Connective Tissue Disorders and Dentistry – PDP222

Jaz’s Introduction:
Like I’ve had a dislocated shoulder and I’ve got stretchy skin and numerous other things, which you’ll see from this podcast with our amazing guest, Dr. Audrey Kershaw. She’s an oral surgeon and she’s so passionate about screening for and helping patients connect these seemingly unconnected issues to discover that they may have a connective tissue disorder.

And so why is it important for dentists to know about this? Well, me personally, and for Audrey, our TMD patients are highly likely to have some sort of connective tissue disorder, or at least have this label of hypermobility. And you’ll see why in the podcast where this label perhaps does it in justice also, we would’ve all had a patient at some point that was just difficult to numb up.

Like, you’ve given like five cartridges and this tooth is not going numb. Did you know that this could be a sign of a connective tissue disorder? And nowadays, we’re not tooth mechanics, right? We are really integrated in the health of the patient. The clinics that I see thriving are talking about the patient’s health.

Think about sleep disorder breathing, and how dentists are playing a key role in managing and screening for patients, obstructive sleep apnea, how we are giving this message of reducing sugar that’s so important for a patient’s overall health. Periodontists are getting very good at screening for and helping patients get diagnosed with diabetes.

And now we get to screen for connective tissue disorders. So for those of you who want to play a role in the patient’s overall health, which I think makes our career more fulfilling, this episode will really be right up your street. This episode is of course, eligible for CPD or CE credits. We are a PACE approved provider.

The way to get that is through the Protrusive Guidance app. The website for that is protrusive app. We have over 3000 dentists on there. It’s the nicest and geest community of dentists in the world. And we don’t use the Facebook group anymore. The Facebook group is now defunct, so please do join us on the app. So I would suggest going on Protrusive app, the website, making your account, and then downloading the Android or iOS app and then using those credentials to log in.

Dental Pearl:
Now, every PDP episode I give you a Protrusive Dental Pearl, and one of the messages from this podcast is about the medical history. Now, I know we all take a medical history and we update it, but the problem is the word relevant.

We often take a relevant medical history, and if you only take a relevant medical history, you miss out on the patient’s overall health. For example, if I was going to the dentist where it says relevant medical history, I would never have thought to write about my several dislocations I’ve had on my right shoulder or various other health issues, which I just don’t think are relevant for my dentist.

So for example, your patients might have IBS or other things, and they aren’t telling you ’cause you’re the dentist. Why do you need to know? How is it gonna affect dental care? But actually all these things are important in the medical history ’cause part of screening for a connective tissue disorder, they are incredibly powerful and incredibly relevant.

So let your patients talk about their medical health and really encourage ’em to open up about everything. You’ll have a bigger and more complete picture about their general health. And the patient will also understand that, hey, this dentist, he’s more than just a dentist. This dentist, he or she is genuinely interested in my health.

So if you’re trying to practice dentistry in a way that looks after the patient’s general wellbeing, then this is a really important step. Like I said, it makes our job more enjoyable, more fulfilling, and it’s why I think airway and sleep disorder breathing in dentistry has really lifted off ’cause clinicians really feel that they’re making a difference.

Like for example, when I do my sleep testing and I get it reported from a sleep physician, and those times I’ve got a positive diagnosis, which is more often than not. So more often than not when I suspect that a patient has sleep disorder breathing and they get tested, I’m right. And you know what? That gives me a huge boost that I was able to help potentially add 10 quality years to this patient’s life.

Now you would’ve heard about that when I recorded that episode with Max Thomas. Go back a few episodes, check that one out if you haven’t already. We go deep into sleep testing and the role of the general dentist in screening for sleep disorder breathing. But I very much see this in the same realm. It’s all to do with the patient’s general health and wellbeing.

So hope you enjoy this podcast and I’ll help you to look out for things which perhaps seemed unconnected, but actually you’ll see that they may be connected. I’ll catch you in the outro.

Main Episode:
Dr. Audrey Kershaw, one of the newest members of our community, and it is so, so nice to finally see you virtually, I guess, and have this long anticipated chat. Now, honestly, since I spoke to you on the phone, since my lung collects happened and everything just aligned, people are messaging me saying, have you spoken to Audrey? And like wow, there you are. How are you doing? 

[Audrey]
I’m very excited Jaz to be here. It’s just like everything is falling into place to try and help a lot of our patients and a lot of ourselves.

[Jaz]
Yeah. And the first thing I wanna unpack is, just tell us about yourself into your journey into oral surgery, but then also why are you so well known? Why did you niche into connective tissue disorders and Ehlers-Danlos and relevance to dentistry, which we will unpack today, but your journey is gonna be really fascinating I think.

