The Longevity Index

Hygiene (Skin & Oral)

The TL;DR

Oral and skin health represent your body’s first line of defense against pathogens and environmental damage. Poor oral hygiene directly contributes to systemic inflammation and cardiovascular disease through bacterial translocation and chronic immune activation. Skin, your largest organ, serves as a critical barrier that deteriorates with age and UV exposure. Evidence-based protocols for both systems offer high-impact, low-cost interventions that compound over decades to reduce chronic disease risk and slow biological aging.

Accessibility Level

Level 1 (Foundation): Barrier defense is foundational, low-cost, and delivers compounding returns over a lifetime. Bryan Johnson allocates significant resources to this category for good reason: preventing damage is far more effective than repairing it. Master these protocols before moving to Level 2 interventions.

Part 1: Oral Health - The Systemic Connection

Why Oral Health Is a Longevity Priority

The mouth is not an isolated system. It serves as a gateway to the systemic circulation, and the health of your oral microbiome and periodontal tissues directly influences whole-body inflammatory status. This connection, once considered speculative, is now supported by robust epidemiological and mechanistic evidence.

The Oral-Systemic Axis:

Periodontal disease affects approximately 47% of adults over 30 in the United States, with prevalence increasing to over 70% in those over 65 (Eke et al., 2015). This chronic inflammatory condition does not remain localized to the mouth. Research has identified several pathways through which oral pathogens and inflammatory mediators affect systemic health:

  1. Bacteremia: Oral bacteria, particularly periodontal pathogens like Porphyromonas gingivalis, enter the bloodstream during routine activities such as chewing and brushing, especially when gum tissue is inflamed (Forner et al., 2006). In healthy individuals, these transient bacteremias are rapidly cleared. In those with periodontal disease, chronic bacterial exposure overwhelms immune clearance mechanisms.

  2. Systemic inflammation: Periodontal disease elevates systemic inflammatory markers including C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) (Paraskevas et al., 2008). These same markers are elevated in cardiovascular disease, diabetes, and other chronic conditions associated with aging.

  3. Molecular mimicry and cross-reactivity: Heat shock proteins produced by oral bacteria share structural similarities with human proteins, potentially triggering autoimmune responses and vascular damage (Ford et al., 2007).

  4. Direct tissue invasion: P. gingivalis DNA has been detected in atherosclerotic plaques, suggesting direct bacterial colonization of arterial walls (Kozarov et al., 2005). This pathogen produces virulence factors that can degrade arterial tissue and promote plaque instability.

The Cardiovascular Connection

The relationship between periodontal disease and cardiovascular disease (CVD) represents one of the most clinically significant examples of oral-systemic interaction.

Epidemiological Evidence:

A comprehensive meta-analysis by Humphrey et al. (2008) examining prospective studies found that periodontal disease was associated with a 24-35% increased risk of coronary heart disease, independent of traditional cardiovascular risk factors. This association remained significant after adjusting for confounders including smoking, diabetes, socioeconomic status, and obesity.

More recent evidence from the ARIC (Atherosclerosis Risk in Communities) study followed over 6,000 participants for 15 years, finding that severe periodontal disease was associated with a 25% increase in cardiovascular events (Desvarieux et al., 2013). The relationship appears dose-dependent: greater periodontal disease severity correlates with higher cardiovascular risk.

Mechanistic Evidence:

Beyond epidemiological associations, mechanistic studies have elucidated the biological pathways connecting oral and cardiovascular health:

  • Endothelial dysfunction: Periodontal pathogens impair nitric oxide production and endothelial function, a critical early step in atherosclerosis development (Amar et al., 2003).
  • Lipid metabolism: P. gingivalis infection alters lipid metabolism and promotes foam cell formation within arterial walls (Miyakawa et al., 2004).
  • Coagulation: Periodontal bacteria activate platelets and promote a hypercoagulable state, increasing thrombotic risk (Papapanagiotou et al., 2009).
  • Arterial stiffness: Intervention studies demonstrate that periodontal treatment reduces arterial stiffness, a marker of vascular aging (Saffi et al., 2015).

The Inflammation Link

Chronic periodontal disease creates a persistent inflammatory burden equivalent to having an infected wound the size of your palm that never heals. This chronic inflammation accelerates biological aging through the process known as “inflammaging” (Franceschi et al., 2018).

The Oral Microbiome

Your mouth harbors over 700 bacterial species in a complex ecosystem (Dewhirst et al., 2010). Like the gut microbiome, oral microbial balance is critical for health. Dysbiosis, an imbalance favoring pathogenic species, underlies periodontal disease and caries.

Key Periodontal Pathogens:

  • Porphyromonas gingivalis: Primary pathogen in periodontitis; produces gingipains that degrade tissue and evade immune responses
  • Tannerella forsythia: Associated with periodontal tissue destruction
  • Treponema denticola: Mobile spirochete that penetrates tissues
  • Aggregatibacter actinomycetemcomitans: Produces leukotoxin that kills immune cells
  • Fusobacterium nucleatum: Bridge organism connecting early and late colonizers; also implicated in colorectal cancer (Kostic et al., 2012)

Protective Factors:

  • Adequate saliva production (antimicrobial proteins, pH buffering)
  • Beneficial commensals that compete with pathogens
  • Regular mechanical disruption of biofilms (brushing, flossing)
  • Avoidance of excessive sugar feeding pathogenic bacteria

The Oral Hygiene Protocol

Daily Foundation: Brushing

Technique Matters More Than Frequency:

The American Dental Association recommends brushing twice daily for two minutes (ADA, 2023). However, technique significantly impacts effectiveness:

  1. Modified Bass Technique: Position bristles at a 45-degree angle to the gum line, using short, gentle circular or vibratory motions. This angle allows bristles to reach slightly below the gumline where plaque accumulates.

