Lifestyle Medicine and Oral-Systemic Health

Dr. Crystal Marruganti explores multimorbidity — the overlap of periodontal disease with conditions like diabetes, cardiovascular disease, and mental health disorders — and how lifestyle and behavior shape outcomes. Learn how to translate this perspective into everyday decision-making, from risk assessment to treatment planning and patient coaching.

Transcript

Introduction to Let's Talk Oral Health

Martijn 0:19

So, welcome everyone to Let's Talk Oral Health by GUM, your source on conversations about oral health and beyond. My name is Martijn, and I'm sitting here in our studio in Switzerland at the Sunstar headquarters, and I'm joined by my co-host, Rachel Chau.

Rachel 0:34

Hello Martijn.

Martijn 0:35

Hello, Rachel. So today we have another exciting conversation ahead of us because we are joined by Dr. Crystal Marruganti. Hello, Crystal.

Dr. Crystal Marruganti 0:44

Hello Martijn. Hello, Rachel. Thanks for inviting me.

Martijn 0:47

We are very happy to have you here. Indeed. So Crystal is a periodontist who is currently practicing in London but also does some research in Italy. But I'm pretty sure she can introduce herself way better than I can. So, Crystal, the floor is yours. Could you please maybe share to our audience who you are and what you do?

Dr. Crystal Marruganti 1:04

So I'm Dr. Crystal Marruganti, and I completed my clinical and research training in Italy. And it all concluded

Meet Dr. Crystal Marruganti: Clinician and Researcher

Dr. Crystal Marruganti 1:12

with a PhD back in 2023. And currently, yes, I live mainly in London, where I limit my private practice to periodontology. And I, until last year, have done one year of research fellowship at UCL in London, but now mostly I do my teaching and my research at the University of Siena in Italy. So it's a lot of traveling, but I combine both research and clinical practice limited to periodontology.

Rachel 1:36

I understand that you uh wrote a paper, published a paper in a couple of years ago, about um how to approach periodontitis a bit differently, not as a single uh disease, but rather uh from the perspective of multimorbidity. In that sense, uh I would like to ask you what do you mean by multimorbidity? And especially is it different from comorbidity?

Dr. Crystal Marruganti 2:02

Okay. So the concept of multimorbidity was is actually not a new one if you think about it, because if you look at papers, if you look at the research, the first time the multimorbidity, the term multimorbidity was proposed was like in the 1970s. But it wasn't until I would say 2019, 2020 that this term has actually started to be used consistently across studies, across reviews, and across clinicians and researchers. And multimorbidity refers to all the patients that are affected by two or more chronic conditions, but they can include either physical conditions or also mental health disorders. So it's probably the first time that also mental health disorders are recognized, you know, like within also the physical kind of ailments that one can have. And there's a there are a there's a fundamental difference also in terms of approach between multimorbidity and comorbidity, because in the past the approach was more like a comorbidity type. What does it mean? So whenever we talked about comorbidity, it's more about the fact that the focus is the just one disease, and then you've got other diseases alongside the primary disease. So even the approach that you follow is more, let's say, centered on the disease, on the treatment of that disease. So what many papers I would say were proposing that

Comparing Dental Systems: UK vs. Italy

Dr. Crystal Marruganti 3:24

with a multimorbidity approach, it's more treating all conditions equally, let's say, and the main goal is more related, the main center of attention is the patient. So there's a patient-centered approach where basically the goal is not only to treat one disease at a time, you know, by different specialists that don't talk to each other, but more to treat all of them equally and also to study the interplay among them.

Martijn 3:50

Yeah.

Dr. Crystal Marruganti 3:51

Basically.

Martijn 3:51

Yeah, I suppose in the medical field that has always been a bit more prominent because you have the same type of medical specialist treating these patients. So maybe the communication between, for example, a cardiologist and an internist treating a diabetic patient is is already sort of there's already sort of an intrinsic connection between the two specialists because they're treating the same patient in the same hospital. Um, but how does that work for periodontitis? Because even though we always propagate a closer, you know, connection between the specialists in that treat, you know, the mouth and the specialists that treat the rest of the body, uh the reality has taught us that that's not really the case yet. So, how what has that changed in in recent times with um how you approach periodontology from this multi-multimorbidity perspective?

Dr. Crystal Marruganti 4:39

So let's say that um of course it is difficult for us as either dentists or a healthcare provider in general to actually communicate very smoothly, either with a general practitioner or with a diabetologist or with any with any other type of medical uh specialist in a way. Um in terms of referring, I think it's easier and it's more common that us as dentists or either as a specialist or a hygienist at some point, um, especially if you screen, I was probably gonna see later, if you screen for systemic condition chair side, then it's easier for us to refer, for example, to the general practitioner for further exams than the other way around. Of course, the fact that we trigger the conversations between dentists and medical physicians in general, I would say, should make it easier. Still, I think it's not super easy for physicians to refer to dental practices, especially in some countries, because dental care is still mainly private in most countries. So, what happens most of the time is there's a financial barrier to this. In the UK, there are some, in the UK, in England, actually, there are some guidelines from the NHS, so the National Healthcare System in England, which is a pathway for referrals for diabetes patients, whereby it's let's say a little bit easier within the NHS for patients that have been just diagnosed with diabetes to be referred to at least a general practitioner or a dental hygienist, of course, still within the NHS. Okay, so uh probably it's the only type of guideline that I've seen so far at a national level. Then practically, of course, it's diff quite difficult because of the access, if that makes sense. So, yes, there have been some steps forward at an at let's say at a population level, but still, of course, it's sad that you communicate through private practices, but sometimes there's a financial barriers. Dental care is mainly private.

Martijn 6:37

Yeah. How big is this problem of multimorbidity? And I'm mainly interested in um, as I said, if you combine medical conditions like diabetes or cardiovascular disease, they're they get a lot of attention, they're prominent diseases. But if you look at, for example, the the prevalence of type 2 diabetes or um cardiovascular disease, it's much lower than the prevalence of periodontitis, for example. So in the past, when oral conditions were not included in this multimorbidity concept, you were talking about maybe a few percent of the population, but when you add periodontitis to that concept, it increases to

Bridging the Gap Between Research and Clinical Practice

Martijn 7:11

I don't know, 40-50% even of the of the adult population. So, how big is that that that problem of multimorbidity from the oral care professionals perspective, the periodontist perspective? And does that mean they need to adjust also their approach to this to this problem?

Dr. Crystal Marruganti 7:29

So, in terms of the prevalence of multimorbidity per se, we've got some meta-analytical data that were published in the Lancet in 2023, whereby the prevalence of multimorbidity, which does not include periodontitis though, is about 37%. Of course, there are regional differences with the highest prevalence is in South America, where it's almost 50%, and the lowest prevalence in Asia, that's around 35%, and Europe stands at around 39%, 38%, 39%. Okay. Um, of course, if you include periodontitis, this prevalence is way higher, right? Especially if you consider the older population, because both multimorbidity in general, but also periodontitis are related with age. If we look at multimorbidity per se, around half of the population over 60 years old is affected by multimorbidity. So, of course, even from a public uh health perspective, the problem the problem has like a huge one. Yes. If that makes sense. Um, from a clinical perspective as a clinician, of course, the most common combinations, let's say, of diseases that I can see are the combinations between periodontitis and diabetes, periodontitis and hypertension, diabetes and hypertension together as well. Also together with some kind of mental health disorders like other depression or anxiety as well. This starts to be really like a rising, a rising, arising problem. Um and uh uh that's that's mainly it. But in terms of what

