrew word for balance and the idea was to restore the balance in the in the oral cavity so I assume his Hebrew word for Bell 

Howard: so amazing how the language faded away and then almost 1,800 years later was brought back to life yeah anybody ever tried done that before have you do you know of any other languages that disappeared for two millennia and then we were brought back to life I don't know I needed thumbies is the English Reborn wasn't bred in Manhattan New York and when he just amazing that somebody was so motivated to bring calm my oldest sister's flow in Hebrew oh really she's a Catholic not man when she joined the nunnery I had bought her a MacBook Pro and then her memory wanted a bunch of stuff translated and so she learned Hebrew Greek Hebrew Greek and Latin among all the clan Golan yeah and I'm she's my oldest 1957 she's 60 and my gosh she's one of the fastest translators when the Kois turn Carmelite monastery and I give credit for Steve Jobs MacBook Pro I think it's because she's the only nun who had a MacBook Pro or maybe some is the first moistured monk who had a MacBook Pro so that's i zoom Hebrew meaning well-balanced it kind of like game yang symbol because

Dr Gabriel Nussbaum:  we also are a company focused on using botanicals in order to treat gingival inflammation and the tanning plant correct we use only natural plant materials so the idea is also restoring the balance from nature to to restore health is a worn animal you're using plans right song was a for eukaryote so actually aunt we're a eukaryote right and a complex Imperium we're a multi so multicellular eukaryotic organism and then there's archaea well you can think of them as a type of bacteria a tec-9 carrier but I knew it 

Howard: I knew it gets I don't know when my kids were in high school I was like okay this has gotten a lot more complicated than when I graduated from college I can't wait to tell my grandkids again my fourth way to turn into five minutes I can't wait to help with their homework because I'm sure it's maybe a third more complex so what was the first product that you guys decided to make where did all this lead to first and how many products have you made okay