  2. Pressure: Apply gentle pressure only. Excessive force causes gum recession and enamel erosion. Electric toothbrushes with pressure sensors can provide feedback.

  3. Duration: Use a timer or electric toothbrush with a 2-minute timer. Most people brush for only 45-70 seconds (.”);” 2017).

  4. Coverage: Systematically clean all surfaces, outer, inner, and chewing surfaces, including hard-to-reach posterior teeth.

Electric vs. Manual:

A Cochrane systematic review found that electric toothbrushes, particularly oscillating-rotating types, reduce plaque 21% more effectively than manual brushing and reduce gingivitis 11% more effectively over 1-3 months of use ( 2014). The benefit likely stems from:

  • Consistent brushing motion and speed
  • Built-in timers ensuring adequate duration
  • Pressure sensors preventing tissue damage
  • Greater motivation and compliance

Equipment Recommendation

An oscillating-rotating electric toothbrush (e.g., Oral-B series) represents a worthwhile investment for most people. Replace brush heads every 3 months or when bristles fray.

Interdental Cleaning: Flossing and Water Flossing

Approximately 40% of tooth surfaces exist between teeth, where brushing cannot reach (ADA, 2023). Interproximal plaque harbors periodontal pathogens and, if undisturbed, mineralizes into calculus within 24-72 hours.

Traditional Flossing:

Daily flossing removes interproximal plaque and reduces gingivitis. A meta-analysis by Slot et al. (2008) found that flossing in addition to brushing reduced gingivitis significantly more than brushing alone. The technique matters:

  1. Use 18 inches of floss, winding most around middle fingers
  2. Guide floss between teeth using a gentle rubbing motion
  3. Curve floss into a C-shape around each tooth
  4. Slide up and down against tooth surface, going slightly below the gumline
  5. Use clean sections of floss for each interdental space

Water Flossing (Waterpik/Oral Irrigators):

Water flossers use a pulsating stream of water to flush debris and bacteria from interdental spaces and periodontal pockets. They offer particular advantages for:

  • Those with orthodontic appliances, bridges, or implants
  • Individuals with dexterity limitations
  • Patients with periodontal pockets greater than 3mm
  • Those who struggle with compliance to traditional flossing

Evidence Comparison:

A randomized controlled trial by Lyle et al. (2016) comparing water flossing to string flossing found that the Waterpik was 29% more effective at reducing plaque and 51% more effective at reducing gingivitis over a 4-week period. Goyal et al. (2013) demonstrated that water flossers reduced bleeding on probing significantly more than string floss.

The mechanism likely involves the ability of water flossers to:

  • Reach deeper into periodontal pockets (up to 6mm)
  • Disrupt biofilms through hydraulic action
  • Access areas around dental work where string floss cannot reach
  • Provide a massaging effect that improves gingival circulation

Protocol Recommendation

For optimal results, use both methods: water floss to flush loose debris and reach deep pockets, followed by string floss for mechanical plaque removal against tooth surfaces. If choosing only one, water flossing may offer superior compliance and efficacy for most individuals.

Tongue Scraping

The tongue’s dorsal surface contains papillae that trap bacteria, food debris, dead cells, and fungi. This coating contributes to halitosis (bad breath) and serves as a bacterial reservoir that can recolonize cleaned tooth surfaces.

Evidence for Tongue Cleaning:

Scrapers are more effective than toothbrushes for tongue cleaning. Pedrazzi et al. (2004) found that tongue scrapers reduced volatile sulfur compounds (the cause of halitosis) by 75% compared to 45% for toothbrush tongue cleaning. Regular tongue cleaning also reduces Streptococcus mutans counts and may lower caries risk (Bordas et al., 2008).

Technique:

  1. Use a dedicated tongue scraper (stainless steel or copper preferred for durability and antimicrobial properties)
  2. Extend tongue and place scraper at the back (without triggering gag reflex)
  3. Apply gentle pressure and draw scraper forward
  4. Rinse scraper between strokes
  5. Repeat 5-10 times until tongue appears pink
  6. Perform daily, ideally in the morning when bacterial load is highest

Mouthwash: A Nuanced Tool

Antiseptic mouthwashes can reduce bacterial load but should be used judiciously:

Chlorhexidine: The gold standard for antimicrobial mouthwash, chlorhexidine reduces plaque and gingivitis effectively. However, long-term use causes:

  • Tooth staining
  • Taste alteration
  • Potential disruption of beneficial oral microbiome

Reserve chlorhexidine for short-term therapeutic use (e.g., post-surgical healing) rather than daily maintenance.

Alcohol-Free Alternatives: For daily use, alcohol-free mouthwashes with antimicrobial ingredients like cetylpyridinium chloride (CPC) offer modest benefits without the tissue-drying effects of alcohol-based products.

