Oral Microbial Nitric Oxide Production Linking Oral Health & Cardiovascular Disease

Nathan S. Bryan, Ph.D.Texas Therapeutics Institute

International Academy of Biological Dentistry and MedicineHouston, TX Oct. 11-13, 2013

Structure of Presentation

What is Nitric Oxide (NO)

NO as Mediator of Oral/Systemic Link

How to Diagnose NO insufficiency

Therapies and Strategies to Restore NO and Enhance Oral/Systemic Health

Disclosure: N.S. Bryan is the founder and Chief Science Officer for NeoGenis Labs, Inc.Stock owner and advisor for SAJE Pharma

Chronic Diseasesaccount for 61% of deaths worldwide.

Most of these preventableby diet and lifestylemodifications.

Nitric Oxide

N O

What is Nitric Oxide?

The chemical compound nitric oxide is a gas with chemical formula NO٠.

It is one of the most important signaling molecule in the body of mammals including humans, one of the few gaseous signaling molecules known.

It is also a toxic air pollutant produced by automobile engines and power plants.

NO should not be confused with nitrous oxide (N2O), a general anesthetic, or with nitrogen dioxide(NO2) which is another poisonous air pollutant.

The nitric oxide molecule is a free radical, which is relevant to understanding its high reactivity. It reacts with the oxygen in air to form nitrogen dioxide, signaled by the appearance of the reddish-brown color.

NO

Cardiovascular System

Respiratory Tract

Immunology

Cell Proliferation

Central Nervous System

Peripheral Nervous System

Gastrointestinal/Urogenital Tract

VasorelaxationBlood Cell RegulationMyocardial ContractilityMicrovascular Permeability

BronchodilatationAsthma, ARDS

NANC nerve-mediatedRelaxation

Learning and MemoryPain SensitizationEpilepsyNeurodegenerationCentral BP Control

ApoptosisAngiogenesisTumor Cell Growth

Unspecific ImmunityInhibition of Viral ReplicationTransplant Rejection

Penile ErectionPre-term Labour

Nitric Oxide Plays a Key Role in the Regulation of Numerous Vital Biological Functions

Regeneration

Mobilization of resident stem cellsTargeted differentiation

''The discovery of NO and its function is one of the most important in the history of cardiovascular medicine.'‘

Dr. Valentin Fuster

1998 President of American Heart Association

NOS

L-citrulline

L-arginine

NOENDOTHELIUM

Shear Stress ACH

M

SMOOTHMUSCLE

Relaxation

GTPcGMP

NO

guanylylcyclase (inactive) guanylyl

cyclase (active)

+Viagra

Nitroglycerine, a 100 year old explosive and heart medicine

In atherosclerosis, plaques reduce blood flow in the arteries. This decreases oxygen supply to the heart muscle causing chest pain (angina pectoris) and sometimes even myocardial infarction. Treatment with nitroglycerine provides NO, dilates the vessels, and increases blood flow. Thanks to the 1998 Nobel Laureates we now understand how nitroglycerine, an important heart medicine, works. It acts as a NO donor, causes dilation of the blood vessels, increases oxygen supply and protects the heart from damage and cell death.

L-Arg

Diet

L-Arg

Arginase

ADMA

Transport

NOSUncoupling

Reduced Oxygen

Reduced Cofactor + Subst rate

Oxidat ive St ress

Ant ioxidants

NO2

NO3

Oxidat ion

Bacterial Reduct ion

NO

+

O2-٠

ONOO-

Health

Disease

BH4 Ca/CamFAD+ FMNNADPH O2

Heme iron GSH

MitochondriaXONADPH oxidase

The L-Arginine-Nitric Oxide Pathway

Urea Cycle

L-Arg

GSNO

GSSGNADH NAD

GSH

10 20 30 40 50 60 70

0

20

40

60

80

100

% D

eclin

e in

NO

Pro

du

ctio

n

Age in years

men women

Gerhard et al Hypertension 1996Celermajer et al JACC 1994Taddei et al Hypertension 2001Egashira et al Circulation 1993

Humans lose abilityto produce NO with aging

Consequences of NO insufficiency

HypertensionAtherosclerosisThrombosisAlzheimers Erectile DysfunctionPeripheral Artery DiseaseImmune DysfunctionChronic InflammationUncontrolled Cell Proliferation – Cancer