Dr Gabriel Nussbaum:  so the basic idea was to use botanicals and apply them topically to areas of inflammation in order to reduce the clinical end points of inflammation and what we did was we screened botanicals early on we would win the begin the very beginning we had a matching machine and we would just a tableting machine we would make mucosal adherent tablets and we had all of these botanicals and the idea was that you could use botanicals that had a very strong ethno botanical safety record and you're using them in their full form rather than trying to extract a compound from them so you really have the safety confidence of a very long history of safety for many botanicals and we would tablet them into small tablets and look on the ginger bone clinically Sherry's free shirt yeah well that was really very early clinical research clinically driven research rather than going to a mouse or going to you know cell culture which I'll tell you about in a second so we found that a very defined ratio of 3 botanicals this is sambucus nigra centella asiatica and echinacea purpurea those are three botanicals that when combined we had the best clinical event and then the idea was okay we're scientists we're physicians were dentists we're not you know out out there in the in the world of complementary medicine we're trying to do this in a very scientific manner we really need to know that each time we produce this it's gonna have that bioactivity we need to know how to control it when it's manufactured we need to know how to formulate it so all of these things became the reason why we have established our own laboratories we have a lot of chemistry and biology going on and all of that is in order to have the best quality control system for production of what's essentially a multi a multi component project okay so if you make you know a set of mini fan or if you make codeine or something here your quality control is trying to get to greater than 99 percent pure of a compound we're using botanicals there's hundreds of compounds in there so how do you get your head around that and do it in a scientific manner so the way to do it is to do quality control okay is to really know what your material is so we do quantitative chemistry we have several HPLC machines I'll take you through the lab and we're  actually following marker compounds that can be quantitated in each of these botanicals but really the major leap forward was to build a quality control system that's biologically based so I told you we want to control inflammation so basically what we've done is show with a battery of tests using cells in vitro okay so now we're talking about cells in a culture dish where you can stimulate them you can stimulate them with the same kinds of factors that are stimulating them in the oral cavity such as lipopolysaccharide we all learned about it right this is what's coming from the gram-negative bacteria that's activating the inflammation in the oral cavity so you can take that LPS that lipo poly all right activate cells in culture and they will produce all of those cytokines that we know are associated with inflammatory disease in the oral cavity well what we showed whether the canticles it was one of the ways we confirmed our activity the botanicals will block that production of cytokines by the cells in vitro so that's a nice experiment but what we did which was much better is use that as a quality control system to assure the fact that when we produce the products which I'll tell you about in a second those will have botanicals that are actually we know we're confident that they're biologically active botanicals so we had these three botanicals we figured out the right ratio we figured out the best way to extract them to get them into a medium that they could be formulated into a dental product and then we have two goals we said we want to treat areas where there's a lot of inflammation you know some people have inflammation all over their mouth and some people just have them very localized the area that needs to be controlled so we developed two products one is a patch so it's a mucus of patch that's the perio patch so do you have so we have a pareo patch it comes like this and it's a mucus of the patch okay so you get a package of six and this is really designed to be applied and you can see it actually in the show you look closer to the camera okay so it's a package of six patches and what's inside each each one is the perio patch as you can see color matched for the gingiva and basically one side is Mew cohesive so that when it's in a moist environment it will stick to the gingival tissue and what's happening when it sticks there is that it's releasing these three botanicals in the prior in the ratio wired for reducing inflammation so you you're using an extremely safe natural naturally derived product to control inflammation and we have excellent clinical results which have been published in several papers so that's this is a white paper we have showing we've done clinical studies published in the literature where we reduce gingival inflammation measured by the gingival index okay and where can they find that white paper at so you can go to our website and follow the links for the scientific literature eysan eysan Pharma izn Hebrew from balance right in pharma know the website is actually good oral care we say good but I zone is also fine so he's www.izoompharma.comWWI soon oral care calm okay so which the waters a zoom Pharma so we have a parent company because we're doing a lot of different products not just oral care I'm going to tell you about that in a minute let me I'll finish with this it's an all the way down and tell you about the the other products being developed by this is on soon oral care comm correct okay okay so this is why you were going to tell me it's gonna tell them about the the clinical results with application of this pareo patch for control of inflammation in a localized area now you can love them and control inflammation in several areas but we have a complementary product which is really for whole mouth treatment which is an oral care rinse and that's again using the same three botanicals formulating them in a rinse that doesn't cause any tooth discoloration which you are actually knows correct and that has antibacterial activity so it has some CPC in it has some one same easy the CPC is this bomb was time yeah but anyway CBC's antibacterials acetal 13 'i'm chloride on camera got that per second that's an antibacterial the titles also have antibacterial act and there's three there's three botanicals in there reboot and applause and one of those again those are echinacea purpurea centella asiatica and sambucus nigra and those are all prokaryotes those are automatically those are botanical didn't try to plant plants yeah planetary and those 

Howard: are the names of three plants are this plant said the dentist might have growing in his front yard backyard or these weird exotic america well so sambucus nigra

Dr Gabriel Nussbaum:  is a european plant and then the other two he may have because they've been cultivated in different places so there may they may exist also need none of they are per se how long do these just hatch and mouth been available pension the rings on the American market some three years ago and we be using rip sales representatives representing these or not okay we have a dedicated website for Diggle professionals and but it's right now it's concentrated in the New York and what so art can have you assume that Easter up yes we do and what was the dedicated website is that that's the horrible kid book home ok as you around the world whereas the most early who's been their early adopters is that which countries it's only staging know these were finally number wanted something so is that because Billy is is that the usability well that's that's the market that we know that's that the US market is generally divided most people try to get into it initially assume a guy who was slightly different here the company is predominantly an R&D; company we produce products and other areas of products of the beginning between the second where we look to find partners rather than going direct to market ourselves that's not being a traditional strength

Howard: so are you trying to find a partner now an American career well you're talking to a lot of dentists in America what are you looking for in a partner 

Dr Gabriel Nussbaum: we're looking for someone who's got distribution channels for hair products so that'll be a distributor could it be distributed yes let's you guys call Depot's right I don't know I'm countable familiar with it that I keep hearing I keep hearing in his roles we prefer to shine Paterson burger bingo his Depot's it would be the dental space so he's already me you know having that relationship with the dental professional the is also occasionally I think remember the camp a perfect opportunity with the kid with the way should we be to see you

Howard: so right now it's Billy into the dock that's b2b so yeah so that would be but you might instead of it be to be a b2c business to consumer mouthwash okay our chief microbiologist here okay 

