What can looking at and into a person's mouth tell you about their overall health?
Today we're joined by passionate holistic dentist, Dr Lewis Ehrlich who teaches us to think outside the box when it comes to oral health. Lewis practices the true art of integrative medicine in his dental practice and has so much knowledge to share on how we can connect the dots between oral health and systemic disease.
Lewis takes us through how he's been able to identify serious chronic diseases that have been barriers to people's healing, why sleep makes up a quarter of his patient history forms and why we just can't be considered healthy, without a healthy mouth.
Covered in this episode
[00:38] Introducing Dr Lewis Ehrlich
[01:33] Making dental health a priority
[05:51] Are we approaching dental care incorrectly?
[10:17] The surprising ways dental health is linked with chronic disease
[12:57] The tools of the trade
[22:20] Sleep Stressors: hydration, grinding and snoring
[25:27] Understanding the grading of gum disease
[27:01] Oil pulling: does it have merit?
[30:01] Clinical signs in oral assessment to look out for
[37:38] Sleep: the impact of bedding and posture
[41:07] Improving the dentist experience
Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line today is Dr. Lewis Ehrlich, a dentist who's passionate about the many links between oral and general health. His mission? To educate people to take control of their own health and prevent oral health disease, and in turn, overall health disease. Lewis is a highly sought after holistic dentist who graduated from James Cook University with the Academic Medal.
Before studying dentistry, he completed a Bachelor of Science at Northeastern University in Boston, USA. Lewis practices, along with his father and uncle, at Sydney Holistic Dental Centre. And Lewis is also a bone marrow donor, and this, he says, is his proudest achievement. Welcome to FX Medicine, Lewis. How are you?
Lewis: Good, thanks, Andrew. Thanks for having me on.
Andrew: Now this seems an obvious question but I think it's largely ignored by even seemingly well-educated people, why prioritise dental health?
Lewis: Well, where do we begin? In my opinion, you honestly can't consider yourself to be healthy without a healthy mouth. There's so many reasons why that's the case. I mean, if you're talking about the mouth, which has been seen in isolation from the rest of the body for so many years, which doesn't make any sense to me, you know, we're talking about eating, drinking, you know, the start of digestion, breathing, sleeping is influenced by the mouth, you know, how we breathe when we sleep. And if you think that those things are important, you know, even breaking down your food, and chewing, preparing the food for digestion, then you really can't consider yourself to be healthy if any of those things aren't in optimal shape and condition.
So, yeah, hugely important part of the body, and like I said, you just can't consider yourself to be healthy without a healthy mouth.
Andrew: When we're talking about dentistry, and let's face it, you know, like most people, many people, particularly with a high sugar diet and poor practices, poor dental hygiene, they don't floss, they don't brush enough, how much...if you want good dentition, how much should you be budgeting for, let's say, per year, to be able to make sure your mouth is in tip-top condition?
Lewis: Yeah, this is an interesting question you raise because it really depends on what kind of a state your mouth is in when you find out what kind of a state your mouth is in.
Andrew: Yeah.
Lewis: So, you know, for example, you might come in and you might have 10 holes in your teeth and mild-to-moderate gum disease, and someone else might come in and have no decay and need no work whatsoever besides, you know, tidying up some gingivitis. And that's kind of a tricky one to answer. It's to kind of like how long is a piece of string?
But, you know, assuming that you were healthy, and your mouth was in good nick, and you didn't need a lot of dental treatment and it was just purely for prevention, I mean, a clean every six months. You know, we tend to be creatures of habit, we'll brush the same way over and over again and miss certain spots and, you know, at bare minimum, at six months you're going to have some sort of gingivitis or inflammation in some areas.
So, you know, six monthly cleans, which cost a couple hundred dollars, you know, perhaps some x-rays, a few more hundred dollars, and then your dental hygiene products at home. So your brush and your floss, which, you know, you should be changing your brush head every six...every three months, rather. Or after you've been sick or you've had a flu. Or, interestingly, the research is showing, if you store your toothbrush near a toilet bowl, you should be changing it more frequently, so...
Andrew: Is that so? So that's airborne, obviously?
Lewis: Yeah, so, I mean, just the idea of flushing and particles. Actually, you know, you get some air aerosols and particles flying across onto your toothbrush, etc., and then you go brush...and as graphic as that sounds, you go brushing with that. Yeah, so keeping it away from your toilet bowl is a good idea.
