Oh boy, that is that is hardcore. So this is like rain or shine, snow, sleet, inhale.

This is like my compulsion. And it's also a really excellent form of exercise because when the quickest way to get home is to continue running, you continue running.

There you go. Do you enjoy this? I'm asking you, by the way, who's run marathons? I don't mad.

We're all in academic medicine. Like I feel like this tracks entirely. Like, yes, I like both hated at times and also enjoy it and spend for sure the last like 45 minutes of every marathon really questioning my entire personality. And like what led me to make the decisions I made, but then like immediately want to sign up for another one. So yeah. Yeah.

I'm sure that's true of most like this, this act of self-agulation. And then you just do it all over again for no compelling reason. And are you, are you like an elite level runner at this point? Like if

you ask like an actual like more serious runner about this, the answer like always has to be no unless you're very, very good. I would say I'm like a decent hobby jogger, which is that I am capable of qualifying for the Boston Marathon, which is the whole thing that it's like not worth knowing about or caring about. But I am certainly not in the like super duper fast woman range, which I would consider like a sub three hour marathon. I am not there.

OK, well, still qualifying for Boston. No joke. I that is that is no joke.

Yeah, I qualify every year at Boston, but always fail to achieve my goal and always bonk on Heartbreak Hill. So I've had like many unpleasant Boston marathon experiences where I see all of my friends and family at the end and I'm like dying by the time I get there. I've never had like a positive Boston marathon. Well, I hope I hope this

is going to be the year for you. This this patron, this coming Patriots today. You know, Paul, I don't know if you're going to ask about favorite failure now. It sounds like we might have just heard that, but what do you what do you want to ask before we get on to the set me up for success? Matt just sort of quashed into question, but also bring it up at the same time. But yeah, we at least we always like to ask any particular piece of advice that you like to give your trainees or learners of people that you work with or favorite advice that you've received as a learner.

That's a really great and difficult question. My training path was not what I expected. I did not go to dental school anticipating that more than a decade later, I would be finishing internal medicine residency. So I think I try and bring a sense of equanimity about like how circuitous life can be that things aren't linear and you can be a learner and a teacher all at once as much as possible. But that having been said, I am very happy not to be in training anymore.

Yeah, it felt long just going through one degree program, let alone two and congrats for having gone through all that. But we're lucky and the audience is lucky because now you have all this great knowledge that you can share on this topic. And you can especially speak to us as internists trying to learn about it.

I can spare all your listeners from having to go to dental school, which

I don't recommend. Yeah, listening to like a one hour podcast seems a lot easier than going to

the tuition is a lot lower also.

Okay, by the way, Capone and I text you all our primary care dental questions from now on

just frankly speaking, I live for this. I like this is my actual joy in life is to get both barely identifiable, back of mouth weird iPhone photos and then also questions like that are blatantly personal that people are texting me that are not about their patients. Absolutely.

All right, so fine. So you've answered both questions. Paul and I can ask you our own dental problems going forward. Just weird dark pink selfies of indeterminate structures. That just sounds great. It could be a lot worse than selfies other people get. Let's do a case, Paul. Would you would you read? Sure. I'd be happy to tell you about Bob, who is a 20 year old gentleman who smokes and is otherwise healthy. He comes to your urgent care clinic complaining of one week of worsening pain in the back of his upper right jaw. You explain and Bob probably knows this already that you are not a dentist. So it is hard for us to offer a specific dental advice. We are talking offline that I think most of us in primary care become lightly panicked with dental concerns. But we say that we're happy to take a look and see if we can help while we're sort of trying to get the him situated with more perhaps appropriate care. One examination, we don't see any dumb swelling. We don't see any facial swelling. He doesn't need fever. Otherwise we're just kind of poking around in there and seeing what there is to see. So why don't we start with that? Can you tell us maybe a better approach in terms of beginning an examination for someone coming in with possible dental pain than just kind of