Understanding Multimorbidity vs. Comorbidity

Dr. Crystal Marruganti 9:04

you do different clinically, there's like there's a communication perspective that's absolutely essential. Because, of course, for example, if a patient has diabetes together with periodontitis, it's essential to communicate not only the beneficial impact of periodontal treatment on their glycemic control, for example, but it's also essential to communicate them that they are more susceptible to having a higher risk of progression of the disease, but also that the efficacy or any kind of treatment they were doing is lower if they didn't have diabetes in a way, right? So it means that they might, for example, need more sessions of treatment or more courses of non-surgical periodontal therapy, for example. And also, especially if we think about patients with cardiovascular diseases. They, I mean, they were quite a few articles, especially end of the 1990s, beginning of the year 2000, about the different approaches to non-surgical periodontal care, surgical periodontal therapy, especially with regards to the difference between full mouth and quadrant-wise approach. Especially because whenever you perform non-surgical periodontal treatment, you cause a peak, you know, like a like a like a spike of inflammatory markers, for example, like C-reactive protein. And if we've got patients that systemically are already, let's say, more prone to develop some kind of cardiovascular events, then in the past there are quite a few trials that supported the use of quadrant-wise approach versus the full mouth approach. For example, both in systemically healthy patients, this was published in 2015 by Filippo Graziani. So there was this trial, full mouth versus quadrant-wise approach, and they compared the spike, the production of acute phase proteins in 24 hours after treatment. And this spike of C reactive protein was significantly higher in the full mouth approach versus the quadrant-wise. While, of course, clinically, from a periodontal point of view, they're exactly the same. So we're still giving the same kind of high-end, high-quality, and very effective treatment, but somehow we are reducing this spike in C reactive protein. And also, and I was co-author of this trial that was published in 2023, always with uh Filippo Graziani, and we ran the same trial but on diabetes patients. And what we notice is that, of course, again, same results in terms of the spike of C reactive protein at 24 hours after the treatment. But also within the final multiple regression models, we kind of correlated this relative CRP increase at 24 hours with the reduction of HBA1C, of glycated hemoglobin at three months. And we noticed how there was a significant relationship in the sense that the higher the CRP increase at 24 hours,

The Importance of Interdisciplinary Communication

Dr. Crystal Marruganti 11:59

and somehow there was a lower reduction in glycated hemoglobin levels at HBA1C levels at three months. Of course, the results that we had were only at three months, so we don't know whether this relationship, let's say, was maintained over the month. But at the same time, although we've got partial data, we totally understand that. It may be recommended that in these kinds of patients with multimorbidity, we may be more prone to recommend more like of a quadrant-wise approach instead of a full mouth kind of approach. I see. Of course, it depends on the extent of the disease, whether it's localized or generalized. Uh, but again, in general, um, it would we would probably be more prone, let's say, to stage the treatment. One session, two sessions, depending, of course, on the extent.

Martijn 12:49

Does also mean it's more invasive for patients. We need to come more often for the for their treatment sessions, um, I would suppose, or the quadrant wise.

Dr. Crystal Marruganti 12:57

So in the quadrant wise, it depends on the extent uh of the of the disease. We usually can divide the treatment between one to four sessions.

Martijn 13:06

Okay.

Dr. Crystal Marruganti 13:06

Okay. And it's usually, I don't know, like in a for in a private practice setting, you would do one session a week or something like that. Okay, and then you do the reassessment three months from the last session. In a full mouth approach, usually one hour and a half or two hours, again, depending on the severe the extent and severity of the disease, you do the whole mouth together. Yeah, if that makes sense. Yes. So in terms of um acute phase proteins that you produce and the spark that you have 24 hours, of course, it's significantly higher because you're not staging the treatment in multiple sessions.

Martijn 13:37

Interesting.

Rachel 13:39

Coming back to what you just said, uh, can you just recap for us or give us an overview of the shared biological pathway between all these diseases?

Dr. Crystal Marruganti 13:48

So let's say that we could summarize the shared biological pathways between these diseases into two main sections, I would say. You've got an inflammation pathway, and then you've got, let's say, a microbiome-mediated kind of pathway, I would say. Now, these two pathways were also nicely, nicely, brilliantly summarized by a review in 2021 published by George Hajishengallis. So basically, you've got the inflammation part, whereby, of course, whenever you've got inflammation in the mouth, whenever you have periodontitis, you've got an increased amount of inflammatory markers, let's say, that usually get through the, let's say, broken and damaged epithelial barrier, they just reach the systemic blood circulation. Also, not only have you got systemic markers, so inflammatory markers that reach the systemic circulation, but you also have some bacterial products that reach the systemic circulation, they further trigger the production of other inflammatory markers. Now,

How Multimorbidity Affects Periodontal Treatment Planning

Dr. Crystal Marruganti 14:49

from an inflammation point of view, of course, the common threat between all these conditions is that not only periodontitis, but also, for example, biodiabetes is in part mediated by inflammation. From a microbiological point of view, of course, we know that periodontitis is characterized by dysbiosis in the oral microbiome. And there is the translocation of bacterial products from the oral cavity to other districts. And we also start to have some evidence with regards to the connection between the oral and the gut microbiome. Okay, so we know that patients with periodontitis have distinct tracks of gut dysbiosis compared to patients that are not affected by periodontitis. Also, there was a nice study published last year by an Italian group in the Journal of Dental Research, and it highlighted how if you treat periodontitis, of course, yes, you've got a reduction in the dysbiosis that's present in the oral microbiome, but also the dysbiosis that was present in the gut was kind of reduced, which means that this is a further proof in terms of the microbiome-mediated connection between the oral cavity and the rest of the mouth. But this is also true also the other way around, if that makes sense. So going from the systemic um, going from distant organs to the oral cavity. Whenever we think of diabetes, diabetes can make the patients, every individual more prone to developing periodontitis as well, through kind of the same mechanisms. For example, diabetes um uh triggers the formation of these advanced calculations and products that somehow impair the connective tissue, so the periodontium, and they make the individuals more susceptible somehow to the microbial challenge. Right. So the two main um, let's say, um, pathways are the inflammation mediated and the microbiome-mediated pathway.

Martijn 16:52

And if you then take a step back, um we understand a lot about not everything, but we understand many of the mechanistic biological associations. But if you take a step back and look at this multimorbidity where you have chronic diseases like diabetes, cardiovascular disease, but also periodontal diseases, um they also seem to share a lot of the risk factors, and that, of course, has been a big chunk of your research early in your career. It was the main topic of your of your PhD research. Um, you published a few papers on those risk factors, and they seem to underlie to some extent these inflammatory mechanisms. So maybe we can go through them one by one because you had you know different approaches when uh when talking about these these risk factors. So, yeah, if you can share maybe some a high-level overview of what your findings were when we when you went through these different risk factors, lifestyle risk factors. Sure.

Dr. Crystal Marruganti 17:48

So, yes, the lifestyle risk factors are we what sometimes they're also referred to as the environmental risk factors that are common to most of the non-communicable diseases. Periodontitis, diabetes, cardiovascular diseases, etc. And of course, the big chunk, the big component starts with nutrition and especially with diet. Of course, the research was conducted in Italy. So the type of dietary pattern that we considered was the adherence to Mediterranean diet, and we performed a cross-sectional study, university-based cross-sectional study on the association between adherence to Mediterranean diet and the severity of periodontitis. And what we found was that a low adherence to Mediterranean diet was associated with three times higher odds of having stage 3 for periodontitis, meaning severe and advanced periodontitis that are usually associated with loss of teeth because of periodontitis.

