 Hello everyone, good afternoon. We are live with Dr. Susan Sklar and I am so excited to be here with her. We've got a topic that you either have never heard of it or you're dying to know more because you know no one is talking about answers and that's burning mouth syndrome. So hold, stay still there, hold your thoughts. We're coming back with that before I do, I wanna do a little housekeeping. So you probably know by now we're live most Tuesdays and Fridays. You can catch all of the videos on our YouTube channel which is just under my name, Jill Carnahan. All free content, go there if you've missed anything. This will be there in about a few days, maybe a week live and you can watch that. You can share it with friends who maybe have the syndrome and especially on this topic, I really encourage you to share this, especially if you know someone who's suffering from burning mouth syndrome because as Dr. Sklar and I talked right before we came on, this is such a needed topic and there's not a lot of experts that are able to talk on it from a perspective of root cause and we will get into all of that. Also, if you want to look up other blogs and things, my website is jillcarnian.com and you can find all products and other things at drjilhealth.com. Okay, I wanna introduce Dr. Sklar and then we will let her jump right in. So Dr. Susan Sklar has been an active physician in Southern California for the past 35 years. She finished her training in OB-gyny or obstetrician and gynecologist specializing in women's health at the Beth Israel Hospital, a Harvard teaching affiliate in Boston, Massachusetts in 1981. Then she moved to Southern California but the climate's a little better there. Delivered baby in here for gynecological needs of her patients until 1989 when she limited her practice to gynecology and began a long career specializing in the care of midlife women. After many years of caring for women in the important areas of hormones and hormone imbalance, she saw a need and a lack of service in an important area of sexual function problems. She developed a specialty practice in the treatment of female sexual function problems. She did clinical research in this important subject and served as a reviewer for the Journal of Sexual Medicine. Such a needed topic because again, a lot of docs, especially middle-aged women not addressing this. And this kind of set you for the foundation of the next step, right? Because of the gain perspective in the field of restorative, also anti-aging and functional medicine, these are all interlined. Her clinic is actually, it's the Restorative Medicine Center, Sklar Center for Restorative Medicine and we will include her website as well. And recognizes this basically types of medicine, recognizes the biochemical changes and hormonal decline that causes humans to age in ways that are not necessary or inevitable. So there is hope for all of us. Replacement and balancing of these natural substances results in improved vitality and longer, healthy lifespan. I could not agree more and I am just absolutely so happy to have you here, Susan. I'd love to start by just hearing kind of how we, seeing the journey like as far as your credentials but how did your personal journey manifest to where you are now? Yeah, so it's really interesting. And I feel like kind of my life has been on a path and there have been various threads that have entered and it's just all culminated right now, right here. And like you said, I started out as an obstetrician gynecologist and had two children and realized that delivering babies and being gone two to three days at a time if I was on call was not compatible with being the kind of mother I wanted to be. And so at that point, I stopped delivering babies and my hours became more regular and I could get to my children's sports and games and participate in their lives more because at that point they were like pre-adolescents and I thought if I wait five years, they're gonna be in college. So either I do it now or I don't do it. And so by getting into doing only gynecology, I really was able to focus on midlife women and all of their health issues, cardiovascular, osteoporosis and eventually sexual health. I remember one day a woman said to me, I'm not having orgasms and I don't think I ever have. And I didn't know what to tell her. And I said to myself, this is never gonna happen again. I am gonna learn what I need to learn. And it's, I mean, it's sad even though I went through an OBGYN residency, sexual function was not addressed. And so I went on a quest and I spent time with mentors, some of the famous people around the country on women's sexual health and made that a part of my gynecology practice. And so each step of the way, I learned more about hormones, more about neurology, anatomy, all the things that relate to our health. And at a certain point, and I was really almost close to retirement age, I was almost 60, I got completely burned out on the whole seeing 30 patients a day, and companies guiding my life. And I was like, I can't do this anymore. And so I was trying to figure out what else to do. And I don't know anything else to do besides medicine because I never wanted to do anything besides medicine. It's my passion, I love it. I mean, I have hobbies, but you know, not something else professionally. So