You know, everyone knows how much a toothbrush costs and, you know, you'd probably be changing that three or four or five times a year, depending on how healthy you've been. And really, that is enough to kind of keep your mouth in good order. Having said that, there's also some costs involved with keeping your mouth healthy via diet, so you've obviously got to factor in healthy foods into that as well, I suppose, if you were, you know, really doing the math on it.
Andrew: So you mentioned about keeping your toothbrush away from the bowl. And I get you don't want to be cleaning the bowl, you don't want an infection issue raising its head. But being on a farm and you look at cows, and they'll lick their bums, and they will clean up their offspring's, you know, bums and things like that, without any seeming ill-effects to their dentition. Is part of this because of us, because of what we've become, how we've lost our way from our ancestral microbiota? Is this, like, part of the...you know, the hole that we've dug for ourselves?
Lewis: Well, I think one of the issues that we have with a lot of our dental hygiene products, and just our approach generally to food, and our soils, and treatment of diseases, is we take this kind of adversarial approach to bacteria.
Andrew: Yeah.
Lewis: And we try and obliterate all bacteria. You know, if you remember the Listerine ads where you pop...
Andrew: The bomb.
Lewis: ...the mouthwash in your mouth and it's like a bomb that, you know, explodes and kills everything off.
I think, you know, one of the issues that we're having is that, instead of having this kind of symbiotic mentality, we take this adversarial approach and kill off everything. But, you know, in the same way that antibiotics kill off the good stuff, there's a lot of good stuff in the mouth that we need to keep everything in order.
And, you know, interestingly, I was reading a paper the other day about the link between gum disease and precancerous stomach lesions..
Andrew: Yeah?
Lewis: And one of the findings that they showed in that research was that not only were there high levels of the bacteria that cause rampant sort of aggressive gum disease, they also showed that people that had these precancerous lesions, that had gum disease, had a lack of bacterial diversity.
Andrew: Right.
Lewis: And that got me thinking, is it something to do with the way we clean, you know, and the products we use and the chemical-laden stuff that we have that's kind of obliterating some things that, you know, are potentially good in our mouths, that are leaving us susceptible to more systemic things?
So I think, you know, there's something to...But it's food for thought. I mean, I don't know the answers specifically, but it certainly does raise a few questions about the way we approach it.
Andrew: Yeah. One has to make the decision of which society you want to live in, I guess. You know, we live in a 21st-century society, we have now a hell of a lot of a marketing around the smile being perfect. And let's face it, we associate that initial half of a second that we see somebody's face, we get a first impression about friend or foe. Do you have a similarity? So there's a lot of forces at play here. I don't think I'd like to be the first one that doesn't brush their teeth, I've got to say. You know, I don't think I'd like to be that person.
Lewis: And that's one of the best things that we can do, is just, you know, the mechanical removal of plaque and keeping the bacteria friendly rather than a foe, is really important, and, you know, and mechanical removal of plaque is hugely important for our oral and general health. But the kind of question is whether or not the actual products that we use are going too far and obliterating a lot of the good stuff that we need for our immunity as well.
So, there's some interesting stuff coming out which just kind of been skimming the surface of, and going to delve a little bit deeper into it in...over the next few months just researching about it. But, you know, this whole probiotic toothpaste..
Andrew: Yep.
Lewis: And mouth rinses and things like that. So there could be a bit of a paradigm shift that we see in, you know, at least certain circles of dental hygiene products. So yeah, watch this space.
Andrew: So you mentioned about long-term sequelae of bacteria that might influence diseases in other parts of the body. We know Helicobacter pylori does that. As a dentist, how often do you practically swab somebody or investigator Helicobacter pylori?
Lewis: Honestly? Never.
Andrew: Right.
Lewis: Yeah.
Andrew: But it's a known thing, about Helicobacter pylori in the stomach. Certainly influences cardiovascular disease, endocarditis. There are other bugs as well, right?
Lewis: There's a stack of research out there, you know, linking the bugs that are found in deep pockets in your gums that are leaving people more susceptible to, you know, cardiovascular disease, diabetes, you know, breast cancer, even, precancerous stomach lesions...
Andrew: Wow.
Lewis: ...rheumatoid arthritis, preterm birth weights - so, you know, early births - and difficulties falling pregnant, erectile dysfunction, sperm motility.
Andrew: Wow.
Lewis: Just a stack of research that's coming out more...I'm a massive nerd when it comes to this stuff, I'm just...I'm constantly reading the links between oral health and general health, and it's just crazy. You know, every couple of months it's, you know, endometriosis or it's sperm motility. You know, with that, I should mention that we just focus so much when it comes to fertility, on the woman, that it's amazing, you know, how much...I mean, it makes sense because it takes two to tango, but there's so little out there about, you know, the influence of the male, and I just... You know, as a general rule, the majority of people that come into our practice that are more health conscious tend to be women, and I just tell them, you know, you’ve got to...if you're planning on getting pregnant, you've got to get your husband or your partner in here and get their gums in tip-top shape.