Essential Oil Mouthwashes: Products containing thymol, eucalyptol, methyl salicylate, and menthol (e.g., Listerine) have demonstrated efficacy in reducing plaque and gingivitis in long-term studies (Stoeken et al., 2007).

Microbiome Consideration

Aggressive use of antimicrobial mouthwashes may disrupt the oral microbiome, including nitrate-reducing bacteria that contribute to cardiovascular health through nitric oxide production (Kapil et al., 2013). Consider limiting antiseptic mouthwash to once daily or using only when needed.

Professional Care

Even optimal home care cannot remove calcified deposits (calculus) or reach areas of established periodontitis. Professional dental care remains essential:

  • Cleanings: Every 6 months for healthy individuals; every 3-4 months for those with periodontal disease history
  • Examinations: Annual comprehensive exam including periodontal probing to detect pocket depths
  • X-rays: Periodic radiographs to detect bone loss and interproximal cavities
  • Scaling and root planing: Deep cleaning for patients with periodontal pockets greater than 4mm

Part 2: Skin Health - The Aging Barrier

The Skin as a Longevity Organ

Skin is your body’s largest organ, comprising approximately 15% of total body weight. Beyond its aesthetic importance, skin serves critical physiological functions:

  1. Barrier function: Protection against pathogens, chemicals, and mechanical injury
  2. Immune surveillance: Langerhans cells and dermal dendritic cells provide first-line immune defense
  3. Temperature regulation: Vasodilation, vasoconstriction, and sweating maintain core temperature
  4. Vitamin D synthesis: UVB exposure converts 7-dehydrocholesterol to vitamin D3
  5. Sensory perception: Touch, temperature, and pain detection
  6. Wound healing: Regenerative capacity that declines with age

Mechanisms of Skin Aging

Skin aging results from both intrinsic (chronological) and extrinsic (environmental) factors. Understanding these mechanisms informs evidence-based intervention strategies.

Intrinsic Aging:

  • Decreased collagen synthesis (approximately 1% reduction per year after age 20) (Shuster et al., 1975)
  • Reduced elastin fiber integrity
  • Slower epidermal turnover
  • Decreased sebum production
  • Thinning of dermis and epidermis
  • Reduced melanocyte activity
  • Impaired barrier function and moisture retention

Extrinsic Aging (Photoaging): UV radiation is responsible for an estimated 80% of visible facial aging (Flament et al., 2013). The mechanisms include:

  • DNA damage: UV radiation creates thymine dimers and other DNA lesions that accumulate with repeated exposure (de Gruijl, 1999)
  • Matrix metalloproteinase (MMP) activation: UV exposure upregulates collagenase and other MMPs that degrade dermal collagen (Fisher et al., 1996)
  • Oxidative stress: UV generates reactive oxygen species (ROS) that damage cellular components
  • Glycation: UV accelerates formation of advanced glycation end-products (AGEs) that cross-link collagen
  • Inflammation: Chronic UV exposure creates persistent low-grade inflammation
  • Telomere shortening: Accelerated in photoexposed skin (Buckingham & Klingelhutz, 2011)

The Photoaging Reality

A striking demonstration of UV’s impact: compare skin on habitually sun-exposed areas (face, hands) to protected areas (inner arm, buttocks). The difference in wrinkles, pigmentation, and texture reflects cumulative photodamage, not chronological aging.

The Skin Care Protocol

Sunscreen: The Single Most Important Anti-Aging Intervention

If you implement only one skin protocol, make it daily sunscreen use. The evidence supporting sunscreen for photoaging prevention is unequivocal.

The Evidence:

A landmark randomized controlled trial by Hughes et al. (2013) followed 903 Australian adults over 4.5 years. Participants randomized to daily sunscreen application showed no detectable increase in skin aging (measured by microtopography), while the control group showed significant deterioration. The daily sunscreen group had 24% less skin aging than discretionary users.

This finding is remarkable: sunscreen completely halted measurable skin aging in the intervention group.

Additional evidence demonstrates that sunscreen:

  • Prevents solar elastosis (breakdown of elastic fibers) (Boyd et al., 1995)
  • Reduces actinic keratoses (precancerous lesions) by 40% (Thompson et al., 1993)
  • Decreases melanoma risk by 50-73% with regular use (Green et al., 2011)
  • Reduces squamous cell carcinoma by 40% and basal cell carcinoma by 24% (van der Pols et al., 2006)

Chemical vs. Mineral Sunscreens:

Sunscreens fall into two categories based on their active ingredients:

Mineral (Physical) Sunscreens: Active ingredients: Zinc oxide, titanium dioxide

Mechanism: Sit on skin surface and physically reflect/scatter UV radiation

Advantages:

  • Broad-spectrum protection (especially zinc oxide)
  • Photostable (do not degrade in sunlight)
  • Gentle on sensitive skin; lower irritation potential
  • Reef-safe formulations available
  • Immediate protection upon application
  • No systemic absorption concerns

Disadvantages:

  • Can leave white cast, especially on darker skin tones (modern micronized formulations reduce this)
  • May feel heavier or less cosmetically elegant
  • Can settle into fine lines

Chemical (Organic) Sunscreens: Active ingredients: Avobenzone, oxybenzone, octinoxate, octisalate, homosalate, octocrylene, and newer filters like bemotrizinol and bisoctrizole (available in Europe, not yet FDA-approved in US)

