The link between healthcare and your mouth is more complex than most people realise. There is mounting evidence that poorly executed dental treatments and natural occurring cysts can lead to serious health issues. We can link the inflammation in the jawbone caused by these problems to a large array of systemic illnesses: Fibromyalgia, Breast Cancer (link), Depression, Chronic Fatigue , Rheumatoid Arthritis and many more.
The way dentistry is being practiced in many clinics around the world has not evolved to be able to properly diagnose these issues, and 2D film Xray and clinical observation during check ups, that sometimes take 15 minutes, is still the norm.
We need to disrupt this method of clinical evaluation in 2022 and ensure that dentists, or at least those that really care about connecting dots between oral issues and systemic issues, start asking more questions and using better technology to diagnose, such as 3D-CBCT (Cone Beam Computer Tomography) and also blood tests looking for RANTES\CCL5 cytokines produced when there is inflammation present in the jawbone.
We can objectively trace the source of the inflammation back to the origin during oral surgery through biopsies and with a proper clinical protocol dramatically reduce the inflammation with immediate health benefits to the patients.
We can no longer sit back and look at teeth as simple mechanical structures separate from our immune system and neurological network. Getting this right can save lives if not seriously improve them for millions of sick people desperate for answers but not getting them, as their dentists are telling them, "all is good", based on outdated diagnostic tools.
This is the foundation on Biological , Functional and Integrative Dentistry . I like to call it Immune Dentistry .
The link between healthcare and your mouth is more complex than most people realise. There is mounting evidence that poorly executed dental treatments and natural occurring cysts can lead to serious health issues. We can link the inflammation in the jawbone caused by these problems to a large array of systemic illnesses: Fibromyalgia, Breast Cancer (link), Depression, Chronic Fatigue , Rheumatoid Arthritis and many more.
The way dentistry is being practiced in many clinics around the world has not evolved to be able to properly diagnose these issues, and 2D film Xray and clinical observation during check ups, that sometimes take 15 minutes, is still the norm.
We need to disrupt this method of clinical evaluation in 2022 and ensure that dentists, or at least those that really care about connecting dots between oral issues and systemic issues, start asking more questions and using better technology to diagnose, such as 3D-CBCT (Cone Beam Computer Tomography) and also blood tests looking for RANTES\CCL5 cytokines produced when there is inflammation present in the jawbone.
We can objectively trace the source of the inflammation back to the origin during oral surgery through biopsies and with a proper clinical protocol dramatically reduce the inflammation with immediate health benefits to the patients.
We can no longer sit back and look at teeth as simple mechanical structures separate from our immune system and neurological network. Getting this right can save lives if not seriously improve them for millions of sick people desperate for answers but not getting them, as their dentists are telling them, "all is good", based on outdated diagnostic tools.
This is the foundation on Biological , Functional and Integrative Dentistry . I like to call it Immune Dentistry .
Hi, welcome to another episode of biting into healthcare with me, your host, Dr. Miguel Stanley, could your dentistry be killing you? Could it silently be really harming your health? And why is a dentist asking that question? Why am I asking that question? Should I be asking this question? And how many people is that going to offend? All of these things are jumping into my head. But I need to ask this question. Because what I've been seeing consistently for the past 13 to 14 years, since I acquired 3d, CT technology, which I'll explain in a bit, what that is, has led me down a path that goes against what most people are thinking dentistry is. So in order to explain why I'm asking this question, why it needs to be answered? And what are the telltale signs that you might be suffering from this problem without even knowing it. And it might be contributing to other health issues you have like depression, fibromyalgia, cancer, autoimmune diseases, the whole spectrum, chronic fatigue, so many other illnesses that are at the core inflammatory diseases, they have inflammation, as the biomarkers in the blood tests that you have. And all of your physicians that are looking into the systemic illnesses are looking for these biomarkers, cytokines in your blood inflammatory markers. And this is now January 2022. And the whole world now understands the PCR test, looking for inflammatory markers to see if you've got COVID-19. And that's also a marker. So our blood has telltale signs that we are inflamed. And specific markers tell us what might be causing that inflammation, and what our physicians have to do in order to stop it. So let's try and segment this conversation in a way that it would make sense to a non medical listener because I always like my, my talks and these conversations to be for the general public and not for the dentist. But I also do hope that dentists listening can pay attention. Because I'm not