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Guest: Dr. Lewis Ehrlich
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The Truth About Root Canal Treatments: Myths, Facts & What Really Matters
00:00:05 – Intro & topic overview (root canals)
00:02:44 – What a root canal is & why it’s needed
00:04:20 – Infections can exist without pain
00:05:13 – How 3D X-rays improve diagnosis
00:08:21 – Nuance in deciding treatment
00:10:39 – Why starting treatment matters
00:13:51 – Skill, tools & training affect success
00:21:40 – Importance of magnification/microscopes
00:24:24 – Cleaning canals & killing bacteria
00:27:38 – You can’t get 100% sterile
00:31:48 – How root canal success is measured
00:35:21 – Risks & benefits of keeping a “dead tooth”
00:39:44 – Alternatives: extraction, implants, bridges
00:46:38 – Why a “perfect” root canal can still hurt
00:48:20 – The “97% cancer patients” myth
00:54:02 – Cancer patient case study
00:57:33 – Importance of comprehensive oral exams
01:00:06 – Final takeaway: avoid extremes, value skill
The Truth About Root Canal Treatments: Myths, Facts & What Really Matters
Dr Ron Ehrlich(00:00:05)
Hello and welcome to Unstress Health. My name is Dr. Ron Ehrlich. Well, we’ve covered many dental topics in the 600 plus episodes that I have done, podcast episode, and I’ve had many guests on to talk about oral health from many different perspectives, be it periodontal health, be it toxicity, be it cardiologist Dr. Thomas Levy, who has very strong views about the importance of a comprehensive oral exam, a point that I totally agree with him on.
And today we are going to be covering a contentious issue, root canal treatments. What is a root canal treatment? Should you be having a root canal treatment? What are the consequences of having one or not having one? I’ve often said in my 40 plus years of practice that I wish I was more dogmatic because it would be much easier to just to say to a patient, all root canals are bad, all root canals must come out. Well, that’s really simply not the case.
And by guest today is Dr. Lewis Ehrlich. Lewis was, I guess, last week talking about evidence-based medicine. And it was for a very good reason that we started with that to lay down the foundations of this week’s episode on root canal treatments. And well, I’m not going to spoil it for you. I think it’s an important episode. It is the truth about root canal treatments and spoiler alert here, the answer to should you have a root canal treatment or not.
Here’s the spoiler alert. It depends and it depends on quite a lot and that’s what this episode is about I hope you enjoy this conversation I had with Dr. Lewis Ehrlich. Welcome back to the show again Lewis.
Dr Lewis Ehrlich
Good to be back Ron.
Dr Ron Ehrlich (00:01:48)
Lew, last episode we talked about evidence-based medicine and that is hopefully the foundation or at least evidence-informed Medicine is the basis on which a lot of clinical
work and decisions are made. Today I wanted to touch on a topic that people will have heard a lot about. The most of what they will have heard if they’ve been following the story at all is very negative and that is the root canal issue to do or not to do a root canal treatment. Headlines that people will often read is ‘97 % of cancer patients have this treatment’ or root canals are bad, blah blah blah blah blah. So I wanted to really explore this treatment a little bit and for those listeners that may not be familiar with what we’re actually talking about, what is a root canal treatment?
Dr Lewis Ehrlich (00:02:44)
Okay, so essentially within a tooth, there is a nerve and that has a blood supply which keeps it alive, has its own immune system. And when it gets damaged, either through tooth decay, which is where bacteria eat away at the tooth, softening the tooth structure and creating what people would know as a whole, or they, you know, grind their teeth a lot or…
Hit their tooth on the side of a pool or what have you. There’s a traumatic reason that the nerve, the blood supply within the tooth can die off. You can get an infection of that tooth where you get a, if you take an x-ray, you’ll see a little round black area at the tip of the root. And that’s where the bone, is usually really, really solid and strong becomes soft and mushy on the on the back of you know bacteria eating away at the bone so they get into the canal system the root canal system and make their way up the tip of the root and start eating away at the bone which is obviously an immune stressor so not good for your system you want to be you want your immune system to go and fight other things other more important things in the body and so if it’s distracted by an infection in the jawbone as a result of trauma or tooth decay, then you need to do something about it to support your immune system.
Dr Ron Ehrlich (00:04:20)
Now, people would often say that sounds incredibly painful. It doesn’t necessarily need to be that, which makes it even more insidious in a way. Pain isn’t always associated with these things.
Dr Lewis Ehrlich (00:04:30)
Yeah, exactly. So, you know, we can find a infection within a tooth and a patient will often go, I’m not in any pain whatsoever. And this is often the case, right? So using pain as a barometer of whether something is wrong or right, or if you’re in health or not in health is not great because they’ll often…be in a chronic state. So it can be either chronic or acute. Acute is when you’re in agony, you’ve got a full-blown toothache, you can’t sleep, it’s sensitive to hot, cold, a chronic state. It can just be sitting there and you’ve got no idea that that’s there at all. But nonetheless, it’s still an immune stress.
Dr Ron Ehrlich (00:05:13)
Now you mentioned this shadow at the tip of a root which is picked up with X-rays and I know that we have sat in an office many times over the last 10, 15 more years and looked at 3D X-rays. What difference has 3D X-rays made to the ability to diagnose these kind of conditions?
