Holistic Dentist's Guidance for an Excellent at-home Routine

Did you know that the oral microbiome, specifically P. gingivalis bacteria may influence brain health and contribute to Alzheimer's disease risk?

I had the pleasure of sitting down with Dr. Iman Abdeshahian, a Dentist at Holistic Dental Wellness Center. Patients within QC Natural Health got to compile their questions for him, and he answered everything from fluoride to mouthwashes to mercury fillings.

I want to share every detail with you! Here is transcript of our podcast together:

Dr. Iman, thank you so much for joining us today! This is a great opportunity for people to learn more about holistic and biologic dentistry.

Let's talk!

What should a complete at-home dental wellness routine include?

I always start with the basics, because you can buy every fancy dental product in the world, but if you're not mechanically removing the biofilm, none of it really matters.

For most people, I recommend an electric or sonic toothbrush twice a day. Then, at least once a day, you need to clean between the teeth. That could be string floss, interdental brushes, or a water flosser depending on the individual.

And that's an important point: everyone's mouth is different. There isn't one perfect routine for every person.

One question I like asking patients is, "Has anyone ever actually put a toothbrush in your hand and watched you brush?"

Most people say no.

Think about how strange that is. This is something you do every single day that has a major impact on your health, yet most people have never actually had a professional watch them do it and show them how to improve their technique.

I also like tongue scraping, particularly for people who accumulate coating on their tongue. Oil pulling is something people can add if they enjoy it, but I don't consider it a replacement for brushing or cleaning between the teeth.

When it comes to mouthwash, I don't think everyone automatically needs one. I'm also cautious with alcohol-containing rinses, particularly in patients with dry mouth, because alcohol can be drying.

Something as simple as salt water can sometimes be useful, and depending on the patient, there may be other targeted rinses that make sense.

And remember: home care does not replace professional care. Most people will still need calculus professionally removed periodically by a hygienist.

One of the simplest things patients can monitor at home is bleeding. If your gums consistently bleed when you're brushing or flossing, that's something we should investigate.

Can you set the record straight on fluoride? What about toothpaste, drinking water, and fluoride treatments at the dentist?

Fluoride is probably one of the most controversial topics in dentistry, and I think the conversation often becomes too black and white.

I don't think it's scientifically accurate to say fluoride has no effect on cavities. It does have an anti-cavity effect, particularly when used topically.

The question I have is different:

Does that mean everybody needs fluoride coming from multiple sources throughout their entire life?

That's where the IAOMT takes a much more precautionary position. Their concern is cumulative exposure. Fluoride exposure can come from water, toothpaste, dental products, food, beverages, tea, and other sources.

The IAOMT's argument is essentially that even if fluoride can have a beneficial topical effect on teeth, that doesn't automatically mean routinely ingesting it is necessary.

And I think that's an important distinction: drinking fluoride and applying fluoride topically to a tooth are two different conversations.

There are also legitimate questions being studied about fluoride exposure and neurodevelopment.

The National Toxicology Program has reported an association between higher fluoride exposure and lower IQ in children. At lower exposure levels, however, there is more uncertainty, and the NTP specifically says there are not enough data to determine whether drinking water containing 0.7 milligrams per liter of fluoride affects children's IQ.

So I think we have to be careful not to overstate either side.

I also don't think every patient automatically needs a professional fluoride treatment every six months.

Dentistry should be risk-based.

Is this patient getting cavities?Do they have dry mouth?What does their diet look like?How much plaque do they have?What is their saliva like?Are they actually at high risk for decay?

There shouldn't be a one-size-fits-all treatment.

In my practice, I put a lot of emphasis on diet, biofilm control, saliva, mineral balance, and remineralizing materials such as hydroxyapatite rather than assuming fluoride has to be the answer for every patient.

Is hydroxyapatite a good alternative? What percentage should people look for, and are there systemic concerns?

Hydroxyapatite is something I'm really excited about.

Hydroxyapatite is a calcium-phosphate mineral that naturally makes up the mineral structure of our teeth.

That's one reason it's so interesting. Instead of relying exclusively on fluoride chemistry, we're using a mineral that is already a natural structural component of enamel.

And this isn't just theoretical anymore. We now have clinical trials showing that hydroxyapatite toothpastes can support remineralization and cavity prevention.

People often ask me what percentage they should look for. I generally like products around 10% hydroxyapatite, because that concentration has been directly studied.

A study using 10% hydroxyapatite found remineralization and protection against demineralization comparable with the fluoride formulation tested. That doesn't mean we've proven that exactly 10% is the magical ideal concentration, but I like using something for which we have clinical data.

So yes, I think hydroxyapatite is a very promising fluoride-free option for remineralization, sensitivity, and cavity prevention.

