This week is Australian Dental Health Week and I am joined by my partner in the surgery, Dr. Lewis Ehrlich. Lewis and I bring the dentist to you, we discuss what we are looking for during a general checkup and why it is important for your health.
Selected Links from the Episode
Dr. Ron Ehrlich: Hello and welcome to “Unstress”. I’m Dr. Ron Ehrlich. Now, this week is Australian Dental Health Week and I am joined by my partner in the surgery Dr. Lewis Ehrlich. Welcome to the show Lew.
Dr. Lewis Ehrlich: Thanks for having me on again Ron.
Dr. Ron Ehrlich: Lew, it’s dental health week in Australia and actually we were just talking about this before we started and that was that… the actual fact that it’s called dental health week I have a little bit of a problem with.
Dr. Lewis Ehrlich: Why is that Ron?
Dr. Ron Ehrlich: Funny, you should ask. Funny you should ask. But there’s so much more. I think it should be called oral health week at the very least. I mean there’s more to what’s going on in people’s mouths than the dental tooth aspect and interesting that the Australian Dental Association has called it dental health week. I’d like to call for a change oral health week. So, for our listeners’ point of view, it’s oral health week.
Dr. Lewis Ehrlich: Couldn’t agree more. There’s so much more to it than just the teeth. But it could be a bit of marketing at play there. Perhaps dental is a little bit more marketable than perhaps oral health.
Dr. Ron Ehrlich: How long has it been since people have been to the dentist? I don’t know but this was an opportunity I thought for us to come to you, our listener for a check-up. So, we thought we’d run through what we consider to be a standard check-up and so go through a few things that might alert people to “Hey, maybe there is more going on there in the mouth” because I think one of the things we’ve reflected on before is that when you think about oral health you’re thinking about, “Well, okay, tooth decay, gum disease, oral cancer and mouth ulcers, a whole range of things. 95 percent of what we see in the surgery and in the practice, has no pain associated with it at all.” And that often surprises me even after all these years.
Dr. Lewis Ehrlich: Yeah. And a lot of people just think that that’s good enough but there’s it’s more to improve and it’s all about achieving people’s potential for greater health. So, an absence of pain isn’t a great indicator.
Dr. Ron Ehrlich: No. Well, I often use the analogy that if you go to see the cardiologist and the cardiologist said to you, “Hi, Lew, how are you? Were you in any pain?” And you went “No, I’m not”. And he went “Great, we’ll come back when you’re in pain.” You kind of think hang on this isn’t cardiology as I think it should be practiced.
Dr. Lewis Ehrlich: No, it wouldn’t be a good idea.
Dr. Ron Ehrlich: And the same is true, dental. So, there are a lot of reasons why people could come to the dentist. We’ve got a list of them within the practice. Do you want to share that with our listener?
Dr. Lewis Ehrlich: Yeah. Headaches, neck aches or jaw pain.
Dr. Ron Ehrlich: Yeah, a lot of people don’t associate that with oral health issues, but they certainly can, and we’ll touch on that.
Dr. Lewis Ehrlich: Such a sensitive part of the body the mouth and can have an impact on you on your ability to avoid headaches, neck aches, and jaw pain. So, a lot of people don’t know about that. Snoring, sleep apnoea, poor sleep. So, sleeping is not just letting your head hit the pillow it’s about breathing well while you’re asleep and we want to know if you’re not sleeping well.
Dr. Ron Ehrlich: Yeah, we’ll go into that. We took a lot about sleep hygiene. I think one of the nice things about a visit to the dentist is that it’s a fairly, one would hope a fairly regular thing at least once every six or twelve months. So, it’s a great way for a health practitioner to check in on your own sleep hygiene. It’s not just about brushing, and flossing, oral hygiene is obviously important but sleep hygiene just to keep that going throughout your life is important.
Dr. Lewis Ehrlich: Yeah, 100%. We also do consultations on root canal treatments which have some controversial information out there on the Internet. So, we see a bit of that coming through the door.
Dr. Ron Ehrlich: We do, we do. I mean that’s an issue which we can touch on as well, we can talk about what it is. Another one is well dental implants, are they appropriate for you? Are they good for you? Are they a good alternative? Bad breath. I mean people are focused on the bad breath.
Dr. Lewis Ehrlich: Yeah, we see a lot of that actually. I’ve noticed an increase over the last few years.
Dr. Ron Ehrlich: Of people being aware of that.
Dr. Lewis Ehrlich: Yeah, yeah partners complaining about breath, people noticing bad breath and not just in the morning just throughout the day.
