Laurie Kaiser: Frank Scannapieco had no interest in school as a kid. He was having too much fun goofing off with his friends.

Frank Scannapieco: Yeah, I really wasn't a good student. I went to college because my dad told me I had to go.

Laurie Kaiser: It's a remarkable beginning, considering the illustrious academic career he's had. A SUNY Distinguished Professor at UB’s School of Dental Medicine, where he's been on the faculty since 1991, Scannapieco is an internationally renowned oral biologist. He has published more than 170 peer reviewed articles and chapters, won multiple awards, and is one of the most highly cited scientists in his field. Although his research is wide-ranging, he's probably best known for his pioneering studies linking oral health to systemic diseases such as diabetes, pneumonia and Alzheimer's.

Welcome to Driven to Discover, a University at Buffalo podcast that explores what inspires today's innovators. My name is Laurie Kaiser, and in this episode, I'll be talking to Dr. Scannapieco about the connection between oral health and overall health, and what we can do as individuals and as a society to maximize both.

Welcome Dr. Scannapieco. Thank you so much for being with us today. First, let's talk a little bit about your career journey. You said you went to college because your dad wanted you to. Were you the first in your family to go to college?

Frank Scannapieco: First, let me thank you for inviting me. Yeah, my family is from Waterbury, Connecticut. My dad was a child of Italian immigrants, and although he had the opportunity to go to college, he decided to make money for the family. So, I think he always regretted that, and so he always encouraged me and my brother and sister to go to college.

Unfortunately, I really had no focus when I was a kid, so when I went to college, I test-drived a lot of majors and stumbled into biology, and really liked that. And I had the good fortune to have a couple of really good teachers who inspired me to pursue that.

Laurie Kaiser: Well, you clearly did well in your academic career. You got your BA in biology, then you went on to get your master’s in biology, then a doctorate in dental medicine, then a PhD in oral biology. So, do you know at what point you got interested in oral biology in particular?

Frank Scannapieco: I never really thought of being a dentist or even pursuing a PhD. My first thought when I was ending my college time was to pursue a master's in biology. And really it was a very simple idea—I  would learn a little bit more and perhaps teach. I also, when I was in college, I volunteered to work in a micro lab in a hospital, and then I had the luck to be hired the next summer. So I really had a great experience there, and I got interested in the microbiology of infection and stuff like that.

So, I went on to Northeastern University in Boston, and right across the street was a place called the Forsyth dental center [currently called the ADA Forsyth Institute]. Now that was a very famous, and still is a very famous, research institute, and I had a friend who was working there, and he told me there was the opportunity to work in a lab there. So, I was fortunate to be able to work with a fellow named Johannes van Houte, who turned out to be a world expert in oral microbiology. So, I was able to do my master's with him, and he really inspired me. You know, I couldn't believe you could, you know, get paid to do that kind of stuff. But I realized I had to go on and get educated, and I thought it was important to have a clinical degree. So I first went on to do my dental training, and then I wound up here in Buffalo in the graduate program in oral biology, which was very well regarded and still is even today.

Laurie Kaiser: UB was the first oral biology department in the country, correct?

Frank Scannapieco: Yes, yes.

Laurie Kaiser: So, you wrote a paper back in the 1980s suggesting a link between oral bacteria and pneumonia, and critical care patients. It was a seminal work which eventually led to oral hygiene becoming a routine part of care in critical care units, but it took years to get it published. Why was that?

Frank Scannapieco: Interesting question. I had the opportunity, of course, in dental school, to study a lot of medicine, and I had some experience in oral biology, and so I became aware that microbes in the mouth might cause serious medical infections, such as pneumonia. The mouth as a source of medical infection, however, was not taken very seriously by medicine.

So we did this project here in Buffalo. I worked with a fellow in the medical school, Joe Mylotte, who was an infectious disease professor. He was very supportive. And after we did the project, I wrote it up, and I thought it really deserved to be published in a medical journal, because I thought the medical doctors needed to know this stuff. And I was very disappointed, because it was rejected multiple times without review. But I stuck with it, so finally, it was published in a journal called Critical Care Medicine.