[Audrey]
So I qualified from Glasgow in 1987 and I didn’t want to go straight into GDP, so I left Glasgow to Birmingham. I got a house job there, enjoyed oral surgery, so just kept sort of traveling around England. I fell into a lot of good jobs, Jaz, and at that time the Sunderland job probably still is a brilliant job.

Sunderland job came up after Birmingham, and then the Walton job in Liverpool. Your younger listeners won’t maybe recognize these names, but there was word booth in Sunderland and or in Liverpool. There was Il and David Vaughan. I just landed in good jobs. I enjoyed oral surgery, so I kept on, I got my fellowship. Ended up in Dundee, made it back to Scotland and ended up in Dundee. 

[Jaz]
At that time, Audrey, were there many women in oral surgery? ‘Cause I see so many women in oral surgery now. Was it always the case when you were training as well? 

[Audrey]
I don’t think there were just so many, Jaz, weren’t so many. So I have always changed what I’ve done in my career. ‘Cause I think if we’re going to be working for 35, 40 years Jaz, I don’t think we can keep doing the same thing. And I think you are doing that, aren’t you as well? So, I was doing a lot of Max Facts jobs and then went into sort of Dundee, dental hospital, the teaching there. Then I went into medicine and surgery teaching.

I left there about seven years ago, seven or eight years ago, and I went into private practice. I’ve always kept sort of just moving on and do you know those patients, Jaz, that we know there’s something going on. Local anesthetic doesn’t work. I’ve known my whole career, there’s something going on. The patients are not making it up.

They’re not putting it on. They’re trying their very best. And we have some colleagues that will say to these patients, you’re just feeling pushing. This isn’t sore. You’re just feeling pushing. I dunno who these colleagues are ’cause nobody will admit to it. But I knew there was something going on with all these patients. And about seven years ago or so, I discovered what it was. 

[Jaz]
And just to clarify, this wasn’t just the redhead patients, which are famous also for that. And so sometimes, we as dentists, we think that, oh. The patient is just very nervous. Hence why they’re feeling it, but it’s not always just the case.

[Audrey]
So I discovered what it was chatting to a very good medical friend, joy, and she said, do you think this is Ehlers-Danlos surgery? I said, you’re talking rubbish joy. You’re talking rubbish because Ehlers-Danlos, as we all know, Jaz is blue sclera, stretchy skin, and very mobile joints. Now that is what I was taught back at dental school, and that is really still just about what’s taught these days.

As far as I can see. I didn’t understand Ehlers-Danlos, and a lot of our colleagues don’t understand it. So what I say in the lectures we give here is there is no place for doctor or dental bashing in this. Everybody’s trying their very best. There’s probably a very good lecture that I gave Tara Renton asked me to do a lecture for them. We gave it in December. Could you maybe put the link to that on your site? 

[Jaz]
Certainly. 

[Audrey]
On that talk, we have Linda Bluestein, who does a Bendy Bodies podcast in the States. I think I sent you her details already. Linda’s amazing. Linda is now 59. Linda shares her details very, very openly. She was only diagnosed when she was 47.

Now Linda is a doctor. I’ve also picked up several doctors on my travels now who have been unaware that they’ve had Ehlers-Danlos. Linda speaks very, very openly. She does amazing podcasts on this. She’s got 140 podcasts on all different things to do with connective tissue disorders, and we don’t pick it up unless we know what we’re looking for, and that is why I am excited to be here Jaz, and be excited to share all this with your listeners.

[Jaz]
It’s something been so topical for me and you helped me so much because as many of our listeners know that last month I had a spontaneous pneumothorax.

[Audrey]
Could we also add the word minor in there? Love that word. Minor pneumothorax Jaz. 

[Jaz]
Minor pneumothorax, this is a small little thing, which I mean, that hit me hard, right? And so when I was looking into that, and then you sent me some literature, show me that, okay, there’s actually a red flag for a connective tissue disorder. And that’s saying, I’m seeing it crop up everywhere when you can’t connect the issue, think connected tissue.

And it makes so much sense. And then you told me I was on the phone in the taxi on the way back from hostel and you said to me, how stretchy is your neck? And I was like, well, it’s about this stretchy. And then so you’re like, okay, well, and then my shoulder dislocations sub locations, history of that stretch marks in my chest.

I dunno if that’s one, but it’s a strange location to have stretch marks. So who knows? And then obviously because I’ve been so strung up trying to get my lung actually sorted. So seeing the thoracic people now, they weren’t interested ’cause I had this chat with ’em. No one was interested in exploring further or even thinking about, it wasn’t even their remote differential that this could be something, anything to do with connective tissue. They just think, well, it happens sometimes. 

[Audrey]
So just to tell your listeners, I think it was on the Wednesday that a colleague in Glasgow, Lorna. Hi Lorna. Lorna put my name forward to you saying you might want to talk to Audrey to learn about connective tissue disorders. Julia was organizing for us to talk on the Monday and she sent me a message at the weekend saying, Jaz should be okay to talk.