Dr. Ron Ehrlich: Yeah, well, so I think that’s worth touching on I mean 70% of bad breath is coming from the mouth itself. That’s most common and if you want to explore that a bit further just go and floss your teeth if you don’t do that regularly and then have a sniff of the floss and that could give you a little bit of a hint as to where that might be originating from. But occasionally bad breath can be a reflection of more serious illnesses like diabetes, like kidney disease, like liver disease. That’s a little less common but mostly in the vast majority of cases, it’s coming from the oral cavity, not just the teeth. The oral cavity.
But anyway, why don’t we kick off with… because a very important part of a comprehensive oral exam is to take a good history and people are often surprised at some of the questions we ask but they do have relevance and that’s part of what today is about, it is to share some of those things. So, let’s kick off with the first one Lew which is a really common one and that is bleeding gums. People get asked to do your gums ever bleed when you brush or floss your teeth.
Dr. Lewis Ehrlich: Yeah and the vast majority of people that come in the door actually tick this box and it’s a little bit of a worry because it’s a sign of chronic inflammation and inflammation is not good for the body, for your overall health and a lot of people ignore it but really, it’s something to get on top of because if you’ve got a lot of chronic inflammation you leave yourself susceptible to a range of systemic diseases. Gum disease is linked to heart disease, diabetes, preterm birth weights, erectile dysfunction even, rheumatoid arthritis the list goes on. And so, getting on top of that and not ignoring it we a lot of people tend to do is very, very important for overall health.
Dr. Ron Ehrlich: Again I use another analogy there and we will often ask them, yeah but there’s only bleeds when I floss and so it’s not a real problem and I say to them well now listen if every time you washed your hands the cuticles of your nails bled would your response to that be “Oh, gee, I better not wash my hands for the next couple of days and that won’t happen”. No, you’d be thinking what the hell is going on there? And you should be thinking the same about bleeding gums too. What about mouth ulcers?
Dr. Lewis Ehrlich: Mouth ulcers? Well, I mean that can be a range of things. It can be an indication of nutritional deficiencies, immune problems you might be sick rundown stressed but an ulcer that doesn’t heal for a long, long time can actually be a sign of oral cancer. So, it can be sinister, it can be something that’s very routine and easy to deal with.
Dr. Ron Ehrlich: I mean I think if an ulcer and people do often come in and they say “I get an ulcer for about a week and then it clears up”, that’s what’s called an aphthous ulcer and it’s usually as you say a reflection of a rundown immune system. So, it’s a little bit of an alert. What about dry mouth and cracked lips that’s something we focus a lot on isn’t it?
Dr. Lewis Ehrlich: Yeah, well, waking up in the morning with the dry mouth can indicate that you might be mouth breathing at night instead of breathing through your nose and breathe in through your nose is very, very important for your overall health and it’s the way nature intended us to breathe but unfortunately, we got a bit of an epidemic in society of people mouth breathing. I’m a big people watcher, Ron. You’ll see a lot of people around the place walking around with a head forward posture with their mouths open and that has huge dental implications. One because you want your saliva to be in your mouth and not dry it out because that’s got a protective effect in the mouth. So, you’re going to leave yourself more susceptible to decay, gum disease but also, you’re more likely to get a crowded upper and lower jaw as well if you’re a mouth breather. So, they can have an impact on your ability to sleep well at night time and wake up refreshed and keep your immune system strong but also not a great cosmetic look either if you’ve got crowded teeth as well.
Dr. Ron Ehrlich: Yeah, well, that dry mouth is again something and cracked lips is a sign that you kind of blow drying your lips that is every time you breathing your ears rushing in and out of your lips cracked lips. So, they are kind of alerts to us to become aware of exactly that problem. Noses are for breathing, mouths are for feeding and talking…
Dr. Lewis Ehrlich: And it’s important to retrain the patient to breathe through their nose.
Dr. Ron Ehrlich: That’s something we’re going to. Clenching and grinding of teeth. Another common one, what do we make of that?
Dr. Lewis Ehrlich: Well, there’s so many reasons for doing are such a common problem in today’s society and when you’re asleep you should actually be relaxed but if you’re clenching and grinding your teeth over nighttime think about how much energy you’re actually expending there when you should be resting. Your jaw can exert about a thousand pounds of force and instead of having a really nice relaxed sleep it can be quite stressful. It’s like going to the gym and doing bicep curls for eight hours you’d wake up pretty exhausted but there are so many reasons for clenching and grinding, it can be stress, it can be mouth breathing, sleep-disordered breathing, sleep apnoea, recreational drug use can do it, previous injury postural stress etc. There’s a whole range of factors that we need to kind of get a really good history of in order to diagnose well.