Martijn 18:45

You're obviously very used to the Mediterranean diet because of your location in Italy, of course. I'm from the Netherlands, so to me it's not always super clear what is a Medit-, considered Mediterranean diet. Could you maybe explain to our viewers who are not living in southern Europe what a Mediterranean diet exactly is or is made up of?

Dr. Crystal Marruganti 19:03

So let's say mainly there are different food components. Um the different food components basically include that you consume uh fresh fruits and veggies, fruits and vegetables. You consume also red meat, but in small portions, you consume white meat, but you also consume mainly uh fish and nuts, if that makes sense. In theory, Mediterranean diet would also include, for example, and would also let's say define as acceptable. For example, a glass of wine per day if you're a man, or a couple of glasses of wine, uh two glasses of wine if you're a man, or one glass per day if you're if you're a woman, let's say. Um, and also I think the key success of the Mediterranean diet is the seasonality of foods with regards especially to fruits and vegetables, so and the variability then of the foods that you eat. That's the key success of the Mediterranean diet, because of course, yes, there's climate change in Italy as well, and in the Mediterranean countries, but still there are some specific fruits and specific vegetables that are typic either from the autumn or winter session, like for example, you can have cabbages, you can have kale, you can have broccoli, or in summer you tend to um eat courgettes, for example, or aubergines. So the key success of the Mediterranean diet is the variability of the foods, but also the seasonality.

Martijn 20:26

That's very interesting.

Rachel 20:27

So and would the Japanese food also enter in this uh good diet to follow? Because we we all know that Japanese food is in general very considered healthy, yeah.

Martijn 20:37

Healthy, exactly.

Dr. Crystal Marruganti 20:38

Yeah, yeah, yeah, absolutely, absolutely. There are some studies, and also it's considered healthy because of the high consumption of foods that contain omega-3 fatty acids that were found to be rich in antioxidants and be quite positive, quite good in terms of reduction of inflammation as well. It's been considered quite healthy as well because there's not enough consumption of uh fatty saturated fats, for example. Same thing in the Mediterranean diet, because we tend to not use butter and to use more extra virgin olive, if that makes sense. So it's the consumption of specific anti-inflammatory foods and also the seasonality and the variability of it. And uh also, yes, within the same study, we uh uh kind of uh um investigated the association between specific foods and the prevalence of severe and advanced periodontitis. And of course, the foods that stood out were yes, fresh fruits and vegetables, but specifically the consumption of at least uh, let's say two, four um tablespoons of extra virgin olive oil. Of course, it should be uncooked, okay, because otherwise it's not healthy, but uh it has um it was found to have a protective effect against stage three for periodontitis, so severe advanced periodontitis. And of course, um not only we measured diet in that study, but we also measured physical activity. With the general question, so we didn't differentiate among the different types of physical activity in that study, but we found kind of a relationship between diet physical activity and the

Biological Pathways: Inflammation and the Microbiome

Dr. Crystal Marruganti 22:11

prevalence of periodontitis, whereby the protective effect of the diet was increased also if the patient was, of course, um physically active.

Martijn 22:21

Interesting. You published a separate paper on the physical activity, if I'm not mistaken, right? So yeah, quickly going, was that the main finding of that paper, or did you uh have additional findings uh when you investigated the physical activity uh as a risk factor?

Dr. Crystal Marruganti 22:34

So yeah, we published another paper later on um because also if you have a look at the first paper where we uh investigated the physical activity, the results were not so clear. And also, if you go through the studies on the association between physical activity and periodontitis, sometimes results are either inconsistent because it's not super easy to track.

Martijn 22:54

That's true, yeah.

Dr. Crystal Marruganti 22:55

The amount and type of physical exercise that every patient actually performs on a daily basis. Um, so we used uh publicly available data from the NHANES database and we um differentiated between two different types of physical activity: occupational physical activity and leisure time physical activity. And we kind of found similar articles already published with regards to the association between these two types of physical activity and cardiovascular disease and the incidence of heart attacks, for example. So occupational activities are uh it refers to all the bodily movements that are tied, let's say, to one person's activity. And they're usually characterized by inadequate rest, poor posture, or that you're lifting, let's say, heavy weights, let's say, with inappropriate postures. Uh whereas with leisure time physical activity, it refers to all the bodily movements that are part of the free time or that a patient or an individual usually performs as part of the, let's say, uh leisure time day activities like taking a walk, going to the gym, or I don't know, dancing, cycling, whatever. And what we found is that there is a divergent association of these two types of physical activity with periodontitis. And this is what's been commonly referred to as the physical activity paradox, meaning that occupational physical activity was identified as a risk indicator for periodontitis. So somehow it increases the odds, let's say, of being affected, especially by severe periodontitis, while leisure-time physical activity was found to be kind of a protective indicator against severe periodontitis. And also within the same paper, we found kind of a dose-response relationship between the amount of physical activity and the prevalence and the severity of periodontitis, whereby the higher the amount of occupational physical activity and the higher the prevalence of severe periodontitis, while on the flip side, the higher the amount of leisure-time physical activity and the lower the prevalence of periodontitis. So, and that's of course in line with the physical activity paradox again being studied quite heavily, especially with regards and with in relation with cardiovascular diseases.

Rachel 25:18

Well, we've tackled the uh dietary patterns, the physical activity, but there are also other lifestyle or habits or behaviors that are maybe less uh also very much influencing the periodontal diseases, which is, for example, alcohol and tobacco, for example. Do you have any additional insights on that?

Dr. Crystal Marruganti 25:38

So let's say that. Of course, with regards to alcohol, of course, we know that it's detrimental not only for your gum health, not only for your oral health, but also for your general health in a way. Uh and it also depends what you drink and how often you drink. Uh, in terms of dietary patterns, the Mediterranean diet somehow, as mentioned before, allows for, again, in women, on average, one glass of wine per day. Yes. While in men, a maximum, like a couple of glasses per day. Um, while of course, nowadays we still have more and more research on the long-term effects even of moderate moderate consumption of alcohol on systemic health. So, of course, um, I always ask my patients how much they drink, but since I practice in the UK, nobody really drinks wine. A lot of people just drink beer and not

Lifestyle Risk Factors: The Mediterranean Diet

Dr. Crystal Marruganti 26:35

moderate, or both and not moderate. So, so uh, of course, there are multiple studies investigating, of course, the fact that um consumption of alcohol has been associated with higher prevalences of periodontitis, but not only through a direct effect, meaning biologically, but also because if sometimes there's an alcohol abuse, it can be linked also to other other types of disease, but also that someone is stressed, someone doesn't sleep, someone doesn't eat well, doesn't exercise, or they're going through something whereby they kind of abuse alcohol in a way. So usually there's like a bigger framework to take into account that it's not just someone that's super healthy, but they just drink 10 gintonics per day, if that makes sense. Yeah, so that's usually like a broadest perspective. With regards to um tobacco, of course, um nowadays probably less and less people are consumed smoking cigarettes, but more and more people are vaping.

Martijn 27:31

Yeah.

Dr. Crystal Marruganti 27:32

So um we don't have a lot of evidence, let's say, with regards to vaping yet. We know for tobacco that since smoking cessation, it takes five to ten years, right, to have the same kind of periodontal risk for profile uh compared to a patient that has never smoked in their own life. So the damage is actually continue even after uh you stopped smoking. With regards to vaping, from uh we've got some studies they highlight how actually the systemic and the oral health impact is actually quite similar to smoking. Especially because sometimes when someone vapes, they tend to vape more often than what they would do if they were smoking.

Martijn 28:14

Yeah.