Because there's just more and more research showing those oral health - general health links. And it's the bugs that live underneath the gums that cause the most drama, the most chronic inflammation. And we all know acute inflammation is beneficial but it's the chronic irritation and...that's the cause of the most problems, and that's the stuff that we need to get on top of.
Andrew: You mentioned probiotic toothpaste before. I recall using lactobacilli...forgive me, Lactobacillus acidophilus, and with the warning that if you switched it round your mouth, that was fine, but you should clean your teeth afterwards because the acid secreted by the lactobacilli could damage the enamel. But then, you know, for instance, we saw this...it's a New Zealand company that has a really good probiotic for reduction of dental caries, you know, so it seems...
Lewis: Is that BLIS? BLIS?
Andrew: BLIS, BLIS. That's right, yes, BLIS.
Lewis: It's BLIS, yeah.
Andrew: You know, there you have quite the opposite of what my previous understanding was. What's the truth? What should we be doing with the lactobacilli? What's the danger?
Lewis: There's a lot of research showing that, you know, probiotic toothpastes are actually reducing the amount of Streptococcus mutans, which is the main one for dental decay, and also reduction in candida, actually, in the mouth as well, so...
Andrew: What should we be looking for in a toothpaste? You know, can we maintain good dentition with something as simple as salt? Or do we really need a fully, you know, formulated toothpaste, albeit from a natural source? Or, where from?
Lewis: Yeah, it's one of the most common questions I get asked day-to-day. And one of the things that you need to weigh up in responding to that is, what kind of a state that patient is in..
Andrew: Yep.
Lewis: And what their habits are like. So, one of the things about being a dentist who think holistically, it's not being dogmatic about a particular product or, you know, ingredient that's in or not in a product. It's about weighing up that person's particular risk and being a bit more pragmatic about it.
So for example, I've got a patient who had cancer of the… that spread into his parotid gland, and he had that removed and he...his mouth is like a desert, it's literally...You know, he’s just producing no saliva whatsoever, which is obviously very...
Andrew: Right.
Lewis: ...important for neutralising acids and reducing your risk of decay. And, you know, every single time he came in, he had decay under his crown. And then I had to cut off his crown, and then do a new crown, and then, you know, and on this...and so on and on this would go. And, you know, for someone that has no protection, I actually recommended him to use a topical fluoride toothpaste because we just need all the help we can get in his case, you know, because what's...The end point is that, you know, he continues to get decay and he...and, you know, if the decay's underneath the gums and down into the roots, you go...you got no choice but to extract it. And am I doing him a favour if he doesn't have natural teeth to chew and break down his food?
Andrew: Yeah.
Lewis: And then there's other people that are 41 years old, you know, their patient is 41 years old and he's using natural toothpaste, no nasties in it whatsoever, has never had a filling in his life, eats an impeccable diet, he's brushing and flossing all the time, he takes his regular appointments, you know, he's a model patient. And, you know, to someone like him, just the mechanical removal of plaque, you know, and excess food that can get trapped in the mouth and in the gums, etc., what he's doing is absolutely fine.
So, it's really case-by-case. Personally, I try to go as naturally as possible, and we know that mechanical removal of plaque's the main thing. But is also...you know, primarily, tooth decay is a disease of diet.
Andrew: Yep, yeah.
Lewis: So, if you're not looking after that, then, you know, the decision on what toothpaste you use is influenced dramatically by what you're putting in your mouth.
Andrew: And then we go to...you spoke about mechanical removal, so obviously the type of brush that you choose. We've now got, you know, brushes that have, what is it, 20,000 revs per minute? I'm waiting for us to get grinders out, but anyway...But also flossing?
Lewis: Yeah, it's very important. And I would say, you know, one of the questions, you know, in our medical history form is, "Do you floss your teeth?" and I would say on average probably, if I was to guess, 90% would say "no." Even knowing...
Andrew: Still?
Lewis: Yeah, yeah, yeah. Like, maybe, you know, one a week or one every two weeks, but it's not a regular thing like it should be.
Yeah, it's kind of annoying to get your fingers in your mouth and, you know, it's tricky, and you need to learn some technique and find a product that works for you, but a lot of people don't actually know why they floss, and once you actually educate them on that, they're far more likely to do it. And what you're actually trying to do, we know that the bacteria that live underneath the gums cause the most inflammation and some of the systemic diseases that I've actually, you know, mentioned previously.