The experience also revealed to me something very important, and that is that dentistry was, and still is in many ways, disconnected from medicine. And this has, of course, historical, political and economic roots, but it is something I've puzzled about over the last 40 years and still struggle with a little bit.

Laurie Kaiser: Can you explain the connection between oral health and overall health in layman's terms? You know, what is the mechanism by which, say, a tooth infection can lead to pneumonia, and what other diseases are we talking about here?

Frank Scannapieco: So, most of the major common chronic diseases, from cancer to cardiovascular disease, stroke, diabetes, respiratory disease, dementia, etc., all have multifactorial causes. Many of these causes, which are often called risk factors, are shared by many diseases. So, for example, smoking, poor diet, environmental exposures to chemicals, etc., are all risk factors for many diseases.

One important common risk factor is inflammation. So the oral cavity is a common source of inflammation that can impact the body. Periodontal disease is the result of inflammation against bacteria that stick to the teeth. Because it is usually painless, gum disease can persist for long stretches of time and add to the whole-body inflammatory burden. Also, bacteria can enter the blood from the gum tissue to impact diseases such as diabetes or, you know, atherosclerosis. They could be aspirated into the lung to cause problems like pneumonia or swallowed to impact gut diseases.

So, very simply, oral hygiene and preventive care, which would include tooth cleaning and, you know, fillings and things like that, will not only help preserve teeth, but also lower the risk for these other chronic diseases.

Laurie Kaiser: So Frank, that's a huge list of diseases, and even today, it's not well understood. Why is this?

Frank Scannapieco: Well, I think, you know, number one, all of these problems are very complicated. But we really have made great strides over the last 20 years. So there's, you know, growing evidence that bad oral health is going to impact, or at least be associated with, things like, you know, cardiovascular disease or pneumonia or whatever. And there are growing numbers of smaller studies, some small trials, etc., that are showing that if we keep good oral health, it lowers the risk for these chronic medical problems.

So one of the problems, of course, is we don't have a large number of big, randomized trials that would prove a lot of these connections. And the reason for that really is funding; some of these studies would cost a lot of money, and we simply don't have the resources. Or at least society is not prepared to spend the kind of money that we would need to do these multicenter trials to prove, for example, that tooth brushing would prevent heart disease.

But some of the investigators are pretty clever. They're doing large-scale, longitudinal epidemiologic studies to show that, you know, receipt of dental care over time will reduce the risk for some of these diseases. So I think we've made a lot of progress over the last few years.

Laurie Kaiser: And you're currently a co-investigator of a study right now, correct? Looking at the connection between oral bacteria and Alzheimer's disease. Can you tell us about that research?

Frank Scannapieco: Sure. There is a growing awareness that oral inflammation and bacteria might impact Alzheimer's disease. So the hypothesis is that oral microbial agents initiate inflammation, as I mentioned, that triggers systemic inflammation, the products of which can reach the central nervous system through the blood. It's also been shown that oral microbes and oral inflammation from the mouth might also access the central nervous system through routes such as the trigeminal nerve or through olfactory nerves.

So, I was invited to work with a group in the School of Nursing at Emory University, and they got NIH funding to follow a cohort of adults who have mild cognitive impairment. So, these are older folks that have, you know, a little touch of symptoms. And they're following them over time, and they're comparing them to an age-matched group of adults that have no symptoms. And then they're looking at a variety of things like clinical periodontal status, they're looking at the oral microbiome, and they're looking at markers of inflammation and immune response in the mouth and in the blood, and comparing this to, you know, cognitive testing over time. So, I think this is a great opportunity to try to gather more substantial information that there's a connection between oral health and dementia.

Laurie Kaiser: That's fascinating. And also frightening, when you think about taking care of your mouth now to prevent something later. Other than brushing and flossing, what can people do to prevent oral diseases, especially as they get older?

