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When you think of preventative health care, oral health is probably not the first thing that comes to mind. Sure, healthy gums and a bright smile are important, but they pale in comparison to a strong heart, a well-functioning digestive system, and clear lungs. Or do they?

The term “heart-healthy” might not make you think of oral health. However, your mouth and heart are intricately linked. Read on to find out why achieving your 100 Year Heart is dependent on great oral health!

Research shows that people with poor oral health have higher rates of heart disease.

Not only is oral health tied to cardiovascular health, but it’s intricately linked to the health of your entire body. So, in addition to diet, exercise, and sleep, you may want to consider beefing up your oral care routine to keep your heart and body healthy and strong.

Why Your Doctor Doesn't Talk about Oral Health

Have you ever left your annual physical with a prescription to take better care of your teeth and gums? It’s unlikely. Most medical doctors don’t acknowledge the intricate relationship between the mouth and overall health and wellbeing.

Physicians are schooled in a faulty system that divides the body into parts without recognizing their unique interconnectedness. This is why we end up with a prescription for every symptom rather than an investigation into the root of sickness – which often starts in the mouth!

The Mouth: a Window to Your Health

The human body works in incredible ways. It is beautifully connected through different systems that work together in harmony. While the current medical model often looks at body systems in isolation, they are all closely associated. The health of one system influences the others.

Physicians are schooled in a faulty system that divides the body into parts without recognizing their unique interconnectedness. This is why we end up with a prescription for every symptom rather than an investigation into the root of sickness – which often starts in the mouth!

The eyes may be the window to the soul, but the mouth is the window to the body. After all, the mouth is the initial point of entry to the lungs, stomach, and entire body system.

"More than 90% of all systemic diseases have oral manifestations, meaning that your dentist could be the first health care provider to diagnose a health problem."

Raymond Martin | Spokesman for the Academy of General Dentistry

Understanding the microbiome

Hippocrates once said, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” The father of medicine introduced an idea that society would debate for many years to come: health depends on the body’s internal environment rather than the germ itself.

Today, this controversial topic is at the forefront of health discussions. While we try to “win the war” against cancer or “kill” viruses, people are sicker than ever. A growing number of scientists and health professionals are beginning to understand that it’s the body’s terrain, not viruses and bacteria, that create illness.

Did you know that the human body is home to trillions of tiny living organisms? These bacteria, viruses, and fungi coexist and form what is known as the microbiome, or microbiota.

The microbiome consists of “bugs” that are both helpful and harmful. In a healthy person, these living microbes coexist peacefully. However, any disturbance to the home of these microbes can throw off the delicate balance and create chaos and disease.

From the moment we enter the world, our microbiomes constantly change and adapt. A baby’s microbiome is drastically shaped by birth, feeding methods, antibiotics, and the parent’s underlying health.

The Oral Microbiome

You may have heard of your gut microbiota. However, your mouth also has its very own community of living organisms called the oral microbiome. Home to over 700 microorganisms, the oral microbiome is the second-largest microbial community in the human body.

Multiple studies have established a link between the oral microbiome and overall health. For example, a 2020 study concluded that dysbiosis, or an imbalance of the oral microbiome, has far-reaching impacts on the entire body.

What does a healthy oral microbiome look like?

The majority of the microbes in the mouth are aerobic, meaning they require oxygen to live. Together, they form a thin and transparent protective layer on the teeth called biofilm. When the biofilm is healthy, gums appear pink, and teeth feel smooth and clean.

However, when the oral microbiome is out of balance, this once healthy biofilm becomes sticky, thick, and odorous. Over time, this sticky biofilm builds up and becomes hard-to-remove plaque. While plaque is often one of the first signs of a microbiome imbalance, other signs include cavities, mouth ulcers, sensitive teeth, and gum disease.

What causes an oral microbiome imbalance?

Just as the overall environment in our body can become imbalanced, so can the mouth. There are numerous reasons for an unhealthy oral microbiome. One of the key contributors is the use of harmful oral care products. Many oral care products, such as toothpaste and mouthwash, aim to kill “invaders” in the mouth. However, in doing so, we inadvertently eliminate healthy bacteria meant to keep our oral microbiome in balance.