I kind of pivoted and we have a foster son and our foster son designs furniture and he was designing furniture for somebody, a woman who's doing anti-aging medicine. And he said, this woman is doing something with hormones. And I think maybe you might be interested and she became my mentor. And she told me about going to AFRM and getting credentialed and scenogenics back in the day, I got training there and got my start on anti-aging medicine. And at the same time, I was having my own health issue. So I was going through all menopause problems and had colitis and had osteoarthritis and had psoriasis and all these things. And I was not getting answers. And so it's like it all came together in for me personally and in a way I could translate to patients. And so functional medicine's a lot more than hormones. So I had to learn about GI health. And it's like you go to medical school. So back to biochemistry, right? Like you're like, oh, I actually need to know this. I know my first AFRM, I was like, oh, those steroid pathways, I really do need to look at them again, you're right. So that's exactly what happened. And so I've been practicing functional medicine and one of my early patients in the anti-aging was a woman who was a physical trainer. So she was very aware of her body composition and her muscle mass and definition, all of that. And she wrote a nice little like review of me that we posted on my website and it said with her hormone restoration, she said, my energy is so much better. My muscle definition is better. And my burning tongue is not nearly as bad. And I was like, what? What is that? And then other people, cause they thought of my website started getting in touch with me. And that's kind of how I got into burning mouth syndrome. And then we've been in the study group with Dr. Bredesen. And so learning about hormones and nerve function, I had to take, I was like, why would a hormone program make pain better? Why would being on estrogen, progesterone, DH, she had pregnant alone? What does that have to do with nerves and pain? And so I did a lot of reading in the, you know, neuropsychoendocrine immunology literature, reading things like brain research reviews and things about what progesterone does and what estrogen does. And of course it all really became important working with patients with cognitive decline because all of the same hormones and neuro steroids are in play. So I feel like, you know, all these different threads have really come together for me and so burning mouth syndrome is kind of the culmination of all of that as well as learning a lot more about pain and pain pathways. Cause I must say I had never really, I mean, we dealt with pelvic pain and gynecology which usually came down to either, you know, musculoskeletal pelvic floor endometriosis. We dealt with vulvodynia, which is another very puzzling pain disorder. But burning mouth I think is one of the most enigmatic for all practitioners. So I love your journey and love how it's woven together. And isn't it funny like the things that we don't necessarily expect in these twist and turns and like children and then okay, I'm gonna switch this way. And then we have this view. I wanna just say this for people listening because sometimes you're in the middle of a transition and most of us are right now for some reason or another because this year has been the last year, I should say has been quite different than any other. And so if you're in the middle and you're confused or feeling lost or not sure or wondering why this happened, just know that when you, your story isn't over yet, but the end, the last chapter has yet to be written. And I get excited about that because I look back and I'm like amazed at how breast cancer and Crohn's disease and mold illness and my move to Colorado, all these things were like, they were hard at the time. And now I'm like, they were the best gifts ever. I would never be the physician with the heart that I have today without those things. So I love your journey, Dr. Sklar. And the other thing I wanna mention is you hit on something. We have allopathic training, both you and I, very good schools and we're trained in the best in the world in those centers. And we lacked some very important knowledge. And I love, we have our foundation on this allopathic medicine. I have no apologies because it's the, you know, right now it's still the best medicine in the world. But what's happened is we've been able to expand our toolboxes. And what we both realized is when we came to tough questions in the clinic, we didn't have all the answers. And the difference between you and I and a physician who may not know this information, I think is that we ask the questions, well, I wonder what else or why, either what else is possible or why? And I'm no more intelligent or no better than anyone else, but I do ask why a lot and you do too. And I love that because you had this case and instead of just, you know, brushing it aside, you went deep and you got information. And today I know that information is going to touch a lot of lives because this is a big deal and people aren't always talking about it or aren't always able to find a physician who has experience. So let's dive in. Let's talk about first, what is burning mouth syndrome? This is actually a clinical diagnosis