The bacteria that live underneath the gums are the ones that leave you more susceptible to those things. Because they're...they live without oxygen, so you can imagine how tenacious they are.
Andrew: Yep.
Lewis: You know, they're anaerobes. And what you're actually doing with your floss is, you're not trying to get rid of all the bacteria - you know, that's kind of adversarial mentality again. What you're actually doing is basically putting oxygen down into a...an area where...
Andrew: Right.
Lewis: ...oxygen doesn't live, to make the bacteria a friend rather than a foe. So, once people actually understand why they're doing it...You know, I grab my floss and I'm like, "Ah, I got to get the oxygen down there, you know?
Andrew: Yeah, yeah.
Lewis: It's a bit more of a motivating factor if you know actually what you're doing. And then, you know, the dark side of it is that you're reducing your risk of dental decay because your brush can't get to the areas in between the teeth. But you're also reducing your risk of all those systemic disease that I mentioned previously.
Andrew: Right. I've seen somebody use...I don't know whether it's a airborne pick, but it certainly emits a sound kind of like when I get a clean, but it's like a handheld device?
Lewis: The water picks?
Andrew: Is that what it is, a water pick? So what do you do? You fill up, like, a cartridge if you like, almost like the battery compartment, and then it goes to work, does it?
Lewis: Yeah, and then it's just...it's quite a powerful rush of water into the gums. And personally I haven't used it. But I've read some studies that show it's actually quite effective. And in some studies show that it's more effective than floss.
Andrew: Oh, wow.
Lewis: So it's an interesting one but I'll have to double check if that research was sponsored by a water pick company that...
Andrew: Yeah, yeah, that's the obvious question to ask.
Lewis: Yeah.
Andrew: I think in both cases, though, I think the old adage that was spoken to me by my dentist, "You only have to floss those teeth that you want to keep," remains intact.
Lewis: Yeah, it's a great quote.
Andrew: Yeah.
Lewis: It's great.
Andrew: But how long has flossing been around?
Lewis: Johnson & Johnson brought out, like, a silk, unwaxed floss in late 1890s?
Andrew: Yeah.
Lewis: But yeah, I think it was established in, like, 1815 or 1819 or something like that.
Andrew: Wowee.
Lewis: And the guy that discovered it believed that that was the most important thing for your oral health, basically getting to the real source of disease, he called it.
Andrew: Yep.
Lewis: Which makes, you know, a bit of sense in hindsight, with all those bugs that live underneath the gums. So yeah, they were onto something.
But yeah, I mean, the other thing as well is that, you know, it's really important to not only do the right thing by your own health, but I think you've also got to think a bit holistically about, you know, the environment as well. And a lot of dental products go into landfill.
Andrew: Yep.
Lewis: You know, in Australia we use about 30 million toothbrushes a year that go into landfill...
Andrew: Whoa.
Lewis: ...and, you know, I've been...Well our practice has actually have their own...we've made our own - or got them made -- some bamboo biodegradable toothbrushes. So, you know, if we can do some good for our teeth but also for our environment, it's a good thing as well, and that...you know, that's an important thing to think about. We tend to always think about our health and we think about ourselves only, but it's a good thing to keep in mind.
And even, like, floss. You know, a lot of floss has got Teflon all over it, which is pretty tough to break down, so there are some brands out there that are actually biodegradable, so you can track down them as well and do the right thing by your mouth and the environment.
Andrew: Can we put those links up on our FX Medicine website?
Lewis: Yeah, sure.
Andrew: Brilliant. I'll get those off you later and we'll put them up on the fxmedicine.com.au website for our listeners.
What about simple things, even like mouth hydration, Lewis? Like, I remember, you know, typical snorer, and you wake up and your mouth is dry, and I've always...you know, and pasty and horrible, despite having cleaned your teeth that evening, it always feels like in the morning, you really need to clean your teeth. So what about these simple things, about chewing gum after a meal, and mouth hydration?
Lewis: Yeah, thinking a little bit more holistically about the chewing gum side of things, we know that showing stimulates saliva which has got a lubricating and flushing effect and reduces your risk of gum disease, but also tooth decay. So that's really important, to keep your mouth hydrated.
But the other thing as well is that the majority of people clench or grind their teeth, and that puts a lot of force on the muscles of mastication, jaw joints, chronic pain, orofacial pain, etc...
Andrew: Gotcha.