Consuming a diet high in sugars or refined carbohydrates is another cause of imbalance. Not only do sugars produce an acid that erodes enamel, but they also change the mouth’s pH. Healthy oral microbes prefer a slightly alkaline pH. However, a high sugar diet lowers the pH, creating a more acidic environment.

In addition to a high-carbohydrate diet, stress also causes a shift in the oral pH. Stress reduces saliva production in the mouth, causing many problems. Since saliva plays a significant role in maintaining the oral microbiota composition, decreased saliva can have profound health implications.

Common oral health problems

Oral health doesn’t get nearly the attention it deserves, and it shows. According to the Centers for Disease Control and Prevention, more than 1 in 4 adults in the United States have untreated dental cavities. Equally concerning, nearly half of adults show signs of gum disease. Tooth decay is the most common chronic disease for children and adults. While multiple health conditions impact the oral cavity, the most common include:

Tooth Decay

Tooth decay, the most common dental health problem, occurs due to the destruction of enamel, the hard outer layer of the teeth. Also called dental cavities or caries, these damaged areas start as small holes in the teeth. However, if left untreated, they can lead to sensitivity, pain, infections, and even tooth loss. Research shows that untreated tooth decay can nearly triple the risk of heart disease.

Signs of tooth decay may include:

Periodontitis (gum disease)

Gum disease is an infection of the tissues surrounding and holding the teeth in place. Gingivitis, the earliest stage of gum disease, causes the gums to be red, swollen, and more likely to bleed. If left untreated, gingivitis progresses to more severe periodontitis. Nearly half of the adult population over the age of 30 is impacted by some form of gum disease.

Signs of Periodontitis may include:

Oral Cancer

Oral cancer, also known as mouth cancer, is the sixth most common cancer in the world. Most often found on the tongue, lips, or floor of the mouth, it also occurs on the inner lining of the cheek, the gums, the palate, and the throat.

Signs of Oral Cancer may include:

Jaw Cavitations

Not to be confused with cavities, cavitations are chronic jaw bone infections. Cavitations are tiny holes in the jawbone that typically occur due to blood flow blockages. Difficult to identify on x-rays, cavitations almost always happen near the wisdom teeth. Research suggests that dental cavitations are an ideal breeding ground for toxins that could affect the whole body.

Signs of cavitations may include:

Oral health and systemic disease

The mouth is relatively easy to visualize compared to the internal body. Therefore, a careful oral examination can often reveal clues to overall health. For example, oral lesions in the mouth may be the first outward signs of systemic conditions like HIV, Crohn’s disease, or lupus. In addition, studies have found that bleeding gums may indicate ear infections or asthma. Even bad breath can signify various conditions such as liver failure, diabetes, or pneumonia.

Multiple conditions may stem from poor oral health, including:

  • Rheumatoid arthritis
  • Stroke
  • High cholesterol
  • Obesity
  • Lung infections
  • Cancer
  • Heart disease
  • Pregnancy complications
  • Death risk in elderly
  • Erectile dysfunction
  • Alzheimer’s disease
  • Mental health disorder

The mouth is also a source of testing for systemic disease. Physicians can diagnose many conditions through the examination of saliva fluid. For example, studies have found that cancer, heart disease, and immune disorders all leave traces of their presence in saliva. Saliva can also measure medication levels and hormones such as cortisol.

While science has come a long way in uncovering the relationship between the mouth and the body, much is still left undiscovered. For example, a recent study points to the possibility that the mouth plays a role in transmitting Covid-19 to the lungs and digestive system through virus-infected saliva from the oral cavity. Scientists suspect that infected tissues in the mouth transmit the virus to the rest of the body.

Oral health and heart disease

For years, cardiologists and dentists have identified a link between oral health and cardiovascular disease. Numerous studies have linked poor oral health with hypertension. For example, a 2021 study found that individuals with severe gum disease are twice as likely to have high blood pressure than those with healthy gums.

Oral health is also linked to other cardiovascular problems, such as arrhythmias.


Studies have found an increased risk of AFib in patients with unhealthy mouths. A 2016 study concluded that individuals with gum disease were 31 percent more likely to develop AFib than those with good oral health. Research suggests that a clean mouth may reduce the risk of heart palpitations.

Even more concerning, periodontitis is associated with heart attacks. Scientists have determined that the presence of gum disease increases the risk of heart attack by nearly 50 percent.