just, you know, a simple dentist, I run one of the world's leading dental practices, very focused on high end, high tech dentistry, and I've been doing that for 24 years. And in order to understand why I want to talk about this today, let's go back into history and look at why your GP, why your physician isn't also capable of doing dentistry, and why your dentist isn't capable of being a GP. And what's the difference between a dentist and a GP ( general practicioner) . So over 100 years ago, dentistry and medicine separated and you've got a whole different universe, a different education system. It used to be in the past that your GP would then study dentistry and become specialised in the mouth. But in the last two to three decades, there's specific universities to train people in the Art of Dentistry, and somewhere along the way, sentences like "oh, you're not a doctor, you're just a dentist", pervaded society. And the difference between a great dentist and a really bad dentist is imperceptible to you, the listener or the audience or the consumer of dentistry, because as long as they're nice, and they have a nice cabinet and the price is good and they don't hurt you and your insurance covers your treatment, it's just dentistry, right? Well, no. And that's a whole different other conversation that we can get into. Because the more weaponized your dentist is, the more experienced he has, the more training they have, the the better materials they use, and more importantly, the time that they spend to diagnose and treatment plan and execute said treatments, will dramatically impact the quality of that treatment. From a simple filling to a root canal, to a crown or dental implant or a simple tooth extraction. And the care that your dentist takes in creating a sterile environment when blood is involvedtoo. So from a simple extraction to an implant to certain procedures that should require sterilisation that definitely do in a hospital setting. You know, for minor surgeries, when you go and have a minor surgery a hospital, when you break your arm, and you have an exposed fracture or something, or a controlled elective surgery like removing your appendix or something like that. It's always done in a controlled surgical setting, surgical sterile gloves, surgical cloths and special procedures are put into place for your safety and for the doctor's safety and for the staffs safety so that there's no contaminating things that can happen that could result in your death. Because surgery is a very serious thing, but why not in dentistry? Why is your dentist allowed legally to take a tooth out of your skull without all of these parameters set into place? Have you ever asked that question? Simple, because we're not trained to think like that at school. I went to a good university, and I've lectured in over 54 countries and I know a lot of very good dentists. Tooth extraction today is one of the cheapest treatments in dentistry, many clinics actually offer you the the extraction to gain clientele, and then later will charge for the dental implant. But my question is, first of all, why are you taking the tooth out? Was there an infection? Usually, anecdotal evidence would say that, most teeth are extracted because there's an infection or something, went wrong. You don't really extract healthy teeth, maybe wisdom teeth, but excluding wisdom teeth, you'll take a tooth out because there's an infection. And if there's an infection, should we not be taking extra care in disinfection and making sure and not just relying on antibiotics or the patient's immune system to clean up that infection? But we'll get to that in a bit. So I've been asking myself these questions over many years. And let's get back to that separation of "You're not a doctor, you're just a dentist", and dentistry becoming in recent years, very focused on aesthetics, very focused on the mechanics, on aligners and orthodontics and implants and crowns and bridges and all those amazing things that I love to do and dentists love to do. To deliver beautiful smiles and Dentistry has become associated to smile therapy and I've got a team and that's what we do. We're very good at it, but that's the end game. That's the decoration of the house. That's the interior design. It's not the foundations, the sewage system, and the plumbing, and the foundations and the wiring, and the insulation of the house. If I'm using that analogy. Nobody really wants to talk about that. But if those foundations aren't safe and solid and sound, then, you can have the nicest decoration and artwork and furniture, and things can look beautiful, but if there's a storm coming or there's an issue with the plumbing, you're going to have some major problems. So your teeth are connected to your brain, literally. There's nerves shooting out of your teeth that are connected to your trigeminal nervous system and directly connected to your brain through the ganglia. So your trigeminal ganglia is and if anything that goes wrong with your teeth directly affects your brain. Moreover, they are also connected to your bone. And if you have infections around your teeth in the bone, then that's also going to be affecting your immune system because bone marrow is very responsible for immunology and for your immune system. And we'd have not yet developed tools in our DNA and in our immune system to actually clean up dental infection. And that's why dentists become very essential and very necessary. You know, over millions of