Dr. Crystal Marruganti 28:15

So while potentially the I don't know, damage program would be less, patients tend to do it more often. So some somehow it evens out, yeah. I would say.

Martijn 28:25

Yeah. And those lifestyle risk factors we've been talking about now, so diet and physical activity, maybe even substance use, they are physical related risk factors, right? But there's also a psychological component to the risk factors, and then you're of course you're talking about stress, and more and more we are seeing, of course, that stress is also an important risk factor. Yeah. Um, I understood you also published a paper on stress and on sleep, I think. So um, yeah, if you have some insights about those findings.

Dr. Crystal Marruganti 28:54

So we initially performed a cross-sectional um study um again, citing the association between perceived stress, sleep quality, and periodontitis. Now, perceived stress, uh, of course, and sleep, they were both measured through validated questionnaires. And the difference between, let's say, regular stress uh and biological stress and perceived stress is that perceived stress focuses on what is perceived from the patient's perspective in terms of feeling of unpredictability, uh lack of control, or also coping mechanisms, right? Because the stress, what's what can be a stress for me, maybe it's not a stress for you. So there's a very, very big subjective component when you talk about stress. And what we found is that separately, perceived stress and also uh poor sleep quality were associated with approximately three times higher odds of having stage three, four periodontitis, so severe advanced periodontitis. And we also found a cumulative effect between stress and sleep, meaning that whenever a patient had high perceived stress and poor sleep quality, the odds of severe advanced periodontitis jumped to 10 times higher. Okay, so there's like a almost a multiplicative effect between stress and sleep. Of course, nowadays we've got the advantage that all these factors can be measured.

Martijn 30:20

Yeah, sure.

Dr. Crystal Marruganti 30:21

So even with wearables, uh either smartwatches or rings, right, we have a way, we have some surrogates like the heart rate variability, right? Whereby these watches or rings they somehow can track stress and sleep. So for from a patient perspective, it's good because whenever you measure an issue, right, you can see it, it's written on your screen. Somehow you can do something to uh make it better, or you can also optimize your habits to reduce your stress or uh also improve your sleep quality, for example.

Rachel 30:56

But as you said here, it's from the patient perspective. Yeah. But our audience uh is composed of oracle professionals, dentists uh or hygienists, um, and they they are very pragmatic

The Physical Activity Paradox in Periodontal Health

Rachel 31:10

and they are focused on mechanical um treatment, surgical treatment. So they might ask themselves how impactful, how significant is the impact of uh these uh risk factors on my periodontal treatment? Yeah. How would you respond to them then?

Dr. Crystal Marruganti 31:27

So um following these cross-sectional studies, we also um performed a cohort study, longitudinal cohort study, whereby we recruited approximately 120 patients affected by stage 2 / 3 periodontitis, and of course, if they needed periodontal therapy and they were systemically healthy. We measured all these lifestyles at baseline. So adherence, humanitarian diet, stress, sleep, physical activity. And then we performed uh step one, steps one and two of periodontal therapy, and afterwards uh we reassessed the patient three months after the treatment. So this is basically something that you would do in your practice as well. And then we somehow related the site level and patient-level periodontal outcomes that we had after periodontal therapy also with the baseline lifestyle factors. What we notice is that um taken singularly, so taken taking every lifestyle separately, um, every lifestyle somehow reduced the probability was associated with poorer periodontal outcomes. Okay. We also um created the variable endpoint of therapy. Uh the variable endpoint of therapy, which is basically what we aim for after we do the periodontal therapy, which is the fact that we don't have any sites with a probing pocket depth of four millimeters or more that's bleeding, and that we have no sites with probably a pocket depth of six millimeters or more. And we saw that if patient had um all unhealthy lifestyles, so had a low adherence to Mediterranean diet, let's say physically inactive they were physically inactive, high stress, and poor sleep quality, this was associated with a 15% lower probability of reaching the endpoint of therapy three months after periodontal therapy. What does it mean? It means that if you have a patient that's systemically healthy, but they have all this combination of healthy lifestyles, that it means that even from a communication point of view, the outcomes of your treatment are compromised, even though you're still the same clinician, still the same hands doing the same treatment that you do every day, if that makes sense. Okay. So they there is a um an impact also on the success and the efficacy of the treatment that we're doing.

Martijn 33:48

Is there a cumulative effect? Because you in your cross-sectional studies you in you analyzed all these risk factors individually, but I can imagine um it happens very often that you have a patient in your chair who's not just uh not really adhering to a Mediterranean diet or is having a generally bad um bad diet, but is also um you know not physically active enough. So uh that do they is it like a cumulative effect of these risk factors?

Dr. Crystal Marruganti 34:17

Same thing for the outcome of therapy. So whenever we created the models and we studied the effect of every lifestyle on the outcome of therapy, we always adjusted for the other lifestyles. For the other ones, yeah. Yeah. And then we also calculated uh the cumulative effect. So we created a subgroup of patients that had all these unhealthy results. Yeah. Yeah. And then in those patients, we noticed this 15% less probability, probability of reaching the endpoint of therapy.

Martijn 34:43

Yeah, and I can imagine that is a significant proportion of patients of a period of clinic.

Dr. Crystal Marruganti 34:48

Yeah. Because it means that from a clinical point of view, that you've got 15% of patients where you need to do additional

Impact of Alcohol and Tobacco on Gum Disease

Dr. Crystal Marruganti 34:57

treatment. It's either you need to repeat the course of non-surgical periodontal therapy, or in some cases, if you've got deep pockets or pockets of six millimeters or more, this would trigger the need, for example, to perform periodontal surgery. But what if we probably, I don't know, modify the lifestyle so that we can avoid this, that would probably reduce the need for either repeated non-surgical treatments or periodontal surgery.

Martijn 35:22

Sure.

Dr. Crystal Marruganti 35:22

No patients like to do periodontal surgery, right? So of course, we would like to try and be as minimally invasive as we can. So if we can make the lifestyles better and reduce the need for surgery down the line, of course, this would be totally a benefit from a patient's point of view. Yeah.

Rachel 35:40

It seems that like uh lifestyle is really your your core topic with what you have uh studied and also um has been interested to for all these years. So I would love to hear your journey while you were interested in lifestyles uh uh in uh uh impacting periodontal uh health.

Dr. Crystal Marruganti 35:59

So let's say that um at the beginning of my journey, probably I wasn't very sure that I wanted to do dentistry. So that's how I started.

Martijn 36:09

What was the other option?

Dr. Crystal Marruganti 36:11

So I wanted to go into banking, uh, I started to study mathematics, so yeah, I don't know. Like I've always read a lot of stuff. Yeah, absolutely. Always read a lot of stuff. And if you look at articles in uh either fields of medicine, the lifestyle medicine part, let's say, is a little bit more advanced than what it is in dentistry. You know, if you think about diabetes management, you know, of course, um, you know, all my family, everyone has diabetes basically. So I'm I kind of I kind of know what happens, and um, everyone is so focused on lifestyles. And then I remember reading about some programs where they would tell patients, you know, what to eat and how to exercise. And I was like, I mean, do you I mean, do you really need to be a doctor to do this? So I was taken, I was like, that's so impactful. Just imagine if anyone could give this kind of advice. Sure, yeah, right? If this is so significant. So I think then I started to read a little bit, and at the time, it was like 2020. That's how I mean at the time there were few articles um on lifestyles and the importance of lifestyles, especially of course smoking and uh periodontal health. Uh, but again, there was really nothing about specific diet and also stress or sleep or this kind of lifestyles. Also, because the also the amount of teeth that you have in the mouth impacts the type of diet that you have as well.

