Functional Dentistry: Why Do Teeth Keep Failing?

Eon Engelbrecht, eRadio SA (0:04)
Welcome back to Save Your Money, Save Your Teeth, the podcast where we look at what genuinely protects your teeth and also your wallet. Last week, if you listened, we looked at lasers, a new tool for treating teeth. Today we're stepping back from the tools altogether and asking a bigger question.

Why do teeth fail in the first place? Most of us know the cycle of filling, then a bigger filling, then a crown, then a root canal. Each one fixes the damage, but nobody asks why it keeps happening.

So functional dentistry starts with that question and the answer often lies outside the mouth in sleep, breathing, diet, stress and general health. Today, what is functional dentistry? How do sleep and blood sugar affect your teeth?

Can your dentist spot health problems before your doctor? And what are the claims to be wary of? Joining me, as always, is Dr Clifford Yudelman from OptiSmile in Sea Point, Cape Town. Dr Yudelman, welcome back.

Dr Clifford Yudelman, OptiSmile (1:10)
Thanks, Eon. Great to be back. And yeah, summer's here.

Eon Engelbrecht, eRadio SA (1:15)
Yes, it would appear so. Just, just. Okay, so Dr Yudelman, starting off with the basics of what is functional dentistry and how is it different from holistic or biological dentistry?

Dr Clifford Yudelman, OptiSmile (1:30)
So when we've spoken before about holistic and, and biologic dentistry being more of a belief system, functional dentistry is not a belief system. It's not an alternative dentistry like what we've spoken about before. And also not to get mixed up with biomimetic dentistry that is evidence-based, etc.

So we, we now started to talk about this functional dentistry because we're seeing it a lot on social media and a lot of people are talking about it. So it's, it's about thinking before acting. So before we fix the damage, we actually ask, you know, why did it happen?

What happens if we only fix the damage? So biologic, biological dentistry focuses on the materials and functional dentistry focuses on the forces driving the disease. It's, it's not like anti-drilling and anti-crowns, etc.

And it's not softer dentistry, it's smarter dentistry. So I know that wasn't like the shortest answer, but I think once we go through the next few questions, you'll have a better idea of what we mean by functional dentistry.

Eon Engelbrecht, eRadio SA (2:44)
Okay. And why are dentists now looking at nutrition and sleep and breathing as root causes of dental problems?

Dr Clifford Yudelman, OptiSmile (2:52)
So, you know, because teeth live in a body, not in a vacuum. So they're part of the body and it's now becoming more accepted and, and more mainstream. For instance, mouth breathing dries out your saliva and saliva is your, your teeth's natural defence, reflux.

So mouth breathing, you could have allergies or deviated septum or nose blockage, etc. So we start looking like, why is this person mouth breathing? Why they have a dry mouth?

Why are they, why are they getting cavities, etc. So we start sort of working our way backward from the problem. The same, for instance, reflux, which brings up your stomach acid into the mouth.

This is something called GERD. We've done podcasts. I think by now we've done podcasts on almost everything, but not quite.

But GERD, gastro-oesophageal reflux disease, it's often called silent reflux. And it happens at night when people are sleeping, you wake up with a sore throat or like a sour taste in your mouth. And basically the acid comes into your mouth, especially at night.

And then it erodes the inside surfaces of the upper teeth, almost like bulimia. So then one has to start, when you see that, then you start asking the patient, have they had a gastroscopy? You know, you maybe refer them.

Then something that we see a lot of is snoring and sleep apnoea, which relates a lot to nighttime grinding in the same patient. And whenever I have a patient that's got quite a lot of wear on their teeth, and even if they're not overweight or have a large neck or someone that looks like they might be a snorer. In fact, today I had a lady who's actually, she's not overweight at all.

She has a narrow neck. You wouldn't actually guess that this person would snore. And it's not something that you can do.

You've got to ask people.

Eon Engelbrecht, eRadio SA (4:55)
Yeah.

Dr Clifford Yudelman, OptiSmile (4:55)
And her teeth are quite worn away. And I asked her, do you snore? And she said, yes, she does.

And then I started asking her about tiredness and things like that. And she's going to have a sleep study. And you know, that's because of me seeing the wear on the teeth.

So, you know, you can rebuild the mouth beautifully, but if the patient has got untreated reflux or they grind all night, then the damage comes back every time. And, you know, dentistry fails not because the work was bad or substandard, but because the environment was hostile based on all this other functional stuff that we just mentioned.

Eon Engelbrecht, eRadio SA (5:38)
Doctor, should your dentist be talking to your doctor, your cardiologist, or even your dietitian?