Dr Gabriel Nussbaum: so that sort of it was the approach behind developing these to oral care products the perio patch localized delivery for an inflamed area the the whole mouth approach with very active now prince now you could imagine that controlling inflammation has many potential indications right for controlling inflammation and the zulan has looked and has developed product and as Liz mentioned were primarily an R company looking to develop products for medical indications dental and medical indications so where would you want to control inflammation well this is when we're talking about systemic diseases so one is when there's too much inflammation in a wound that's not repairing so that's a very common condition in diabetics right the condition is called diabetic foot ulcers examine cause an amputation for Africa number one cause of amputation it's a big chunk of the healthcare dollar if you just look across America is treating diabetic foot ulcers and one of the problems there is stagnated inflammation so inflammation is one phase in wound healing but you got to get over the inflammation and progress towards the healing phase and the diabetic foot ulcer many of those lesions are just stuck and they're stuck because there's just too much inflammation there and that has a lot to do with the diabetic process so of course the less control you are is a diabetic the more at risk you are for these diabetic foot ulcers and we said well here we have a topical treatment that can down regulate inflammation why not use it in diabetic foot ulcers and we then went through a formulation phase and developed a hydrogel that incorporates the three botanical ingredients and divid 80 patient trial in diabetic foot ulcers showing great results in terms of accelerating the time to wound healing so that was one very exciting there well that has to make you feel very warm and fuzzy the biggest professional validation in your life so far I mean you imagine eating your foot and that's a major one of the exciting things is going on here is the ability to develop well I move back to the mouth because you were doing my periodontal disease but as you know the fastest growing part of Dentistry is placing implants and the biggest problem in implants is peri-implantitis and you can find almost as many theories on what peri-implantitis is as there are theories you know about this I mean some people you know I don't want to go into that but have you looked at this product with peri-implantitis yes we have and this is that's a great one in your follow-up podcast with Bill because he was in charge of that study we did it very unpleasant I thought it should be a good time to talk about it behind his back in New York but yes absolutely have been very and plant itis which we know that the inflammation there is progressing even faster and is more difficult to control than imperium tightest and it's a ideal place since it's the localized to use the patch and then you can add on the rinse to the max to wrap around the patch can go around the mucosal tissue that's that's around the implant yes see the one of the biggest problems with imperium when Titus's patient selection 

Howard: I mean the person who starts losing their teeth that's not the person free of disease had great home care you know go to yoga every day and each tofu it's usually billy-bob you're smoking drinking buddy friend and so the people who need implants the most are at most risk are a motorist that's the nice political way to say it so um so what do you how do how does that make you think about the implants were placed in the most at-risk patients and now they have peri-implantitis change 

Dr Gabriel Nussbaum: part of risk assessment before placing any place has to include the patient characteristics I think if someone is someone you know how many times have you seen your loved one do something it wasn't a great idea I mean you know you're not gonna take care of it it was kind of

Howard: my boys you know I notice they want to say they wanted a bike if I bought him the bike they  believe it on the front porch but if they pay half of it and skin in the game they Park it in the garage it's tough because they're young dentist and you think the dentist is the dog wagging the patient tell but when you're young some of these patients are the tail wagging the dog and of some of these young gonna say that now I shouldn't do this but the patient talks them into it it's your money at your life at your time so that's what I'm saying is this a big debate even even one of the biggest legendary implantology all-time carl mich and his younger brother Craig is one of the greatest implantology of all time today had that issue crane will put an implant in a smoker Carl would your bought it your money journals I mean obviously no one's saying you should smoke more obviously everyone knows they should not smell but some people can't quit smoking and so I think what I 

Dr Gabriel Nussbaum: yeah so I I hear it and and I'm not a dentist myself but I do think that one of the things that would be nice for dentists would be to have a toolbox of options to treat an early periodontitis lesion a more progressed peri-implantitis lesion before you actually lose that implant and then I think the variable patch and the rinse are excellent options for early intervention you start seeing inflammation developing around those implants well you now have something in your toolbox don't just sit there and just you know scale back to one thing I've been noticing more and more and more the 

