JW: Welcome to Simplifi Health. This is Dr. Jill Wade. Today we are going to cover the burning secrets about acid reflux. My good friend, Doctor Mehendale is here with us today to help go over this great subject matter. Dr. Mehendale, thanks for coming. NM: Thank you for inviting me, Dr. Wade. I look forward to talking about this burning subject. JW: Exactly. Let’s tell everybody first exactly what your specialty is. NM: Okay. I am an Ear, Nose, Throat Physician, otherwise known in the medical terms as Otolaryngologists. We treat cysts, process cysts that basically occur from the shoulder and above. We don't deal with a lot below. However because as you're finding out in dentistry and how things impact overall health, we’ve expanded a little bit and we realized that a lot of the gut does or the intestinal system does affect above the shoulders so now we are learning to incorporate that into our especially as well. JW: Exactly. It's amazing how things aren’t really separate parts and pieces anymore although you specialized in that area, you now know that head and neck or the ENT (ear, nose, throat) is connected to the rest of the body too, isn’t it? NM: Absolutely. It used to be where everything was nice and compartmentalized in nice boxes and we feel like, we’re realizing a lot of those boxes overlap now and to really be a good clinician, you need to be able to look outside of your box a little bit to take care of the whole patient. JW: You are singing my song, let me tell you. I believe the same thing. It has been such a joy and honor to work with you so closely over the last several years as we really found in our dental office as we were clinically observing patients how much acid reflux, this burning topic that we’re going to talk about today, is showing up in people’s mouths with, for example, just real quick, patients who maybe have been with me for a long time who hadn’t had any type of cavities or anything in years and then all of a sudden, boom, here’s four or five new cavities. They’re looking to me and like, “What the heck? I didn’t stop brushing. I’m not eating candy. What in the world is going on?” One of my first questions that I ask them is, “Hey, are you having any problems with acid reflux, i.e. heartburn?” I have to say it a couple of different ways because some people don’t really know what I mean by acid reflux. And they’ll say, “You know what? I don’t think so,” but then as we get to talking about it more, I realized that they do. So one of the first things I wanted to go over with you is tell me symptomatically, what do most people kind of come in complaining about or even maybe having a symptom they didn’t even realize that’s associated with it? NM: Absolutely. I have to thank you in the fact that you’ve brought a lot of this to my attention. We knew that reflux occurs. We know, I'll talk about it in a moment how it occurs in maybe non-obvious ways, but the whole dental aspect of it was, I read about it in training and residency but really didn't see a lot of it until you brought a lot of that to our attention. It kind of completes the picture of what we're seeing in the oral area. This type of reflux, you can have reflux called GERD, which is the typical Gastroesophageal Reflux Disease, that typically occurs with heartburn, with indigestion, with bloating, with gassy feeling. Think of the Alka-Seltzer commercial that you see on TV, that’s what most people associate with reflux. Well, there's a whole different side of reflux that is called laryngeal reflux or otherwise known as silent reflux. Silent because a lot of people don't have a lot of symptoms or not obvious symptoms. It’s called laryngeal reflux because this type of reflux reaches all the way up past the larynx or voice box up into the throat area, and even up into the oral cavity, or even the nasal cavity in certain cases. Some symptoms that patients may have are a dry cough, throat clearing. JW: Absolutely. NM: Oftentimes, patients don’t even realize they’re doing it, it's their family member that says, “My husband is driving me crazy because he clears his throat.” We are in an area where allergies are high so most people just assume, “Oh, it must be just my allergies.” JW: Drainage going down rather than something coming up but we have that all the time, people say that. NM: Correct, and that can be the case but often I tell them, “Look, there's this silent partner where silent reflux comes into play where it may not cause the heartburn, indigestion but it can still be acid and it can still cause the same damage.” So we look for more subtle signs of it on their symptoms. Those do include the post-nasal drainage, a feeling like I need to clear my throat, feeling like I have a ball stuck in my throat otherwise known as a globus sensation where you feel like there's something stuck in your throat. You want to clear it out or you want to swallow it but it doesn't seem to go away. Then again those are very common symptoms of the silent reflux. JW: Right. We also ask people do they feel any gurgling almost like a gurgle or a bubble that kind of comes up through the throat and they either may hear it or feel it in the mouth. We also talk about just a change in your breath and that could be some of that acidic juice, if you want to say, kind of gurgling up. NM: Absolutely. That’s a great point. We do get a fair number patients now who come in saying, “Well, I taught one to my dentist and my teeth are okay. But