But he’s had a minor collapsed lung and I spent a fairly sleepless night Jaz thinking, I just feel this guy is an undiagnosed connective tissue. And then on the Sunday morning I put a lovely message to you saying I know that you’re asking what could this be? And you think it’s nothing.

And I thought, I’m blowing my chances for a podcast with you here, and then 12 hours later, you replied saying, Audrey, you’re a hundred percent right. And so the timing of this Jaz was just out of this world. It was like, how do these things happen? Yeah. 

[Jaz]
It’s the universe’s way of telling us. 

[Audrey]
You feel that there’s maybe some underlying cause for your pneumothorax? 

[Jaz]
Yes. The more I think about it, the more I look at everything and the more I look into it. But again, like I said, the doctors were just not interested. Now I know you put me in touch with some people that I’m gonna chase up on the emails, but it very much is the onus on the individual to get your diagnosis. So I’d like to know how you ended up getting your diagnosis. 

[Audrey]
Just to take a step back, your story is so, so familiar. Nobody is going to suggest a connective tissue disorder to you with everything. It’s gonna be some crazy dentist in Scotland that’s gonna send you a text on a Sunday saying, oh, do you think?

It’s such a familiar story. I laugh ’cause if you don’t laugh, you’re gonna cry. I found last year, 120 patients with a possible undiagnosed connective tissue disorder, 120, and it breaks your heart, Jaz, because these people go to their doctor and say, I’ve got this, I’ve got that. They get nowhere, absolutely nowhere.

So you’ve got to have all your ducks in a row before you go and get help. And then you’ve got to be very, very, forceful is not the word I want to use, but you have to be very, very sure of what you want. Now it is easier for you and me to do that because we have the knowledge education, eloquence sort of to do that.

Can you imagine what that’s like for somebody from one of the less well off areas, less well educated, less confidence to do that? It’s very, very hard. So Jaz, this is the first time being open about my diagnosis. This is the first time I’m being open about it. This is not about me, this is about our patients.

And I haven’t been open before because the journey has been very hard. I still have people in my life that don’t believe me, and it’s taken time after my whole life to get my mind around this and to be able to be confident enough to be able to talk about it. I also professionally don’t want people knowing too much because I don’t want people pointing the finger thinking, oh, well, if she’s got all this going on, how can she possibly be a oral surgeon?

So I’m still finding my feet on this. Whereas you are much maybe more open about it. But I’m very, very happy to share my journey. I’ve made a few notes here, Jaz, so excuse me if I just sort of read them. So I knew for my whole life, Jaz, there was something going on. I knew there was something that wasn’t making sense.

I knew it and I couldn’t put my finger on it. So I will tell you from a professional point of view, some of the things that people would notice if their colleagues are like me. So I said my first job was in Birmingham. Every Wednesday in Birmingham, we had a GA list for six months. Without fail, everybody waited for me to fall over to faint. Now that’s a sign of low blood pressure, maybe POTS, something like that. I thought I was going to have to give up being a oral surgeon because I couldn’t stand upright. 

[Jaz]
So it wasn’t necessarily like the site of blood, which some people might associate with that is, yeah. 

[Audrey]
I didn’t have a clue what it was. I think in those days, I don’t think the diagnosis of POTS was around, people didn’t know. 

[Jaz]
Tell us more about POTS, ’cause POTS only came into my radar when one of my TMD patients, she had POTS and I looked further into it basically. And obviously it’s all interconnected. 

[Audrey]
POT says Postural Orthostatic Tachycardic Syndrome. It’s all quite difficult ’cause some people fit the criteria of pots on certain days, but not others. So it basically means your blood pressure can be low. It doesn’t have to be low, but it means when you stand up, you can’t keep your blood pressure up. There can be many different reasons for pots, and at this point I would ask you maybe to put on the notes for this Linda Blue’s podcast on it because she gives a really good, yep. 

[Jaz]
A hundred percent. 

[Audrey]
So it basically means we find it very hard to stand up. Now, I don’t know about you and I don’t know if things will come out in this conversation that you think, ah, light bulb’s going on here again. I have had several nurses, they sit with their arms crossed on clinic. They stand with their arms crossed, they’re being told off on a regular basis.

Would you stop crossing your arms? And I don’t know if you can see me. We sit with our legs crossed as well. Now what we are doing there, we’re not just being closed off, we are pushing on our vena cava to try and get the blood back up to make ourselves feel better. Now we just think we’re being difficult ’cause everybody’s told us we’re difficult.

So when we’ve pointed out a lot of these signs and symptoms, I hope that your listeners will just spot people and they can maybe help them. So that’s POTS. When I was 28, I went to the doctor because my blood sugar was so low and I was told there’s no reason for having low blood sugar unless you’ve overdosed on diabetic drugs.