Frank Scannapieco: As complicated as all of this sounds, happily, it's a pretty simple solution. It does require all of us to maintain good oral hygiene, which is not easy to do, because oftentimes we're busy, we have other obligations, or we're tired, things like that. But I think if we all spent 10 minutes a day, in the morning and evening to do simple oral hygiene. And what is that? Brush your teeth, floss or use interdental cleansers. We have lots of things available. If you go into any drugstore, supermarket, there's a whole aisle of tools that you could use. I'm a big fan of interdental brushes, and this is really to clean all of your teeth and remove the bacteria. So, our teeth are always being assaulted by bacteria which are resident in our mouth. So removing them every day and perhaps using a rinse, using fluoridated toothpaste—fluoride is very important because it does prevent decay, and there's also connections between decay and some of these problems as well. The other thing, of course, is to at least go to the dentist once a year or twice a year to get your teeth cleaned and examined to make sure that you don't have problems. And I think just those simple things alone will go a long way to reduce your inflammatory burden and reduce the risk that we've discussed.

Laurie Kaiser: What about your diet? How does that affect your oral health?

Frank Scannapieco: Well again, the oral cavity is no different than any other part of the body, and a good diet is essential. So, you know, we want to have a balanced diet, which will allow us to have a good, healthy immune system. Some dietary components are antioxidants that will help reduce inflammation. Also, a bad diet, especially a sugar-rich diet, will promote diabetes, and there's a connection between diabetes and poor oral health. So, people who have diabetes have a higher risk for gum disease, and if you have gum disease, you have a higher risk for having high blood sugar.

Laurie Kaiser: So, in addition to your research, you also advocate for Medicare to provide dental coverage to seniors. Given everything that you said today, it seems shocking that it doesn't already do that. What does this work entail? And are you achieving any results with your advocacy work?

Frank Scannapieco: Yes, it is very interesting that dental care is not part of the Medicare program. There’s a history there. So back when it was conceived, back in the ’60s, dental care was deliberately not included. And, uh, a lot of complicated reasons for that, but I think there was some resistance from dentistry because they felt they would have been hamstrung by the fee structure of Medicare.

I think as time has gone by, though, and you know, obviously, from the discussion we've had already today, there's more and more recognition that oral care is important and should be included in some way. So, in the last few years, there have been small baby steps taken. So there are now a few procedures for which dental care is reimbursable through Medicare. So, for example, if you're going for things like chemotherapy or stem cell therapy, bone marrow transplants, things like that, I think Medicare will pay for, you know, a tooth cleaning or some minor dental work before you have your procedures.

I'm working with a group now called the Coalition for Oral Health Policy, and this is a group of 250 or so health organizations that have gotten together to advocate for inclusion of dental benefits in Medicare. They're also trying to advocate to improve dental benefits that are offered in Medicare Advantage plans, which are, you know, optional plans for which you have to pay premiums. And there's a huge variability amongst these plans with respect to dental benefits. So the group is trying to advocate for more comprehensive coverage for good dental care through the Medicare Advantage plans.

Laurie Kaiser: That's important work, especially as the population is aging. More people are going to be on Medicare.

Frank Scannapieco: Yes. I know I'm certainly more and more interested in this topic from a personal point of view, of course. But I think, you know, we all deserve at least some essential medical care. And I think the biggest argument is really the cost saving. There is a growing body of evidence showing that more dental care, especially preventive care, is cost effective insofar as it would reduce medical outcomes, and therefore the cost of diabetes care and, you know, hospital infection treatments and things like that. So, I mean, it's common sense, but, you know, we need to get the data to support it. But I think there's a good momentum going forward.

Laurie Kaiser: And that's encouraging to hear. Thank you so much, Dr. Scannapieco, for coming and talking with us today. This is all very fascinating. It gives you a lot to think about.

Frank Scannapieco: Well, I really appreciate the invitation, and I enjoyed our conversation. Thank you.