Dr. Ron Ehrlich: Yeah, we know now that in probably 70% of cases it’s a reflection of sleep-disordered breathing meaning you’re not breathing as well as you should while you’re asleep which is another reason why we focus on sleep quality.
Other things that we look at the sensitivity of teeth to hot and cold and that’s quite interesting because it tells us different things. Sensitivity to cold tells us that people are clenching or grinding their teeth or if a particular filling or crown is sensitive to cold then that filling or crown may need an adjustment of the bite. But sensitivity to cold is often alerting us to teeth contacting too much clenching or grinding. When people are sensitive to hot and cold that sends out a different alert to us and that tells us that there’s probably an inflammation within the nerve of the tooth. It could be decay, could be an infection. So, that is something that is really important. We also look listen to whether the jaw is clicking or not. And clicking jaw tells us the disk is out of place within the jaw joint and if you’ve got a restriction in opening the normal opening should be about 45 to 55 millimeters. I think if you put three fingers spread teeth, I just demonstrated have all the listeners can follow that. But you need to be opening your mouth at a normal level which is around 45 to 55 millimeters and jaw aches and all of that are obviously pretty important. So, our question going on about do you get headaches, do you get neck aches are really important because when you clench your jaw not only do your jaw muscles tighten but so do the muscles around the neck and shoulders and that is they can refer pain into the forehead into the temples into the back of the head. So, the connection between clenching or grinding of teeth and what is common chronic tension headaches and neck aches is really important and that’s part of an oral health exam.
Dr. Lewis Ehrlich: Yeah, I think it’s really important that people actually understand that some of the headaches and neck aches and jaw aches that they feel can be coming from the mouth. The number of patients that come in and say yeah, I get headaches all the time and they’ve got those worn-down teeth and huge muscles around the jaw and they tell me it’s got absolutely nothing to do with what’s happening in the mouth. This is part of the reason why we are such comprehensive questions because it’s all about educating people on the fact that it could be coming from the mouth and a lot of people just don’t realise that.
Dr. Ron Ehrlich: Yeah, yeah. Well, that’s exactly right. I mean people know what they know but there’s an awful lot they don’t know and that’s what this is about. So, this is oral health week this is why it is an oral health week, not dental health week. Sorry, I’m beating the drum here. Then we do ask commonly these questions about sleep and the questions that we asked routinely?
Dr. Lewis Ehrlich: What time do you go to sleep?
Dr. Ron Ehrlich: Yeah, yeah that’s an important one because sleeps a question of quantity getting enough sleep and quality how much sleep should people be getting?
Dr. Lewis Ehrlich: It really depends on their age, but an adult would be hoping to get around seven to nine hours of sleep. Ideally, they should be asleep by 11:00 the most reparative sleeps between 11:00 and 4:00 so if you’re not sleeping during that time waking up having disturbed sleep etc. you may still be waking up refreshed, but you certainly won’t be at your potential. So, finding out when people are sleeping is important because the number of people that go to bed at 1:00 in the morning 2:00 in the morning they’re on electronics late at night etc. It’s very common.
Dr. Ron Ehrlich: It’s very common. So, we ask some very basic questions and I’ll ask as the listener and ask you this is it easy for you to fall asleep at night? Yes or no typically ideally, you’d want to be falling asleep within 20 minutes of putting your head on the pillow. Do you wake through the night? Very important question. People do wake through the night for varying reasons and a lot of people go to the bathroom. That surprises people why they do that surprises people. Do you want to share that with our listener?
Dr. Lewis Ehrlich: You talk… You can talk us through the biochemistry there.
Dr. Ron Ehrlich: Okay. Well, I think if you’ve listened to some of our podcast you will know that getting up at night to go to the bathroom can sometimes be a reflection of sleep-disordered breathing because when you’re breathing goes out of balance it affects the carbon dioxide level in your lungs and that has a profound impact on smooth muscle throughout the body and the bladder is smooth muscles. So, when you’re breathing goes out of balance you may get up at night to go to the bathroom. And so, that gives us an alert as to whether there’s a sleep disordered breathing or do you wake up in the morning with a headache? Well, that tells us there’s a clenching or grinding issue probably. It may also be related to your posture at night which is another thing we would check in our comprehensive oral health exam. Do you sleep on your stomach side or back? All very relevant.