my breath is my wife complains or my husband complains that my breath this terrible. I don't know what it is.” You’re absolutely correct that reflux hitting all the way to the back of the throat area actually causes that halitosis or bad breath. JW: Right. That's what gets people attention. They’re like, “I don't care about acid reflux but man, if I'm at work and I'm trying to talk to my coworkers in a closed environment and they’re back in a way, that’s going to cause a problem.” That may get them into the office to find some solution. NM: Absolutely, absolutely. JW: We talk a lot about going after symptoms and not trying to just put a band-aid on the situation, actually trying to find the root cause of the symptom. So in this particular case with acid reflux, let's talk a little bit about, if you were just going to, let’s say, band-aid the situation, what would that be versus maybe really trying to find the root cause of the problem? Can we make acid reflux go away? NM: Right, great question. That's a topic we deal with a lot with my patients. There are obvious reasons to place band-aids on it but usually, those are shorter term reasons and the reasons to look for longer term solution. A band-aid, we're really looking at medical therapy. There are typically acid reflux medicines, there are over-the-counter medicines such as Zantac, people have heard of them, Prilosec. Those work, there are different types, Zantac is a histamine blocker, Prilosec is what's called a proton pump inhibitor. Bottom line is both they try to neutralize acid. The proton pump inhibitor tries to decrease the production of acid, the Zantac really tries to neutralize it a little bit more than just reduce the production. But either way, both of those are really just trying to decrease the acid but not decreasing the cause of the acid. Those can be very important parts of the treatment because typically this is not something that just came up out of the blue, this is something that has been occurring for months to maybe years before they even realize that they're having symptoms or before maybe you see them in their office and you bring it to their attention because they just assumed they had a tickle in their throat all the time for no reason. So the band-aids do serve a purpose because this is not something we’re typically going to cure in a very short period of time but at the same time, the band-aids aren't fixing the problem. JW: Absolutely. I agree with you. You can even get stronger than even over-the-counter medications. NM: You can. JW: Prescription-strength. NM: There are some prescription-strength and oftentimes, even the prescription-strength we may dose it even higher than a typical dosage would be and sometimes you have to take it once to twice a day, not just once a day. There are some strict regulations for taking it without food and with food. But the prescription medication does work. Now the thing that we do tell patients is even on the prescription medications, it’s not as if we give you a dose of medicine and you’re better the next hour. Even taking the medicine, it can take three or four weeks before you even notice an improvement in what you now realize are symptoms of this silent reflux. JW: Right. I know that you recommend lifestyle changes for the patients as well. Can we cover a few of those? Because I think some of them are common sense. But yet even when you're a smart person, sometimes just hearing them you're like, “Oh, yeah. I do lay down like fifteen minutes after I just ate a late dinner.” NM: Absolutely, no. That's really where treating the root problem comes into play because a lot of us in our society, we’re busy, we’re go, go, go and we don't realize that we can make some small changes that can make a big improvement in our overall health with acid reflux being one of the symptoms of our changing overall health. So one of the first things I'll talk about is diet. Diet is a big issue with acid reflux. JW: Dang! It always comes back to diet. NM: It does, it does. And so, things that make acid reflux worse are spicy foods, eating late at night, fried foods, acidic foods like tomatoes, oranges, lemons, pineapples, caffeine, it’s a big one in our society, chocolate, mints, nicotine, and alcohol. All of those things are big contributors. Now oftentimes, I give that speech to patients and then patients look at me like, “You are not my friend anymore. I do not like you because…” JW: You are the enemy. NM: Exactly. “I want to eat my chips and salsa and I want to have a beer. I want to have my two cups of coffee in the morning.” What I tell them is, “I'm not telling you need to get rid of these things, it's all in moderation. We just want to be careful and look at overall, in the day, how much of those aggravating factors are you having? If you really enjoy your two cups of Starbucks in the morning, maybe you shouldn't end the day with a pasta with red sauce and three glasses of red wine. Maybe that day you want to just back off a little bit on some of the other acidic things.” That's a big dietary thing. Things that you can do to also with diet is timing, and you touched on this earlier, timing of eating is we really encourage you to eat a good one to really two hours prior to laying down. So what I tell people is, “If you eat at ten o'clock at night, that's okay, but you probably shouldn't lay down at ten fifteen, you probably should get up, walk around, do some sort of non-sedentary