Mechanism: Absorb UV radiation and convert it to heat, which dissipates from skin

Advantages:

  • More cosmetically elegant; lighter texture
  • Better for daily wear under makeup
  • No white cast
  • Modern formulations offer excellent broad-spectrum protection

Disadvantages:

  • Some ingredients (oxybenzone, octinoxate) show systemic absorption and endocrine-disrupting potential in laboratory studies (Matta et al., 2019, 2020)
  • May cause irritation or allergic reactions in sensitive individuals
  • Some ingredients are photounstable (degrade in sunlight); require stabilizers
  • Environmental concerns (coral reef damage with oxybenzone and octinoxate)

Protocol Recommendation:

For daily use, particularly facial application, mineral sunscreens offer the best risk-benefit profile. Modern formulations using micronized zinc oxide provide broad-spectrum protection without heavy white cast. Key considerations:

  • SPF 30-50: SPF 30 blocks 97% of UVB; SPF 50 blocks 98%. Higher numbers offer diminishing returns and often contain more potentially problematic chemicals
  • Broad-spectrum: Ensure UVA protection (zinc oxide provides this; check labels for “broad-spectrum”)
  • Apply adequately: Most people apply 25-50% of the amount used in testing. Use 1/4 teaspoon for face, 1 ounce (shot glass) for full body
  • Reapply: Every 2 hours during extended sun exposure, or immediately after swimming/sweating
  • Daily use: Apply every morning, regardless of weather or planned outdoor time. UV penetrates clouds and windows

The Systemic Absorption Question

FDA studies found that chemical sunscreen ingredients (oxybenzone, avobenzone, oxybenzone, ecamsule, homosalate, octisalate, and octocrylene) absorb into the bloodstream at levels exceeding the FDA threshold for waiving toxicology studies (Matta et al., 2019, 2020). This does not mean they are dangerous, it means we need more data. Until long-term safety data is available, those preferring to minimize uncertainty should choose mineral formulations for daily use.

Retinoids: The Gold Standard for Skin Rejuvenation

Retinoids (vitamin A derivatives) represent the most evidence-backed topical treatment for reversing and preventing skin aging. No other over-the-counter or prescription topical comes close to the breadth of evidence supporting retinoid efficacy.

The Evidence:

Kligman first demonstrated tretinoin’s anti-aging effects in 1986, and subsequent decades have confirmed and expanded these findings:

  • A 48-week randomized controlled trial found that tretinoin 0.02% significantly improved fine wrinkles, mottled hyperpigmentation, roughness, and laxity compared to placebo (Olsen et al., 1992)
  • Long-term studies (12+ months) demonstrate continued improvement with ongoing use (Kang et al., 2005)
  • Histological analysis reveals increased dermal collagen, reduced melanin, and normalized epidermal architecture (Griffiths et al., 1993)

Mechanisms of Action:

  • Increased collagen synthesis: Retinoids upregulate procollagen gene expression and inhibit MMPs that degrade collagen (Varani et al., 2000)
  • Normalized cell turnover: Accelerates epidermal renewal from 28+ days to approximately 14 days
  • Reduced hyperpigmentation: Inhibits tyrosinase and accelerates melanin dispersion
  • Improved texture: Thickens epidermis while reducing stratum corneum
  • Acne prevention: Normalizes follicular keratinization

Retinoid Hierarchy (Weakest to Strongest):

  1. Retinyl palmitate/acetate: Minimal evidence of efficacy; requires multiple conversions to active form
  2. Retinol: OTC; converts to retinaldehyde then to retinoic acid in skin; approximately 10-20x less potent than tretinoin but still effective with fewer side effects
  3. Retinaldehyde: One step from active form; well-tolerated with good efficacy
  4. Adapalene (Differin): OTC since 2016; synthetic retinoid originally for acne; less irritating than tretinoin with emerging anti-aging evidence
  5. Tretinoin (Retin-A): Prescription; the gold standard with most extensive evidence; available in 0.025%, 0.05%, 0.1% concentrations
  6. Tazarotene: Prescription; most potent but also most irritating; used primarily for acne and psoriasis

Protocol for Retinoid Introduction:

Retinoids commonly cause initial irritation (retinization): dryness, flaking, redness, and sensitivity. This typically resolves within 4-12 weeks. To minimize:

  1. Start low: Begin with low-concentration retinol (0.25-0.5%) or adapalene for first-time users
  2. Start slow: Apply 2-3 times weekly initially, gradually increasing to nightly over 4-8 weeks
  3. Buffer: Apply moisturizer before retinoid initially to reduce irritation (the “sandwich” method)
  4. Use at night: Retinoids degrade with UV exposure and increase photosensitivity
  5. Protect: Sunscreen is mandatory when using retinoids (increased photosensitivity)
  6. Be patient: Visible results typically require 12+ weeks of consistent use

Retinoid Precautions

  • Discontinue before waxing or laser treatments (increased sensitivity)
  • Avoid during pregnancy and breastfeeding (teratogenic potential with systemic retinoids; topical absorption is minimal but caution is standard)
  • May not be suitable for those with rosacea or very sensitive skin (consult dermatologist)
  • Initial “purging” (increased breakouts) is normal and typically resolves within 6-8 weeks