Dr. Lewis Ehrlich: Yeah, well, also just going back to the waking throughout the night waking up around the sort of 2:00 a.m. zone can actually be an indication of adrenal fatigue. So, constantly on the lookout for that as well. People shouldn’t be producing so much cortisol your stress hormone while you’re asleep. It should be reparative sleep and often that can be a sign that your cycles are all out of whack and sometimes you need some support which we is why sometimes refer on to integrative GPs and naturopaths but people should also be taking time to relax throughout the day.
Dr. Ron Ehrlich: Yeah and the sleeping position. Stomach sleeping without a doubt the worst it’s it puts a strain on your neck on your jaw on you on the muscles of the upper part of the body it affects the airway, it’s a really bad position. Sleeping on your back it is better but the problem there is that as we get older it’s so easy for the jaw to drop back at night the lower jaw and the tongue is attached to lower jaw so sleeping on your back and promote snoring or blocked airway. Sleeping on your side as it turns out is probably the best and not just for your sleep for your muscles for your airway but also for your digestion. Sleeping position is something also we go into but the most important question is do you wake up feeling refreshed? Because after all, that’s what sleeps about.
Dr. Lewis Ehrlich: Yeah builds resilience into our immune system. Repair overnight so we can live a long life and if you’re in deficit night after night after night for 25 years which is how long we sleep for in an average lifetime you can’t really expect to be healthy if you’re not waking up refreshed night after night.
Dr. Ron Ehrlich: Yeah, well I often I will now refer to sleep as a non-negotiable built-in life-support system. I either use it or lose it but that we also ask about snoring, do people snore? And this is a throwaway line for “I snore but it’s no big deal”. Well, it is, isn’t it?
Dr. Lewis Ehrlich: Yeah, it is. It can affect relationships which are pretty important. There’s a number of patients that come in that haven’t slept in the same room together for 20 years so there’s a relationship angle there. It is a sign that you’re not breathing well and that can be a sign of sleep apnoea. And sleep apnoea is linked to heart disease, diabetes, depression, anxiety. It’s a lot of people are depressed and anxious out there but a lot of the reason for some of the time is actually that they’re not breathing well.
Dr. Ron Ehrlich: They haven’t actually surprised me how often when we’re taking a medical history and people will tick that box. Yes, they’re on antidepressants but no one has done a comprehensive question of their quality and quantity of their sleep. But if you accept that sleeping and I think this is the most important part of the day, it’s your life support system. And if you are fortunate enough to share your bed with somebody who you truly love then dealing with the snoring which is disturbing that most important part of the day for their health is a serious issue. So, I try to encourage people patients to take that really seriously. And sometimes solving a person’s health problem involves getting their partner to stop snoring and there are so many different ways of doing that whether it be losing weight, whether it be using an appliance in the mouth a plate that holds the jaw. A little bit forward and maintains a better airway or in really severe cases using a CPAP a mask that produces air that keeps the airway open, but it is not to be… it’s one of the most important things this idea “Do you snore at night?” and it’s something we really focus on.
We also do a fairly comprehensive medical history and people are often surprised at why we might ask that. Why do we need to ask that kind of questions? What does it tell you?
Dr. Lewis Ehrlich: Well it really depends on the condition, like for example we want to know about whether a patient has respiratory problems that can be an indicator that they’re not breathing well when they’re asleep and that can, as we previously mentioned, have huge health implications.
Dr. Ron Ehrlich: Yeah, well, the idea of breathing through your nose is that you warm humidifier and filter the air before you take it into your lungs so if you are a mouth breather you are far more predisposed to upper respiratory problems like allergies asthma enlarged tonsils and other airway and respiratory problems so that gives us a little bit of a hint.
Dr. Lewis Ehrlich: Yeah and so many kids come in with all those issues and they walk in with their mouth open and their stuffy and they’ve got bags under their eyes and they’ve got a head forward posture because they can’t breathe properly.
Dr. Ron Ehrlich: Yeah, so we also want to know do they have digestive problems. Do they have reflux heartburn indigestion? Rising acid is a problem for people in general but it’s definitely a problem for people’s mouths because if we’re getting rising acid into the oral cavity that’s not a good thing. So, digestive problems are also important and being regular in bowel movements and are you suffering from bloating, gas, indigestion, reflux? I mean so much of the immune system is in the digestive tract so if you’re having digestive problems then we know we’re dealing with somebody probably with a compromised immune system.
Dr. Lewis Ehrlich: Yeah, I think people need to be a little bit more aware of how food makes them feel. There’s kind of this idea that you just ate and then you go about your day and there’s no sort of conscious thought about what’s going on and what that food doing to you but if you’re eating a diet that’s making you really, really bloated and excuse my language but farty and things, you just need to be aware of that and think probably this is not great for my digestive system and you need to make adjustments.