years of evolution. We only produce one extra set of teeth. So your milk teeth fall out and are substituted for your adult teeth. And, 10,000 years ago, people were dying at the age of 40. So your teeth lasted till the age of 40 -50, and then you would pass away, but now we're living till 100. And that means that our teeth have to last a lot longer. But we don't produce a third dentition. And that's where dentistry comes in, to preserve and to prolong and to sustain your teeth, so that you can chew and bite and have that function. But that's the mechanics. I'm worried about the physiology and the immune side of dentistry. And the question that I started this conversation with was, could your dentistry be killing you silently or contributing to your health problems and systemic health disorders. So, Dentists have been so focused on the mechanics that many of them are overlooking the relationship that teeth have with your immune system. And that's the conversation that I want to have today. But you can't even begin, dentists can't begin to have that conversation in a 15 minutes or 20 minute appointment using two dimensional film X rays. So if the way that your dentist is doing a checkup, or a yearly checkup on your mouth, is with film X ray, the big ones are called panoramic X rays, and the small ones are called periapical X rays. And if that's the only way that they're using to the only diagnostic tool they are using to analyse the state of your mouth, that's not enough. Now, evidence will show that the large majority of dentists around the world are using two dimensional film X ray. And I want to bring to the conversation and you the patient should start asking these questions saying, Well, when I do a checkup with my doctor, he will take an x ray, he will listen to me and the doctors will observe you in their mouth. So they'll open up look with their mirror, and they'll look inside and check out your teeth. And they'll ask you a few questions and they'll be quite thorough, and they'll take X rays, series of little X rays and the series of the panoramic X ray, which are two dimensional. So by default, will not be able to see certain elements of your skull and the relationship of your teeth in a three dimensional way with the bone and gum. Now, I don't know many dentists, it's very rare that would ask for blood tests. And you could say, well, why should a dentist asked for blood tests? And what blood tests would they ask for? We'll get to that in a bit. But if no other doctor is looking at the mouth, other than the dentist, then is there a missing link in health care? That would analyse chronic infections in the mouth that cause no pain or no symptoms? Is there a missing link in healthcare that if doctors are only looking for cosmetics and mechanical issues with two dimensional X rays and a quick clinical observation, and by asking such questions as well? "What are your complaints?" Does it hurt?Are you happy? Yes? Then come back in six months. That's not a proper, profound checkup. I'll explain why. Most problems and most pathologies in the mouth, cause no pain.Which means that there's no alarm sign to the patient, that they should visit a dentist. And we also study, most dentists in the world will know this, that almost every illness in the human body has some form of symptom that will appear in the mouth. And we're very proud of that saying, we can be early detectors of cancer. If you take the time to actually look into it and a bunch of other systemic illnesses, where telltale signs will appear in the mouth first, yet with this cosmetic driven approach to dentistry, and short appointments, where there's a high turnover, and we're not using the right diagnostic tools to look at our patients mouth, are we missing something? And I'm saying yes, we are. Yes, we are. And it is very important that we have this discussion, because now it's become evident that there are dentists and dentists and their dental practices and dental practices. And I hope that this helps you try and figure that out, because every dentist on their website says that they're the best dentist and they have the best technology. And they're the most, you know, experienced, I haven't yet to see a website that, you know, the dentist says, we're okay. We just focus on this, we don't really use the best technology. But you know, we're okay. I don't see anybody doing that. Again, I've visited over 54 countries professionally, and to lecture around the world. And, you know, I speak to people and I hear things. So, Dentistry has become very high tech. And I'm very pleased to say that a lot of clinics are investing in technology. Some of them mostly focused on aesthetics and straightening your teeth, and but let's forget Generation Z and millennials. And let's go into Generation X and baby boomers, not to mention, you know, senior citizens, but let's go to Generation X, which would be somebody between the ages of 44 and 55-60. And then somebody from 60 to 80. That still has got a lot of life ahead of them, but they've had a lot of dentistry done in the last 20 to 30 years. And the likelihood of that dentistry, such as mercury amalgam fillings, normal fillings, Crown work bridges, dental implants, extractions, root canals, having been done to the highest standards of quality, recognised in 2022, is very low. Because what we thought was good in 2005, changed 2015 and changed to 2020. So we know things today. And we know how to do things better today than