Gum disease can even shorten your life. For example, a study found that post-menopausal women with periodontal disease had a 12 percent higher risk of premature death from any cause.

Some holistic dentists have identified another dental-heart connection related to jaw bone cavitations. Since bone death, or osteonecrosis, has been linked with a greater risk of heart disease, some dentists have found that cardiac symptoms such as arrhythmias clear up with the proper treatment of cavitations.

Inflammation:

The Possible Link Between Oral and Cardiac Health

The mechanisms by which gum disease and poor oral health cause heart disease are still not fully understood. The prevailing theory involves inflammation.

As gum disease results from plaque build-up, scientists speculate that the body creates an inflammatory process to rid the mouth of bacteria around the gums. This inflammation is systemic, affecting all areas of the body, including the heart. Further, the oral bacteria can enter the bloodstream and travel through the body, slowly infecting the cardiac tissue.

A 2021 study found that gum disease leads to arterial inflammation, which increases the risk of heart disease. The research suggests that local inflammation in the gums activates immune cells, triggering inflammation in the arteries. The findings confirm earlier studies that suggest that gum disease primes a type of white blood cell called neutrophils, which then overreact to infections elsewhere in the body.

Other scientists suggest that oral and heart health are connected through the role of calcium. Some dentists speculate that excessive plaque build-up is more than just poor oral hygiene. Instead, it is the result of an inability to metabolize calcium properly.

While calcium is essential for strong teeth and bones, it’s dangerous in the artery walls. Too much calcium in the vascular system causes hardening and narrowing of blood vessels. Since K2 is the gatekeeper for calcium, individuals with a vitamin K2 deficiency may be at higher risk for artery calcification.

Problems with modern dentistry

Dentistry has evolved over the years from a primitive and sometimes painful experience to advanced science. From smart toothbrushes to digital x-rays, new dental technological advances are propelling the field forward.

While there’s no doubt that dentistry serves an integral role in health, there are aspects of dental care that have not served humanity well. Many holistic health practitioners raise valid, yet controversial concerns around certain dental practices.

Most people have had a cavity filled at some point in their lives. For many, cavity holes contain dental amalgam. Often referred to as silver fillings, amalgams are made with elemental mercury. Mercury toxicity can lead to many health problems, including heart disease. Unfortunately, the FDA has deemed amalgam fillings safe. Some dentists continue to use them due to their low cost and durability.

Another problem with modern dentistry includes the use of fluoride. This naturally-occurring mineral has antimicrobial and anti-cancer benefits. However, fluoride is a neurotoxin in higher doses, which is destructive to the brain and nervous tissue.

Unfortunately, in the late 1940s, communities began adding fluoride to water. Now, almost 95 percent of toothpaste contains added fluoride. Excessive fluoride levels are linked to numerous health problems, including decreased IQ levels, cancer, and heart disease.

Finally, and perhaps most importantly, is the issue surrounding root canals. When the nerve of a tooth dies due to decay, trauma, or a previous dental procedure, there is no longer ample blood supply to the tooth. As a result, it often becomes infected with bacteria. Therefore, a dead or dying tooth requires removal or a root canal.

Root canals have many risks. In addition to the toxic fillings used to seal the dead tooth, root canals can harbor dangerous bacteria. When a root is sealed and blood supply removed, the oxygen-free environment allows the remaining bacteria to thrive.

These bacteria can leach into the body and cause various health ailments. For example, studies have linked unfinished root canals to cardiovascular disease. However, it’s nearly impossible to tell if a root canal is done correctly due to the countless tubules that feed each tooth.

At Home Oral Care

Health begins at home. While you should not forgo your bi-annual dental visits, there are many things that you can do between appointments to keep your mouth healthy. The following seven suggestions will ensure a diverse oral microbiome and a healthy body.

1. Brush Your Teeth

The value of brushing your teeth extends beyond a pearly white smile. Studies have found that brushing teeth at least three times a day lowers the risk of AFib by 10 percent and heart failure by 12 percent.

Brush your teeth at least twice a day using a non-toxic toothpaste free of fluoride, dyes, chemicals, and synthetic flavors. While a handful of excellent natural kinds of toothpaste are on the market, you may also choose to make your own.

Ingredients like baking soda, hydrogen peroxide, trace mineral drops, coconut oil, and peppermint or cinnamon essential oils are great additions. Be sure to change out your toothbrush regularly.