Dr Lewis Ehrlich (00:05:36)
Yeah, it’s been massive. If we think about diagnostic interventions, whenever you do a diagnostic test, for example, a three-dimensional X-ray, you want to make sure that that diagnostic test gives you the ability to make that patient better. So there’s a range of diagnostic tests in medicine and dentistry, which are all the rage. They can come with a lot of excitement, but they actually don’t mean that you can do anything about it. Right. So…you, you, the good thing about the three-dimensional scan is that if I know, if I send a patient off and it comes back that there’s an infection that we didn’t know about, I know that through either doing a root canal or extracting the tooth, I can make that patient’s health far better. So whenever we think about diagnostic testing, we always want to make sure that our, our intervention that follows up that doesn’t over-medicalize them for no reason, that we can actually improve their outcomes, their health outcomes long-term, which is one of the best things about three-dimensional scans. And the accuracy is just far better than the traditional two-dimensional scans. So we’re far more likely to get accurate results, but also often infections can actually hide behind routes that we can’t see on a two-dimensional image and so we’re able to identify far far far more infections but equally analyzing existing root canals. So a lot of people get concerned about you know whether root canals are affecting their health and I know we’ll get on to that in this conversation but if I was to have a root canal I would be very very
I’d be putting my mind at ease knowing that I have access to three-dimensional scanning to assess whether or not they’re still healthy and in a good state as opposed to 20 years ago when they weren’t available. And you really could have an infection on an existing root canal or an existing tooth without a root canal and have no idea that that was there.
Dr Ron Ehrlich (00:07:56)
Yeah, I mean, the ability to not only pick up the area of infection, which as you said is typically a shadow in a bone where there was healthy bone, there’s now pus or granulation tissue, but also to really get a good three-dimensional image of the anatomy of the tooth you’re actually dealing with or having to treat really makes a difference.
Dr Lewis Ehrlich (00:08:21)
Yeah, correct. And I think this, I know I mentioned in the last podcast we recorded the importance of nuance. You know, a lot of people will come in saying they’ll just be really, really, really dogmatic on the fact that they’ve heard root canals about, they don’t want to even go near a root canal. And they don’t even want you to, to start a root canal.
So just to give people some context, what I mean by this is that if you identify on a three-dimensional scan that you have that granulation tissue or pus in the bone that’s eating away at the bone, making it soft and mushy as opposed to hard and honeycomb like, then that’s a current infective process. So I have patients that won’t even let me start the root canal to minimize and shrink that infection down because they’ve heard that root canals are bad.
Now I can tell you hand on heart that you are going to be infinitely worse off if you do not start to shrink that infection via either an extraction or starting the first stage of a root canal because remember it’s a multi, usually a multi-step process weeks apart. So it can be two to three appointments weeks apart to let the medicine that we put down the canals actually take effect and shrink the infection. I have patients that are so dogmatic that they won’t let me start a root canal because they’ve heard root canals are bad and they’d rather have that chronic infection, that granulation tissue, that bacteria eating away at the bone and that immune stress rather than actually starting the root canal. So I think that…
People need to realize that even if you don’t want to complete a root canal, you know, if you decide that you go off and research or it doesn’t feel right and you’re with well within your rights to do that, to have it removed, you should at least start it because it’s going to be way better than, you know, the current, the state that you’re in when we find out that information, you know.
Dr Ron Ehrlich (00:10:39)
I think you may, I mean, you mentioned it, but our listener may not have picked up on it, that when the nerve and blood vessel in a tooth is dead, dying, you actually not only have, you have gangrenous tissue inside that tooth. So you’ve got gangrene in that tooth. And by not at least opening the tooth up to get that gangrene out of the tooth, nevermind whether you decide to proceed right to the end and we’re going to talk about what’s involved there. You’re saying no, no, no, I’ve heard root canals are bad, but I want to leave the gangrene in the tooth and the infection in the root rather than have any treatment at all.
I mean, when you put it like that, you’d have to go, really? But anyway, everyone’s entitled to their opinion.
Dr Lewis Ehrlich (00:11:22)
So let’s play a little scenario here, You come in to see me. You’re concerned that you’re having a little bit of pain on the lower right-hand side molar. I take an x-ray. There’s an infection at the tip of the root like we described, right?
In order to start the healing process of that tooth, to get that gangrenous tissue out, like you mentioned, we have to go into the tooth and start cleaning it out, flushing it, cleaning it, putting medicine down there to shrink the infection. We have patients that come in that refuse that because of the reputation around root canals and some of the information that’s out there.
But what I would stress to people, just to be really clear, and I wasn’t sure if I was 100 % clear, is that you’re far better off doing that first step and making a decision because you’ve got really aggressive bacteria in your jawbone creating an infection, creating an inflammatory immune response on the body, and then you can decide what you want to do thereafter.
What that procedure, that initial procedure will start to help your immune system overcome this immune stress that it is under. So that’s an important thing to realize, you know, because you can’t, you can’t walk around so dogmatic that you would rather have a, an infection eating away at your jawbone rather than actually doing something about it.
Dr Ron Ehrlich (00:13:13)
I think it’s worth just mentioning at this point because some people may be thinking, these guys are just lining us up for how great the root canal is. No, we’re not. We’re very well aware of some of the problems, even with a superbly done root canal treatment. But I think it’s fair to say that of all the techniques in dentistry, and there are many finicky techniques in dentistry, I would rate doing a technically excellent, and we’re going to cover what that means.
A technically excellent root canal treatment is perhaps one of the most challenging techniques a dentist will ever undertake. Would you agree with?