and how would that present? And then we'll dive into kind of some of the underlying causes. Great, yeah, that's a wonderful way to line it up. Well, there's something in the journal of oral facial pain that I quote a lot. It says practitioners dread seeing a patient with oral facial pain and mucosal cavity, meaning in the mouth. And why? And that's a fancy way of saying burning mouth syndrome, right? Burning mouth syndrome, that's right. Why do practitioners dread seeing patients with that? Cause they feel like they don't know what to do about it. You know, we as practitioners, our whole lives are involved with getting people better and when we can't get people better, it's hard to see them. I mean, we feel inadequate and plus we feel bad for the patient who's in pain. So what burning mouth syndrome is, it's a pain condition in the mouth, often starting in the tongue, but can also travel to the cheeks. I've had people tell me their gums up into their nasal passages, down into their trachea and her breathing tube that are involved with a burning pain. And the official definition is that it needs to be present for two hours a day for at least three months. That's one of the official definitions. In the absence of anything else that you could diagnose that might be causing that pain. So the first thing that needs to happen with people who have, and it feels like you've drunk a lick with it's too hot, you know, that scalded feeling you get, only it doesn't go away. And the pain can be really intense. It destroys people's lives. I've had people say things to me like, I went through breast cancer treatment, I had surgery and radiation, and it was nothing compared to this burning mouth syndrome. And so I would say really, I wanna talk about the psychological aspects of it first. And there are some definite physiologic connections between pain and depression. There are some root causes that bring those two together. But what happens with people who are in pain, anybody with chronic pain tends to get isolated. Eating is such a social thing to do. And, you know, we've seen with the pandemic what happens when we can't socialize at restaurants and over food. You know, we miss a lot of our socializing and that's what happens to people with burning mouth because they never know, am I gonna be able to eat? Am I not gonna be able to eat? I don't wanna be with people and not be able to and people wonder what's happening. So people get isolated. A lot of people are made to feel like they're crazy because everything looks totally normal. I had one patient tell me, her doctor told her that she had a singular delusional disorder, meaning that she was focused on one thing and it was a delusion. Unbelievable. Really, so, you know, this gets the lack of knowledge of the medical profession gets put back on the patient as it's not me and my inadequacy or lack of knowledge in general, it's you, you're nuts. And 90% or more of the people that have burning mouth syndrome are perimenopausal and menopausal women. And, you know, we certainly, you know, we're all, at this point in history, very much wanting to address equality in medicine and healthcare delivery. Women get written off very easily. And so when a doctor, unfortunately, or dentist, any kind of practitioner is confronted with someone who's telling them having this pain, it's destroying their lives. There's no imaging, there's no lab tests. There's nothing diagnostic you can see in the person's mouth. It gets put back on the patient, they must be crazy. And there are articles in the literature of there was one article that said it was due to television moans, meaning women were watching too many soap operas and getting, you know, all involved in the drama of the soap opera and it was amplifying their pain. And so the whole issue of this is not psychogenic, this is not imagined. I can tell you the more that I'm reading and the more that I read about chronic pain in general, you know, it's really important to understand what's the difference between chronic pain and acute pain because we're good at handling acute pain. You break your arm, it hurts like crazy, you get it set, you get some narcotics and it immediately relieves the pain. Everything goes back to normal and your arm, you know, starts working again, great. Chronic pain doesn't do that. And it starts to set up its own pathways in the spinal cord in the brain and it perpetuates itself even when the original injury is no longer present. And the old wagon wheels of the West, when they go out and they be, I mean, there's places you can drive in Wyoming, Montana where there's wagon wheels still made these huge crevices in the rock and they're from a hundred years ago and the wheels created this pathway that's still there today. Exactly, exactly. And so what happens is these chronic pain pathways become well-worn pathways in the spinal cord in the brain. And certainly one of the things that is helpful for anyone with any kind of chronic pain is there are a number of ways to lay down new pathways. And there are a number of different techniques from journaling to meditation. And I won't go into that a lot, but you do wanna lay down new pathways. But one of the things that has been really important for me to learn and transmit to patients is that lack of dopamine is definitely involved