activity for an hour or so before you lay down and preferably two hours before you are fully prone. JW: That makes so much sense, I mean, just think about it, you've got this full stomach and you're going to lay down and then just this sheer force of gravity is going to allow some of it to come on back up again. NM: Absolutely and you brought up a great point. That's where a lot of these patients notice that their “drainage” is worse in the morning. The reality of it is that may not be drainage, it’s a lot of it as you described, the acid reflux that’s spilling all the way up into the back of their throat in mouth cavity and oral cavity and that's where we actually think more of the dental enamel erosion occurs is throughout the middle of the night because people will do these offending things, go to bed right away, and then while they're sleeping, their teeth or the back of their tongue, or their throat, or their back of the nose will be bathed in acid. JW: Absolutely. NM: And just that constant exposure where people aren't having the symptoms where they’re sleeping, that's what's creating the damage over months and months. JW: Absolutely. We not only see it forming cavities, we see it in generalized, more sensitive teeth. Also something they don't necessarily feel but we see in the mouth is a more generalized redness and inflammation happening on the gum tissue that’s surrounding the teeth. We have a lot of patients talk about their voice also being like more raspy kind of in the morning, just growling almost. NM: Right and I'll touch on that. We do see patients who end up having a hoarse voice, a lot of it’s due to that constant irritation from the acid reflux. It can also lead to vocal cord nodules, it can lead to polyps. Again, what I tell patients is, “Think about it, if you constantly put acid on your skin or any sort of irritant on a piece of your body, after a while, it’s going to form a reaction, a callus, or a polyp, or some other thing. It’s just that unfortunately if I put acid on my skin, I'm going to pull away because it’s going to hurt. In this area, luckily, our body protects us from hurting, but in a negative way, it also masks some more symptoms for a while. JW: That makes so much sense. I love, personally, that when you have a patient of ours over at your office that you are able to, I'm going to call it scope, there may be another name for it, if you would like to share that with us, we're more than happy to call it something else, but we use a simple term called scoping. Can you share with our listeners what that is and why you utilize that technology? NM: Absolutely. All of the things we've talked about are signs and symptoms of acid reflux. We have not yet discussed what an objective finding would be of acid reflux. One of the things that if patients come in and especially if you found some oral cavity issues that believe they have acid reflux, I talk to them, they also have some findings. So then what I would suggest is in the office I do what's called a fiber optic laryngoscopy. It's a really small flexible tube that's really, really like that size of a spaghetti. It’s a fiber optic scope and it goes through their nose, into the back of their throat. We do it while they are awake. We numb their nose. It takes about twenty seconds. It's uncomfortable in as much as if you’d ever laughed with a Coca-Cola in your mouth that’s gone up your nose, that’s what I tell people. It's not the best thing but it's not terrible. It’s absolutely tolerable. It gives me a direct view of the back of their nose, the back of their throat, their voice box, their vocal cords. We're really looking for, “Do we see evidence of irritation.?” You talked about the redness in the gums, in the gingiva, we are looking for that in the voice box area. If I see that, and it goes along with some of the symptoms they’re describing, almost always that's going to be acid reflux that's causing it. JW: So basically then, you know. You know right then and right there that they are actively in process of having reflux. NM: That is correct. There are additional tests that can be done for that. They just tend to be a little more cumbersome, a little more not patient-friendly. For example, there's something called the 24-hour pH probe where think of it of putting a string down your nose and it hangs down into your throat and it measures the acid but it stays there for 24 hours. JW: Oh, nice. NM: Most patients don’t love that so typically the twenty-second fiber optic scope gives us a much better idea that this is what's going on in which case then what we'll do is we’ll either treat them medically or we’ll say, “Hey, let's make some dietary or lifestyle modifications,” and I'll come back to that because we talked about the diet step. But there are some other lifestyle medications that play a big impact in reflux as well. We’ll try that and obviously if that doesn't give us the benefit we need, we maybe we need to search a little further. But I would tell you, 90% of the time, that's going to have some sort of improvement in their symptoms. JW: Sure. Let’s come back to what you just said in a few minutes. But I just want to quickly, I have a lot of patients who will ask me, “Why the ENT specialist and not the gastroenterologist?” You know, I'm going to tell you what my answer is and then you tell me if you agree or not. NM: Perfect. JW: My big thing is knowing you guys, how wonderful you are, and how easy it