Dr Clifford Yudelman, OptiSmile (5:45)
Yes, 100% in complex cases, for sure. For everyday stuff, not necessarily because you take a medical history and you go over the medications. But I've, you know, one of the things is gum disease and diabetes, which affect each other in both directions.

Meaning if you've got gum disease, it would be harder to control your blood sugar. And if you've got diabetes, it's harder to control your gum disease. So, they work two ways.

Gum disease also linked with heart disease very much so. But we can't say 100% that if you treat the gums, it's going to prevent heart attacks, but it's one of these factors. And then if a patient keeps losing bone, despite good flossing and oral hygiene and coming in regularly, then I've often referred patients for a HbA1c test, which checks their blood sugar over the previous three months.

And a lot of patients, not a lot, but over the years, I've actually helped patients get diagnosed with blood sugar problems or diabetes, type 2 diabetes. And yeah, so dentists that don't look at the full picture and how it relates, you know, they're just stuck in one groove.

Eon Engelbrecht, eRadio SA (6:59)
And then I want to ask you, can your bite actually cause headaches and jaw pain? And what about the claims that fixing your bite cures neck and posture problems?

Dr Clifford Yudelman, OptiSmile (7:10)
So, yeah, look, let's be honest here. Clenching and grinding are linked with jaw pain and headaches, and they wear down and crack the back teeth and the fillings and protecting the teeth with a well-made bite guard or Michigan splint makes sense. The bigger claims that adjusting your bite fixes your posture, your back, your neck are not really supported by research.

There are dentists that sell expensive bite reconstructions. We've spoken about this type of thing. That's not the one where we spoke about production dentistry.

That's more to do with these things like your mouth is going to explode and you need a full mouth rehabilitation. And this is another one of the things where the dentists that do these kinds of things, when they've got a patient with neck problems, they'll tell them, we're going to fix your bite and reconstruct your bites, and that's going to fix your neck. So, the research that I've done in preparing for this podcast, I couldn't find any good proper evidence-based research.

Good functional dentistry removes unnecessary strain, but it doesn't promise miracles.

Eon Engelbrecht, eRadio SA (8:27)
Exactly. And is it possible for a dentist to spot a diabetes or other health problems before a doctor actually does?

Dr Clifford Yudelman, OptiSmile (8:35)
Yes. So, going on from what we were talking about earlier, we don't actually diagnose it, but we often see the warning signs first. Gums that bleed despite good care, slow healing, someone gets an extraction or some kind of procedure and it doesn't heal properly.

If they keep getting infections or they got dry mouth, I'd rather ask them to ask their GP or their doctor to send them for a blood test just to be safe. We mentioned that there was a big review article in Cochrane, which is the C-O-C-H-R-A-N-E. They do reviews of hundreds and hundreds of articles and then they throw out all the ones that are not good.

And they did find that treating gum disease in people with diabetes can measurably improve their long-term blood sugar control. And the teeth and gums will whisper something that the body hasn't yet shouted out to you.

Eon Engelbrecht, eRadio SA (9:38)
Interesting. And also, what is the inflammatory load from the mouth? And also, how do you measure it?

Dr Clifford Yudelman, OptiSmile (9:46)
Think of it as chronic low-grade fire, like a bushfire. Gum disease across the whole mouth is a large inflamed wound and the body notices it. We've said before, it's basically spread out.

It could be like a wound the size of your hand or even bigger. If it's a lot, then it could be the size of an A4 sheet of paper. And the simplest measure is bleeding when we gently probe on the gums.

Healthy gums don't bleed. Sometimes I blow air on the teeth and the gums start bleeding. Then you know there's a problem.

And we also look at pocket depths. We've spoken about periodontal probing and what the numbers mean. And we look at the bone levels on x-ray.

And also, when we do treat inflamed gums with cleanings and root planing or special toothpaste and mouthwashes, we know how they normally respond. But if somebody's not responding, they've got a much higher inflammatory load. And healthy gums are not just cosmetic.

Nice teeth or nice smile means nice, firm, pink gums, not puffy and bleeding. And so, it's part of your general health. It's not just cosmetic.

Eon Engelbrecht, eRadio SA (11:10)
Doctor, does functional dentistry cost more than traditional drill and fill?

Dr Clifford Yudelman, OptiSmile (11:17)
So, it could depending on what practice you go to. I would think that a lot of good dentists are doing some level of functional dentistry as part of their way of practising rather than just looking around, finding a few cavities and putting fillings in. So, for instance, we book a 90-minute exam and more than half an hour of that can be just talking about the medical history and talking things over before we start looking.