in chronic pain. And lack of dopamine will give you depression and not wanting to initiate things as well as amplifying your pain pathways. And so it's not that, yes, burning mouth is very associated with stress, depression, and anxiety. Not that they cause it at the same underlying root cause it's causing both the pain and the emotional parts of it. So we need to address that. And there are various ways of doing it. There are some supplements that will help you make more dopamine. Things like ltyrosine and mucuna that can help with those pain pathways. The other thing is that pain, when you injure your thumb, there's a nerve that goes from your thumb and it goes to your spinal cord. It goes up to your brain. And when it gets to your brain, it doesn't just go to the place where your thumb is represented in your brain. It goes to the frontal part of your brain, which is your judgment thinking executive. It then goes to the limbic part of your brain, which is your fear and emotional center. Those are descending pathways. And then it goes up to the representation in your brain of where your thumb is to register that this is a pain. So the whole acknowledging pain and feeling pain intimately involves your thinking, judging process and your emotional process. And that's really important for people to understand. So, you know, wow, you just brought something like so important that I want to just stop and pause and highlight. I do mold illness, not the burning mouth center, but I've seen this. And what you just put together was, I've been talking about how mold causes this trauma loop. And you talked about to this limbic and this is the same pathway for pain. So it's very parallel what you're saying because it's not just that you get this exposure and you're like, I'm fine. I know I'll be okay. You might consciously know that. Same with the burning pain or the chronic pain. You might know, okay, someday this will go away or you might have a very logical way to deal with it. But what we're talking about here are the subconscious triggering of the limbic system and other parts of the brain that they're almost, it's not beyond our control. Cause some of the solutions are the meditation, the neuroplasticity loops that creating exactly. It feels like a lot of these things, unless you actually address it. And again, for my little world mold illness, you have to address the limbic system or you won't get well. It sounds like very similar to what you're saying with chronic pain or burning mouse syndrome specifically. You have to address those loops, those wagon wheels and the dirt or the rock, because if you don't, you're going to keep perpetuating that cycle. Right. And you know, I'm in Southern California. So I always explain it to people like, if you're on the freeway and there's an accident in front of you, you have to get off and go around on city streets. So. I love that analogy. Cause that's what it is. And what you said was neuroplasticity. Cause we're talking about like creating new loops, right? So I love it. Exactly. Yeah. So you might be really used to going on the freeway and it's a little bit different doing the work around. It takes a little bit more thinking, but it'll get you. So you need to, you know, develop those alternative pathways. So that's really important. So when I saw that first review by somebody who said her burning mouth wasn't nearly as bad once she was on her hormone program, I was like, well, why would that happen? Yeah. I mean, what do hormones have to do with pain? And so, and this was like 13 years ago when I first encountered it. And there was no book on it. And so I started looking in the scientific literature and thank goodness for the internet. Pubbed, which has, you know, almost all of the really important journals and articles that you can access. And I started finding answers in what's called the psychoneuroendocrine immunology literature. And it really exemplifies what pain is. It's neurological, it's immunological and it's endocrinological, meaning hormones. And so as I was reading, so I read about progesterone and I was like, why would progesterone, you know, what would it do? Progesterone helps calm nerves down. It helps improve nerve to nerve transmission. It decreases toxin effects on nerves. There was a study of using progesterone like on the battlefield for traumatic brain injuries. And unfortunately, and it was a well done study. It didn't show benefit. I'm not sure why, but we do have lots of other evidence that progesterone is brain protective. Estrogen helps with brain speed, nerve to nerve transmission. We use DHEA, Dehydroepiandosterone. It's a neuro steroid, it's a steroid hormone made in the adrenal gland. It has tremendous anti-inflammatory properties and also incredible properties for neuropathic pain, which is this kind of chronic pain that takes on a life of its own. Now quick pause there because of course, like I use that frequently with perimenopausal, postmenopausal, but I'm using the lower doses and I'm wondering, you don't have to give specifics, but are you going higher because I've seen the studies with autoimmunity and inflammation where they go quite high with the DHEA? Go high with DHEA and high with pregnant alone. And really my limit is, you know, if it's high enough to cause side effects like acne