Martijn 37:32

Sure.

Dr. Crystal Marruganti 37:33

Right? If you think about it, because the more teeth you lose,

The Multiplicative Effect of Stress and Poor Sleep

Dr. Crystal Marruganti 37:37

the more you would want to have palatable fruits.

Martijn 37:39

Yeah, and the more difficult it is to properly chew, yeah, for food for sure.

Dr. Crystal Marruganti 37:42

So you reduce the consumption of fruits, vegetables, right? Um, and then your health declines in. So it was more looking at general health first, and then uh I was like, why has it not been done, you know, before? Like uh it can be done, yeah, that's doable. And it was COVID time as well, so I had lots of time to write. To write and read, like to resulted in this uh in this beautiful book.

Martijn 38:11

Yeah. Healthy Lifestyles for Healthy Gums. We always call it our little book in uh in the Netherlands, at least when you publish uh your PhD thesis, and it's it's amazing. I recognize the book, and it's it seems to the audience who's watching, it seems like a very daunting task to sort of get to this as an end point. So um uh if you have any advice on on students, uh dentistry students or students in general who are watching who also aspire or are interested in doing research, uh, do you have some some tips on of course your situation was maybe uh very specific because it was during COVID, so you had a lot of time, but just to some some general tips on how how to get through that that time of of of of your career.

Dr. Crystal Marruganti 38:50

Yeah, so I would say probably just know where you're going, like the be practical, you know. So if you know where you're going, then you just need to think about how to go from A to B, right? If that makes sense. And uh also, of course, the journey wasn't easy. I mean, as well. So it's like the journey is not easy. Sometimes when you feel that you need to publish articles, if it looks far-fetched, looks so far, they're like, Oh, I'm never gonna do it, right? I don't see this coming. Um, but it's good also throughout the journey to I always say like treat success and failures like in the same way so that you're balanced because otherwise the PhD feels like a like a roller coaster. Sometimes, some days you feel so good and sometimes you feel so bad, and in the end you don't know how to progress and proceed. While if you treat them the same way, you know you had your own sense of self-worth that's independent of things that can go wrong sometimes because it can happen or your project can get delayed for any reasons.

Martijn 39:50

Yeah.

Dr. Crystal Marruganti 39:51

But you still had your own sense of self-worth and step by step by step, basically you're gonna make it anyway. And good advice for life in general. I'm sure researchers.

Martijn 40:00

It's actually too, it doesn't just apply for uh just be very ballads, yeah. The one thing I always had to tell myself is stop procrastinating, but that's also easier said than done. Yeah, it's easier said than done. So one of the the things that this resulted in, so you publishing your PT thesis is your quite recent nomination into the Forbes 30 under one 30 under 30. Um maybe I'm not saying that entirely correct. So yeah, could you maybe share us um share a little bit about what what you were nominated for and uh um yeah, what I meant for you.

Dr. Crystal Marruganti 40:32

So the um that well it was a totally unexpected achievement, let's say, and uh the reason for the nomination was because of the significance of the research on, let's say, the oral systemic link. Because, of course, the main goal of let's say changing

Study Results: How Lifestyle Shapes Treatment Outcomes

Dr. Crystal Marruganti 40:46

the patient lifestyle chair side is to also prevent other conditions or let's say improve the management of other conditions like hypertension or diabetes, they usually cost billions and billions to public healthcare systems and they cost a lot of lives from a morbidity kind of perspective. Um, so of course, the goal, the final goal is to actually try and prevent this kind of very prevalent, highly prevalent systemic conditions starting from the dental chair, especially because oral healthcare professionals, hygienists and dentists are the ones that see the patients more often.

Martijn 41:20

That's true.

Dr. Crystal Marruganti 41:21

Way more often than the general practitioners and than any other physician in a way. And there's like this trust between the healthcare provider, the oral healthcare providers and the patient. So it's way easier for us to do that in a way, because we see the patient so often that we can monitor, track progress, etc. So there was the reason for the nomination, and I think it's quite important for dental research in general, because most of the time, uh research on oral health, let's say, I don't want to say that it's excluded, but it's not always included in broader healthcare discussion, if that makes sense. But in light of all the connections that we have between oral and systemic health, we should definitely be included there. So let's say being on the list, it's it's like it's a it's a it's a neat thing, you know, everybody wants it, you know, for different reasons. But it and it's good that for once it's something about oral health. So and it's not just a physician being on the list talking about diabetes or talking about, I don't know, cancer or other diseases, because again, what we are doing in this type of research is essential from a public health perspective.

Martijn 42:30

Um nice that the spotlight it is on you personally, of course. I mean, I I suppose that's a big honor, but it's also nice that you get recognition for the actually for the work that you're doing and uh that the entire field of parental medicine and gets the attention. Yeah. Well, very nice.

Dr. Crystal Marruganti 42:49

It's okay, it was cool, yeah. Yeah, it was weird also to go to the events, you know, because it you've got people from uh not only the medical fields, but even within the medical fields, you know, the other people were more related with startups, uh, you know, and this kind of topic. So um yeah, I think it was quite niche probably within that sector.

Martijn 43:09

Yeah. Interesting experience, I'm sure.

Rachel 43:12

Definitely, definitely. Coming back to uh your little book, and you know the lifestyle.

Martijn 43:17

Don't call it little book. No, I know.

Rachel 43:18

Sorry, the big book and the lifestyle-related factors, yeah. Um, it actually comes back to behaviors, yeah, right. And uh which is good in the sense that we can modify behaviors, although it's probably the most difficult thing to do, modify a uh a lifestyle or a behavior. However, um, because it's modifiable, the oral care professionals in general can act upon it, can intervene on it. So, why why how do you see that uh as uh integrated in a dental practice?

Dr. Crystal Marruganti 43:49

So let's say, especially in terms of periodontal care, um, again, as mentioned before, the oral healthcare providers in general, we are the ones that are more in contact with the patient. So um Say we've got we have to build a relationship with our patients. So we are in the position to be able to do that. Especially within the periodontal care pathway, also within the EFP guidelines, it was already kind of mentioned that some kind of lifestyle modification should happen within the step one of periodontal therapy, meaning when whenever you change your patient's habit with regards to interdental cleaning and supragingiva, let's say domiciliary oral hygiene habits, if a patient smokes, it's already recommended that the oral healthcare provider, either if it's a periodontist, general dentist in the treatment, or a hygienist, they should discuss smoking cessation. And then of course, depending on the necessity, let's say, of intervention, you can either do a smoking cessation interview chest side or you can refer the patient if needed to a specialist. But of course, it is essential, yes, to change lifestyles at this stage of the treatment while we are educating the patients for interdetal cleaning. We can also discuss lifestyles in a way. And of course, there are as well as there are different techniques to motivate the patient for supragingival home blood control, there are different techniques also to motivate patients for lifestyle changes. And some of them, of course, are shared. So, of course, yes, the model of the GPS works because you set goals, even small achievable goals, and you give like a plan to the patients. And as long as you tell your patients what they need to do, it's easier because they don't need to go home and guess what they need to do. And it's it's the same thing when you talk about interdental cleaning, right? And you're giving them the sizes of brushes that they need to use. And it's the same for, for example, nutritional advice. Of course, you cannot give them a diet, right? But you can absolutely discuss some small changes that they can make, some small healthy changes that they can make for their diet, or in order to do, for example, more physical activity throughout the day. And this is a conversation that's quite easy to have while you're already seeing the patient due in the step one.