Current Paradigm

Despite almost 30 years of research after its discovery, very few clinical drugs on the market for NO.- organic nitrates (used for over 150 years for treatment of angina)- inhalative NO therapy for neonates- phosphodiesterase inhibitors such as sildenafil (Viagra) which act downstream from NO

L-Arginine supplementation is ineffective and in fact detrimental in some populations

L-arginine therapy in acute myocardial infarction: the Vascular Interaction With Age in Myocardial Infarction (VINTAGE MI) randomized clinical trial. (JAMA. 2006 Jan 4;295(1):58-64)CONCLUSIONS: L-arginine, when added to standard postinfarction therapies, does not improve vascular stiffness measurements or ejection fraction and may be associated with higher postinfarction mortality. L-arginine should not be recommended following acute myocardial infarction.

L-Arginine ParadoxKm for NOS is 5µM. Plasma levels of L-arginine ~100µMHow can you get modest improvement in NO output when enzyme theoretically saturated withsubstrate?

Physiological systems are fraught with redundancy. Where is the redundant NO pathway? Why does such a critical molecule only have a singular complex and complicated pathway to production????

Reduced NO availability is a hallmark of a number of cardiovascular disorders.

- Endothelial dysfunction is a physiological dysfunction of normal biochemicalprocesses carried out by the endothelium, the cells that line the inner surface of all blood vessels including arteries and veins (as well as the innermost lining of the heart and lymphatics).

- Loss of endothelial NO function is associated with several cardiovascular disorders,including atherosclerosis, which is due either to decreased production or to increaseddegradation of NO (Davignon and Ganz 2004).

- Experimental and clinical studies provide evidence that defects of endothelial NO function, referred to as endothelial dysfunction, is not only associated with all major cardiovascular risk factors, such as hyperlipidemia, diabetes, hypertension, smoking and severity of atherosclerosis, but also has a profound predictive value for the future atherosclerotic disease progression (Schachinger, Britten et al. 2000; Halcox, Schenke et al. 2002; Bugiardini, Manfrini et al. 2004; Lerman and Zeiher 2005).

- The dysfunctional eNOS/NO pathway is considered as an early marker or a common mechanism for various cardiovascular disorders. Over the last two decades, it has become evident that decreased bioavailability of endothelial NO, produced from endothelial NO synthase (eNOS), plays a crucial role in the development and progression of atherosclerosis.

Cardiovascular disease (CVD) is the number one killer of both men and women in the U.S. Close to 1 million people die each year and more than 6 million are hospitalized due to CVD. The cost of CVD, in terms of health care and lost productivity, is over $270 billion and increasing as the baby boom population ages.

Ischemic heart disease, including myocardial infarction, remains the leading cause of morbidity and mortality in all industrialized nations

What is the physiological consequence of enhanced NO productionin Ischemia-reperfusion injury?

Can we trace the phenotype biochemically?

FACTS

Cardiac Specific Overexpression of eNOS results in Increased Cardiac NO Production and Protects from I/R Injury

Elrod et al ATVB 2006

Increased Cardiac NO Production Results in Increased Circulating Nitrite and Nitrate

Elrod, PNAS 2008

Local NO Production in the Heart Results in Accumulation of NO Products in the Liver

Elrod, PNAS 2008

Cardiac Derived NO Promotes Distant Organ Protection: Evidence for an Endocrine Role of Nitrite

Elrod, PNAS 2008

Atmospheric Nitrogen CycleThe store of nitrogen found in the atmosphere, where it exists as a gas (mainly N2), plays an important role for life. Most plants can only take up nitrogen in two solid forms: ammonium ion (NH4+ ) and the nitrate ion (NO3- ). Most plants obtain the nitrogen they need as nitrate from the soil. When released, most of the ammonium is often chemically altered by a specific type of bacteria (genus Nitrosomonas) into nitrite (NO2- ). Further modification by another type of bacteria (genus Nitrobacter) converts the nitrite to nitrate. All nitrogen obtained by animals can be traced back to the eating of plants at some stage of the food chain.

Dietary nitrate is rapidly absorbed into the bloodstream, where it mixeswith endogenous nitrate from the NOS/NO pathway. A large portion of nitrate is taken up by the salivary glands, secreted with saliva and reduced to nitrite by symbiotic bacteria in the oral cavity. Salivary-derived nitrite is further reduced to NO and otherbiologically active nitrogen oxides in the acidic stomach. Remaining nitrite is rapidly absorbed and accumulates in tissues, where it serves to regulate cellular functions via reduction to NO or possibly by direct reactions with protein and lipids. NO and nitrite areultimately oxidized to nitrate, which

again enters the enterosalivary circulation or is excreted in urine.