or oily skin or hair growth where you don't want it. So I go pretty high with DHEA and pregnant alone is another steroid also made in the adrenal gland that has incredible effects for neuropathic pain. And I actually, when I was early on doing this, I tried to figure out what I could put in a supplement. So there was some literature about lipoic acid and neuropathic pain and lipoic acid. There's a lot in the literature about diabetic neuropathy. There's some in the literature about burning mouth syndrome and lipoic acid. We know that vitamin B12, methyl B12 is really important for proper nerve function. And I couldn't put estrogen in a supplement because you need prescription. I couldn't put testosterone in or thyroid or progesterone. I put the two things in that you didn't need a prescription for that you could get over the counter, DHEA and pregnant alone. And I put it in a supplement and I would say 30 to 50% of people that use it get relief, significant relief of their burning mouth syndrome. That's tremendous. I want to pause and I want to make sure that people can get access to that. So at the end we'll make sure that's tremendous, tremendous. What were your like per cap doses of DHEA to bring up? It had like 25 of DHEA and a hundred of prignine alone. Perfect. So, and I didn't, I honestly hadn't read anything about why it worked until I came across a website called Practical Pain Management that was started by a pain specialist, Dr. Forrest Tenant. And he was the pioneer about talking about hormones and pain. And his first article came out in 2013 and I didn't know about it. I only came up on his website in the last year and I've been in touch with him. He didn't know about burning mouth syndrome. He was really interested, but on his website and he has two websites, one for patients and one for professionals. So, his lots of references and everything. He talked about prignine alone and DHEA and it was like, oh my goodness, I've finally gotten validation from an outside source on what I'm doing because I knew it worked, but it's kind of nice not to be the only one. You know. Yeah. We all kind of like, oh, and sometimes I'm lecturing in my clinical experience, right? And you just frame it like, I see this in clinic and I know it works, but I don't have a large study. So it is so good when you, and what I found more and more is there are these great minds like you and you're parallel in this journey and you found, you basically serendipitous found this great solution, but how wonderful to be validated. That's all. Yeah, I did. I also had another validation. And again, it's like, thank goodness for the internet. It was a Fourth of July weekend, golly, 10 years ago. I was on reading about burning mouth syndrome and there was a study from France that mentioned the hormones and it ran a general way and a researcher named Dr. Alan Woda. And, you know, thank goodness for clickable links. He had a clickable link on his name and it went to an email. And I thought, I don't know, give it a try. So I sent him an email and I said, hi, I'm a doctor and you know, the United States and I've been using hormones for these burning mouth patients. And like, is there anything like, can you tell me anything about that? You know, I saw something about hormones in your research article. And like the next day he emailed me back and said, oh my goodness, I have known this theoretically but have not had the ability to actually prescribe the hormones and implement it. And, you know, yours is like the first kind of clinical evidence of actually having it work. And you know- Oh, that's tremendous. You probably made this day, week, month. I know what he made mine. We were in communication for quite a while. And you know, it's like halfway around the world. Oh, how fortunate we are to have, you know, these resources. So with burning mouth syndrome, some people do well with the supplement and then other people want to become a patient at my center where I can prescribe the full, what I call the full range. So with burning mouth syndrome, some people say you don't call it burning mouth syndrome unless you've addressed the thyroid because hypothyroidism can cause burning in the mouth. And so we looked very carefully at thyroid and you know, Dr. Jill, because you're in functional medicine, we don't just use the regular lab ranges as what's optimal. We measure free T3, which is a thyroid hormone that is your active thyroid hormone, which the conventional medical system generally doesn't measure. I feel like it varies too much during the day or I don't know, there's some reason. I'm not exactly sure why. So they measure your thyroid stimulating hormone, which is a hormone made in the brain that governs the thyroid. And if that's abnormal, they'll measure something called your free T4 or thyroxin, which is not your active hormone. It's your precursor hormone that then has to buy a series of steps and with certain nutritional factors, iodine, zinc, selenium turn into T3. So we look at T3, we look at T4, we look at reverse T3 because under stressful circumstances, reverse T3 gets made. And it is an opposing chemical to free T3 and it will block the action of free T3. So even if your free T3 level looks okay, if your reverse T3 is high, your free T3 can't do the job. So thyroid is an important