Lewis: And then so people to...you know, that are stressing their jaw out throughout the nighttime, mouthbreathers are renowned for clenching and grinding because their tongue should be at the roof of the mouth and they should be breathing through their nose. And if that doesn't happen, what can happen is you...your tongue's obviously connected to your lower jaw and it can drop into your airway, and it's a natural reaction to kind of drive your tongue forward to get it out of your airway, but that's when you start clenching and grinding your teeth. So you're making something that should be a relaxing time, into quite a stressful time when you sleep. And that has a range of health problems like sleep apnoea and all those sorts of things.
But the people that clench and grind -- I digress a little bit - the people that clench and grind their teeth because of some sort of airway disturbance or snorers or what have you. They're stressing their jaw out potentially hours and hours at night. And if you go prescribing them, you know, chewing gum, they're using all their muscles and mastication throughout the nighttime, stressing their jaw joint, and then you want them to go and chew on gum all day?
Andrew: Right.
Lewis: You know? So, it's not so simple if you think outside the box a little bit. What I would have a tendency to say is, always stay hydrated. Try and steer clear from the...you know, the diuretic stuff, like loading up on coffee. And eating natural, healthy, crunchy foods when you actually do snack. Because the very act of mastication, chewing, will stimulate saliva. So nuts, and celery, and carrots sticks and things.
Andrew: Yep.
Lewis: You know, that's really good stuff promoting saliva, and you don't have to be chewing gum all day. You know, it's just a small period of time where you're having a snack and then you can stay hydrated after that, and that's enough.
Andrew: I had a thought about prevention versus repair. And I guess where I'm thinking here is regards to, as you mentioned, gum disease. Can you repair regression of gums?
Lewis: Basically, everyone thinks that gum disease affects the soft tissue only. But what's happening there, just so people to kind of get a grasp before I answer your question is that, it's a disease of bone as well.
So you've got plaque and, you know, pretty nasty bacteria that live underneath the gums and your bodies pretty intuitive and it'll do anything to avoid an osteomyelitis. So, you know, a bone infection - and it'll actually run away from the irritation. Once you've lost bone, you can never really get it back per se, you can only stabilise it.
You can get improvements in pocket depth, so when we...You've been to the dentist, and you've heard all the numbers called out, one, two, four, five.
Andrew: Yeah, one, two, yeah, yeah. Yep, yep.
Lewis: What we're measuring there is the height of the gum to the underlying bone, essentially. And you can...you definitely can reduce pocket depth through good diet, good brushing, deep cleaning, etc., but bone height itself is kind of a tricky one to get back.
Andrew: And the higher the number, the more gum regression, correct?
Lewis: Yeah, the deeper the pocket. And that means that there's going to be more aggressive bugs there, so it's just like a perfect reservoir for bacteria to live in, in an anaerobic environment.
Andrew: Can you comment about - I've heard this, I've never done it - but oil pulling? Have you come across this?
Lewis: Yeah, yeah, I do it.
Andrew: Yeah? And?
Lewis: Yeah.
Andrew: How well does it work?
Lewis: Yeah, it's an interesting one. There are some small studies that show that it's quite effective at reducing things like gingivitis, which is a reversible condition. Not like your full-on gum disease with the bone loss and the aggressive bugs and all that sort of stuff. Not so effective with that. But in smaller studies it's been shown to help reduce gingivitis, we've certainly seen that in our practice as well.
Andrew: Yeah.
Lewis: The idea is that the oil and the lipids, the...basically pull plaque from underneath the gums, and hence oil pulling. So it's a teaspoon or a tablespoon of coconut oil or sesame oil in the morning, flushing it...or swishing it round your mouth, and obviously don't swallow it because you're pulling all those bugs out. And don't spit it down your drains either because you'll have a plumbing problem. Always a good tip.
Andrew: Yeah.
Lewis: But yeah, we've actually seen some positive results in our practice, for reducing, you know, gingivitis, bad breath, and, you know, some mild, mild gum disease.
Andrew: Yeah.
Lewis: And there are some studies that support it, albeit very small study.
Andrew: Yeah, so coconut oil, was it, and sesame oil?
Lewis: Yeah, coconut oil, sesame oil, yeah. But, I mean, we just recommend coconut oil.
Andrew: Coconut oil.
Lewis: It's so readily available and the taste is not too bad.
Andrew: No. And forgive me, so you swish it round your mouth, was it two minutes?
Lewis: No, it's actually 15 minutes.
Andrew: Fifteen minutes. Right, okay, gotcha.