New Paradigm - Human Nitrogen Cycle

One-electron reduction is favorable to five-electron oxidation

Mice on Low NOx Diet for 1 Week RevealDiminished Plasma and Cardiac Nitrite and Nitrate

and is Restored with NO Supplementation

Bryan et al PNAS (2007)

Mice on Low NOx Diet for 1 Week RevealIncrease Injury from Heart Attack whichis Reversed with NO Supplementation

Bryan et al PNAS (2007)

LDL

LDLEndothelium

Vessel Lum en

I nt im a

Monocyte

Modified LDL

Macrophage

T Cells Neutrophils

Sm ooth MusclesProliferat ion

Atherogenesis

Foam cells

LESI ON

High Fat Diet

High Fat Diet + NO

Insufficient NO Production Leads to Diabetes

eNOS−/− mice display a disturbed blood-glucose concentration curve

eNOS-/- mice have high proinsulin/insulin ratios

eNOS-/- mice have higher visceral fat

Diabetic patients suffer from higher incidence of hypertension, heart disease and stroke, high blood pressure, blindness, kidney disease, nervous system disease, amputation, and complications of pregnancy and surgery – all conditions associatedwith insufficient NO production.

Diabetes Leads to Insufficient NO Production

NO

Diabetes

Perpetual Cycle of NO and Diabetes

Enhancing NOS derived NOExacerbates injury in diabetes

eNOS gene therapy exacerbates hepatic ischemia-reperfusion injury inDiabetes: a role for eNOS uncoupling

Elrod JW, Duranski MR, Langston W, Greer JJ, Tao L, Dugas TR, Kevil CG, Champion HC, Lefer DJ.Circ Res. 2006 Jul 7;99(1):78-85.

Dietary nitrate reduces body weight and decreases the amounts of visceral fat and circulating triglycerides in

eNOS-deficient mice.

Carlstrom et al, Proc Natl Acad Sci U S A. 2010 October 12; 107(41): 17716–17720.

Dietary nitrate improves glucose tolerance and reducesfasting blood glucose in eNOS-deficient mice.

Carlstrom et al, Proc Natl Acad Sci U S A. 2010 October 12; 107(41): 17716–17720.

0 min 10 min 30 min

1 µM GSNO

NO Signals GLUT4 Translocation

Insulin Receptor

Tyrosine Kinases

PI 3‐KinaseAkt

eNOS

Insulin

AMPKNO

Type II Diabetes

Extracellular

Intracellular

Sensitivity

PSer633‐

PSer1179‐

Diabetes

Glucose

GLUT4‐

GLUT4 translocationto plasma membrane

? GLUT4 Translocation/Function

Traditional Chinese Medicine

Traditional Chinese Medicine (TCM) has been used as a main stream of

medical care throughout Asia for centuries. But it is still considered an

alternative medical system in the western world. Mostly because of a lack of

understanding of their mechanisms of action and/or the active compounds.

Many cardiovascular diseases are characterized by a NO insufficiency.

There are a number of published reports on the association of TCM and NO-

related effects in cardiovascular field. However, their mechanism of action is

far from clear.

TCMs for Cardiovascular Indications

Tang et al FRBM 2009

0 1000 2000 3000 4000 5000

0

20

40

60

80

100

120N

O [pp

b]

Time (seconds)

B

Kinetics of NO Formation

TCMs Generate NO and Relax Blood Vessels and Reverses Endothelial Dysfunction

1E-3 0.01 0.1 1 10

0

20

40

60

80

100

120

###

#

#

#

#

****

*

% R

ela

xa

tio

n

Acetylcholine [µM]

Control ApoEKO ApoEKO+TCM

*

Nitrate, bacteria and human healthLundberg JO, Weitzberg E, Cole JA, Benjamin N.Nat Rev Microbiol. 2004 Jul;2(7):593-602

Acute blood pressure lowering, vasoprotective, and antiplatelet properties of dietary nitrate via bioconversion to nitrite.Webb AJ, Patel N, Loukogeorgakis S, Okorie M, Aboud Z, Misra S, Rashid R, Miall P, Deanfield J, Benjamin N, MacAllister R, Hobbs AJ, Ahluwalia A.Hypertension. 2008 Mar;51(3):784-90.