Moisturizer: Barrier Support

Moisturizers serve several functions in skin health:

  1. Barrier repair: Replace lipids in the stratum corneum that decline with age
  2. Hydration: Draw water into the epidermis (humectants) and prevent water loss (occlusives)
  3. Vehicle: Improve penetration and tolerance of active ingredients
  4. Protection: Buffer against environmental irritants

Key Ingredients by Function:

Humectants (attract water):

  • Hyaluronic acid: Can hold 1000x its weight in water; multiple molecular weights provide surface and deeper hydration
  • Glycerin: Well-studied, inexpensive, effective
  • Urea: Especially effective for very dry skin; also has mild keratolytic properties

Emollients (smooth and soften):

  • Ceramides: Identical to skin’s natural lipids; critical for barrier function
  • Fatty acids: Linoleic acid, oleic acid, and others fill intercellular spaces
  • Squalane: Stable form of squalene, naturally present in skin

Occlusives (prevent water loss):

  • Petrolatum: Most effective occlusive (reduces transepidermal water loss by 99%)
  • Dimethicone: Lighter silicone-based occlusive
  • Plant oils: Varying occlusive properties depending on composition

Protocol Recommendation:

  • Twice daily: Apply morning and evening
  • Layering order: Apply to damp skin after cleansing; before sunscreen in AM; after retinoid in PM
  • Match to skin type: Lighter gel or lotion for oily skin; richer cream for dry skin
  • Look for: Products with ceramides, hyaluronic acid, and niacinamide (anti-inflammatory and barrier-supporting)

Additional Evidence-Based Interventions

Niacinamide (Vitamin B3):

  • Improves barrier function by increasing ceramide synthesis (Tanno et al., 2000)
  • Reduces hyperpigmentation by inhibiting melanosome transfer (Hakozaki et al., 2002)
  • Anti-inflammatory properties; reduces redness
  • Well-tolerated; can be combined with retinoids
  • Effective at 2-5% concentration

Vitamin C (L-Ascorbic Acid):

  • Antioxidant protection against UV-generated free radicals
  • Required cofactor for collagen synthesis
  • Reduces hyperpigmentation
  • Most effective at 10-20% concentration in stable formulation (pH 2.5-3.5)
  • Apply in morning under sunscreen for additive photoprotection (Lin et al., 2003)

Alpha Hydroxy Acids (AHAs):

  • Glycolic acid, lactic acid: Exfoliate stratum corneum, increase cell turnover
  • Improve texture, fine lines, and hyperpigmentation
  • May thin stratum corneum; sun protection is essential
  • Use 2-3x weekly to avoid overexfoliation

Evidence Matrix

SourceVerdictNotes
Bryan Johnson (Blueprint)Strongly RecommendsExtensive oral and skin protocols; considers barrier defense foundational
Peter Attia (Outlive)RecommendsEmphasizes oral-systemic connection and sun protection
Dermatological ConsensusStrong EvidenceSunscreen and retinoids have highest evidence grades for photoaging
American Heart AssociationAcknowledges LinkRecognizes periodontal disease as cardiovascular risk factor
American Dental AssociationStrongly RecommendsFlossing, brushing 2x daily, regular professional care

Key Studies:

  • Hughes et al. (2013): RCT showing daily sunscreen use completely prevented measurable skin aging over 4.5 years
  • Humphrey et al. (2008): Meta-analysis finding 24-35% increased CVD risk with periodontal disease
  • Matta et al. (2019, 2020): FDA studies demonstrating systemic absorption of chemical sunscreen ingredients
  • Olsen et al. (1992): 48-week RCT demonstrating tretinoin efficacy for photoaging
  • Lyle et al. (2016): RCT showing water flosser superiority over string floss for plaque reduction

Measuring Success

Oral Health Metrics

  • Bleeding on probing: Zero bleeding indicates healthy gums
  • Pocket depths: Less than 3mm is healthy; greater than 4mm indicates periodontal disease
  • Plaque index: Minimal visible plaque on teeth
  • Gingival index: Pink, firm gums without swelling or recession
  • hs-CRP: Reduction in systemic inflammation marker
  • Breath quality: Absence of persistent halitosis

Skin Health Metrics

  • Transepidermal water loss (TEWL): Lower values indicate better barrier function
  • Skin hydration: Measured by corneometry
  • Texture and fine lines: Visual and tactile assessment
  • Pigmentation evenness: Absence of new sunspots
  • Dermatologist evaluation: Annual skin cancer screening
  • Collagen density: Ultrasound measurement (advanced)

What Success Looks Like

  • Morning breath improves; tongue coating minimal
  • No bleeding when flossing or brushing
  • Dental cleanings reveal minimal plaque and calculus
  • Skin maintains hydration throughout day
  • Even skin tone without new hyperpigmentation
  • Dermatologist finds no suspicious lesions at annual check

Connected Concepts

  • Diet: Sugar intake directly feeds cariogenic bacteria; antioxidant-rich foods support skin health
  • Sleep: Growth hormone release during deep sleep supports tissue repair
  • Sunlight: Balance vitamin D synthesis need with photoprotection
  • Supplement Basics: Vitamin C, omega-3s, and collagen peptides may support skin health
  • Heat Exposure: Sauna increases blood flow to skin; may support detoxification
  • Blood Panels: hs-CRP, inflammatory markers correlate with oral health status
  • Glycation: AGEs accumulate in skin collagen, accelerated by UV exposure