Lewis: Yeah. So not many people actually have that kind of time, so the way I've kind of done it at my house is I'll put it...I've got a jar of coconut oil in my shower, with a teaspoon. I always have a morning shower, so the moment I pop in the shower, I'll pop it in my mouth, start swishing it round. By the time I'm out of the shower, I dried and dressed, and I'm done, I'm...and then I go about my day.
Andrew: Yeah.
Lewis: So, you can find the time, but it is a bit of a commitment.
Andrew: Yeah, yeah. Oh well, that's great advice, I think. Because I've always been very curious about this, people sort of cried...decrying how its virtues and I've wondered about it. So, you say it's of merit. Brilliant, I'll give it a go.
Lewis: Yeah, I mean, there's also people that absolutely think it does nothing. But, you know, there are some studies out there that show it has been...
Andrew: Try it.
Lewis: Give it a go and see if it works for you. It's also a subtle tooth whitener without having to go down the whole chemical front...
Andrew: Right.
Lewis: ...so, you know, there's some advantages there.
Andrew: So do it, stick with it, and then see if those numbers regress over two visits.
Lewis: Yeah, yeah, that's a good thing to do.
Andrew: What are the top three things that we can watch for in our patients with regards to dentition? Now you've just highlighted a couple of things at the beginning with me, that I've never done. Things like fertility. You know, check their dentition, just ask about it, and if there is an issue, then for goodness sake, get it addressed. If there isn't an issue, great. It's from other causes. But what other things that we...should we be looking for in our patients?
Lewis: I mean, I think a classic one is just, do your gums bleed when you brush and floss them? And that's really basic, but that's a...it's a classic sign of chronic inflammation, and then that's going to have a gamut of, you know, issues potentially. Your fertility, and your heart problems, and diabetes, etc.
So that's a good thing to be looking out for. You know, I always say to my patients, just every time you washed your hands, your palms started to bleed, you know, you'd be in a state of panic.
Andrew: Yeah, that's right.
Lewis: But, you know, so many people bleed when they brush and floss their teeth, and actually the surface area of your gums is about the size of your...the palm of your hand, so if you had a sore, like, that big, you know, you wouldn't leaving it, you'd be pretty worried about it.
Andrew: Yeah.
Lewis: So, you know, it's...it shouldn't be overlooked because it's a sign of chronic inflammation, and the mouth is one of the most common sites of chronic inflammation, so that needs to be addressed.
I think also things like chipped, cracked teeth, you know, when people in particular are a grinder, just I take people-watching to a new level, Andrew. I'm constantly looking at people's teeth and jaw size and things like that. Because, you know, if they're...if they've got squared off front teeth...you know, there should be kind of a natural curve to the edges...the very edge of people's teeth.
You know, and your canines, your vampire teeth -- the big ones that stand out - they should be V-shaped, they shouldn't be squared off. You know, if you've got really worn down teeth…
Andrew: Yeah.
Lewis: Then there's some sort of a stress, nutritional deficiency, breathe...sleep-disorder breathing issue. You know, 80 to 90% of the sleep-disorder breathing or sleep apnoea is actually undiagnosed in Australia. And, you know, clenching, grinding is a sign of potentially poor breathing, poor nutrition, adrenal fatigue, you know, a whole gamut of things. So that's something to consider.
And then even, you know, sticking your tongue out and seeing if there's kind of a scalloped appearance...
Andrew: Right, yep.
Lewis: ...is a neat thing, because what that actually is a sign of is some sleep-disordered breathing. Like I said, your tongue should be at the roof of the mouth, breathing through your nose. Nose is for breathing, mouth is for feeding, I like to say.
If it's not at the roof of the mouth, it drops into the airway, and those little scalloped appearance, you know, these indentations on your tongue, is actually your body trying to push your tongue out of your airway and there's an imprint of your teeth on your tongue.
Andrew: Right.
Lewis: And that can be a sign of some sort of sleep-disordered breathing. And we've seen patients that have had chronic fatigue, depression, anxiety for 25 years, and no practitioner has ever asked them about their sleep. And in our medical history, you know, about a quarter of our questions are on sleep. It's the most important part of the day, in our opinion.
And, you know, if you're asking questions, we ask questions like, "Are you waking up feeling refreshed? Do you wake up with a dry mouth? Do you wake up gasping for air? You know, do you wake up in the middle of the night and go to the bathroom?" These are all signs that you might be breathing poorly when you sleep.
And, you know, we've had, like I said, that patient, 25 years, antidepressants, chronic fatigue, no one asked her about sleep. We send her for a sleep study based on some of these oral signs that also the answer to those questions, and turns out she had severe sleep apnoea, so in an hour of sleep she was actually not breathing for about 40 minutes.