Dietary nitrate supplementation reduces the O2 cost of low-intensity exercise and enhances tolerance to high-intensity exercise in humans.Bailey SJ, Winyard P, Vanhatalo A, Blackwell JR, Dimenna FJ, Wilkerson DP, Tarr J, Benjamin N, Jones AM.J Appl Physiol. 2009 Oct;107(4):1144-55.

Enhanced vasodilator activity of nitrite in hypertension: critical role for erythrocytic xanthine oxidoreductase and translational potential.Ghosh SM, Kapil V, Fuentes-Calvo I, Bubb KJ, Pearl V, Milsom AB, Khambata R, Maleki-Toyserkani S, Yousuf M, Benjamin N, Webb AJ, Caulfield MJ, Hobbs AJ, Ahluwalia A.Hypertension. 2013 May;61(5):1091-102.

Dietary Nitrate Can Be Metabolized to Nitrite and NO

Physiological Role for Nitrate-Reducing Oral Bacteria in Blood Pressure Control

Kapil et al Free Radic Biol Med. 2013 Feb;55:93-100

NO 3-

NO 2-

NO

N 2O

N 2

NH 3

2e-

1e-

1e-

1e-

3e-

Bacteria

Increase NO 2‐

NR

NiR

NOR

N 2OR

Ideal Community:

� Higher Nitrate reduction efficacy

� No NiR enzyme; Nitrite can accumulate,

enrich saliva to form NO when swallowed. 

Tongue Scrapings Reveal Different Nitrate Reductase Activity in Culture

The microbial community structure changes as nitrate reduction decreases. Unweighted UniFrac-based Principal Coordinate Analysis (PCoA) illustrates the first two principal coordinates (PCs) for inocula, best reduction, intermediate reduction, and worst reduction groups. Unweighted UniFrac is a phylogenetic-tree based method that determines the similarity of two microbial communities based on the amount of shared branch length; thus, similar communities cluster closely on PCoA. Each dot represents a single sample and the amount of variance explained by each PC is indicated in parenthesis next to each axis.

NEW PARADIGM FOR NO REGULATION

- There exists specific bacterial communities that provide the human body with continuous sources of nitrite and NO from dietary nitrate.

- Contributes to optimal cardiovascular health

- Absence of these oral bacterial communities affects NO homeostasis.

- Individuals deficient in these commensal bacteria would be NO deficient and perhaps at increased risk for cardiovascular disease

Disruption of Nitrate-Nitrite-NO Pathway

1. Insufficient dietary intake of nitrate/nitrite rich foods(green leafy vegetables, beets, etc)

2. Problems with nitrate uptake in duodenum (sialin (SLC17A5) transporter mutations – Salla Disease)

3. Insufficient saliva production (Sjogrens syndrome)

4. Lack of oral commensal bacteria to reduce nitrate to nitrite (use of antibiotics/antiseptic mouthwash, poor oral hygeine)

5. Insufficient stomach acid production – Achlorhydria(use of PPI’s, H. Pylori infection, iron overload)

6. Increased oxidative stress that scavenges NO

What might this mean?

� Absence of these select bacteria - a new risk factor for cardiovascular disease.

� Patients with periodontal disease , affecting the NO producing communities - possibly linking oral health to cardiovascular disease risk by disruption of NO production

� Use of antiseptic mouthwash or overuse antibiotics can disrupt nitrate reducing communities

� Patients taking proton pump inhibitors to suppress stomach acid production

� Develop this pathway as a primary therapeutic target to affect NO production

Should we be concerned about our NO status how do we correct NO insufficiency?

Western Menu Mediterranean Menu

0

50

100

150

200

250

300

350

NO

X (

mg

)/S

erv

ing

NOX

Daily NOx Intake Varies Depending on Diet

H. Garg, Master’s Thesis

Western Menu Mediterranean Menu

Breakfast Bagel w/ Cream Cheese Toast w/ Jam and Butter

Black Coffee (12 oz) Cappuccino (Espresso+Milk)

AM Snack Carrot Nut Muffin Yogurt (Strawberry)

Diet Coke (12 oz) Carrot Juice (12 oz)

Lunch Big Mac Mediterranean Wrap

Large French Fries Garden Vegetable SoupDiet Coke (12 oz) Mineral Water (12 oz)

PM Snack Snickers Trail Mix

Black Coffee (12 oz) Orange Juice (12 oz)

Dinner Cheese Pizza (4 slices) Salmon (Smoked)

Diet Coke (12 oz) Red Wine (12 oz)