Howard: plastic surgeons which you know 80% of their surgeries on women and they have a rule that they're not gonna do face job tummy tuck breast augmentation unless you quit smoking first just six weeks before the surgery and six weeks after and the one thing I even noticed more and more that a lot of girls you know and when you tell them you got a forever that's that they're overwhelmed but they can get their hands around six weeks and then you have to have the surgery a lot of those people they never go back to it so I think that's a compromise that you might think about it and what have you just got them to smoke quit smoking you say okay you cannot have one cigarette ten days before their simple-ass surgery and if you do I'm not gonna do it well then get through ten days most of the we draw for days right and then get through ten days you hear of an implant you might have just created a nonsmoker 

Dr Gabriel Nussbaum: that's a great you know great public health intervention idea so those first two products you're very active and what was the name of the patch very old patch Ariel patch and pareo active mouthwash how much is the and the so your only sauna be to be yeah it's embarrassing when 

Howard: Dennis sells patient and they find Amazon I remember I got at school they came out with inner black and they  remember the enterprise when the first elector - prices back in that and the late 80s and they had this big push of the dentist to buy them and sell them to the basis so I bought a case and it was a loser big and he was like twelve like eighty dollars a piece which is a lot of money thirty years ago and the after selling the second one she brought it back and so I didn't buy this at Walgreens for eight dollars cheaper and I'm like what you know it's a black and so on so this is purely a b2b product and they would order at okay so any other products since then wait a minute my bouncer has a seeker message you are pointing to the your watch does that mean shut up our door they 

Dr Gabriel Nussbaum: so again the idea control inflammation topically using these very safe and quality controlled botanical ingredients with formulation so we also in addition to the diabetic foot ulcer hydrogel developed a wrench specifically for oral mucositis so as dentists you're probably very aware that cancer patients being treated with chemotherapy and especially if you're getting radiation in addition to the chemotherapy especially if it's radiation to the head and neck field you're at very high risk for developing oral mucositis which is an inflammatory breakdown of the mucosal tissue with ulceration that's very painful actually cancer patients  being treated for cancer are rating it usually that for the most bothersome of the side effects of anti-cancer therapies and of course it also not only is it a big problem for quality of life to the patient but all but it's also a reason that patients can't get their full regimen of anti-cancer therapies chemotherapy and radiation so we developed a rinse specifically to prevent and reduce the symptoms of oral mucositis and have tested that in a multicenter trial in the United States in Israel in head and neck cancer patients being treated with chemo radiation so the results of that trial showed that in the worst in the cases of severe oral mucositis if you're treated with the rinse then you have a better outcome in terms of your oral mucositis so that's in addition to the diabetic foot ulcer very exciting direction for the company thrush candidiasis riot con does that right well again here we're really targeting the host inflammatory response so oral mucositis the breakdown is because well it's multifactorial but it's really the the in in the vasculature of the mucosa okay so those vessels are very inflamed and the inflammation causes a breakdown of the overlying at the the-- liam and so it's really not microbial driven it's inflammation driven right - then do have microbes that now what's micro driven yeah so it's actually it's the damage caused by the antineoplastic or anti-cancer therapies that are causing in fluids to be thought just of a cell turnover that the end because they're the anti-cancer therapies are targeting proliferating cells so it's the epithelium that's proliferating but it's really more much more than that it's the underlying vasculature that's being damaged by oxidative damage another inflow my only is our thinking they're taking one of them after wisdom to dry socket oh you should talk to Bill about that he's used the perio patch of dry socket with amazing results usually he's the clinician so yeah because that's amazing because we do see some strange variables 

Howard: yeah like more common in women and on birth control pills hmm so if it's you know men don't take birth control pills of men aren't women so that makes you think something different she's saying here you're his chief medical officer and les is the chief financial officer so he knows where all the money is hidden and and then we'll do a follow podcast with dr. William Z Levine who's a periodontist yes the DMD yes and where did you go to dental school he went to 

Dr Gabriel Nussbaum: dental school in Columbia which is in Manhattan Columbia Manhattan and they just over about NYU he was in club yes and anyway he by the way is the largest dental school America's 80% of all the dentists graduated from in my Eagle yeah and just over through third dental school oh that's Toro genus yeah yes also it I think it's in Valhalla New York maybe it's outside Manhattan oh it's not sure yeah Valhalla Valhalla Westchester County I believe I put me on that one does the other ones in Buffalo yeah suni suni but this is very close to 

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