Concepts

  • Inflammation: Periodontal disease creates chronic systemic inflammation
  • Autophagy: Skin cells rely on autophagy for homeostasis and repair

Common Pitfalls

Mistakes to Avoid

Oral Health:

  1. Brushing too hard: Causes gum recession and enamel erosion; use gentle pressure
  2. Skipping flossing: Leaves 40% of tooth surfaces uncleaned
  3. Antiseptic mouthwash overuse: May disrupt beneficial oral microbiome
  4. Infrequent dental visits: Calculus removal requires professional tools
  5. Ignoring bleeding gums: Early gingivitis is reversible; periodontitis is not

Skin Health:

  1. Skipping sunscreen on cloudy days: UV penetrates clouds; daily use is essential
  2. Applying too little sunscreen: Most people use 25-50% of adequate amount
  3. Starting retinoids too aggressively: Leads to irritation and discontinuation
  4. Over-exfoliating: Damages barrier function; causes inflammation
  5. Neglecting neck and hands: These areas show age as much as face
  6. Tanning: No such thing as a “healthy tan”; all tanning indicates DNA damage

Implementation Checklist

Oral Health Protocol:

  • Electric toothbrush with 2-minute timer (Oral-B or Sonicare)
  • Brush twice daily using modified Bass technique
  • Water flosser (Waterpik) - use daily
  • String floss - use daily after water flossing
  • Tongue scraper - use daily, morning
  • Schedule dental cleaning every 6 months
  • Request periodontal probing at annual exam

Skin Health Protocol:

  • Mineral sunscreen SPF 30-50 (zinc oxide-based) - apply daily, AM
  • Gentle cleanser - use twice daily
  • Moisturizer with ceramides - use twice daily
  • Retinoid introduction: start 0.25% retinol 2x/week, increase gradually
  • Vitamin C serum (optional) - apply AM before sunscreen
  • Annual full-body skin exam with dermatologist
  • Extend protection to neck, ears, hands

Daily Protocol Summary

Morning Routine

Oral:

  1. Tongue scrape (5-10 strokes)
  2. Water floss (60 seconds, all interdental spaces)
  3. String floss
  4. Brush with electric toothbrush (2 minutes)

Skin:

  1. Gentle cleanser
  2. Vitamin C serum (optional, wait 1 minute to absorb)
  3. Moisturizer
  4. Mineral sunscreen SPF 30-50 (1/4 teaspoon for face)

Evening Routine

Oral:

  1. Water floss
  2. String floss
  3. Brush with electric toothbrush (2 minutes)

Skin:

  1. Double cleanse if wearing sunscreen (oil-based then water-based)
  2. Retinoid (if tolerating; start 2-3x/week)
  3. Moisturizer (can apply before retinoid to buffer if irritation)

Further Reading

Books:

  • “Outlive” by Peter Attia: Chapter on preventive care including oral health
  • “Blueprint” by Bryan Johnson: Detailed protocols for barrier defense

Research:

  • Humphrey LL, et al. (2008). Periodontal Disease and Coronary Heart Disease Incidence: A Systematic Review and Meta-analysis. Journal of General Internal Medicine
  • Hughes MCB, et al. (2013). Sunscreen and Prevention of Skin Aging: A Randomized Trial. Annals of Internal Medicine
  • Tonetti MS, et al. (2013). Periodontitis and atherosclerotic cardiovascular disease. Journal of Clinical Periodontology

Guidelines:

References

Amar, S., Gokce, N., Morgan, S., Loukideli, M., Van Dyke, T. E., & Vita, J. A. (2003). Periodontal disease is associated with brachial artery endothelial dysfunction and systemic inflammation. Arteriosclerosis, Thrombosis, and Vascular Biology, 23(7), 1245-1249.

American Dental Association. (2023). Oral health topics: Brushing your teeth. Retrieved from https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/brushing-your-teeth

Bordas, A., McNab, R., Staber, A. M., Guarnieri, J. P., Dy-Liacco, M., & Arweiler, N. B. (2008). Impact of different tongue cleaning methods on the bacterial load of the tongue dorsum. Archives of Oral Biology, 53(Suppl 1), S3-S8.

Boyd, A. S., Naylor, M., Cameron, G. S., Pearse, A. D., Gaskell, S. A., & Neldner, K. H. (1995). The effects of chronic sunscreen use on the histologic changes of dermatoheliosis. Journal of the American Academy of Dermatology, 33(6), 941-946.

Buckingham, E. M., & Klingelhutz, A. J. (2011). The role of telomeres in the ageing of human skin. Experimental Dermatology, 20(4), 297-302.

de Gruijl, F. R. (1999). Skin cancer and solar UV radiation. European Journal of Cancer, 35(14), 2003-2009.

Desvarieux, M., Demmer, R. T., Jacobs, D. R., Rundek, T., Boden-Albala, B., & Sacco, R. L. (2013). Periodontal bacteria and hypertension: A possible link between chronic infection and atherosclerosis. Hypertension, 61(3), 635-642.