Dr Lewis Ehrlich (00:13:51)
Yeah, it’s highly technique sensitive. You have to be extremely skilful. You have to use modern techniques. You have to be up to date with the latest materials to get the best result. You have to be patient. You have to use three-dimensional technology, which is obviously what we do at our clinic. But this technique sensitivity raises a really interesting point, Ron, because people can say all root canals are bad, right? No, will hand on heart say that a poorly done root canal is not good for your health. It’s just not. Like it’s not gonna shrink the infection down to the same extent as an excellent one. There may be missed canal, so there’s…
A certain number of canals within a tooth. And if you miss one canal out of the four that are present, for example, there’s obviously going to be bacteria living within those canals that aren’t good for your health and will result in a failed root canal. So what I would say to people is that if you’re saying all root canals are bad, you’re comparing a root canal done in the democratic Republic of the Congo with no three-dimensional scans, with somebody who hasn’t done extra root canal training, you’re comparing that root canal with somebody that is a specialist that does it under microscope, that uses 3D technology, that uses the latest materials, medicaments, up to date with all the studies, the research, et cetera. You can’t compare those two things. You just can’t.
It’s like comparing somebody that’s the best heart surgeon in the world doing your stent, putting a stent in to make sure that the blood flow keeps going to keep you alive with somebody that is a GP having a go at it. You know, you can’t, they’re apples and oranges. So I think that people as a general rule, just throwing the baby out with the bathwater and saying all root canals are the same. That is not true.
So somebody that does a fruit canal up the road could be far better than somebody that does one down the road in the same city, you know?
Dr Ron Ehrlich (00:16:22)
Yes, I was going to say, let’s not be unfair to people in the Democratic Republic because that could happen from one end of Sydney to the other or literally in the same building. But, I know, this is a technically sensitive, very sensitive technique. I would argue again that it’s the most challenging to do really well. And yet any dentist can have a crack at doing a root canal treatment.
Dr Lewis Ehrlich (00:16:32)
Yeah, 100%.
Dr Ron Ehrlich (00:16:38)
And if the criteria is a patient comes in in pain and that patient, that dentist gets them out of pain to a patient, that dentist has done a great job and getting him out of pain is certainly a great relief. But have they completed the root canal treatment to its technically excellent level? And that is what we’re going to talk about now. What and and let me put a cave it on a cave it on this at the beginning.
Both you and I are very aware of the complexity and structure of a tooth. Not only are there many different canals, but the dentinal tubules are a technical challenge which has been considered and is considered in this process. So let’s just start from that point of view and talk about how do you do root canal treatment really well?
Dr Lewis Ehrlich (00:17:46)
You do a really good root canal with good preparation, good planning. So that starts with, like I said, a three-dimensional scan. You need to assess the anatomy of the tooth. Is there curved roots? How many canals are there? Is there strange anatomy that doesn’t allow you to get to the tip of the root? You know, there might be little branches right down the end of a root, which can make it really difficult to clean to its full extent.
Then there’s technical training. Have you gone off and done additional training in root canal therapy? You know, is it a, is it a short course or is it a, is it a postgraduate, you know, degree where it’s, it’s really rigorous and hard to get through and, know, the latest and greatest.
Evidence is being used on techniques, etc. So I know that Dr. Craig Wilson at our clinic has done postgraduate study in in in root canal therapy and you know, the standards that he sets is very high and it’s the same with, you know, when it comes to say placing dental implants, you can go to a general dentist can go to a short course on the weekend. And after two days start placing implants and then there’s people that are
that have gone off and done postgraduate studies and done it for two, three, four, five years and understand the real nitty gritty nuance of what it takes to do a successful implant. So I think that skill level is important, but having said that, there’s a few things to realize with what results in a great outcome for a patient.
Unfortunately, as practitioner, we can only really control one aspect of that. I can only control the extent to which I do it to a high standard. So I can worry about the technique, but I can’t control the amount of infection, the type of bacteria that are present when that patient turns up. I can’t control how that patient’s immune system will respond to the treatment. Right.
So when one of them fails, like I’ve seen patients that go and have it done with a specialist, it’s done impeccably on a three-dimensional scan, it looks perfect, but it’s failed. It hasn’t worked. They’re still in pain. There’s still residual infection. They’ve needed to have the root canal, the tooth removed. That’s because we can’t control every aspect. We can’t control the host response.
And so this is why we say that the chances are normally on your side, that it’ll still be in your, in your mouth in working function at, you know, 90, 95 % after 10 years, but you can still fall within that small percentage that, that it doesn’t work out for. So that’s important to know the host response is something that we cannot control.
Dr Ron Ehrlich (00:21:03)
And that’s something that needs to be monitored throughout a patient’s life, obviously, and respected and respected. I think that’s important too, just because it looks good and it’s been good. You know, the patient’s immune response and medical history at the time changes things. But coming back to the technique itself, I know that microscopy, using a microscope makes a big difference. Talk to us a little bit about the levels of microscopy that are employed in you know, in root canal treatment and why that’s important.
Dr Lewis Ehrlich (00:21:40)
Yeah, so just to give people context, when you’re trying to find the canals of the tooth, they’re so small, they’re teeny tiny. So if you looked at these canals through a naked eye, you could, with no magnification, you could really struggle to find them. They’re very difficult to pick up. So magnification is hugely important to get a good result because if you don’t…find them, you can’t clean them. And then if you can’t clean them, the bacteria stays there and then you get a root canal that will fail. So yeah, I mean, when I do dentistry, I use magnification as a, as a bare minimum. My, my magnification level is 5.7 times magnification. So when I do a filling, I’m wearing something that’s five, I can see the tooth in 5 seven times the size so your tooth looks 5.7 times the size.
Dr Ron Ehrlich (00:22:35)
And just to be clear, these are little magnifying glasses that are glued onto the lenses of your own glasses. They’re called loops, but it goes way beyond that, doesn’t it?