shining a light and poking with a tongue depressor? Yes. So the first thing I would do is just validate that like for anyone who is listening to this and feels bad that they don't know about oral health, it is not your fault. It is not a part of the medical school curriculum. It's not a part of our internal medicine residency for a large part. And that is because we have a lot of other competing priorities. So it's OK. We will work through it together. The fact that you are willing to go ahead and look in the mouth is already making progress. If you feel confident about the things you're seeing, that's really excellent. And the way I would recommend looking at this is first, as this case kind of makes clear thinking about the medical components of the case, I think sometimes people here, it's a dental problem and kind of freeze and don't think about vital signs or how sick, not sick, the sort of classic stuff that we know to think about. So this guy we're meeting, his vital signs are stable. He's a febrile. He does not appear sick. There we go. That's great. Moving on from there, I think that they did do is like any other physical problem focused physical exam you're going to do is to do it in a methodical way. Do it the same way every time. And that way you can be confident that you're not missing anything. So in this particular case, you know, it's, it's OK to kind of stretch the lips out. People's lips tend to be pretty stretchy. And so you can really get a decent visualization. If you're in an exam room that has the light that you might use for a pelvic exam, that can be very helpful to kind of hang over your shoulder and then you can get a little bit better light. If you don't have that, like you're in a hospital room or you're just in a less well-equipped clinic, you can use your iPhone light. I do that all the time. I'm sure lots of people do that for like the JBP also. So shine a light in there. See what you can see. Things to look for when it comes to identifying a problem to because the thing is you may see you've got this upper right quadrant pain. There may be a bunch of teeth there. Maybe several of them look grossly decayed or fractured. There are things you can do to kind of narrow down which tooth is causing the problem. One thing to know is that the only sensation that teeth are going to transmit is pain. So the way you're going to do this is by invoking pain. So it's important to kind of empower your patient by telling them that as a warning beforehand. And then you can do things like palpating on the gingiva above the tooth. That would be looking for any sort of abscess that gives you a sense of which tooth is a problem. The other things that you would be tapping on the teeth. So the periodontal ligament that kind of holds the tooth in place. Any any sort of stretching at all will cause it to be exquisitely sensitive. Like think about, you know, when you get like a raspberry seed in your teeth, you can it feels like a boulder. So people are very sensitive. That will give you a sense. And you can also test for mobility because that same inflammation will make the tooth a little wiggly. The other thing to know is that if you aren't sure which tooth is causing the problem, the treatment from a medical perspective is probably going to be the same. So you can give yourself a little bit of grace there because ultimately this is someone who needs to see a dentist to.

What about I saw something about like looking for like like a bubble around the tooth. I wasn't exactly sure what was meant by that. Can you expound on that a little bit?

Yeah, I feel like this is actually something that I hear more from patients, which is you might get a story from someone who has more chronic or sub acute tooth pain, where they'll say like, oh, I had really bad tooth pain and then a bubble showed up on my gum or a zip popped on my gum and then the pain felt better. And what that is is actually a sinus tract that's fisceralizing from the abscess inside the bone to the outside of the mouth. And that produces a huge amount of relief when it officializes because it can give that drainage and relieve the pressure. People might say like, oh, now I have a bad taste in my mouth or something because they're tasting the pus. But but that is kind of what what you might see as a bubble on the gum would be a fisceral attract.

Paul, I didn't think ahead of time how gross this episode. Oh, I was. Even if I can start now, I was fully prepared for this to be a fairly gross episode, but that's that's OK. I did want to ask and I so my role on the show is just to be the dumb one. So can you just talk me through what your differential diagnosis would be here? I know this sounds like a dumb question, but I know like there's cavities and then ginger white. This is a thing I've heard about and then I don't know what else kind of goes on in the mouth. Can you sort of someone comes in with sort of tooth pain? Like what sort of things should be thinking about? Is there a long list or the big things that I'm missing there to sort of talk us through? At least your initial approach. Now you kind of triage stuff.