Dewhirst, F. E., Chen, T., Izard, J., Paster, B. J., Tanner, A. C., Yu, W. H., Lakshmanan, A., & Wade, W. G. (2010). The human oral microbiome. Journal of Bacteriology, 192(19), 5002-5017.

Eke, P. I., Dye, B. A., Wei, L., Slade, G. D., Thornton-Evans, G. O., Borgnakke, W. S., Taylor, G. W., Page, R. C., Beck, J. D., & Genco, R. J. (2015). Update on prevalence of periodontitis in adults in the United States: NHANES 2009 to 2012. Journal of Periodontology, 86(5), 611-622.

Fisher, G. J., Wang, Z. Q., Datta, S. C., Varani, J., Kang, S., & Voorhees, J. J. (1996). Pathophysiology of premature skin aging induced by ultraviolet light. New England Journal of Medicine, 337(20), 1419-1428.

Flament, F., Bazin, R., Laquieze, S., Rubert, V., Simonpietri, E., & Piot, B. (2013). Effect of the sun on visible clinical signs of aging in Caucasian skin. Clinical, Cosmetic and Investigational Dermatology, 6, 221-232.

Ford, P. J., Gemmell, E., Chan, A., Carter, C. L., Walker, P. J., Bird, P. S., West, M. J., Cullinan, M. P., & Seymour, G. J. (2007). Inflammation, heat shock proteins and periodontal pathogens in atherosclerosis: an immunohistologic study. Oral Microbiology and Immunology, 21(4), 206-211.

Forner, L., Larsen, T., Kilian, M., &等Holmstrup, P. (2006). Incidence of bacteremia after chewing, tooth brushing and scaling in individuals with periodontal inflammation. Journal of Clinical Periodontology, 33(6), 401-407.

Franceschi, C., Garagnani, P., Parini, P., Giuliani, C., & Santoro, A. (2018). Inflammaging: a new immune-metabolic viewpoint for age-related diseases. Nature Reviews Endocrinology, 14(10), 576-590.

Goyal, C. R., Lyle, D. M., Qaqish, J. G., & Schuller, R. (2013). Evaluation of the plaque removal efficacy of a water flosser compared to string floss in adults after a single use. Journal of Clinical Dentistry, 24(2), 37-42.

Green, A. C., Williams, G. M., Logan, V., & Strutton, G. M. (2011). Reduced melanoma after regular sunscreen use: randomized trial follow-up. Journal of Clinical Oncology, 29(3), 257-263.

Griffiths, C. E., Russman, A. N., Majmudar, G., Singer, R. S., Hamilton, T. A., & Voorhees, J. J. (1993). Restoration of collagen formation in photodamaged human skin by tretinoin (retinoic acid). New England Journal of Medicine, 329(8), 530-535.

Hakozaki, T., Minwalla, L., Zhuang, J., Chhoa, M., Matber, A., Miyamoto, K., Laughlin, T., Giber, I. M., & Boissy, R. E. (2002). The effect of niacinamide on reducing cutaneous pigmentation and suppression of melanosome transfer. British Journal of Dermatology, 147(1), 20-31.

Hughes, M. C., Williams, G. M., Baker, P., & Green, A. C. (2013). Sunscreen and prevention of skin aging: a randomized trial. Annals of Internal Medicine, 158(11), 781-790.

Humphrey, L. L., Fu, R., Buckley, D. I., Freeman, M., & Helfand, M. (2008). Periodontal disease and coronary heart disease incidence: a systematic review and meta-analysis. Journal of General Internal Medicine, 23(12), 2079-2086.

Kang, S., Leyden, J. J., Lowe, N. J., Ortonne, J. P., Phillips, T. J., Weinstein, G. D., Bhawan, J., Lew-Kaya, D. A., Matsumoto, R. M., & Sefton, J. (2005). Tazarotene cream for the treatment of facial photodamage: a multicenter, investigator-masked, randomized, vehicle-controlled, parallel comparison of 0.01%, 0.025%, 0.05%, and 0.1% tazarotene creams with 0.05% tretinoin emollient cream applied once daily for 24 weeks. Archives of Dermatology, 137(12), 1597-1604.

Kapil, V., Haydar, S. M., Pearl, V., Lundberg, J. O., Weitzberg, E., & Ahluwalia, A. (2013). Physiological role for nitrate-reducing oral bacteria in blood pressure control. Free Radical Biology and Medicine, 55, 93-100.

Kostic, A. D., Gevers, D., Pedamallu, C. S., Michaud, M., Duke, F., Earl, A. M., Ojesina, A. I., Jung, J., Bass, A. J., Tabernero, J., Baselga, J., Liu, C., Shivdasani, R. A., Ogino, S., Birren, B. W., Huttenhower, C., Garrett, W. S., & Meyerson, M. (2012). Genomic analysis identifies association of Fusobacterium with colorectal carcinoma. Genome Research, 22(2), 292-298.

Kozarov, E. V., Dorn, B. R., Shelburne, C. E., Dunn, W. A., & Progulske-Fox, A. (2005). Human atherosclerotic plaque contains viable invasive Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis. Arteriosclerosis, Thrombosis, and Vascular Biology, 25(3), e17-e18.

Lin, J. Y., Selim, M. A., Shea, C. R., Grichnik, J. M., Omar, M. M., Monteiro-Riviere, N. A., & Pinnell, S. R. (2003). UV photoprotection by combination topical antioxidants vitamin C and vitamin E. Journal of the American Academy of Dermatology, 48(6), 866-874.