Dr Lewis Ehrlich (00:22:46)
Yeah. So there’s different levels of magnification. You can get these loops, these magnification glasses at 1.5 times, two times. You can go all the way up to like seven, nine times on, on glasses themselves, but then there’s also microscope. So root canal therapy done on the microscope is obviously advantageous because, know, for example, our microscopes at the clinic can go up to 19 times.
So to find little canals, to look at the anatomy closely, to look for little root fractures that might make it fail, that you might not see, you know, just correct. unless it’s really, really obvious, you know, this makes, you know, your, your root canal far more likely to be successful. I suppose what I also stress to people is and won’t show up on an X-ray.
You can’t compare, like a lot of negative data on root canals was done using very, very old techniques, often done with no magnification, no, no modern medicaments and vibration that we use to get them into the little nooks and crannies into the, in the, in the root canal system. So again, you can’t compare apples to oranges. Like if somebody’s doing it under 19 times magnification, it’s very different to somebody that’s doing it with the naked eye.
Dr Ron Ehrlich (00:24:24)
And part of what the technique does is because these canals are so fine, very hard to get medicaments into them. So what you’re actually doing is increasing the diameter of the canal so that you can get antiseptics down. What kind of antiseptics are used to try and address the issue of the anatomy of the tooth being full of dentinal tubules? How do we get that stuff into where there is bacteria?
Dr Lewis Ehrlich (00:24:57)
Yeah. So when you first go into it, when you first look and find, look for and find canals that they’re tiny, like you said, and so you have to shape them clean and shape them. So you are widening the canals to allow medicaments to get to where you need them to go, which is down at the end of the route more often than not. and so you widen them, you put sodium hyperchlorite down there, which is obviously bacterial cytotoxic, so it kills the bacteria that are causing the issue. And we use vibrating techniques to get them into these little tubules and little accessory canals, which branch off the main canals, which is what you can see on an x-ray. You can just see the main canal, but there’s a whole 3D anatomy there. And so there’s things called…like endoactivators, there’s little lasers that vibrate and get all this, all these medicaments into these canals where little bacteria can hide to minimize the amount of bacteria that’s in the tooth so that you can help yourself, the host, overcome this infection. But there’s this notion that, you know, because it’s not sterile, completely sterile, that that is a problem and it can be for some hosts that don’t respond well. But I always stress to people that you can never really get anything 100 % sterile. So at any particular point, your skin isn’t sterile. It’s got bacteria, viruses, fungi all over it. When we do a filling even, there’s no way of knowing that we’ve got 100 % of the bacteria that have caused that decay to happen, that hole to happen that we’ve removed.
100 % of that, but we need to facilitate an environment whereby we’ve got the majority of it that our immune, our host response, can actually overcome the remaining bacteria to win the battle. Right. So I think that that’s important. This notion of a hundred percent sterility can never be achieved, but when you have a knee surgery, it’s never a hundred percent sterile. When you have a filling done, it’s never a hundred percent sterile.
When you have a hip replacement, it’s never a hundred percent sterile, but we don’t implode because we have an advanced immune system that can deal with, you know, the parts that are left behind. We’re trying to assist the host to get an outcome.
Dr Ron Ehrlich (00:27:38)
Yes, which comes back to what we were saying initially about leaving gangrenous tissue and infection in the tip of the root that the body can’t get to is creating a situation that you just you’re just leaving it there and allowing it to fester. But the whole anatomy you were mentioning, the the medicaments sodium, hypochlorite, which I think is Milton’s, isn’t that Milton’s solution?
Dr Lewis Ehrlich (00:28:05)
Yeah, I mean, so it is called as a brand name called that.
Dr Ron Ehrlich (00:28:12)
Yeah, let’s not get down. And but the other one is doing it all in one go is not something that I know there’s this kind of, you can do root canals all in one go. What are your thoughts about that?
Dr Lewis Ehrlich (00:28:25)
I know that there’s a lot of endodontists that do that, but they spend a lot of time cleaning it. Like they might spend hours doing the one. So they’re really getting the medicaments in there and cleaning it really well. I mean, the downside of doing that is obviously I’d like to preface this by the fact, by saying that I’m not an endodontist and obviously an endodontist would know more about this. But yeah, the…I won’t, okay.
I guess the negative is that the body needs time to heal. So having a duration of a couple of weeks between appointments can be beneficial to minimize the amount of infection that’s, that’s in that area. So that’s why we tend to space things out when we, when we do them. but yeah, you can do them.
Some endodontists do them all in one go, but it depends on why the canal has occurred. So if you’ve got a huge hole, decay has gotten into, you know, spread to the nerve and it’s set up a really, really inflammatory response, they’re in a lot of discomfort. That’s very different to somebody that doesn’t have any disease per se, they’ve just had a trauma, you know. So if you’ve smacked your front tooth really hard and it’s an acute blow and there’s not bacterial invasion that’s caused that infection. It’s the trauma itself that’s caused the blood supply to die. That might be one that’s more suitable to doing it in one go because there’s not actually a bacterial reason for it, if that makes sense.
Dr Ron Ehrlich (00:30:11) (Promptional)
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Dr Ron Ehrlich (00:31:24)
Yeah. How do we, but now I know we’re going to say, and we’re going to cover this too, that we constantly need to take a patient’s immune function and medical history in place. So resting that aside for one moment, how do we judge a technically excellent root canal? How is success measured in the traditional sense of the word ‘success’?