2. Scrape Your Tongue

Nearly everyone brushes their teeth. Some might even brush their tongue. However, the individuals who care most about oral hygiene will use a tongue scraper. Though tongue scraping has been around for thousands of years, it is slowly making its way back into the spotlight.

Studies have found that tongue scraping, also called Jihwa Prakshalana, improves oral health. Tongue scraping removes dead cells and bacteria, reducing bad breath and decreasing the risk of dental decay. Many also believe that tongue scraping stimulates various internal organs.

3. Rinse Your Mouth

The importance of water for dental health can’t be overstated. Saliva is 99 percent water, and when dehydrated, our bodies may not produce sufficient amounts. Saliva helps wash away food particles, aids in swallowing and digestion, and keeps teeth strong by providing them with essential enzymes. Saliva contains lysozyme, an enzyme that prevents the overgrowth of bacteria.

Regular rinses with clean, filtered, and fluoride-free water are great for oral health. Better yet, mix in a bit of salt. Saltwater rinses alkalinize the mouth, helping to kill bacteria that cause tooth decay. This practice is especially beneficial after consuming acidic food like citrus or vinegar.

4. Oil Pull

Oil pulling is an ancient (yet effective) detoxifying technique. The National Institutes of Health (NIH) recognizes studies that show multiple benefits to oil pulling. In addition to drawing toxins out of the mouth, oil pulling helps reduce inflammation and lower the risk of infections.

Simply put a tablespoon of organic oil (usually coconut or sesame) in your mouth daily and swish it around for 10-20 minutes. Don’t swallow the oil, as it contains bacteria. Instead, spit it out and brush and rinse normally.

5. Eat Organic Foods

Even without fluoride, x-rays, and routine dental cleanings, our ancient ancestors had much better dental health than we do today. The main reason for this is that oral bacteria feed off sugars and starchy foods, creating acids that erode teeth enamel. While our ancestors had minimal access to these types of food, they are abundant in today’s diets.

In fact, in a 2009 study that replicated a stone-age diet for four weeks, participants were found to have decreased gum bleeding even in the absence of brushing. The results are not a free pass to disregard oral hygiene. However, they point to the importance of diet for dental health.

A healthy diet helps to support a well-balanced oral microbiome. Additionally, eating more K2 in the form of grass-fed beef, eggs, and fermented foods can help push calcium into our teeth and bones. Sadly, our sugar-filled, modern American diet significantly impacts dental health and contributes to gum disease, tooth decay, and poor cardiac health.

6. Take Up Green Tea

Green tea may be more than a gift for your taste buds. Studies have found that green tea is excellent for oral health. According to research, the antioxidants in green tea reduce oral inflammation, remineralize teeth, and fight plaque-causing bacteria. Add one to two cups of organic green tea to your daily oral care routine.

7. Consider an Oral Irrigator

Most dentists recommend flossing your teeth, but the evidence supporting its benefits is weak, at best. It may even be unhealthy if done incorrectly. For example, flossing can cause irritation and damage to the gums. Minor abrasions offer an entryway for bacteria to penetrate deeper into the gums. Additionally, most store-bought floss contains toxic chemicals. Studies have found a link between flossing and high levels of harmful toxins in the body.

In place of flossing, many dentists recommend using an oral irrigator or water pick. These devices use a stream of pressurized water to clean between teeth and at the gum line safely.

How to find the right dentist for you

Talk to anyone who has ever had a painful toothache, and they will tell you that dentists are incredible. However, as with all professions, there is a wide range of skill levels and philosophies.

Unfortunately, dentistry is not immune to some of the challenges that occur throughout the conventional healthcare system. Many dentists are skilled at fixing acute problems such as filling cavities, but very few take the time to identify the root cause of disease. As with a doctor who immediately prescribes medication to treat blood pressure, many dentists have a reactive treatment approach to oral health.

 

Thankfully, a new kind of dentistry is beginning to emerge. Imagine sitting in your dentist’s chair and having a full review of your health history. What if your dentist addressed your anxiety before beginning your examination? Perhaps your dentist offered nutritional counseling and natural remineralization approaches as an alternative to an early cavity.

Welcome to the world of holistic dentistry.