Martijn 46:08

I like what you say there because uh, in essence, um, especially the the hygienists who see the patient on a very regular basis, they are basically already working on the behavior of the patient, or at least they should be doing that. And um, in in that sense, adding lifestyle to that list of um, well, what we endorse as you said, the GPS, the goal setting and the planning and stuff monitoring model. Um, why not on top of uh the goals you set in terms of um oral hygiene habits, complement that with lifestyle goals and a plan for lifestyle? Um, I can imagine there will also be some resistance from patients who come to the to the dentist or dental hygienist who will say, um, what are you talking about? I'm not here for my lifestyle, I'm here to get my mouth cleaned. But still, I think it's uh repetition, it's probably very important here. And um, yeah, I like that point where you say you are already lifestyle, behavioral change coaches in in some way, why not add uh add a lifestyle to that?

Dr. Crystal Marruganti 47:05

Exactly, absolutely, and also there's usually like a different relationship between the hygienist and the patient and the dentist and the patient. You know, some hygienists see the patient four times a year, right? Which is a lot of times, and usually the dentist do not see the patients that often. And um so that's why hygienist appointments should usually be longer to allow for those 15 minutes where you can also pair the habits, like you pair the habits of interdental cleaning with uh, I don't know, like some other lifestyles, for example. I don't know, you do this and then you go take a short walk, if that makes sense. If one of the patient's issues, for example, is that they feel that they're not physically active enough. Okay, so pairing the habits is usually a good way.

Martijn 47:54

Very strong, yeah, right.

Dr. Crystal Marruganti 47:55

So you can either pair bad habits, because this is what sometimes happens, someone doesn't sleep and then they start smoking, for example, right? That's a very common pair, very common combination, but you can also pair the good habits in a sense. And of course, it's easier if they're already talking about oral hygiene, right? Uh of course, also the dentist can do that if they have enough time. But of course, it it's essential to whenever you're changing habits, so it flows more within the conversation, and it's also easier to set goals that are shared across different habits so the patient can go home and they can have something like a list of things, list of tiny goals to achieve, yeah, you know, and they can then move on from tiny changes to be slowly, slowly bigger changes for sure.

Rachel 48:42

Like reaching um having small goals but that we can reach and that we are happy, like small wins, let's say, so that you can actually then end up cumulating all these small wins into a big, bigger win. So that's uh another philosophy of life. Exactly. That's true. No, but seriously, then talking about that, um, do you have maybe an example of um of a sustained uh change of uh of a lifestyle that you implemented and that you saw actually the effect in one of your patients, since you are also, as we mentioned at the beginning, a clinician and that you treat patients. So have you an example, concrete example of that?

Dr. Crystal Marruganti 49:22

Sure, sure, sure. Um, this was so this guy is actually one of my one of the first patients that I've seen in London, okay? Um, an Italian patient, Italian guy, finance guy that just moved uh from uh Italy to London. So highly stressed, long hours, um, who loved his espresso and also his cigarettes though. So quite

Recognition: The Forbes 30 Under 30 Journey

Dr. Crystal Marruganti 49:43

quite bad. Not good. So in his case, for example, he sat on the chair and he was like, we're talking about smoking, so heavy smoker, and he was like, Okay, you know, every time I drink coffee and I drink a lot of coffee because I'm in the office until 3 a.m. every day, I need to smoke a cigarette.

Martijn 50:00

Right.

Dr. Crystal Marruganti 50:01

And it's actually very common, especially in Italy. You take your spectrum, then you smoke your cigarette. And I was like, why? Okay, let's work on the smoking cessation habit, which is not I cannot work on your working hours, that's not my problem, but uh like we can work on replacing the bad habit of uh smoking a cigarette with something else. They can be take a short walk. If you can't go out, you stretch a little bit, or you I don't know, you drink a glass of water, depending. But the uh the component of habit replacement in his case, for example, worked because of course he was in an office, so he preferred to stretch a little bit, for example, in his case, and then at the end he ended up stopping smoking. Um, and also sometimes replacing a bad habit with a good one can cause like a ripple effect. Yeah. So from that moment, the patient feels more self-effective, and they'll say, okay, so I need to use my if I can do this, I can use my interdental brushes on a daily basis, you know, and I can do this more thoroughly. So usually there's like a ripple effect that happened, for example, on this patient, quite young. So hopefully like that now. Uh so in this case, what worked was the habit replacement, but it stopped smoking and uh was good not only for his periodontal health, uh, but also for his general health as well. And uh so he started to monitor his stress, started to monitor his sleep, he started to be to be more health conscious. And then it was like, oh, you know, like I'm still go staying at the office until 3 a.m., but I feel better.

Martijn 51:36

It's interesting because you you did you, as you said, you didn't work on the sort of underlying initial problem of his work stress. Yeah, I mean this work stress is maybe still there, but you were working on his coping mechanisms and how how to deal with that stress. That's uh yeah, that's an interesting one.

Dr. Crystal Marruganti 51:51

Yeah, so yeah, habit replacement is rooted into behavioral science. And sometimes I find that when you find these patients with very, let's say, complex lifestyles, right? Because if there are some jobs where you're required, for example, to work long hours and there are very, very highly stressful jobs. Sometimes doing stretching or doing a straw walk, it can help relieve the stress. So um, yeah, his case worked worked quite well, I would say.

Martijn 52:19

That basically concludes the the loop of I would say of the lifestyle and the multimorbidity uh topic. But that's not the only research work that you have been doing. Um, you are also have another another research track or another research interest that is still on the link between oral and uh and systemic health in some way, or at least connecting the body to the rest of the of the mouth, and that is on the link between periodontitis and skin conditions, which is, and we were talking about this before the before the show is something that is absolutely new to us. Um we are very used to talk about the link between periodontitis and diabetes and cardiovascular diseases. We've been doing this for decades. Um, but skin conditions is not the first thing that came to our mind, and um, also there's not that much literature around, at least not that

Implementing Lifestyle Changes in Your Dental Practice

Martijn 53:08

we know. So we were very interested in uh what in yeah, in your findings and what have you what you've been doing, what you've been researching in this uh in this field of interest.

Rachel 53:16

And and also, first, how did you make the connection between periodontal health and skin conditions? How did you you know come across this uh relationship?

Dr. Crystal Marruganti 53:27

Uh so with that was more of a personal story because I've been suffering from like let's say let's say like a topic dermatitis for like my whole life, literally. And uh when I was finishing universities and also planning that book, uh of course I had quite a lot of flare-ups, I remember. And uh I mean my dermatologist is amazing, but um nothing would work. So I started to read. And when you go into dermatology uh literature, there are loads and loads of studies on the connection between psoriasis and diabetes. Okay. Like multiple studies. And if you read them, so of course, not only you've got intervention studies and cross-sectional studies and nutritional studies, but also if you read the mechanisms of association, it's all um it all boils down to common set pathways of inflammation. At the beginning, my original PhD project was supposed to be periodontal medicine, so not the one about lifestyles, but this one about psoriasis. And I was like, okay, so if psoriasis and diabetes are so much connected and they say that there's a bidirectional relationship, then it might be the case that there's some kind of relationship between psoriasis as well and periodontitis. Sure. Because again, both of them are inflammatory conditions, and the kind of inflammation that's on the skin and in the mouth separately goes to the rest of the body, so there might be something. Um, and then we started to design both preclinical studies on animal models, also clinical studies, both observational and then randomized clinical trials. So we've done one, let's say, on the on the animal models, one, the first one was just about the association between the two diseases and the especially testing whether this inflammatory pathway between psoriasis and periodontitis was confirmed. And what we found was that in the mice that had periodontitis, they also had like a higher inflammation at a histological level on the back, the skin on the skin of the mice. Yeah. Um, same thing for the pa for the mice that just had psoriasis that was induced via a topical cream that was applied. Um, they tended to have high, significantly higher bone loss as measured on the micro CT scan of the mice. And there was a first preclinical model. And also then we've done a treatment, let's say, like a trial on mice as well, testing whether there was a kind of a significant and junked effect of the periodontal therapy and the, let's say, most common therapy for psoriasis, which is the use of uh TNF alpha, so tumor necrosis factor -alpha inhibitors on both the periodontal outcomes, which in the case of the animal models was the bone, the dealer bone loss as measured on the micro CT and the psoriasis outcomes that was measured histologically. And of course, we noticed that um even in the if we've got two groups of mice, so both of them have both periodontal ligator-induced periodontitis and imiquimodes, so let's say cream-induced psoriasis, if you just give, for example, the TNF alpha inhibitors and you don't do periodontal therapy, you still have more inflammation to the skin and less resolution of the lesions compared lesions compared to the mice that also had periodontal therapy, which in the mice was a in the mouse was a combination of mechanical and chemical.