Dr Lewis Ehrlich (00:31:48)
A patient that’s no longer in pain, if they started in pain, that’s one. You want patients to have quality of life. Number two is that you have done the workup with a three-dimensional scan to work out how many canals are present in the root anatomy, and you’re able during the procedure to find those canals that are present and to clean them down to the length of the root to increase the chances of minimizing the amount of bacteria left behind. If there is a large infection at the tip of the root or a small infection at the tip of the root, that bone that has been destroyed in that area has regenerated. So people need to remember that if you have something that shows on an x-ray to have affected the amount of bone and there’s an infection at the tip of the root and that has now filled in with bone again, then something positive has happened. You know, it’s like, if you want like, the human body is an adaptive, like adaptive machine, right? It’s amazing adaptation.
So if you want to get a stronger chest, or biceps and you lift heavy weights and it gets bigger and you’re now stronger in all the tests, then that’s a positive thing if that’s what you wanted to achieve. In the same sense that if you have a root canal and you’ve got, never thought I’d compare weightlifting to root canals, but here we are. If you have a root canal that has an infection at the tip of the root and you do a really, really, nice, successful root canal and that bone starts to regenerate in that spot. How can one argue that that that something positive has not occurred there? You’ve gone from something infected mushy, you know, filled with granulation tissue, and you’ve reformed bone like that wouldn’t happen unless the environment in which to do so was there for the body to regenerate, right?
So that’s where something positive has happened. So that bony fill in so that dark circle that’s now honeycomb in appearance and looks normal, that’s also the sign of a successful root canal. And then, and then like another one is that it’s really well sealed. So it’s one thing to finish it. It’s another thing to seal it well. one of the, well, a couple of the reasons why root canals fail is that there is bacterial ingress into the root canal system because it hasn’t been sealed well, for example, with a crown which is a cover that sits over the tooth and provides strength to reduce the risk of fracture, but to reduce the risk of bacterial ingress into the root canal system, which can result in reinfection. So that’s also a sign of success is how well the root canal is sealed.
Dr Ron Ehrlich (00:35:03)
Yes, because you mentioned something there that when a root canal is done, the tooth itself is weaker for sure and subjected to a lot of pressure in the mouth. So putting a cap or a crown over the tooth and sealing that off is important. What do you say to people who say, I don’t want something dead that’s in my body?
Dr Lewis Ehrlich (00:35:21)
It is a nuanced discussion. I can understand that point of view. But we have to think about this. Like in it to give to give context. What what are teeth there for? This is always a conversation I have. What are teeth there for? They’re they’re there to help you masticate chew your food so that you can get nutrients from your food as much as possible to prepare for digestion so that your body can absorb nutrients and you can maintain your immune system, right? Without eating well, chewing well, we aren’t healthy, right? So yes, it is true that you do have something dead in your mouth, but then you have to weigh up whether or not losing that tooth is going to be a net negative for you.
Because if you can’t chew, you won’t live as long. We know that. You can’t get the nutrients from your food, but equally, a lot of people don’t realize is that if you extract a tooth, you can also affect the balance of the jaw. It can affect your pain levels in terms of TMJ and your muscles and mastication around your jaw can become tighter on one side, or you can favor one side that you’re not chewing on and that can stress the jaw out as well.
But a lot of people don’t realize is that when you chew, you actually have a pumping mechanism of blood flow into the brain. So we know that if you can chew well, you are less likely to get cognitive decline. So we know that we know that those that have dentures that, you know, have have an inability to chew well, they have far higher levels of dementia. Right. So
You have to look at this holistically, which is why we’re Sydney Holistic Dental Center. It’s not as simple as root canal’s bad, extract, no replacement because anything foreign or dead is bad. So if you don’t want to have something dead in your mouth, by all means extract it. But you have to know what the disadvantages of such a decision is. You are not going to have the same amount of chewing force. Your bite is not going to be as balanced.
And you will not get the same amount of blood flow into your brain, increasing your risk of cognitive decline. So everything besides your own natural healthy tooth is a compromise. It’s a decision, a triaging of what you’re willing to compromise on. If you don’t want a dead tooth, but you’re willing to go through, you know, not having the ability to chew as well, by all means, but you just need the information to make that decision. And then, you know.
The other thing as well is you can also monitor that dead tooth. We have the ability to monitor it now, far better than we ever did with three-dimensional scans. So people that are sitting on the fence that elect to have a root canal, and yes, it is something dead, but if it’s done to a good standard and it heals the infection, we know that something positive has happened, and we know that your ability to chew and reduce your risk of cognitive decline and all those sorts of negatives is reduced.
And you can just follow it up with CBCTs, three-dimensional scans every couple of years to see if anything’s changed. And if it has changed, you can extract it and you can look at placing an implant or doing a bridge.
Dr Ron Ehrlich (00:38:57)
Yeah, which is, I know, something that we’d often discussed, and that was that it’s so tempting to be dogmatic. It really is appealing. There’s something appealing about, no, all root canals are bad. I don’t do root canals. I remove root canals. I’ve often felt that I almost wished I’d always been a lot more dogmatic because it’s a much easier conversation to have than this more nuanced one. And not only have you eliminated the most technically challenging thing from your practice, which is a big relief to you, but you’ve introduced another aspect of dentistry, which is, a lot, with all due respect, a lot more straightforward and a lot more lucrative. What are the alternatives to root canal treatment?
Dr Lewis Ehrlich (00:39:44)
Yeah, I think just before I mentioned that Ron, I would like to add that, you know, I think when people hear the word holistic, they’ll come in and they’ll go, do you guys do root canals here? How can you be holistic? Or they say, do you place titanium implants here? That’s not holistic. Or they’ll say, you like?