Yeah, this is not a dumb question and I'm going to put aside all of the like more interesting pathologies that might be associated with medical conditions or just might be like other stuff because the reality is that most dental problems and certainly if you're getting a focal dental problem, like this patient is describing, you know, this is a tooth problem. And it's probably going to be either a gum problem, i.e. the attachment of the tooth to the bone inside the gums or a tooth problem and they end up manifesting pretty much the same way. So gingeritis just means inflammation of the gums themselves. The gums don't attach the tooth to the bone. They don't do anything except like look nice. It can certainly be uncomfortable if someone has gingeritis, but it's not going to make your tooth loose. It's not going to make your teeth fall out. Once you start getting infection that goes deeper, then you're talking about periodontitis, which is inflammation that actually results in bone loss around the tooth. Ultimately, people can have their tooth become very loose. The tooth can look longer, which is sort of where long the tooth comes from. And it can be more uncomfortable. People can have kind of abscesses related to the loss of bone. But by far the most common thing, especially in a younger, healthier population, like the patient we're seeing is going to be tooth decay. So the outside layer of the tooth is enamel, which is stronger than bone. The inside layer of the tooth is dentin, which is also stronger than bone, but not as strong as enamel. So once you get a bacteria turning your sugar in your mouth into acid and breaking through that enamel, it spreads more quickly in the dentin. And then the very inside of the tooth, which is the neurovascular bundle, which dentists for some anti-intellectual reason, can call the pulp. Once it enters the pulp, it spreads into the nerve. The nerve, as I mentioned before, can only feel pain. So that is the sort of primary symptom someone will experience. And it's also sort of this delicious feast for the bacteria at the proliferate and spread. It ascends up the tooth into the roots, or down if it's in your mandible, and that causes the abscess and infection. And the only core takeaway I would note there is that if someone comes to you and they are having tooth pain, and I don't mean the kind where like you, if you drink coffee and it's very hot, you feel some pain or something like that. But if someone is like in pain when they wake up for some sustained period of time, that is a tooth that is going to need either a root canal or an extraction. Because that tells me that the infection is already in the neurovascular bundle of the tooth, a filling only replaces the enamel and dentin. So already we know we're too deep. I think that's a really helpful thing for internists to know because it helps you advise your patient. And also because unfortunately for many, many Americans, the cost of having a more invasive procedure like a root canal is going to be prohibitive for them. And if they are going to be assisted in getting dental care, having that sense of what's in store is really helpful.

Our extractions like a cheaper than root canals, I imagine, because you're not, you're not trying to preserve anything. You're just pulling the tooth. Yeah, they like haven't really changed since the middle ages. We still use tools that

legitimately look like pliers and like a straight edge screwdriver.

It's like 12 monkeys when Bruce Willis is pulling his teeth out. If you have Paul, do you remember that movie now? I was more on the Green Day video geek stink breath. None of this is OK. Apologies, Dr. Simon. I'm so sorry. Oh, you're doing great. That was perfect level.

And also I it's amazing that these two references are passing by. I feel like I know every other negative dental reference, though my personal favorite is Steve Martin, a little shop of four is. Oh, that's great.

Yeah. Yeah. Bruce Willis, you know, he's he's paranoid in 12 monkeys and he I think it's actually happening, but he thinks that there's that, you know, they have something in his teeth. So he pulls he pulls his teeth out. No anesthesia with the pliers or something. We can just polish off this bingo card, mention marathon man and the movie bug. And then I think we've sort of crossed most of the things off the list at this point. All right. So that's a free recommendation for the audience to watch 12 monkeys. And Paul, what was your video that you talked about? Watch marathon, man, not a Green Day video, but, you know, let's let's go. Let's let's move forward, shall we?

Yeah, going going back to the question about tooth extraction. It is a lot cheaper than a root canal. Generally a tooth extraction is going to be in the hundreds of dollars range, usually the low hundreds and a root canal can be is almost certainly upwards of a thousand dollars off it in several thousands. It's also important to note that in most states, an adult on Medicaid will have a tooth extraction covered. They won't have to pay any of it. And in most states, a root canal will not be covered. So even if people had, you know, the means they might elect to have the tooth extracted anyway.