Grape Juice

Apple Juice

Pomegranate

V8 Veg Juice

Carrot J

uice

ReislingShira

zMerlo

t

Green Tea

Red Bull

Rx Stress

Perrier

0

10

20

30

40

50

60

70

400

800

1200

1600

2000

2400

NO

x [

µM

]:P

oly

ph

en

ol G

AE

[m

g/L

]

Nitrite Nitrate Polyphenol

NOx and Antioxidant Capacity of Common Beverages

NO Diagnostics

Flow Mediated Dilatation for

Endothelial Function

Measure of Vascular NO Production

RISK FACTORSHyperlipidemiaArterial hypertensionSmokingAge (45 males: 55 females)

Plasma nitrite concentrations reflect the degree of endothelial dysfunction in humans.

Kleinbongard et al FRBM 2006

Simple to useInstant, easy-to-read results

The First and Only Non-invasive NO Diagnostic

Nitric oxide synthase-derived plasma nitrite predicts exercise capacity

Rassaf T, et alBr J Sports Med 2007;41:669–673

Age-dependent endothelial dysfunction isassociated with failure to increase plasmanitrite in response to exercise

Lauer et al Basic Res Cardiol 103:291–297 (2008)

NO3-

NO2-

NO

Manipulating the NO System Through Diet and Nutrition

oxidation reduction

Facultative anaerobes5-8%Spiegelhalder 1976Lundberg 2004

Mammalian enzymes~ 0.01%Bryan Nat Chem Biol. 2005Feelisch JBC 2008

Beet, kale, etc

Oxygen,ceruloplasmin

Oxyhemeproteins

L-arginine

50-90%

Naturally Restoring Nitric Oxide Production

Strong & sustained Nitric Oxide activity

Neo40 Clinical Trial Results

Zand et al Nutrition Research 2011

0 60 120 180 240 300 360 420 480 540 600

0

2000

4000

6000

8000

10000

12000

14000

NO

[p

pb

]

Time (seconds)

0 10 20 30 40 50 60

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

Blo

od

NO

Le

ve

ls [

µM

]

Time (min)

L-Arginine + antioxidants Neo40 Daily

Day 0 Day 30

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

Pla

sm

a N

itri

te [µ

M]

*

p=0.003

Day 0 Day 30

0

10

20

30

40

50

60

70

80*

p<0.0001

Pla

sm

a N

itra

te [µ

M]

30-day regimen increasedplasma nitrite and nitrate in patients

Zand et al Nutrition Research 2011

Neo40 Clinical Trial Results

Day 0 Day 30

50

100

150

200

250

300

350

400

Tri

gly

ce

rid

es (

mg

/dL

)

A

Day 0 Day 30

0

50

100

150

200

250

300

Tri

gly

ce

rid

es (

mg

/dL

)

*p = 0.02

B

Significant reduction in patients with elevated triglycerides

Zand et al Nutrition Research 2011

Neo40 Clinical Trial Results

Systolic Diastolic

60

80

100

120

140

160

Blo

od

Pre

ssu

re (

mm

Hg

) Before After

Modest reduction in blood pressure

Zand et al Nutrition Research 2011

Neo40 Clinical Trial Results

0 10 20 30 40 50 60

80

85

90

135

140

145

150

#*

*

*

Blo

od P

ressure

(m

mH

g)

Time (min)

Systolic Diastolic

*#

n=30

Baseline 4 hour Neo

0.0

0.5

1.0

1.5

2.0

2.5

3.0

En

do

sco

re

Endopat *

Hypertension Trial – Mark Houston, M.D.

NO

Pre-Hypertension Trial – Cedars SinaiSchool of Medicine

160 160

135 135

90 90

45 45

Group 1

Baseline Follow Up

Group 2

Baseline Follow Up

mm

Hg

mm

Hg

Blood PressureFigure 1

Systole

Diastole Diastole

Systole

30 day placebo controlled study

NO

Thermographic Images

Before NO 10 min After NO

49 yof chronic smoker with Raynauds

Two weeks Neo Improves EndothelialFunction

0 2 4 6 8 10

0.50

0.55

0.60

0.65

0.70

0.75

0.80

LCCA d

iam

ete

r (c

m)

Time (min)

Neo40 Dilates Carotid Artery within 90 Seconds

Augmentation index is a ratio calculated from the blood Pressure waveform. It is a measure of wave reflection and arterial Stiffness.