part of it. Estrogen, I mentioned progesterone, DHEA, pregnant enolone, testosterone has protective effects on nerves and melatonin does. And there are lots of documentation about melatonin and chronic pain conditions. We also always look at vitamin D because vitamin D is called a vitamin, but in fact, it has a chemical structure of a steroid hormone. And so vitamin D is really important for healthy nerve function. And so those are the things that we replace depending on somebody's levels in what I call a full hormone restoration program. There are other things we look at because some of the other things, and I'll just mention some of the things that need to be ruled out, thrush or yeast in the mouth can cause burning. So that's if I can comment real quick because this is more of a gut mouth of my area. The one thing I knew for burning mouth, and again, you're going way beyond that. So this is fascinating was the whole yeast and creation of oxalates in that pathway because the oxalates can create something. So I knew so bad. And often in the organic acids in the urine, which is a test that us as functional doctors, we often do, you could see the oxalates and sometimes that would be associated with pain. But this is obviously way beyond that. So I understand how that yeast could be an issue. And so we look for that, you look for evidence of herpes or a post herpetic neuralgia, which is lingering pain that people can have after herpes or varicella, which is shingles in the face and head. We look at apthus ulcers, which are ulcers that occur. Bichette's disease, which is an autoimmune disease that can cause mouth ulcers. So you wanna rule out ulcerative diseases. There are some anti-hypertensives, particularly the ACE inhibitors, which whose names end in PRIL like Lysinopril that have been known to cause burning mouth syndrome. So people need to go on a journey to rule these other things out. And by the time people see me, they've seen four, six, eight practitioners. And at least they've seen dentists, oral surgeons. So I know that they don't have any of those issues going on in their mouths. And then the other things that we use. So I've learned a lot through treating patients and there's a wonderful pain specialist who we co-managed one of my patients. He's at Duke, Dr. Wolfgang Leakey. And I learned from him about using low dose naltrexone for chronic neuropathic pain. And so patients who have not gotten where we want them with their hormone restoration, we add low dose naltrexone. And do you want me to say a little bit about what that is? Yeah, definitely. Yeah, so sometimes people get freaked out because they go look it up on the internet and they read about naltrexone being used as an antidote for opioid overdose. And it is. And in high doses, it will block the opioid and opioids are things like coding and, you know, dilated, oxycodone, all of those things are opioid medications. And, you know, we know right now in the United States there is the tremendous amount of opioid abuse and overdosing. And so naltrexone blocks opioids in the brain. Opioids kill people by landing on the respiratory center in the brain and slowing it down so much that people stop breathing. And so if you can give them naltrexone, it will block that. That's in high doses, 50 milligrams. What was found is if you use naltrexone in very low doses, one and a half, three, four and a half milligrams, it actually has the opposite effect and it will stimulate our opioid receptors. We make our own pain relieving chemicals in our bodies, many of them, and our own opioids, what we call endogenous, meaning we make it ourselves, opioids help relieve pain. We make them ourselves all the time, but low dose naltrexone helps our body do that. So that is a thing that we add on. Yeah, there's a lot of research with autoimmunity and other pieces besides just pain. So it's a functional medicine we'll use. There was a few studies with Crohn's and colitis with ovarian cancer, with chronic pain, and I find it even in SIBO, it can be helpful because as an opioid blocker, it actually increases motility. So there's all kinds of little ways that we can use this. And it is different from the full dose naltrexone because it kind of ends up having the opposite effect. So you could ask your doctor, there is a LDN research website that actually does a pretty good job of bringing together the research. If you wanna know more, you can go there as well. Right, it's a great site. And part of the anti-inflammatory actions with low dose naltrexone also helps neuropathic pain. Because like I said, neuropathic pain is nerve, it's immunology, so that there's inflammation going on in those nerves and it's endocrine. And then some of the other things that we've worked on trying that have helped some people, oxytocin is a hormone that helps pain and helps anxiety. And so oxytocin can be helpful. Like I said, we're working on the dopamine pathways. And so far I've used supplements on the dopamine pathways, but I'm actually considering using some of the dopaminergic medications. And there are a number of them. Ropineral is one of them, things that are used for restless leg syndrome, which is thought to be due to a dopamine deficiency. And I was interesting. I spoke to a patient just a couple of days ago, a burning mouth patient