Elephant in the room: What about mercury fillings? Should someone get them replaced?

The first thing I would do is call the material what it actually is.

What people commonly call a "silver filling" is dental amalgam, and approximately half of that material is elemental mercury.

The concern is that amalgam restorations release mercury vapor, and exposure can increase significantly when you're drilling into them during removal.

That's one of the reasons the IAOMT takes a precautionary position on dental amalgam and developed the SMART protocol, which stands for Safe Mercury Amalgam Removal Technique.

But I don't like using fear.

I would never tell somebody, "You have a mercury filling, therefore you're sick, and removing it is going to cure you."

That's not responsible dentistry.

Instead, I evaluate the individual patient and the individual tooth.

Is the filling fractured?Is there recurrent decay underneath it?Is the tooth cracked?How large is the restoration?How much healthy tooth structure will we lose by removing it?What are we going to replace it with?And how important is being mercury-free to that particular patient?

It is not always in the patient's best interest to remove an amalgam filling.

Sometimes removing a very large restoration can significantly compromise the remaining tooth structure and potentially move that tooth toward a crown, root canal, or even extraction.

So every case needs to be evaluated individually.

Then there's a second question:

If we decide to remove it, how are we going to remove it?

Removal itself is an exposure event, which is why I think the technique matters.

That's where SMART comes in.

We use isolation and protective barriers. We use high-volume suction, copious water, air filtration, respiratory protection for the dental team, and an alternative air source for the patient. The goal is to reduce mercury exposure to the patient and the dental team as much as possible during removal.

And this is important:

I never promise somebody that removing an amalgam filling is going to cure fatigue, autoimmune disease, brain fog, or another systemic condition.

What I can do is explain what the material contains, evaluate whether replacing it makes sense, and if we're going to remove it, minimize exposure as much as possible.

What about the oral microbiome, particularly P. gingivalis and F. nucleatum?

We're increasingly understanding that the mouth is not separate from the rest of the body.

We're seeing associations connecting periodontal disease and certain oral bacteria with systemic conditions – including diabetes, cardio vascular issues, pre term birth weights to mention a few.

For example, P. gingivalis has been studied in relation to Alzheimer's disease and neuroinflammation, while F. nucleatum has been investigated in gastrointestinal disease, inflammatory bowel disease, and other systemic conditions.

But association is not the same thing as causation.

I don't think it's scientifically responsible to say, "This bacteria in your mouth caused your Alzheimer's disease," or, "This bacteria caused your inflammatory bowel disease."

So if somebody does an oral microbiome test and it says they have elevated P. gingivalis or F. nucleatum, I don't simply treat a laboratory number.

I treat the person attached to the test.

I want to know:

Are their gums bleeding? What are their periodontal pocket depths? Do they have bone loss?Is there calculus underneath the gums? Is there inflammation? And what does the biofilm actually look like?

In our office, we can take plaque from underneath the gumline and look at it under a microscope.

That's incredibly powerful because the patient can actually visualize what we're talking about.

They may see inflammatory white blood cells, motile organisms, rods, spirochetes, and different characteristics of the biofilm.

Instead of me simply saying, "You have gum disease," they can actually see what's happening.

If we confirm periodontal disease, treatment starts by changing that environment.

We disrupt and remove the pathogenic biofilm.We remove calculus.We improve home care.We treat the periodontal pockets.And then we reevaluate.

There may be additional therapies depending on the individual patient, but the foundation is still controlling the disease and changing the environment that allowed that unhealthy microbial balance to develop.

The microbiome test gives us information. It is not the diagnosis. I still have to examine the gums, the bone, the inflammation, and most importantly, the patient.

Are there specific mouthwashes, chewing gums, alkaline water, or foods people should use or avoid for the oral microbiome?

Your mouth isn't supposed to be sterile.

We have this strange idea that the goal of dental care is to kill every bacterium in the mouth.

It isn't.

We have an entire ecosystem living in our mouths. The goal is to create an environment that favors a healthy microbial balance.

That's why I'm not a huge fan of indiscriminately using the strongest antibacterial mouthwash you can find twice a day forever just because you think you're sterilizing your mouth.

If somebody actually has periodontal disease, a targeted antimicrobial rinse or irrigation may have a role.

Chewing gum is interesting because chewing stimulates saliva, and saliva is one of the most important natural protective systems in the mouth. It buffers acids, supplies minerals, lubricates tissues, and helps protect the teeth.

Sugar-free gum, including xylitol gum, can be useful for some patients.

That said, I don't encourage excessive gum chewing in somebody who is already having jaw or TMJ problems.

As far as alkaline water goes, I don't think people need to spend a fortune on specialty water to have a healthy mouth.

What matters much more is how frequently you're exposing your teeth to sugar and acid.