Sensitive marker of arterial status

Predictor of adverse CV events

Higher Aug index associated withtarget organ damage

Can distinguish between the effects of different vasoactive medications when upper arm blood pressure and pulse velocity do not.

Neo40 ImprovesArterial Stiffness

Steady State NO in Dialysis Patients

High cardiovascular death rates for patients on hemodialysis remain a serious problem.

Cardiovascular mortality is considered the main cause of death in patients receiving dialysis and is 10 to 20 times higher in such patients than in the general population.

Expected remaining lifetimes for dialysis patients are only one-third to one-sixth those of the general U.S. population. For a healthy 20-year-old, life expectancy is around another 58 years – compared to 14 years in dialysis patients. A 50-year-old dialysis patient can expect another six years.

To date there is no molecular mechanism that has been shown to explain this increased mortality although nitric oxide has been implicated.

Results

Baseline From Machine Post Dialysis

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

*

*

Pla

sm

a N

itrite

[µ

M]

A

Baseline From Machine Post Dialysis

0

50

100

150

200

250

300

350

**

P

lasm

a N

itra

te [µ

M]

B

A single pass through the dialysis filter removes 67% of plasma nitrite and 84%plasma nitratePatients’ total blood volume is filtered on average 40-50 times during the 4-5 hoursession 3 times per week.

Nitrite Nitrate

0

100

200

300

400

500

600

700

800

*Sa

liva

ry N

Ox [µ

M]

Pre-Dialysis Post-Dialysis

*

Results

Dialysis removes as much as 90% of salivary nitrite and 85% of salivarynitrate disrupting the human nitrogen cycle to maintain NO homeostasis

NO Supplementation Rescues Inborn Error in Metabolism

The Urea Cycle converts ammonia to urea for excretion

� Hyperammonemia

� In addition:– Progressive liver dysfunction and cirrhosis

– Coagulopathy

– Neurological dysfunction independent of recurrent hyperammonemia

– Hypertension

– Renal dysfunction

� More than hyperammonemia?

ASL deficiency is an Inborn error in metabolism

Urea cycle disorders- treatment

Ammonia Urea

Food

Breakdown of body proteins (stress)

Restrict Protein intake

Benzoate

Arginine

NO Nitrite

X

3/22—116/753/23—122/783/24—133/803/25—106/803/28—120/753/29—114/773/30—124/723/31—126/73 4/1—109/80

Neo

Neo

From: Bryan & Jamie Sent: Wednesday, August 03, 2011 9:52 PMTo:Subject: Jon

Just wanted to share something with you guys. Jon wanted to play chess tonight with Bryan. They have done this forever. Bryan has tried to teach him how to play over the years. He knows the pieces by name and what move that they can make but has never been able to comprehend the strategy needed to be successful. For instance, he has never understood how he needs to "protect" his pieces. Tonight he actually "foiled" Bryan's plays without Bryan's guidance. He thought through his plays, planned ahead and won the game. Bryan helped him but he truly came up with the plays himself and won the game.

Bryan asked him if he had been taking "smart pills" and Jon told him yes, the purple ones. I think he is right!

Jamie

Heirarchy of Treatment Strategies

1. Recommend High NO Index Diet(use NO test strip 90 minutes after high NOmeal to determine if patient responds to nitrate load) – Beet Elite

2. Recommend Exercise Regimen(keeping below anaerobic threshold)

3. Include Neo40 supplement for all dental patients to support NO production and oral systemic health

Why is Neo superior technology?

1. Provides an exogenous source of NO2. Promotes endothelial production of NO3. Provides the body the nutrients

necessary for repairing endothelium4. Plant based natural product chemistry

(all-natural)5. No tolerance development6. Drug-like effects without side-effects7. Clear product experience8. Patented (3 patents issued - 5 pending)

CONCLUSIONS

There are profound effects of NO on health and disease

Recognizing NO insufficiency is critical for prevention of disease

L-arginine therapy is ineffective at restoring NO production in the older patients or patients with endothelial dysfunction

Enhancing NO production in the oral cavity combats pathogenic bacteria, suppresses inflammation and supports cardiovascular integrity

Include Neo40 supplement for all patients to support NO production, suppress inflammation, enhance oral health, cardiovascular integrity and promote wound healing after surgery

Book Highlights:Restoring nitric oxide

production in the body thereby combating:

�High blood pressure�Heart attack

�Stroke�Diabetes�Arthritis

�Kidney disease�Memory loss�Osteoporosis