who went on vacation and she forgot to bring her medications with her. And one of the things she was on was something for focus and attention deficit called vivants, which nobody knows exactly what the mode of action is. And so she couldn't get that. She was in Aruba and she couldn't get it. So they gave her the next substitute, which was Concerta. And she said, you know what, my pain was gone for almost the whole week I was in Aruba. It came back the last couple of days. And I was like, wow, why would that happen? I looked up Concerta and Concerta works on dopamine and also nor epinephrine or nor adrenaline pathways. And so I have not prescribed those. They're usually psychiatrists prescribe them, but I am gonna consider starting to use them as more potent ways of affecting the dopamine pathways. So I love this. And I just, because my mind always goes out here again, we're like thinking ahead and what could we do with this or whatever. At first of all, I love dopamine. I'm a dopamine girl. I have a motorcycle, I climb mountains. I like, I actually just make a lot naturally. But there's definitely a correlation with what you do testosterone will increase dopamine. So that might be part of the way that testosterone is working because testosterone and dopamine together. So that's something that we can safely do. And then I find actually doing things like we talked about the wagon wheels and the routes and the neuroplasticity. So doing things outside your normal routine like going a different way to work or getting a different drink at your coffee shop or choosing to do something different at night for your routine, all these different ways that are really simple going on a different walk or a different hike with your friends or your dogs or whatever. They actually create new neuroplasticity but the diversion and something different can also help dopamine. So there are ways that we can like do not just a pill or supplement which we're all for if they're safe and effective but there's other ways in our life that we can actually and sometimes doing those things that are a little bit like for me recently I climbed the third flatter and I was terrified. But after I was done that exhilaration that was probably all dopamine it lasted for a month maybe longer because I had like done something completely outside the norm terrifying but it actually was so doing those things that made me scare you a little that are safe and exciting and within reason because dopamine can cause impulsive behaviors too. So we don't want that side but I'm just encouraging you to get outside the box a little because that might be a way to help dopamine. We also know serotonin and dopamine are yin and yang just like testosterone and estrogen. So if you have way too much serotonin you're gonna actually dampen your dopamine. So we love serotonin, we need serotonin. I have no idea but I wonder if an SSRI could also lower dopamine too. So these are all things I'm just throwing out there don't have all the answers but the thoughts are these all play as a harmonious symphony and there are ways I think that we can support dopamine like you said to the fava bean which contains the muco purines and also tyrosine you mentioned. Right, right. So yeah, there's lots of crossover and one of the things you had asked me about was histamine and there is a Dr. Dr. Lawrence Affron who has a series he's published a couple of series on burning mouth syndrome as a mass cell over activation or mass cell activation disorder. And mass cells are immune cells and they release a number of different chemicals that can cause problems and mass cells release histamine which people are familiar with who have allergies and get itchy eyes and runny noses but histamine is also involved in the pain pathways along with other chemicals that are produced by mass cells. I have not been real successful in having people get relief with the use of antihistamines and he uses two different types he uses an antihistamine like loradidine which is you take for environmental allergies that hit the H1 histamine receptors and then he'll also use something like flamotidine which is pepsid which we think of for the H2 blocker which blocks stomach acid and so it gets at the two types of receptors. So I am trying to look at that some in patients who look like they might have mass cell activation who have flushing. I always ask about dermatographism which is if you scratch your arm I don't have it but if you are left with a pink line that pink line is a result of histamine release from in your skin from scratching it. So I'm trying to figure out who might have histamine problems where that might be a cause of their burning mouth. One of the issues with this or any neuropathic pain condition is what started it? What is when you talk about root cause really what is the root cause? And with burning mouth nobody has been able to figure out what it is and I'm looking at all the usual things I'm looking at mold I'm looking at Lyme I'm looking at viral infections and I think for different patients it might be different. Yeah, that makes sense. But what really led me to the hormone root is if 90% of the people that have it are perimenopausal and menopausal women and so many of it for women it started either I talked to somebody the other day it started with a