Your teeth are constantly going through cycles of demineralization and remineralization, and the pH of the oral environment plays a major role in that balance.

One of the worst habits for the oral environment is constantly sipping or snacking on something sugary throughout the day.

Every exposure gives acid-producing bacteria another opportunity to lower the pH.

I'd much rather somebody eat a meal, drink some water afterward, and then give their saliva time to recover instead of grazing or sipping something sugary for eight hours.

And when we zoom out, general health matters too.

A nutrient-dense diet, good metabolic health, good sleep, not smoking, adequate saliva, and good plaque control are much more important than trying to find one magical mouthwash.

What are your thoughts on root canals?

Root canals are another area where I think the conversation becomes unnecessarily polarized.

On one side you'll hear:

"Root canals are completely harmless."

On the other side you'll hear:

"Every root canal is toxic and needs to be extracted."

I don't think either extreme is a useful way to approach an individual patient.

The IAOMT takes a more cautious position on root canal-treated teeth. One of its concerns is that root canal treatment does not necessarily make the entire internal anatomy of a tooth sterile and that microorganisms can persist within complex anatomy such as accessory canals and dentinal tubules.

But there is an important distinction here.

Finding residual microorganisms is not the same thing as proving that a properly treated root canal causes systemic disease.

So again, I evaluate the individual tooth and the individual patient.

How does the tooth look clinically?What does the X-ray or 3D CBCT show?Is there a lesion around the root?Is the patient having symptoms?Has the root canal actually failed?Can an endodontist successfully retreat it?What is the condition of the surrounding bone?And what are the risks and benefits of extracting the tooth versus keeping it?

My goal isn't to be pro-root canal or anti-root canal.

My goal is to help the patient make the best decision for that particular tooth and their overall health.

Sometimes saving the natural tooth is the right decision.

Sometimes retreatment is appropriate.

And sometimes a persistently infected or failing root canal-treated tooth may be better removed.

It has to be evaluated individually.

What does airway have to do with dentistry, and how can your dentist help?

Dentists are in a unique position because we're constantly looking at the tongue, palate, jaws, bite, and back of the throat.

So sometimes we may be the first people to notice clues that somebody isn't breathing or sleeping well.

I ask about things like snoring, mouth breathing, waking up tired, waking with a dry mouth, or a partner noticing that someone stops breathing or gasps during sleep.

I'm also looking at the anatomy: the tongue, palate, jaws, and available space in the mouth.

But this is important:

A dentist screening someone for sleep apnea is not the same thing as diagnosing sleep apnea.

Our job is to recognize the warning signs and make sure that patient gets the appropriate medical or sleep evaluation. The ADA similarly supports dentists screening for sleep-related breathing disorders and collaborating with physicians in diagnosis and treatment.

For appropriately diagnosed patients, a dentist can also provide a custom oral appliance. These appliances can stabilize or advance the lower jaw and help reduce collapse of the tongue and surrounding tissues into the upper airway during sleep.

To me, this is another great example of Dentistry 3.0:

We're not just looking at teeth. We're asking what the mouth might be telling us about the health of the entire patient.

Is there anything you wish everyone knew about holistic or biological dentistry?

I think the biggest misconception is that biological dentistry is simply about avoiding fluoride, removing mercury fillings, or saying root canals are bad.

To me, that's not what it's about.

It's about looking at the patient as a whole person instead of treating the mouth as an isolated set of teeth.

What's happening with their airway?What's happening with their sleep?What's happening with their bite?What's happening with their gums and oral microbiome?What materials are we putting into their body?What does their diet look like?Are they breathing predominantly through their nose or mouth?Are we seeing chronic inflammation or infection?

And then, most importantly:

How can we identify problems earlier and prevent disease rather than constantly repairing damage after it has already occurred?

A mentor of mine, Dr. McBride, often talks about the concept of Dentistry 3.0.

It draws on the broader idea of Medicine 3.0 that Peter Attia discusses in Outlive—looking upstream, identifying risk factors and early warning signs, and trying to address problems before they become major disease.

I think more and more patients are looking for that type of healthcare.

They don't just want us to wait until something breaks and then fix it.

They want medicine and dentistry to become more proactive, preventive, individualized, and focused on long-term health.

And that doesn't mean abandoning conventional dentistry.

I still use science.I still use imaging.I still restore teeth.I still use surgery when necessary.I still work with specialists.I still use the tools of modern conventional dentistry.

The difference is that I'm constantly asking one additional question:

How might what I'm seeing and doing in the mouth relate to the health of the rest of this person?

That's really what biological dentistry means to me.

Dr. Iman, thank you so much for your time and sharing your expertise. Where can people go to learn more from you? https://www.longbeachholisticdentist.com/blog/category/articles/