can be to make a determination right there in office, what I consider fairly simple, quick, and easy compared to where I see the GI docs go which is the barium swishes, the x-rays, and this and that. Can you just comment on that real quick of why do you believe that if you think you have acid reflux that a great place to start is the ENT specialist? NM: Right. I actually like to believe it's because we're better looking, funnier, or just nicer people but my GI colleagues may disagree with that, as my wife may also. But realistically, we're blessed in our specialty, we have some tools where we can make the diagnosis in a very short amount of time. We look at the disease process from the nose down to the throat area. GI doctors typically look at from the shoulders down below because that's an area that's more difficult to access. They need to typically do more invasive things to try to view that area. We're able to do it immediately while awake and get a very, very good answer. Now we do work together with GI doctors. There are many times where we need to refer them on but as an initial sort of gatekeeper, we feel like we have a very good service to offer patients to at least get them on the right road and maybe that's all they need. JW: Exactly. I am so glad to hear you say that because that's exactly how I explained it to him. You might need a GI doc, but this is the best way to get started and then they work with the GI doctors and the ones that are good in understanding this particular aspect. Back to just patient care 101, I find that a lot of patients would take care of themselves better if they knew how to navigate the system and so then they don't know, do you go to your primary care doctor? Then you have to have a referral and then you go to the ENT. But what if you needed GI doc? Who's going to give him the referral for the GI doctor? So to me, this just makes common sense. NM: No, you're right and it can be a very daunting aspect is to navigate the medical systems. JW: Right so they just do nothing and then continue to have it and then continue to have cavities that need crowns. It’s more expensive than just dealing with it in the first place. NM: It is. I'm glad you brought that up because frankly, as a medical specialist, I don't care what brings them in. If it is a financial motivation of, “Hey, I'm tired of paying for fillings and cavities,” it's great that you're able to recognize that and you and your colleagues are able to recognize that and get them to not just treat their oral health but also realize, “Hey, there's a potentially bigger picture that's going on here and there are some evidences that link continual acid reflux with throat cancer. I mean there are some bigger issues that can come on and what may start out as, “Hey, I don't want to pay for another filling,” might end up as, “Hey, we’re preventing some really, really big problems on the road. JW: Absolutely. I try, in all honesty, not to use that too much as my motivating factor for people because it comes across a little [inaudible 00:20:29], a little gloom and doom, “Hey, you can have throat and oral cancer if you don't take care of this,” however, as a caring professional, that's exactly what's going on in my mind. I'm like, “Listen, you've had this going on now for at least two to three years, where's that damage? How far has it gone?” I can only see so far down the mouth, I can't see in the throat, I can't help palpate, I can't feel or touch any lumps, bumps, or problems so I need the ENT specialist to be able to take basically that look down the throat and really make sure that people are okay. NM: And you bring up a great point again and the fact that a lot of patients now maybe you and your colleagues have explained to them, “Hey, this could be some acid reflux.” And then what the patient does is they’re curious about it so then they go look at their symptoms online and they put it in Google and all of a sudden they have worked themselves up into panic, convinced that they have throat cancer. So I don't typically bring up throat cancer but I do is when we do the laryngoscopy or the scope in the office. One of the first things I tell them if everything looks clear is, “Look, there are no masses, there are no tumors, there's nothing worrisome. We have a very small disease process that we can control and we're going to take care of it.” Often times, just that alone decreases their stress almost immediately. JW: Absolutely. So stress, wow, you said my key beautiful word that I think is the oh, so much of the root cause of most of these inflammatory disease processes that we're all going through. I find that stress is usually, if I have a patient in front of me who's having some acid reflux, I know them well enough to know what's been going on in their life in the last year or two, who's been sick, who's had a new job, who's had a new baby, who's lost their job, different really stressful things going on. I find that tends to bring on some of this. NM: Absolutely. That is perhaps, I think, just in my personal anecdotal experience, it’s a little difficult to tell the contributing factor but I think that's probably the number one factor in our community, it’s stress. We go and go and go and we push and push and push and we don't give our bodies and our mind time to recuperate. There is no question, I mean, it’s medically proven that stress increases the production of acid, just that alone. Then it’s a