A holistic dentist, sometimes referred to as a functional or biological dentist, has the same education and qualifications as a traditional dentist. However, they differ in their underlying philosophies. Holistic dentists take a whole-body approach to wellness. While oral care is their specialty, they understand that the mouth is simply one part of an integrated system. Often, they will work with other health providers to offer a more comprehensive care approach.

Holistic dentists perform many of the same services that traditional dentists offer, but certain features are unique to holistic dentists.

As a general rule, you can expect the following from a natural dentist:

  • Anti-fluoride based treatments
  • Discouragement of root canal treatments whenever possible
  • Digital x-rays to reduce radiation exposure
  • Use of techniques that preserve the natural tooth
  • Avoidance of amalgam fillings
  • General leaning towards natural remedies over medication
  • Use of biocompatible materials

Finding the right dentist requires more than a quick internet search for a holistic dentist. Remember, just because something claims to be natural doesn’t always mean it is. Seek referrals, evaluate reviews, and feel free to interview the dentist. A good practitioner will always allow for an introductory meeting before initiating care.

Oral Health Podcast

Biologic Dentistry and Integrative Medicine:

Finding the Root of Disease

Dr. Rachaele Carver Morin D.M.D

A Healthy Smile Can Help You Achieve Your

There is not one organ, bone, or cell in the body that works in isolation. Instead, the body is an integrated system working together to maintain homeostasis, or balance. Just as a muscle can’t move without the nervous system telling it to, the mouth doesn’t function in isolation. Everything is connected.

Good oral hygiene is so much more than a beautiful smile. Taking care of your mouth means caring for your heart and entire body. The next time you think about going to bed without brushing or consider canceling that dentist appointment, smile and remember your heart.

Medical Review: Dr. Jack Wolfson, 2022

About Dr. Lauren Lattanza NMD, FACC

Dr. Lattanza Office Visit with Patient

Dr. Lauren Lattanza Fees

20 Minute Virtual Call: $250

Initial In-Person Appointment:

Follow Up In-Person Appointment:       

As a Naturopathic Physician, I am trained to treat the whole person and get to the root cause of disease.

I went to Arizona State University where I graduated with a bachelor’s degree in psychology with a depth in physiology and minor in Spanish. After my undergraduate degree I was working on prerequisite classes towards medical school, which is when I came to learn that my values identified best with the principles of naturopathic medicine. I knew that I wanted to help patients identify the causes of disease and be able to offer treatments which would improve their health rather than simply treating symptoms.

I dedicated the next 4 years to the Southwest College of Naturopathic Medicine in Tempe, Arizona where I attained my Doctorate of Naturopathic Medicine. I served as Class President all 4 years, Board of Trustees – Student Trustee, spoke as the Club President for our branch of Toastmasters, and was voted by my peers and attending physicians to earn the Outstanding Leadership Award for the Class of 2020. Throughout medical school I took it upon myself to work alongside MDs, DOs, chiropractors, and functional medicine practitioners in addition to naturopathic physicians.

As a Spanish speaking student, I was able to volunteer with community clinics around Phoenix and provide free healthcare to low-income families. Due to this combined exposure, I came to find my passion in treating cardiometabolic and digestive disorders that are all too common, yet largely preventable. I took the opportunity to learn the broad spectrum of healthcare so I can ensure that I am able to provide my patients with the best options.

About Dr. Jack Wolfson DO, FACC

Dr. Wolfson Office Visit with Patient

Dr. Jack Wolfson Fees

30 Minute Virtual Call: $1500

Initial In-Person Appointment:

Follow Up In-Person Appointment:       

Dr. Jack Wolfson is a board-certified cardiologist, Amazon best-selling author, husband, father, and the nation’s #1 Natural Heart Doctor.

For more than two decades, more than one million people have enjoyed the warmth, compassion, and transformational power of his natural heart health courses and events.

Dr. Wolfson is the founder of Natural Heart Doctor Scottsdale, his heart health practice in Arizona, and Natural Heart Doctor, an online resource center with natural health information. Doctors from across the globe reach out to Dr. Wolfson for training and education in holistic health practices.

He has been named one of America’s Top Functional Medicine Doctors and is a five-time winner of the Natural Choice Awards as a holistic M.D. Dr. Wolfson’s work has been covered by more than 100 media outlets, including NBC, CNN, and the Washington Post. His book “The Paleo Cardiologist: The Natural Way to Heart Health” was an Amazon #1 best-seller.