Martijn 56:59

Okay. So the therapy of the periodontal treatments reinforced the TNF alpha or the sorry assess treatment. Yes, effects.

Dr. Crystal Marruganti 57:09

Exactly, exactly. And then we also ran clinical trials. Um uh the clinical trial was basically conducted on 70 patients. Um, all of them were affected by both severe periodontitis and severe uh psoriasis. There was under treatment with biological medications, so either TNF-alpha inhibitors or interleukin-17 inhibitors. And we randomized, we split these two patients into two groups. One group received periodontal therapy immediately, the other group received periodontal therapy after 10 weeks, so just at the end of the experimental period. Um, and then what we notice is that the treatment, so the group that actually received periodontal therapy in addition to the psoriasis therapy had less lesions and less inflammation, especially on the psoriasis lesions. Because when a dermatologist assesses the patches of psoriasis, not only they, of course, measure the symptoms of the patients and the extent, so how big the lesions are, they also measured the amount of inflammation and scaliness of these kind of lesions. And they were actually significantly reduced in the patients. Um, they also received periodontal therapy compared to the patients that had untreated periodontal therapy.

Martijn 58:31

So basically, replicating replicating what you already

Real-World Case Study: Habit Replacement for Smokers

Martijn 58:34

found in the mice, it also applied in humans.

Dr. Crystal Marruganti 58:36

Yeah, it's interesting. Exactly, exactly, exactly. And uh also what was also good from a patient perspective is that there was also like a significant improvement in the dermatology life quality index, meaning that adding the periodontal therapy with the reduction of the symptoms or psoriasis also reduced the perception that the patient had of the feelings of having these patches that tend to be quite invasive and they tend to force the patients to change their lifestyles because they have they suffer from psoriasis.

Rachel 59:09

And also reducing the stress, because I assume that these kind of uh lesions can also be quite um difficult on the on a in a daily life uh basis.

Dr. Crystal Marruganti 59:20

Definitely. Not only be from uh an aesthetic, very very simple aesthetic point of view, sometimes they also appear uh on the patient's hands. So there's also like a big social component added to it, and also because some of the topical treatments that are provided for psoriasis they involve some creams, they tend to be very oily, so it's especially if it's summer, sometimes it's not easy to manage this effectively on a on a daily basis, and some patients tend to also prefer not to go out often, for example, if they're having a flare-up. So there's a big, big social and stressful component when it you when it comes to skin lesions, if they because it's something that's very visible also on the outside. So every the perception of every patient, uh, that's also like a big chunk of dealing with this type of patients. So dealing also with the perception that they have of the disease in a way.

Martijn 1:00:15

It's interesting. And um if I compare it to what we uh what we are fighting for or have been fighting for for decades now in the field of diabetes, where we try to um implement screening of the oral cavity in diabetes care guidelines, and there have been success some successes. Uh, for example, the Netherlands now it includes um uh a small section in the guidelines where there are physicians are recommended to screen in the mouth for symptoms for periodontitis and try to get the patient into the chair of the dentist. Um, but it's still a struggle at times, and um progress is not as fast as we would like, of course. But then we were talking before the show, and you actually mentioned that in dermatology there is already sort of a common practice of also including the mount in the examination. I was very, very curious and very interested about in that.

Dr. Crystal Marruganti 1:01:04

Yeah, so in terms of of course, the the goal of screening the mouth in the dermatologic exam, it's more related to the kind of lesions that they may have. So there can be also some melanocytic lesions, for example, in the mouth, that in that case, depending on where they are, they are other most of the times they are the send the patient to the oral surgeon, so they send the patient to dentist or a specialist in oral surgery. Um, but yes, they also screen the mouth because some of the conditions that affect the skin, they always start from the mouth. And sometimes sometimes the symptoms that are present or not present in the mouth can help the dermatologist have more clues about the condition, for example, that affects the skin. Okay, it's the same for some conditions, for example, like syphilis, where you've got conditions, you've got lesions on the skin, but sometimes, and most of the times, it starts from lesions in the mouth. So if you're a dermatologist and you have to spot this kind of case, it's also essential that you actually look in the mouth in a way. Um, because again, it's still like uh it tells a lot about what's happening.

The Surprising Link Between Gums and Skin Conditions

Dr. Crystal Marruganti 1:02:09

What happens in the mouth tells a lot about what's happening in the rest of the body.

Martijn 1:02:12

Well, we always say like the mouth is a mirror of the rest of the body. Yeah, yeah, yeah. It applies to the dermatology as well. Yeah, I never thought about that, but it's super interesting.

Rachel 1:02:20

At the beginning of the conversation, you mentioned uh the microbiome in one of the biological pathways uh between multimorbid uh conditions. So we also hear a lot about the microbiome of the skin, right? And of course, one of the most well-known is the one from the gut. And we are also very interested in the oral microbiome. So, is there some sort of a link between the oral, the gut, and the skin microbiomes?

Dr. Crystal Marruganti 1:02:46

So, exactly. So, in the in the um, especially the animal models uh that uh we've published, uh we focus more on the inflammatory connection. But of course, whenever you look at the literature, there are already some studies and some systematic reviews that focused on uh the oral and gut microbiome of patients that are affected by both psoriasis and also psoriatic arthritis, which is let's say a different type of psoriasis that also has some symptoms on the joints, let's say, but the let's say the pathogenesis is quite similar. And what they found is that there are some distinct um, let's say, strains on the oral and gut microbiomes of these types of patients. And also, it was fine that there was a connection between the gut and the skin microbiome as well. So, of course, we know that the bacteria that stay in one district they usually translocate if they're either in the gut or if they are in the mouth. So, of course, future research should investigate more the microbiome-mediated side of things because of, of course, there's there's a triad, like a triangle can be absolutely hypothesized.

Martijn 1:03:59

Yeah, you've uh you you have studied the the link between oral and systemic health quite extensively, looking at from the lifestyle and how this new angle of um of looking at from a derma dermatology uh perspective. What we always experience and what we'd always talk about a little bit is how can we make all that knowledge and that information practically applicable for our viewers and our listeners? And that's sometimes sometimes quite challenging because um a lot of this work uh is always a bit theoretical, academic. Making that translational step into clinical practice is sometimes a bit of a challenge. Um but we were just wondering if you have some take-home messages on how oral care professionals, dental hygienists, dentists, specialists can sort of leverage what we know about the oral systemic link.