Dr. Ron Ehrlich: Yeah. Now then after we’ve done a questionnaire like this then we would typically and this is a really important aspect of any oral health comprehensive oral health exam and I’m sure everybody’s dentist does this but we routinely every six month we would check lips, tongue, cheeks, palate, floor of the mouth, roof of mouth, back of the throat and the glands under the jaw because oral cancer is now I think it’s about the tenth or eleventh most common cancer in Australia. It’s actually higher in Australia because of our lips exposure to the Sun that oral cancer screening is so important. I mean what are some of the typical causes of oral cancer?
Dr. Lewis Ehrlich: Well, you mention one, exposure to the Sun. Another one is smoking obviously, alcohol. Actually, alcohol and smoking are actually co-carcinogens and so the people that go out and have a smoke when they’re drinking and that’s the only time that they do it, they’re actually leaving themselves susceptible to oral cancer. The alcohol dries the saliva out which has a protective effect in the mouth and then the cigarette smoke can actually get in and penetrate the oral tissue. So, it’s a big no-no in combination I mean in isolation as well, but also human papillomavirus is one of the main reasons why we’re seeing oral cancer increase in the younger generation, traditionally it was only seen as a disease for people that were over 40 but now we’re actually seeing it in late teens early 20s etc.
Dr. Ron Ehrlich: So, once we’ve taken this comprehensive history we then do that oral cancer exam, we then also chart well… part of our staff, our hygiene Department also look at the attachment of the gum to the tooth because around the gum around every tooth there is gum that’s the pink stuff you can see around the tooth and there’s a crevice that should only be about two to three millimetres deep that’s pink, firm, healthy, easy to clean, does not bleed, but if the gum gets pushed away from the tooth then you start to develop a pocket and that changes a whole range of things that we would do. So, a periodontal assessment is really important. I mean part of examining a tooth you’ve got to take x-rays. Why?
Dr. Lewis Ehrlich: Well, there’s only so much we can see with our own eyes. Teeth are so tightly joined together that it’s very tricky for us to see in between the teeth and that’s actually one of the most common places where decay occurs. And so, if you don’t take x-rays you actually run the risk of having that decay spread into the nerve which is when you can get a toothache and require either an extraction or a root canal. So, prevention is better than a cure.
Dr. Ron Ehrlich: Well, we’ve started this conversation by saying that 95 percent of oral health conditions, tooth decay, gum disease, oral cancer have no pain associated with it. So, to not take x-rays is actually… well, it’s not negligent and well it is negligent… I mean as long as the patient understands that they’re really not getting a comprehensive exam and today almost all dentists are using digital radiology or digital x-rays and that is said up to 90% less radiation than more traditional the old-fashioned x-ray machines.
So, I think that’s a really important part of a dental exam. It should I think where people have a lot of fillings we would do that every two years, where they don’t we might take it every five years but certainly if health changes that regular dental x-rays are important. We’re actually also finding that taking photographs, digital high-definition digital photographs have been a phenomenal addition to a comprehensive exam because there’s a limit to what we can see, and this adds to that.
Dr. Lewis Ehrlich: And a great motivator for patients. So, if you think about the mouth there’s not a lot that you can really picture or see or understand but seeing is believing and if you take high-definition photos you can see what’s going well and that’s a motivator for patients, but you can see what’s also needing some improvement and that’s a great motivation tool.
Dr. Ron Ehrlich: Yeah, because you’ve got to like any other part of health, you’ve got to be part of your own journey. If the only thing about oral health is the phone number of your dentist then that’s not a great position to be in. So, look I guess that’s given our listener I would hope something to think about in this week which is called dental health week but we’re reframing it to be oral health week. And I guess the parting message is if you are not taking your oral health seriously, you should because whether you like it or not your body already does. So, I’d encourage you to get out and visit your local dentist and take some active interest in oral health. So, Lew thank you so much for joining me today. It’s been great,
Dr. Lewis Ehrlich: Thanks for having me on.
Dr. Ron Ehrlich: So, there it is. Australian dental health week or as we have just reframed it Australian oral health week. I hope you’ve enjoyed it. Until next week, this is Dr. Ron Ehrlich. Be well.
This podcast provides general information and discussion about medicine, health, and related subjects. The content is not intended and should not be construed as medical advice or as a substitute for care by a qualified medical practitioner. If you or any other person has a medical concern, he or she should consult with an appropriately qualified medical practitioner. Guests who speak in this podcast express their own opinions, experiences, and conclusions.