hysterectomy she had and our ovaries removed a year and a half ago or it starts within a year of the last menstrual period. We know that estrogen has it has some effect on histamine may actually stimulate histamine but estrogen also has a lot of anti-inflammatory reactions and actions in the endocannabinoid system in our body. And so not only do we have our own opioid system inside we have our own cannabis system inside and our cannabis system is millions of years old. And so... Have you found a topical or tinctures of THC or... Some people have. Yes, some people have gotten relief with cannabis. So... And so estrogen some of estrogen's actions is through our endocannabinoid system. So there are many, many layers, you know of how things like how hormones have their effects on the neurotransmitters and on our endocannabinoid and our opioid systems. And I was reading about orexins. You know, orexins is a system of part of our hunger and satiety system and that's involved in our pain pathways. And so, orexins will actually activate those H1 and H2 receptors. And it's thought that acupuncture works via the orexins system partly. That makes sense, because that's a great therapy for pain because you're really treating a lot of that. I've seen that work when other things don't. Right, right. Let's see, I'm trying to fix that. Dr. Esquire, you have really gone the gamma. It's a perfect functional medicine case because it's really so many different pieces of the puzzle. And it sounds like there's a large percentage of hormones definitely is a huge piece of the puzzle, which is neat because you had this expertise background there already and this lends itself well to applying that and the fact that you basically came in contact with some experts in the field that, I mean, to me, this is groundbreaking, what you're doing. And I'm gonna try to help you get the word out because there's not many people talking about it. And it's so important for you to really be able to look at all those different parts. And like you, just continue to look for more options and more treatments and things out there. So that's tremendous. So if someone wants to get a hold of you or see you or get products, what's the best way to get in contact with you? Sure, so there's my website, which is www.sclarcenter.com and my office 562-596-5196. And we do a burning mouth consults. There's a link on our website and our supplement is also on our website. Perfect, this is so tremendous. What great information, like I said, I'm gonna find especially special interest groups and already we have comments of physicians and patients that are like, this is great information. Thank you so much. I know it's just gonna grow. As like you said, when I heard you, you reached out to me and said, hey, can we do an absolutely? Cause it's one of those conundrums that in many, many physicians, if not almost all of them don't know what to do with it. Like you said, did I have some answers? I just can't thank you enough for being that, in the ground doing the work, trying to figure it out and for bringing us your experience. So it's been about a decade that you've been seeing cases like this, right? It has, yeah, it's been quite a while. I have, yeah, you know, I was actually, one of my patients told me that she was gonna go see a burning mouth expert in Los Angeles, Dr. Joel Epstein. And he's written a lot of the scientific papers. And so I just filled out the contact sheet on his website and said, hi, Dr. Epstein. I'm a down in the Long Beach and I'm treating burning mouth syndrome. And, you know, I'd like to know if I can refer patients to you. And he got in touch with me and he said, you have a whole other way of approaching it. And not only do I treat patients with burning mouth syndrome, I work at City of Hope, which is a big cancer center in Los Angeles. And patients post cancer therapy have a huge amount of problems with pain in their mouths and nobody addresses it. And he's like basically, you're it. Wow, I love it. I know I said I was so surprised that actually you took the time to get in touch with me. And he said, well, I don't run across very many people that are interested in burning mouth syndrome and, you know, have your kind of experience. You're kind of it. So, you know, he and I will collaborate some. Mendes, and that's interesting because 20 years ago to this year, I had breast cancer, three drug chemotherapy. And that chemotherapy has a really talkative effect in the mucosal lining. So I remember very well having, now mine was ulceration. It wasn't the burning mouth syndrome, but it was definitely pain, definitely pain all the way down. And I saw, I really, I just had that little flashback. I remember how that was and how you're right. And there's not a lot that being done for that. So thank you. Thank you for your information today. I know people are really going to enjoy this. I will share it wherever I can. And any last words of wisdom or parting advice for our listeners? Yes, keep searching. The people that have found me search the internet incessantly looking for an answer and don't accept that you're crazy or it's in your head. You know, know that there is something going on. You just have to find the answer. Just keep looking. Awesome advice from Dr. Sklar. Thank you so much for joining us today.