Dr. Crystal Marruganti 1:04:48

Sure. So um this is the system that I I'm I will I'm trying basically and I've implemented in my clinical practice. So, first of all, is that I think the most important part to start this journey with a patient is the consultation appointment, or in the case of hygiene, is the first appointment that you have with your patient. Um, where first of all, yes, you need to do your clinical exam or x-rays, whatever you need to do, but specifically you

Clinical Findings: Periodontal Therapy and Psoriasis

Dr. Crystal Marruganti 1:05:16

need to conduct a thorough risk assessment. You don't need to do this on the chair, but it's something that I drew, for example, through short questionnaires that the patients fill in either through a link, for example, you can send it by email, or you can do it on paper when the patient is in the waiting room, for example.

Martijn 1:05:32

Right.

Dr. Crystal Marruganti 1:05:32

Exactly. And it screens for yes, medical history, but also lifestyles. So there are some general questions about diet, general questions about physical exercise and amount of physical exercise. Six, seven questions, then also about perceived stress. You know, how stressed are you? Do you feel that you are on a scale from one to ten, for example, on an average wake? Okay, that's the first question. And also sleep quality. How long does it usually Take for you, for example, to uh fall asleep at night? How on average, how long are your sleep nights? Right? So, this type of question. So, as soon as the patient comes into my room, I already know something about lifestyles that are, I would say, okay if they're already healthy, or some lifestyles that might need to be somehow implemented for the patient's health, I would say. So I already have a lot of background information. Um, also something else that's essential that would be very, very good, especially if you focus your practice to periodontology, would be to start screening for systemic conditions on chest side, especially after you've if you've made your diagnosis of periodontitis, and especially if it's like severe, advanced periodontitis cases, it's good to, for example, have a point-of-care testing for screening testing for diabetes inside the dental practice, especially if it's a periodontal practice, every periodontal practice should have it, right? Because there's a lot of undiagnosed diabetes, and we have the possibility of actually making this change. Of course, this has to be accompanied by a very, very structured conversation about the oral systemic lane. So when you've collected your data at the end of the consultation and you have a discussion on the patient, not only on the x-rays, oh, you've got a vertical defect here, you've got a fricational defect here, which is good. Uh also should be about the systemic effects of periodontal treatment. So what we are doing inside this room, so it's not just for your gums, not just for your teeth, it's not just because you want to do them in ears afterwards, okay? It's also because of your um for the sake of your general health as well. So there has to be a structured conversation. And uh, if, for example, the patient is positive to the screening test for diabetes, of course, if needed, we would need to be able to make a referral either to the patient's GP, because we always need to have the information of the patient's GP every time, or to different specialists if if needed. And then, of course, based on the questionnaires that we and the answers that we've had from the patient regarding the lifestyles, whenever we get to the step one, either again, if it's the dentist doing the treatment or the hygienist doing the treatment, there has to be some time that's been, let's say, taken and reserved to change, let's say, the lifestyles that were, let's say, like a red flag in the initial in the initial questionnaires. And this again can be done with different intensity of intervention, especially following, for example, the framework of the make every contact count, which basically includes the fact that every contact with the patient should be like an occasion to educate the patient about lifestyles, you know, even very, very easily with other visual ads. So you can either signpost the patient to specific apps for smoking cessation, specific websites, or you can have leaflets either in the waiting room, for example. So it can be your receptionist also handling this leaflets, or the leaflets can be in the waiting room. Okay, so even the environment where you're working should be surrounded by let's say it should be covered with the same messages that you're trying to convey on the chair, if that makes sense. So that it's like a philosophy that the whole practice follows in a way.

Martijn 1:09:26

Yeah, that makes sense, absolutely.

Dr. Crystal Marruganti 1:09:28

So, for example, it's uh in the practice where I work, it's like a four-floor practice that's a Victorian building, steep stairs, very steep stairs. And my my my room is actually on the fourth floor. Best view, but it's on the fourth floor, so it's it's far. Okay, everybody takes this lift. So inside the lift, there's like this uh peak representation of the human body, and it says, of course, it just highlights all the connection between periodontitis and different diseases, and there are some daunting percentages, like uh if you've got gum disease, if you've got severe gum disease, or like uh there's like a 50% higher mortality rate because of heart attack or something like that. So sometimes you've got the very, very sensitive patients, they come to my room, they're like, My dentist told me I've got gum disease. Am I gonna die with a heart attack? Not not yet.

Martijn 1:10:20

At least they paid attention in the elevator.

Dr. Crystal Marruganti 1:10:22

Somehow it works.

Martijn 1:10:23

Yeah, it works. So these are all great tips, I think. Um, that can help patients change their lifestyle. But for sure, there will also be patients who are not so sensitive to these lifestyle tips. Um, indifferent patients, um, resistant patients, stubborn patients. Uh, how do you deal with them? Do you have specific tips and tricks for the audience?

Dr. Crystal Marruganti 1:10:49

So many patients are actually,

Why Dermatologists Screen the Mouth

Dr. Crystal Marruganti 1:10:51

I wouldn't say indifferent, but they're resistant to change in a way, right? Um, especially when you talk with smokers or heavy smokers. There are some patients that are not interested at all in quitting smoking, if that makes sense. So in with these kind of patients, it's probably can have like an opposite effect if we go there and like smoking is bad for your health. And I don't know, you're gonna die of lung cancer. They're not gonna stop, they're not gonna quit because of that. So, probably what I tend to do in this case like just meet patients where they are. So that's why I ask a lot of open-ended questions at the beginning, just to try and understand also how open they would be to changing their habits and also some sometimes also what drives them to have the habit, the habit, because especially with smoking, everybody knows that smoking is bad for the health, right? But people still do it. So it means that there is something there, yeah, if that makes sense. So, and from there, even of course, if the patient is not interested at all, I never force the patient on the first visit, but I try again during the following encounters, during the following visits or treatment, treatment visits or other consultation visits to try and make the change. And whenever, at some point, if you keep giving the message in a non-forceful way, at some point there will be an opening. And then you're gonna start okay, so now you're smoking 20 cigarettes per day. So let's do that from today till the next time you see me again, you're gonna start to smoke 18 cigarettes per day. 18 is still better than 20, if that makes sense. So um, and then if they make that positive change, uh we can go through the pathway of slowly, slowly arriving to quitting smoking together. But it's always, even with those patients, it's even more important to have the tiny small incremental improvements in lifestyle. So they don't even remember that they used to smoke 20 cigarettes per day. Right. So, like, oh no, but I was smoking 10. I was like, Yeah, sure, absolutely. So at some point, they're just gonna notice that they're gonna quit smoking, but never force them. So try and understand where they are first and be there with them, uh, and then m take it from there. Yeah, because they sometimes the patients don't know what you know, and they're not as sensitive and as health-conscious as we are most of the times. So it's more about don't force them.

Martijn 1:13:14

Yeah, yeah, and I think with uh with those practical tips for uh for our audience, I think we've uh we've uh drawn to a close of uh of our conversation of today. So uh thank you, Crystal, and um your conf your contribution to the whole research work around the oral systemic link has been has been fantastic, and I think um there are many useful tips for our uh for our audience to take away from that. Um, and I'm also sure we will hear more from you in the future because um yeah, you're still very active in research, and there's uh I'm I'm sure there's more to come. So I wanted to thank you for your uh yeah, your inspirational contribution today, and hopefully we'll see each other again soon.

Rachel 1:13:51

Thank you so much. Thank you for being with us today.

Martijn 1:13:54

Thank you so much. So, thank you also to our audience for tuning in for another Let's Talk Oral Health episode. We're happy to connect with you again for a next conversation on anything interesting around oral health. So, thank you again for watching and see you all next time.