Dr. Wolfson and his wife Heather have four children and are committed to making the world a better place to live. They provide for those in need (including animals) and support natural health causes through their philanthropic efforts.

Chiropractic

Our chiropractor is an expert at adjustments and holistic chiropractic care and works closely in conjunction with the other health care experts at Natural Heart Doctor.

Call (480) 535-6844 for details and scheduling.

IV Therapy

We use specially formulated natural vitamins and minerals that are injected into a vein to prevent or treat dehydration. Ideal for people in Arizona.

Call (480) 535-6844 for details and scheduling.

Acupuncture

Stimulate your body’s natural healing abilities and promote physical and emotional well-being with acupuncture at Natural Heart Doctor.

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Health Coaching

Our health coaches use evidence based skillful conversation, clinical interventions, and strategies to engage you actively and safely in health behavior changes.

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Cardio Tests

We use the most advanced testing in the world to assess heart health and to identify the root cause of your health issues.

Call (480) 535-6844 for details and scheduling.

Office Visits

Schedule an office visit with one of our cardiologists, holistic physicians, chiropractor, or health coaches.

Call (480) 535-6844 for details and scheduling.

Frequently Asked Questions

I’d like to receive an online second opinion from Natural Heart Doctor. What do I do next?

You can initiate a second opinion online through our website at any time. To begin, select the team member you’d like to speak with and open an account.

Click here for cardiologist Dr. Jack Wolfson.

Naturopathic Medical Doctor Dr. Lauren Lattanza. Get details.

Click here for  Natural Heart Doctor Health Coach.

Alternatively, you can email health@naturalheartdoctor.com. A member of our care team will help guide you through the process of starting a second opinion.

What is the cost of a Natural Heart Doctor Online Second Opinion?

The cost for most second opinions varies by team member. This fee includes information collection, a phone or video consultation, a second opinion from a Natural Heart Doctor specialist and guidance throughout the process from your personal Care Team at Natural Heart Doctor.

Cardiologist Dr. Jack Wolfson’s Second Opinion Fee is $1500.

Holistic Physician’s Dr. Lauren Lattanza’s Second Opinion Fee is $250.

Note: We apply the Online Second Opinion Call fee as a credit to any future consultations with Natural Heart Doctor, should you choose them.

Will my insurance cover the cost of a Natural Heart Doctor Online Second Opinion?

Most likely, no. Most health plans do not cover online second opinions or consultations. You are responsible for the cost of our second opinion. Natural Heart Doctor cannot file a claim with your insurance carrier, nor can we provide a procedure (CPT) code for this service.

What is the timeline to receive an online second opinion?

We do our best to schedule your second opinion as quickly as possible. Typically, it takes 5 to 7 business days after your information has been collected to receive your phone or video online second opinion.

What information do you need in advance of our call?

Our office will send you a short questionnaire to complete and return. We DO NOT need your complete medical records.

How many questions can I ask the expert during our call?

You may ask a maximum of five questions. This is to ensure that the expert has sufficient time to devote to each question. All questions must be finalized before your online meeting.

What should I expect to receive once my second opinion is complete?

You will receive a summary of our discussion along with our second opinion. The second opinion will be in written form. After you have reviewed the second opinion, a Natural Heart Doctor clinician will follow up with you by phone to address general medical questions about the information provided in the second opinion.

What if I have follow-up questions for the expert after I have reviewed my second opinion?

If you have a clarifying question about an expert’s response to one of the questions in your second opinion, and the Natural Heart Doctor clinician is unable to address it, then you may request a follow up session for an additional fee. 

Is my medical and payment information secure?

Natural Heart Doctor is strongly committed to protecting the privacy and security of all our patients. Our website meets all federal requirements for protecting personal health information under the Health Insurance Portability and Accountability Act (HIPAA). All financial transactions are processed by Natural Heart Doctor securely using industry standard payment processing tools.

I would rather visit Natural Heart Doctor for an in-person appointment. What should I do next?

If you would prefer an in-person appointment at Natural Heart Doctor instead of an online second opinion, please call (480) 535-6844 for details and scheduling.

Can I schedule a follow up appointment with the specialist who provided my online second opinion?

Yes, we’re happy to help you on an extended basis. Our clinician can discuss options with you when presenting our second opinion summary.