what we did 20 years ago. But if you've got that dentistry in your mouth, still, we now know and evidence can tell us that that might be causing you health concerns, and the dentist, your loving, caring kind dentist who is probably the nicest person is the person that did that treatment to you. Should they be the person telling you that it's okay. Is there not some bias there? Albeit unwitting from your health care, your oral health care provider, your dentist? And are they using the right tools with the appropriate amount of time to investigate if that dentistry needs an update, or to be removed or replaced? So what are the right tools that would help your dentist understand if things are going wrong? Well, 3d CBCT technology.So it's three dimensional Cone Beam computer tomography. These tools are quite expensive. They're usually found in hospital settings, but had been in the last years developed specifically for the dental setting. These machines can cost anywhere between $100,000 to $200,000. And require a special, you know, installation in these dental clinics. But what's the big differential? Well, the big differential is these are low radiation technologies because they're digital by default. And they will allow a reconstruction of the patient's jaw, giving the doctor the opportunity to see beyond the gums and have a 3d visual of the jaw. So let's get past the teeth. And let's look into the jaw, which is part of your anatomy part of your, you know your skeleton. And we all know that bone marrow and bone needs to be clean bone is something that should never be exposed to the elements. And that's why every orthopaedic surgeon does bone surgery in a hospital setting in a sterile environment. But dentists don't. There's no corporate governance or legal system in place in any country that controls the sterilisation process of a dental surgeon to extract it to do a root canal or to place a implant in your mouth, let alone the quality of the implant, the quality of the extraction, so on and so forth. So let's just understand that right now. This discussion is for the patient, not for the dentists. So there's a lot of bad actors in dentistry, and there's a lot of great dentists in the world. But I hope that this discussion can help you the patient, understand maybe you might need to upgrade the quality of your of your dentistry and upgrade the course Have your diagnostics which is more important than that. So having said that, a 3d CBCT technology is something that I acquired for the white clinic back in 2008. That's a long time ago, when only 1% of clinics in the world had this technology in their practice here in Portugal, I was using that. And 100% of my patients, adult patients will have this on their first appointment, just it's not a discussion. Meaning a patient that comes in for a veneer or cause a bleaching or a cleaning or filling something basic. They will all get a 3d cone beam Computed Tomography of their mouth. Why? Because I am a physician of the oral cavity, not just a quick fix dentist. And please check out my podcast on slow dentistry, on biting into healthcare, where I talk about slow dentistry. And you can also visit slow dentistry.com, a nonprofit foundation that I created which inspires dentists and recognises clinicians that take time to do things properly, you know, not seeing 3040 patients a day. I've never done that. I've always been few patients a day doing high quality dentistry. So my I might not, you know, I'm not saying that my skills are better than dentist A, B or C, I'm just saying, I take a lot more time with my patients. And if you do that the probable outcome of you practising better dentistry is a lot higher. So if your dentist is seeing 3040 patients a day and thinking that's okay, it's not just from a hygienic standpoint, let alone if he's doing his surgery on you, how can you set up a proper safe environment to do things safely, you understand what I'm saying? So this conversation is very uncomfortable for a lot of business owners in dentistry. And a lot of dentists whose whole business strategy is offering affordable dentistry to the community on the premise that they're going to do high volume. And I'm sorry if this scares you or offends you, or upsets you. But that's not what you trained to do. You didn't train to teach to treat the largest amount of people the day, you didn't train to make a bulk of money, you trained to do quality dentistry and help individuals one at a time. And you need to do so properly. And if we need more dentists and let's get more dentists. But if there's a lack of dentists in your community doesn't mean you should, for go, Safety and Quality, because each life matters. And that's what matters to me the most. And you can't do this in a rush. And we have to look back and think that maybe we made some mistakes. In the past as dentist, I made mistakes in the past as a dentist.One that I'm very proud of not making was lead-mercury fillings, for example, I haven't touched the stuff since '96. But there's things that we were trained as dentist and the dental community at large just accepts, you know, having a little lesion at the base of a root canal tooth in a two dimensional X ray that's stable over time. Anybody complaints doesn't hurt, you know, it's fine. And the patient got 20 years with a poorly executed root canal in their mouth with a small little cyst at the base of that tooth. And because there's no symptoms, and there's no pain, and the dentist