Andrew: This really interests me, Lewis, because I know somebody who denied going to...or forgive me, getting a CPAP or a BiPAP machine for years. A decade? And finally there were new developments in the comfort of the BPAP. And so now this person has a BPAP, and it was amazing the amount of times that they stopped breathing.
Now we're not talking holding our breath, but stopped breathing, stopped the action of respiration. Was something like, I don't know, 80 times a minute or some...And I was going, "What? You don't have 80 breaths a minute, and it's got...not got to do with that." But after one week of use, it dropped to 14.
Lewis: You literally cannot to be relaxed, and have a strong immune system, and do your day-to-day activities, and perform at your best, if you're breathing poorly when you sleep. And, you know, sleep apnoea's linked to depression, anxiety, road accidents, diabetes, heart disease, intestinal permeability, fibromyalgia, you know, the list goes on. If you're not sleeping well, you know, you can pretty much forget the rest of your health.
Andrew: Yeah.
Lewis: And, you know, with this lady, we...you know, her apnoea hypopnea index was, basically in apnoeas where you got complete cessation of breathing for 10 seconds up to a couple of minutes. And then there's hard apnoeas, which is a partial blockage of the airway.
So it's a measure per hour, like you were saying with that patient that you were talking about, she was having 58 per hour.
Andrew: Oh my God.
Lewis: So say she's having, you know, a minute at a time where she's not...or 30 seconds at a time… for half of every hour she's not breathing, you know.
Andrew: Yeah.
Lewis: So then we sent her for a sleep study, she got her sleep ap machine. There's other forms, we do mandibular advancement splints - that's where the dentist plays a role in all of this, and that's why we ask, you know, a lot about sleep. You know, if there's mild and moderate sleep apnoea, that's where you consider a mandibular advancement splint where you hold the jaw forward. But in this case, she had severe obviously, so she needed a CPAP machine.
She was off her antidepressants, she had never felt better, and, you know, we asked her about this, her sleep. And she said, "you know, Lewis, I can sleep anytime, anywhere, sleeping's not the problem." And I sort of said, "Well hang on, that's an alarm bell, you shouldn't be"...
Andrew: Yeah, yeah, you're tired.
Lewis: ..."sleeping anyplace, anywhere. You should be waking up and you should be refreshed." So, and, you know, not need to nap throughout the day.
So, yeah, I mean, even just analysing the tongue can be a sign of some sort of sleep-disordered breathing.
Andrew: What about things like beds and pillows? Can they have a dramatic effect on how you sleep and maybe your breathing, and therefore as a sequelae, your dentition?
Lewis: Yeah, for sure. I mean, sleep posture's really important. Side sleeping’s the best from the postural standpoint and airway standpoint, back is okay and stomach sleeping's not good at all, because you got a kink in your neck and a kink in your lower back, and then you're more likely to mouth breathe and all those sorts of things. And then you start grinding… and an interesting finding that I've seen in my practice is that a lot of stomach sleepers have crowding. They don't have enough space for their teeth because their tongue is not where it needs to be.
Andrew: Right.
Lewis: And the tongue is the...is nature's best orthodontic appliance. So if it's at the roof of the mouth, it'll always win over the forces pushing inward by the cheeks and the lips, but if it's not there, those cheeks and lip pressure, you know, basically use a lot of force, can actually start shifting teeth.
Andrew: Wow.
Lewis: And that predisposes someone to a narrow airway, and then that predisposes people to sleep-disordered breathing, and then it's just a vicious cycle. So, sleeping posture is very important. But also from a pain standpoint as well, you know, if you got a kink in your neck and a kink in the back, you know, osteos, chiros, physicos, you know, that keeps them in business. But it can also create a clenching-grinding habit, because if you're in pain while you sleep, you will clench and grind your teeth more than likely.
So, sleeping posture's important. Obviously you need to have your pillow at the right height, you don't want to have it too low or too high if you got a kink in your neck there, even if you sleep on your side. A neat little trick is to get someone to take a photo and put some tape down your back, from your neck all the way down to your back, the top of your bum, and you can actually see where there's a...
Andrew: Oh, right, from the side.
Lewis: From the side, you can actually see if there's...if it's at the right height it should be, like, perfectly aligned.
Andrew: Yeah.