And that can cost more because the dentist is having to spend more time. But paying once for a thorough smile assessment and oral health assessment is better than teeth that keep chipping or breaking or fillings that fall out and you've got to keep paying over and over to repair something that could be predictable.

And the most expensive dentistry is dentistry that's done twice.

Eon Engelbrecht, eRadio SA (12:17)
Exactly.

Dr Clifford Yudelman, OptiSmile (12:18)
In fact, I always say the most expensive dentistry is the dentistry you didn't need, getting a filling that you didn't need. And then this is the second most expensive, getting fillings done when you don't have a proper diagnosis.

Eon Engelbrecht, eRadio SA (12:34)
Exactly. Doctor, how does stress damage teeth and where does managing it fit into a dental plan?

Dr Clifford Yudelman, OptiSmile (12:43)
So, we did that wonderful podcast all about stress and how it shows up in the mouth all the time. People clench and grind their teeth in the day and at night and they snack more when they're stressed. They maybe eat a lot of lollies and candy, etc.

They sometimes will skip brushing because they're stressed out and they're in a hurry. Their gums flare up. A stress patient can destroy excellent dentistry without knowing it.

Sometimes the most useful thing I can do is to protect the teeth with a mouth guard, a night guard. It's not just a rubber mouth guard that you wear for sports. It's a hard mouth guard that's made especially to stop you from grinding in your sleep.

Yeah, we point out the pattern rather than rush into more treatment.

Eon Engelbrecht, eRadio SA (13:36)
And now, what are the warning signs that should actually make a patient ask, why does this keep happening?

Dr Clifford Yudelman, OptiSmile (13:44)
There's quite a few red flags. Some of them are teeth or fillings that just keep breaking, teeth that are getting shorter, flatter or more sensitive, gums that bleed even though you brush and floss well, constantly dry mouth, snoring or if your wife or husband complains that you're snoring, you should listen to them. Get the app called SnoreLab and record your snoring at night and listen back.

You'd be quite worried.

Eon Engelbrecht, eRadio SA (14:15)
It's very, very scary and I think it sort of amplifies it as well. You kind of hear it in stereo and you feel sorry for your partner.

Dr Clifford Yudelman, OptiSmile (14:27)
Or if your partner complains that you sound like a cricket, like your teeth are grinding together, making like a creaking and squeaking sound. That means we should, instead of questioning what do we fix, we should ask what's causing this.

Eon Engelbrecht, eRadio SA (14:44)
Yeah, exactly. Finally, I want to ask you, how does OptiSmile put functional thinking into everyday care?

Dr Clifford Yudelman, OptiSmile (14:53)
So like I mentioned, OptiSmile and other practices similar to ours we book an hour and a half for a new patient exam. We spend quite a long time going over the patient's history. We ask about sleep, snoring, reflux, medication and stress.

We observe everything that's going on. We take photos. We take 3D scans.

We do 2D x-rays and if needed. We do a 3D x-ray. We run them all through AI.

We do high resolution photos along with the scans and then we sit with the patient. We look over all of these and we have a discussion based on what it is that they're complaining about. Then we co-diagnose along with the patient.

So that's called co-discovery. Then we co-diagnose in discussion with the patient after we both, me and the patient, see what's going on and then decide what should be appropriate. For instance, if we send someone for a sleep study and it comes back that they got mild or moderate sleep apnoea, we prescribe and make a sleep appliance to stop them from snoring or to reduce the apnoeas.

If it comes back and that's not sleep apnoea, but it's mainly grinding, we refer them to a physiotherapist to work on their posture and their jaw. When she says that they're ready, we might make them a Michigan splint or a bite splint. Then like I mentioned, we refer patients for blood tests.

If we suspect that they've got B12 deficiency or diabetes or other medical conditions, I've often offered to refer a patient to a psychiatrist or a psychologist when they have severe stress depending on what I think they might need and they've never seen someone or I send them back to their GP. Every decision goes through a question. It's how do we keep this tooth working as long as possible with the least harm.

That's what functional dentistry is about and that's the essence of save your money and save your teeth.

Eon Engelbrecht, eRadio SA (17:19)
I think one of the big takeaways today is the most expensive dentistry is the same repair done again and again. Functional dentistry asks why before it asks how and that question alone can save teeth and money for decades. Dr Yudelman, thank you so much.

Dr Clifford Yudelman, OptiSmile (17:40)
Thank you and great to speak to you and looking forward to next week's episode which is how to keep your teeth until you're 100.

Eon Engelbrecht, eRadio SA (17:54)
That's going to be interesting. Dr Yudelman, thank you so much and until next time.

Dr Clifford Yudelman, OptiSmile (17:59)
Thank you and great to chat and see you next week.