You guys are a completely anti-fluoride, aren’t you? You know, and our definition of holistic is not being dogmatic. You know, I’ve seen some really negative results of people, holistic dentists being too dogmatic. So for example, I’ve got a patient who has had six root canals removed, right? Because the dentist said that all root canals, no matter what state that they are in, notwithstanding what I just mentioned about cognitive decline risk of the, the inability to chew have had six teeth removed, right? And then they haven’t replaced them with dental implants because that’s a foreign body, which is a no-no according to this particular holistic dentists, right? So I’ve seen 40, 50 year olds in dentures that can’t chew very well and they haven’t been able to eat really nutrient dense, hard foods for years. And then you think, well, have you really done that patient a service? I don’t know that you have, you know, each their own and people can make whatever decisions they make. But I think, you know, you’re going to be infinitely better by restoring what nature gave you having the ability to chew than saying all root canals need to be removed. You can’t do implants. You can’t do anything. You know, I don’t know that that’s necessarily best practice and best for quality of life. So what, what our definition of holistic dentistry is, is who am I, who have I got in the chair? What’s their circumstances, medical history wise, you know, goals, where they want to go, etc.
And what solutions can I provide them that are tailored to their particular circumstances rather than going, I don’t have to think, I don’t have to be nuanced. I’ll just take out all root canals. you know, it’s not based on individual circumstances. So we pride ourselves on, you know, making sure that we tailor things. Like for example, a lot of people go, you know, do you ever recommend a fluoride toothpaste? Because you’re holistic, clearly you don’t and I’m like, well, no, like I do, because there are certain circumstances where that’s important. So for example, I’ve got a patient that has had radiation to his, he’s had oral cancer, he’s had radiation to his mouth. He has no saliva whatsoever. None. he, every time I see him, because he doesn’t have the saliva to neutralize the acid that he gets from chewing and drinking and living his life, mouth breathing, whatever he might be doing.
Then he comes in every single time it has tooth decay. Now, if I say to him, I’m anti-topical fluoride, am I doing him a service? I’ve got him on the highest level of fluoride toothpaste and we’ve been managing to arrest that process from getting worse for a period of time. But then I’ve got another patient that is 45 years old, has used a natural toothpaste his whole life, his diet’s impeccable, he’s healthy. And then I’ve, you know, he said, should I use a fluoride toothpaste? And I said, absolutely not. You’ve been using a natural toothpaste for the last 20 years. You’ve never had a hole. Your teeth are perfect. So you need to tailor your treatment to the person in front of you rather than being dogmatic and taking the nuance out of decision-making just to, just to add to your point there, Ron, I thought I’d give a…Cup.
Dr RonEhrlich (00:44:06)
No, no, good. And I mean, this is what patient centered means. I mean, it’s about the patient who’s sitting in the chair being the center of what’s being done to them, not just because you like or don’t like something. It’s what’s appropriate for them. No, the alternatives then are extract the tooth and do nothing, which you’ve identified problems, extract the tooth and do an implant.
Well, by putting an implant in, by the way, an implant is dead too. So that’s worth noting. An implant is dead, very much more lucrative. I mean, it’s actually easier. No, it is easier to extract a tooth, put an implant in and the crown on top of it. And it’s more lucrative than trying to restore a tooth endodontically. I think that needs to be said. Let’s call the spade a spade. And the third alternative is to do a denture, a removable appliance which is very challenging because you have to remove that after every meal. And if you don’t periodontally a gum wise, you are compromising your health. So there’s so much to consider here in that it’s also worth mentioning Lou and I think we’ve had many patients like this who have had a technically perfect root canal done. I mean, the 3D X-ray looks magnificent. They have got a beautiful restoration on top but they’re sitting there telling us that the tooth feels uncomfortable. Why? Why would that tooth be uncomfortable? They’ve been told by their endodontist it’s perfect. They’ve been told by their dentist the crown is perfect. They can’t be in pain. Lou, why are they in pain?
Dr Lewis Ehrlich (00:45:50)
A few reasons, one other alternative before we move on there Ron is obviously a bridge. That’s where you have to do a crown preparation on either side of the gap. You have to remove a little bit of tooth structure either side, and then it sits over the top and that’s another option which doesn’t involve implant surgery. The disadvantage of that is that you have to remove tooth structure on teeth that don’t necessarily need tooth structure removing. That’s another pro and con is that you’re obviously the pro is that you avoid surgery. The con is that you have to remove, remove some tooth structure. And if something goes wrong with either tooth on that side, it can be problematic for the bridge.
Dr Ron Ehrlich (00:46:38)
And and Lew, the other pro to that scenario is if the teeth on either side of the tooth that’s been extracted need crowns on them anyway. Yeah. Why not do a bridge? So then you then you’re actually ticking two boxes at the same time. But go on. Yes. Why is the patient who’s had this technically superb dentistry done still in pain?
Dr Lewis Ehrlich (00:46:56)
Yeah, so there could be some microscopic crack within the tooth that hasn’t been identified, which is extremely difficult to see on an x-ray or visually. So that could be one reason. There might just be a host response that hasn’t gone well. Like I mentioned to you, you can do a technically perfect root canal. You can do all the right things, but the host, the immune system of the host hasn’t responded well. And they can still be pain, but also there might be an issue with the way that their teeth meet, AKA their bite. It might be that the crown is too high. This is what we talk about in, it’s called occlusion, the way the teeth meet. It may be that there is a high spot, a traumatic spot where they’re biting into and sometimes a small adjustment to make the bite more balanced, the way the teeth meet more balanced, and then the pain can go away. So there are a few of the reasons. They might be clenching and grinding their teeth at nighttime and traumatizing the periodontal ligament, which contains nerve endings, blood vessels that can be crushed over nighttime when you clench and grind. So they might be needing a nighttime appliance to protect their teeth from further wear and tear. So there’s a few reasons.