cycle, you have stress, you then start feeling something in your throat, or now your dentist tells you’ve got these cavities which then increases your stress of, “Why am I having this?” JW: Snowball effect. NM: Absolutely and what people end up doing, they're happy to take medicine, they’re happy to maybe say, “I'm not going to drink caffeine,” they’re happy to stop nicotine, they may be willing to do all that. I think one of the tougher things that, we, as a society, we don't tend to just take time to take care of our mental health and or emotional health. I think that's one of the bigger things that's difficult. I’m as guilty and I'm sure, Dr. Wade you are as well, I'm as guilty as anybody else but stress plays a huge, huge role in this and as you’ve said earlier with a lot of inflammatory processes. JW: Absolutely. Going back to what you mentioned earlier of some lifestyle kind of situations that you can kind of help, I don't want to say cure yourself of acid reflux, but that's control, manage. I'm assuming then just like what you were just saying stress control is one of the biggest ones. NM: Absolutely and just trying to tell people, “Look, everybody has their limits, you just have to know what your limit is.” I'm not saying that's an easy process and that is not an overnight process. But sometimes just opening a person's eyes to that and telling them, “It is okay sometimes to say no or it is okay to say, ‘I can't do that,’” sometimes gives them the freedom to to say, “Okay, I'm going to take control of the situation by not doing as much.” JW: Absolutely right, it’s so hard to do. NM: It’s so hard to do, it really is. And I tell patients that's why this whole process is not an overnight process. It didn't come overnight and we're not going to fix it overnight. JW: I think that’s funny because sometimes people think literally it just happened overnight like, “Last night, I woke up, I'm strangling, I'm burning, I'm in so much severe pain,” and they literally think it just happened overnight. NM: You're right and what I tell them is that was probably the first time they really realize the symptoms but the symptoms were probably there before. Then as you found, when you start questioning those patients about more subtle symptoms, then they start looking back and says, “Well, yeah I did have that a few months ago or I did have that six months ago.” JW: Right. Any other lifestyle changes or suggestions that you're just burning to tell us about? NM: Beach vacations are always good. They’re always good for stress. JW: Beach vacation, I love it, I love it. NM: Beach vacations, it’s amazing how much that can help reflux at least it does in my case as well. I think it's a very important and a really new topic that's being explored a lot more. Again, as you touched on earlier, in the past, reflux has been isolated to stomach indigestion, ulcers and really realizing that it's causing a lot more issues now than we originally thought and so we're looking at treating it not just from the stomach standpoint but as an overall health standpoint. JW: I love this. I could talk to you about this all day long but I I shall not. Dr. Mehendale, thank you for being here with us today on Simplifi Health and sharing your expertise. NM: Thank you for having me, Dr. Wade. As always, I love working with you, I love work with your patients, and I love that we can collaborate together in this important health concept in the fact that we’re realizing that even though we're looking at things from a different angle, we're still trying to take care of the patient and take care of the entire patient. JW: Oh, absolutely, whole health. NM: Absolutely. JW: If our listeners want to get in touch with you, what do you feel like is the best way for them to be able to find you? NM: We are on the internet so www.enttex.net, also via phone 972-731-7654. We also have a Facebook page that we update regularly. So for those of you who are on social media, we are on there as well so feel free to reach out. If anybody has any questions, there's also an email address. It’s firstname.lastname@example.org and we're happy to answer any questions that any listeners or other providers may have. JW: Wonderful. Thank you again so much. We are also going to be hosting some of this information on youniversityhealth.com for a handout based on the wonderful information we’ve provided to you today. If you are professionals in the dental world and would like to learn with us more, we can be found with our events and online courses at relevancehealth.com. This is Dr. Jill Wade, keep smiling from the inside out.
The mouth is the start of the digestive tract. Strong acid of the stomach was never meant to be in the mouth and if it back flows, even in vapor form, it can wreck your teeth and eventually erode your throat to harbor cancer causing environments.
This episode of Symplifihealth shares easy lifestyle common sense changes that can help you and your family stay healthier. Join Dr. Jill Wade and Dr. Neelesh Mehendale having a burning conversation that needs to be heard on silent reflux. Listen for detailed descriptions on what you might be experiencing like dry coughing, bad breath, burning, tickle in the throat, something stuck in your throat, or new cavities. Hear from an amazing Ear Nose Throat specialist explain the difference between Band-Aid therapies and root cause solutions. Small lifestyle changes can make a huge impact on calming reflux down.