did the treatment, and he wants to be nice. And the alternative is horrible, because it would be extraction or complicated surgery. Nobody's talking about it, but we have to have that uncomfortable conversation. So I want to talk to you a little bit about a blood test that can be performed, that we'll look for a special cytokine a cytokine is an inflammatory marker. And you can go on Wikipedia and Google cytokines and they are markers used in cancer treatments. So your cancer specialist or specialist in fibromyalgia or in in many chronic illnesses will be looking for cytokines in your blood as an indicator of the levels of inflammation. And through the work of Professor, Dr. Johan Lechner, from Munich and a bunch of other doctors around the world but I'd say as a dentist, he's the guy that's been talking the most about this. There is a marker called RANTES or CCL5 which is usually specially associated to inflammation in the mouth. And after years of evidence he's understood that this marker lowers after cleaning up the mouth, from these chronic inflammation and or chronic infections. And we have a book coming out in early 2022. Just as a timestamp here, we're now in January 2022. The book will be coming out shortly to discuss exactly this, the illness or the sickness. The technical term is fatty degenerative osteomyelitis of the jaw, FDOJ, and it is a silent inflammatory condition that happens in the human maxilla. So , the Maxilla and the jawbone as a result of low grade chronic infection that most times will be caused by poorly executed dentistry, poorly executed dental implants, poorly executed and healed a tooth extractions, which was the most common treatments in the world and poorly executed root canals. And again, I'm using the word poorly executed, because when they're well done, usually this wouldn't happen. So, according to the American Academy of endodontists, 15 million root canals are performed every year in the USA alone. That's something like 43,000 a day. For argument's sake, let's just suggest that 5% are not done properly. 5% are done in a rush, where a two dimensional X ray will say that it's okay and the absence of pain will tell the patient that I'm okay. But is that enough? Is that the right way to diagnose this? Could there be remnants of infection associated to the tooth and the adjacent bone that could be silently and consistently throughout time sending out this inflammatory and infectious markers into your bloodstream? And as a consequence, what would that do to your body? Well, evidence and more evidence is coming out. In the realms of functional dentistry and biological dentistry and immune dentistry, a term that we are coining the original name out of Germany is maxillomandibular osteo. immunology, which is a very big word. I like to call it immune dentistry is looking at the consequences of these low grade chronic infections and low grade chronic inflammation that most dentists say well, you know, it's stable,but are like a toxic battery sending out these inflammations into your bloodstream through your bone marrow. And also, the studies of Edward Bullmore from Cambridge University who published a book called The inflamed mind. Most of his book is about cytokines and his 20 year old theory which he has recently proven as recently as 2013. So if you go by his book, The inflamed mind. He says that depression, anxiety all the way up to dementia, is caused by inflammation. So we know that infection one plus the blood brain barrier, and we have a very large nerve inside your mandibular, which is part of that trigeminal system, which I was explaining before, it's very large, it's the size of a well cooked spaghetti. But we know that bacteria doesn't pass the blood brain barrier. But we now know that cytokines do. So the grantees, CLL5 and other ones like interleukin 6 and a bunch of other inflammatory markers, will, the language of inflammation passes the blood brain barrier, and can activate negative things in your brain? inflammation in the brain can cause brain fog, memory loss, anxiety, depression, and a bunch of other things. And you should look into the work of Edward Bullmore. So I'm starting to think Well, based on my evidence of the last 14 years of using CBCT technology, with patients that come to my clinic, Generation X and baby boomers that have a lot of older dentistry that I didn't do that if they're coming to ask for, you know, a redo of that cosmetic work or dentist work, we've been saying, hey, there's a bigger picture here. You have cysts and inflammation in the bone that needs to be addressed. And all of them say I don't want to do that it doesn't hurt me just take care of the aesthetics. And that's where we go further and say no. So tell me about your health, depression, chronic fatigue, muscle aches, joint aches, skin problems, and a huge array breast cancer, fibromyalgia, and there's a correlation. And it's undeniable as a correlation I'm not saying that you can have, you know, that, that it's always there, you know, but almost everybody that has chronic inflammation in the mouth has one of these symptoms in the rest of their body. And that's the bridge between oral health and systemic health. And people have been looking at it the wrong way around, they've been thinking that all dentistry is great, and that all treatments performed the last 50 years are fantastic, they're not, we need to be realistic about this. And we need to address this problem and diagnosing it