Lyle, D. M., Qaqish, J. G., & Goyal, C. R. (2016). Efficacy of the use of a water flosser in addition to a manual toothbrush on plaque and gingivitis: A randomized clinical trial. Journal of Clinical Dentistry, 27(1), 3-8.

Matta, M. K., Zusterzeel, R., Pilli, N. R., Patel, V., Volpe, D. A., Florian, J., Oh, L., Bashaw, E., Zineh, I., Sanabria, C., Kemp, S., Godfrey, A., Adah, S., Coelho, S., Wang, J., Furber, L. A., Nguyen, M., & Strauss, D. G. (2019). Effect of sunscreen application under maximal use conditions on plasma concentration of sunscreen active ingredients: a randomized clinical trial. JAMA, 321(21), 2082-2091.

Matta, M. K., Florian, J., Zusterzeel, R., Pilli, N. R., Patel, V., Volpe, D. A., Yang, Y., Oh, L., Bashaw, E., Zineh, I., Sanabria, C., Kemp, S., Godfrey, A., Adah, S., Coelho, S., Wang, J., Furber, L. A., Nguyen, M., & Strauss, D. G. (2020). Effect of sunscreen application on plasma concentration of sunscreen active ingredients: a randomized clinical trial. JAMA, 323(3), 256-267.

Miyakawa, H., Honma, K., Qi, M., & Kuramitsu, H. K. (2004). Interaction of Porphyromonas gingivalis with low-density lipoproteins: implications for a role for periodontitis in atherosclerosis. Journal of Periodontal Research, 39(1), 1-9.

Olsen, E. A., Katz, H. I., Levine, N., Shupack, J., Billys, M. M., Prawer, S., Gold, J., Stiller, M., Lufrano, L., & Thorne, E. G. (1992). Tretinoin emollient cream: a new therapy for photodamaged skin. Journal of the American Academy of Dermatology, 26(2), 215-224.

Papapanagiotou, D., Nicu, E. A., Konstantinidis, A., & Loos, B. G. (2009). Periodontitis is associated with platelet activation. Atherosclerosis, 202(2), 612-618.

Paraskevas, S., Huizinga, J. D., & Loos, B. G. (2008). A systematic review and meta-analyses on C-reactive protein in relation to periodontitis. Journal of Clinical Periodontology, 35(4), 277-290.

Pedrazzi, V., Sato, S., de Mattos, M. D. G. C., Lara, E. H., & Panzeri, H. (2004). Tongue-cleaning methods: a comparative clinical trial employing a toothbrush and a tongue scraper. Journal of Periodontology, 75(7), 1009-1012.

Saffi, M. A., Furtado, M. V., Polanczyk, C. A., Montenegro, M. M., Ribeiro, I. W., Kampits, C., Rodhe, L. E. P., Alencastro, M. G., Giuglianni, E. R., & Rosing, C. K. (2015). Relationship between vascular endothelium and periodontal disease in atherosclerotic lesions: review article. World Journal of Cardiology, 7(1), 26-30.

Shuster, S., Black, M. M., & McVitie, E. (1975). The influence of age and sex on skin thickness, skin collagen and density. British Journal of Dermatology, 93(6), 639-643.

Slot, D. E., Dorfer, C. E., & Van der Weijden, G. A. (2008). The efficacy of interdental brushes on plaque and parameters of periodontal inflammation: a systematic review. International Journal of Dental Hygiene, 6(4), 253-264.

Stoeken, J. E., Paraskevas, S., & van der Weijden, G. A. (2007). The long-term effect of a mouthrinse containing essential oils on dental plaque and gingivitis: a systematic review. Journal of Periodontology, 78(7), 1218-1228.

Tanno, O., Ota, Y., Kitamura, N., Katsube, T., & Inoue, S. (2000). Nicotinamide increases biosynthesis of ceramides as well as other stratum corneum lipids to improve the epidermal permeability barrier. British Journal of Dermatology, 143(3), 524-531.

Thompson, S. C., Jolley, D., & Marks, R. (1993). Reduction of solar keratoses by regular sunscreen use. New England Journal of Medicine, 329(16), 1147-1151.

van der Pols, J. C., Williams, G. M., Burton, A. J., Kariminia, A., Green, A. C. (2006). Jolley, D., & Marks, R. (2006). Preventing skin cancer with sunscreen: a randomized controlled trial. Journal of Clinical Oncology, 24(23), 3749-3756.

Varani, J., Warner, R. L., Gharaee-Kermani, M., Phan, S. H., Kang, S., Chung, J. H., Wang, Z. Q., Datta, S. C., Fisher, G. J., & Voorhees, J. J. (2000). Vitamin A antagonizes decreased cell growth and elevated collagen-degrading matrix metalloproteinases and stimulates collagen accumulation in naturally aged human skin. Journal of Investigative Dermatology, 114(3), 480-486.

Yaacob, M., Worthington, H. V., Deacon, S. A., Deery, C., Walmsley, A. D., Robinson, P. G., & Glenny, A. M. (2014). Powered versus manual toothbrushing for oral health. Cochrane Database of Systematic Reviews, 2014(6), CD002281.

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