Dr Ron Ehrlich (00:48:20)
I know there’s something that patients, know, which is pretty disturbing, which patients are exposed to when they read an article which says ‘97 % of cancer patients have this dental procedure, root canal treatment’. I mean, I know I was looking at a website many years ago, mercola.com. And I think we both have looked at the website and I think there are many things on that site that I think are fantastic. But then I read this and saw this article which said ‘97 % of all root canal treatments have this procedure done’ and then had 10 references. And I went and looked up all 10 of those references. And this goes back to the study, the episode we did last week on evidence-based medicine and not one of the studies said that. I read every part of every article and not one of them said that. What’s your experience with this kind of issue?
Dr Lewis Ehrlich (00:49:15)
Yeah, I think, look, as a general rule, like when you see a headline like that, it certainly is attention grabbing. But it’s not really rigorous science, like just to throw a number like that out, because you could drive 97 % of cancer patients drank water, you know, like it’s, it doesn’t necessarily mean that, you know, there’s this correlation doesn’t mean causation.
And like we’ve been mentioning in this chat, Ron, there’s so much nuance to what a good root canal is. you’re basically saying that 97 % of, if you’re saying 97 % of cancer patients have a root canal, it’s like, well, what type of root canal? Is it done well? Is it not done well? Is it a successful root canal by the…by the criteria that we’ve already discussed, all those sorts of things. I’ve had a look at some data on root canal and cancer. There’s not a lot of studies on it at all. And one that keeps kind of being mentioned on social media or on some of these websites is one that was done in a lab and they looked at they looked at changes in cell characteristics, almost like stiffness of cells. So remember it’s done in a lab, not on humans. And they found that it just changes the stiffness of a particular cancer cell. So this specific bacteria that are commonly found in root canals, know, root canal, sorry, in infections in the jawbone.
can cause the structural stiffness change in cells that were treated in a lab, so not in somebody’s mouth, obviously. And then they found that their recommendation, so it’s actually interesting, their recommendation was increased oral hygiene because they’re just bacteria that you find in the mouth anyway. So nothing to do with root canals yet they’re being used to demonized root canal. And if at the end of the paper, it says, this speaks to the importance of root canal therapy. Okay, so doing root canal therapy was a solution to this problem. Right. And the oral hygiene is important because the bacteria that were in these infections have the have the ability to change the structure of certain cancer cells in a petri dish, right. So then they’re saying
The solution is to do a good root canal to actually reduce the amount of these bacteria present, right? Because that’s what it does.
Dr Ron Ehrlich (00:52:22)
This was an article that’s used to justify.
Dr Lewis Ehrlich (00:52:26)
The link between cancer and root canal. So the paper actually is flawed because it’s obviously, you know, basically looking at a specific metric, which is, okay, does it change the characteristics of cells? Okay, so just because a cancer cell becomes stiffer, what does that mean clinically? It doesn’t address that in the paper. Right. So
Then the paper says, this speaks to the importance of a good root canal therapy, because a good root canal therapy will minimize the amount of those bacteria. And it also said it speaks to the importance of impeccable oral hygiene, because those bacteria are present in the mouth anyway.
Dr Ron Ehrlich (00:53:19)
Right. Yes, it’s interesting because when you do and I’ve done this for the course that I give called Mastering Oral Health, which is for health practitioners and patients, there’s a plug for a course. But but, know, when I looked at the incidence of of infection at the tip of a root, which is coming back to the diagnosis, I found the incidence of periapical periodontitis, which is the name of that periapical being the tip of the root and infection is really high, even in root canal filled tooth. And this speaks to the importance of how well it is done. Coming back to what we’ve been discussing anyway.
Dr Lewis Ehrlich (00:54:02)
Yeah. And I think that, you know, if you, if you’ve got, like, for example, yesterday, I had a patient with stage four pancreatic cancer. She’s got a break in her treatment. I sent her for a three dimensional scan, right? It showed she had two root canals, one on the top left molar that had a chronic infection at the tip of the root, even after a well done root canal. Okay. So that’s a problem for her immune system.
And I recommended she not try to save that tooth. I recommended her to have that removed because of her clinical specific situation, not dogma. The fact that she has pancreatic cancer means that she needs all the help that she can get to minimize the immune stress on her body. So she had a break in her treatment. I removed the tooth yesterday. There was so much granulation tissue in the bone, right?
So it was just mushy at the end, I cleaned all that out, I put some PRF in there to help with the healing. So platelet rich fibrin. So I drew blood from the patient, I spun it in the centrifuge, all her growth factors come to the surface of this, this tube, and then I pack it in to help with the with the healing and the regeneration of the bone. So again, a very holistic technique using your own body to help with the healing one of the many advancements we’ve got at the clinic, but on the lower right-hand side, there was a root canal with no signs of any infection on the three-dimensional scan. The patient didn’t want to have that tooth removed. And I was fine with that because there weren’t any signs that there was a problem. Now, what’s interesting is that in her last PET scan, so this is where they inject the glucose, and then they take a…
Scan of the body to see where those, where those, where it kind of lights up on the scan. The doctor, the treating oncologist had no idea that there was a tooth issue, but yet on the PET scan, the doctor identified the top left-hand side on the PET scan as potentially being a problem because it was showing up as a certain color.