with Does it hurt, you know, two dimensional X ray is not sufficient. You need blood panels in to check the vitamin D levels you need to but most importantly, look for these CCl5 markers. And if those levels are high, and unfortunately in my patients 90% of them are, then a deeper therapy needs to be advised not nothing to do with the teeth, the teeth need to come out the associated implants need to come out the infected wisdom teeth need to come out not for cosmetic purposes or functional purposes, but for immune purposes. And there's a special protocol for this. I like to call it Jawbone detox, which uses our video Yag lasers, ozone therapy and stem cell regeneration. And once performed properly, a few months later, we go back and take the blood test and those markets have gone down. And then dentistry kicks in and we rebuild the beautiful smile with you know, implants and beautiful teeth. But to rebuild that without cleaning the bone from low grade chronic infection and inflammation is a mistake. And to overlook that in the diagnostic phase is a mistake. And if you have systemic illness, that your GP and your physicians and your specialist don't seem to figure out where it's coming from. And they're saying now, it's lifestyle, it's stress, it's smoking, which of course is very bad for you. So let's say you don't smoke, it's lifestyle. It's stress. It's your diet. And you've tried everything you've tried mindfulness and yoga and meditation and nothing seems to be working and you've changed your diet and you can't find out what's wrong with you, you need to find a dentist that knows what he's doing. That's not just looking at the mechanics with a two dimensional X ray. And doing these blood tests and using 3d CBCT technology to look deeper into the situation. And that has the capacity to remove this and rebuild it. Because it's a whole new form of dentistry out there. So also, Dr. Johan Lechner. I'm not connected to this company at all, but he's developed a sonar technology called the cabbie towel that will allow you to find inflammation in the jaw that hopefully in due course, will become affordable and ubiquitous and more people can use this. But I guess the punchline here is to sum this up is that you got to stop looking at your dentist, as a mechanic and dentists out there watching this stop looking at yourself as just somebody that can fix teeth. And let's do a mayor Cooper has an entire industry and realise that maybe dentistry in the last 30 years, we did a lot of mistakes. And we got to own up to it and clean it up and I God knows any dentist has done bad treatment. But overlooking it and and ignoring it is a problem. You know, we were putting asbestos in roofing and in our buildings in the 50s and 60s because it was a great insulation material. Later, we found out that it caused cancer and a lot of other nasty things. But for 10 years, the industry said no, no, no, no, no, no, no, no, no asbestos doesn't. We now know that it's highly toxic and very dangerous. We did the same with tobacco. Doctors in the 50s were promoting cigarettes. And in the 90s. Big Tobacco said no, no, no tobacco doesn't cause cancer. And then finally, tobacco causes cancer. We known for 100 years that sugar causes tooth decay. Yet a Mars bar and a can of Coke doesn't come with a warning. It should. It should candy should come with a warning. But it doesn't. So dentists should also explain to their patient that they are limited with the technology that they have if you're only using two dimensional X ray film to diagnose a patient with a lot of previous treatments done. It's not the right technology, you have to ask for a 3d CBCT and if you have any systemic illnesses, from a simple chronic fatigue waking up tired headaches, depression, anxiety all the way up to you know serious things like fibromyalgia Rheumatoid Arthritis Cancer, then you definitely need to be looking into the RA nt e s, the rent is CC or CCl, five cytokine marker in your bloodstream, and then find a physician that knows how to remove this safely, properly. It's a very special protocol, we can discuss that at a later thing, but I really wanted to just have this discussion because bad dentistry, yes, it could be contributing slowly to your negative health and it could silently be killing you. And it's not acceptable to have chronic infections in your mouth, and not correlate that with your systemic illnesses anymore. Not in the 21st century, and definitely not in 2022. So I wish you all the best. And I know this is a tough conversation to have. But the technology exists. There's a lot of doctors out there that know how to do this. It's not their primary business. But I believe this will be the biggest trending topic in dentistry in years to come. It's functional and biological, integrative dentistry, that is connecting systemic health to dental issues. And we need to stop thinking that all dentists are great because they're not even a great dentist can have a bad day, but it could be you it could be in your mouth. So be curious, do investigation. And I hope you heal fast. And this is how you connect the mouth to the body. So thank you for your time. Stay safe, stay healthy, distributed and D levels because if you're going to need this surgery, you're definitely going to have to have high vitamin D levels as well. And we've also published on that. So I look forward to exploring this topic a lot more in depth throughout the year. Thank you
Transcribed by https://otter.ai