Lewis: That's a neat little trick. But also just what you put on your beds as well. Like, I sleep with a dust mite cover and I vacuum my bed with a a HEPA filter vacuum once a week. Because, you know, if you have irritations on your...you know, on your bed, then you're more likely to get blocked up in the nose, and then that will make your mouth breathe, if your mouth breathe, you're more likely to get crowding, you're more likely to grind, you're more likely to wake up and go to the bathroom. A whole gamut of things.
Andrew: You need to be running courses.
Lewis: Yeah. It's a fascinating thing, this is why I say that, you know, health...you know, the mouth sets the tone for your health, and there's so much more to it than just the teeth and the gums. There's breathing, there's sleeping, there's nutrition and, you know, all of this plays a role in good oral health, and, you know, good general health, but those sorts of things are imperative. Just little tips and tricks that can make all the difference to your breathing. Because, you know, your sleep's a third of your lifetime - you know, you want to be doing it well.
Andrew: Well I've got to say, you know, you've certainly answered question why we should prioritise our oral health.
Can I ask a couple of last questions? The first one of which is, you know, you see Japanese cultures and they have a roll to put under their neck, and it hyperextends the neck, but it actually seems more relaxing when you do that. And, like, I don't know the effect on mouth breathing or anything like that, but it certainly does appear to reduce the tension in your neck.
Conversely, whenever I go to the dentist, I have to squirm around to try and find the right position to be able to have a hyperextended neck so that my mouth will be open enough for him to shove his hands in my mouth. Why are dentist’s chairs are so horribly designed? That's number one. And number two, I have to ask -- how can people get a hold of these toothbrushes that you guys have had manufactured?
Lewis: So, with regards to the chair, we...I think the dental profession just...we just love to go out of the way to make it as unpleasant as possible, I think. But yeah, our chairs, you know, do have some room to maneuver there so, you know, we offer patients different pillows, and different heights, and all those sorts of things. But yeah, it's very important to be comfortable in the dental chair because, you know, you've got your mouth open for such a long period of time, and that can stress the neck and the jaw if you're predisposed to neck and jaw issues.
Andrew: TMJ, yeah.
Lewis: Yeah, and TMJ. And yeah, I mean, people have left the dental office with lockjaw or neck spasms and things like that, so that's why a case history before you start is really important. That's why we check the health of the jaw joints, and the amount of opening, any deviations and all that stuff, and we record it so that when the patient comes in, we know who's susceptible and who's not. And if you are susceptible, we will give you a break, sit you up, have a stretch, come back, do the second filling, if you've got two fillings to do, or what have you.
So, yeah, I mean, they're becoming more ergonomic and more comfortable so there's always a position that will be more comfortable, but yeah, we're pretty average at making the whole experience a good one, but, yeah...
And with regards to the toothbrushes, there are some companies online that do a reasonably good bamboo toothbrush. Our ones, we ordered...we got about 5,000 made, just to try and get some...you know, make some healthy changes in the world. And we give them out to our patients when they come in. So if you want one, come to visit us, but if...
Andrew: I would love to. Definitely, I will be there, mate. I really take my hat off to you guys for thinking about this. About the...you know, the wider ethics, if you like, of your profession.
Lewis: I mean, I think it's an important thing and, you know, there's more and more and more stresses on the world, you know, with every year that passes, so I think any little positive change is a good thing. And just getting some awareness out about how toothbrushes actually go into landfill and it's just not a good thing - 30 million toothbrushes into landfill every year.
Andrew: That's amazing, yeah.
Lewis: Yeah.
Andrew: That's a lot of things to clean cars with.
Lewis: Sure is, yeah.
Andrew: To clean car...
Lewis: Well, that's the other thing, is...
Andrew: ...air conditioning vents.
Lewis: Yeah, that's the other is, don't throw them away. If you got to make a...make the change, actually keep them round the house and use them for...to cleaning bathrooms, or cars, and mag wheels, or whatever it is that you can do with them.
Andrew: Lewis, I can't thank you enough for joining us today and imparting some of your wisdom. That was really enlightening. You've really opened my eyes to a few things where, I thought I had it, you know, down pat, but nope. So, thanks so much for teaching us today.
Lewis: No, I...it's absolute pleasure, and we're always on a learning journey and trying to improve the health outcomes for our patients and the wider community, but, you know, I'm always learning every day. And some of the stuff that I said today will probably end up being wrong soon, but, you know, that's the beauty of it all…
Andrew: Well I look forward to podcasting with you again at a later date. Maybe we'll investigate some of these systemic diseases. What do you reckon?
Lewis: Sounds great.
Andrew: Excellent. This is FX Medicine, I'm Andrew Whitfield-Cook.
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