Whereas the lower right-hand side did not show a single bit on the PET scan. So yesterday I extracted the tooth. The patient will be infinitely better off with that and it will support her journey to try and gain back her health from pancreatic cancer.
Dr Ron Ehrlich (00:56:43)
And just to be clear, that patient was unaware of that infection, had no pain in that infection in that tooth, had had it done technically well, but still had infection there. And you chose, because of her medical, current medical history, to remove that tooth and do everything you did.
Dr Lewis Ehrlich (00:57:06)
Yes, but one step before that, Ron, I identified the fact that she was diagnosed with this issue and I knew she had root canals. And I said, I think that this warrants doing a three dimensional scan. And then the result of that is that we found the infection that has now been dealt with and she’ll be better off.
Dr Ron Ehrlich (00:57:33)
Which interestingly, amazingly, the oncologist had picked up in the PET scan that something was happening up on that top left hand side. And this speaks to a much bigger story. And I think probably a good story, you know, as we’re coming towards the end of this episode, that if you have a complex medical history, if you’ve been diagnosed with heart disease, cancer, any one of 100 autoimmune conditions, diabetes, I mean anything really, any medical condition, the importance of having a comprehensive oral exam. I mean, I can’t overstate the importance of that. And that includes if you’ve had complex dental work done, having a 3D x-ray done.
Dr Lewis Ehrlich (00:58:21.)
Yeah, I just think, you know, this is not a criticism of other practices because there’s amazing dentists all over Australia. But I just think that spending time with patients that have complex, well, anyone, but particularly those that have complex medical history is important because if you’re doing a checkup, clean x-rays in 15 minutes.
If somebody’s got pancreatic cancer, you’re not going to be able to be thorough enough and spend the time with patients to identify what investigation, further investigations need to be done in order to make sure that they’re actually not having any additional immune stress from the oral cavity. And in her particular case, that’s what we did, you know? So it’s important to take time with people.
Dr Ron Ehrlich (00:59:16)
Yes. And that, I think we would refer to that as a comprehensive oral exam, which typically as a new patient, you would spend, how long would you spend just doing a comprehensive exam on a patient that you’ve just met?
Dr Lewis Ehrlich (00:59:31)
Yeah, one hour, one hour. Yeah, no, no treatment, no cleans, no nothing, just just diagnosis and conversation and you know, going over things in great detail.
Dr Ron Ehrlich (00:59:49)
Lew, we’ve covered some territory here today. I mean, it’s a very contentious issue. It’s an issue that I know we in our practice have grappled with and considered all of the alternatives for many, many years. And I know you guys are doing that still to this day with a whole lot of new technology. Thank you so much for joining us and sharing your knowledge and wisdom with us.
Dr Lewis Ehrlich (01:00:06)
No worries Ron, pleasure.
Dr Ron Ehrlich (01:00:12)
Thanks, Lew.
Well, as I said, it depends. It depends on quite a lot. It depends on the technical ability of the practitioner doing it, because as I mentioned, it is without a doubt, I believe, well, in my opinion, one of the most technically challenging things to do in a technically challenging profession like dentistry. mean, when we talk about specialties and we talk about skin specialist, nose and throat specialists, dentists, heart specialists, lung specialists, blah, blah, blah, blah. Well, in dentistry, we get even more specialized and you don’t get more specialized than focusing on the root canal of a tooth. That is a very, very minute and intricate work and it requires careful approach. So it depends. It depends on the skill of the practitioner.
It depends on the preparation before the treatment. depends on whether you’re using 3D X-rays to do your assessment, whether you’re using microscopes to see the minutiae, which if you miss is going to result in a failure. It depends on whether you can get the medicaments down throughout the tooth. And yes, dentists are very aware of the challenges that tooth anatomy has, not just in branches of canals, but in the structure of the tooth. And it is about a balance as well.
You never get anything sterile, 100 % sterile. It is about restoring a balance to put the immune system in control. So it also depends on your immune system. It depends on your long-term immune system. It depends on how well the crown is, the tooth is crowned and supported and sealed. It depends on a whole lot more.
So I will have a download brochure for you to look at and maybe share with your own dentist, but it is reminds me of that bumper sticker that I was once, Petria King actually shared with me. And that was ‘my karma just ran over your dogma’.
And it is so easy to be dogmatic and say all root canals are fine. You have no problem with that. I don’t believe that’s true. And it’s equally dogmatic to say, you know, no root canals, you should have every root canal out. You’ve just eliminated the most technically challenging thing in dentistry and replaced it with one of the most lucrative and straightforward things to do in most cases, which is the placing of an implant. Not always straightforward, I know, but it’s a lot easier to do than a root canal treatment.
So we’ll have links to the website if you’re looking to have a comprehensive oral exam, which I believe you should look to have, would suggest you have that. I would also encourage you to look at the course, Mastering Oral Health, and I’ll have a promotion code that you can use. It’ll be in the show notes. You can use to get 50 % off that course. It’s a five-module course called Mastering Oral Health, the Clinician’s Guide, and it deals with everything from what a comprehensive oral exam is, what periodontal, what the…implications of periodontal disease are to every disease, about also about toxicity of mercury, the root canal issue in more detail, about airways, about sleep, about breathe, about chronic headaches and neck aches, all part of mastering oral health. So I’ll have a special promotion code for you in the show notes. I hope this finds you well. The other thing I might say is that if you join the unstressed health community, you actually get that course included in the membership.
There’s an even bigger giveaway. Hope this finds you well. Until next time, this is Dr. Ron Ehrlich. Be well.
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