[Jaz]
How low is low? Do you remember the measurement? 

[Audrey]
Somewhere between four to eight millimoles per liter is the normal blood sugar. Depends if you’re a diabetic or not a diabetic. And when I taught medicine and surgery, this was argued about every year anything under four can be seen as low. Anything under three, definitely low.

[Jaz]
So the reason I mentioned that is just so the chiming in basically, it’s nice little self-discovery here as well. I did one of those, not Zoey, but there’s another brand, I forgot which one it was and I was like, it was like a blood glucose monitor the whole time. I don’t know how accurate they are, but mine was consistently 3.9, 3.8 at rest, basically.

[Audrey]
Very interesting. Very, very interesting. I have also tried one of those monitors a few times because with Ehlers-Danlos syndromes, you can also get a higher blood glucose than you deserve with your lifestyle and your diet. So you can have it low, but you can also have trouble controlling your blood sugar.

The way that I found a 10-year-old patient few years ago was she came in to have ortho teeth out and the letter said, a borderline blood sugar. And I thought, okay, so we’re going to see quite a maybe und. Girl come in here quite, quite a grown up girl. She looked like a seven or 8-year-old stick thin. We then asked more and more questions.

Why did they find the blood glucose like this? Oh, because they sent us to Glasgow because she had GI symptoms. And GI symptoms are also a sign of Ehlers-Danlos syndrome. So, it was like more and more of the story came out. She was anxious, she was whatever. She ended up being an undiagnosed Ehlers-Danlos case.

[Jaz]
What this is already reminding me of, you know how TMD tempomandibular disorders. They are known as the the great imitator, but already, Ehlers-Danlos with this varying presentation and this multisystem effect, it can be really difficult to nail a diagnosis. So I’m excited to see how actually. What advice do you give throughout the episode for our patients ultimately? 

[Audrey]
I think we’ve discussed TMD before Jaz. Almost every TMD patient I get referred to me as an undiagnosed connective tissue disorder. Now you’ve got to remember, I don’t see representative sample of the population. I see T MDs when people have struggled for like 18 months and think, what can we do, send it to Audrey.

But almost all T MDs I see are that and TMD is a sign of, yeah, so when I was pregnant, really bad. Really bad morning sickness. That’s not the correct term these days. I can’t remember what it is, but really bad morning sickness. That’s a sign of Ehlers-Danlos childbirth. Age of 31st one almost bled to death.

You just gotta laugh. They saved me, but almost bled to death. Again. Bleeding is a sign and symptom of undiagnosed connective tissue disorders. I then moved to Dundee at the age of 33. People thought I was a final year student at the age of 33, this is another sign in symptom of Ehlers-Danlos.

I’ll come a little bit nearer to the camera. I am in my sixties. It’s not showing off in any way, but it’s another thing is when you go out to the waiting room to call your patient in, you’re looking for a 35-year-old and there’s a 17-year-old sitting there. Had a patient last week, 38-year-old curriculum lead for the English in a busy high school.

People mistake her for a pupil in the school. It’s just a bit funny really. And the thing to say to somebody with Ehlers-Danlos is not, it’s so lucky you look young every other sign and symptom going, I think most people would give a good old wrinkly body to just not have it. But hey, you’ve just got what it is.

You’ve got, so I was always cold and cold as well as a sign of dysautonomia. But you get with, so lot of our colleagues are very, very cold. They come in with their leggings on underneath their chin X. They always have the long sleeve top on things like that. That is me. Everybody knows I’m always called. We also forget names. Jaz, that’s another thing amongst our colleagues. We forget names. I think it’s you’re raising those eyes to the ceiling there, Jaz. What’s that? 

[Jaz]
I’m terrible at names. Like I refuse to go to events where people don’t have their name on their chest. I mean, that is so reassuring to me. When I go to an event and have people have a name badge, I feel relaxed. When people don’t have name badges, I get anxiety. 

[Audrey]
Jaz, I can’t even remember my own son’s names. I call one of my nurses my dog’s names. But it takes it as a compliment, Jaz, it’s a compliment. There are all these little things. We don’t do caffeine very well after a certain age maybe. So we don’t seem very sociable, if you don’t go for coffee with the nurses or the staff, it can sort of look as though you’re not trying to fit in. We also don’t do well with sugar and an unhealthy diet. So, if somebody’s offering you a cake and work, you say, oh no, no thanks.

It’s not that I’m being really good, it’s just I know I’m gonna suffer a high gi. Diet as in too much sugar in your diet that makes your POTS worse. So, there’s many reasons and what we find about a lot of people like ourselves is we’ve already taken on the lifestyle without knowing there’s something wrong with us.

So we always make sure we’re well wrapped up. I noticed a post you put on today, Jaz, about going to bed at nine o’clock. We need a lot of sleep. We get tired really, really easily. So that’s another thing as well. 

[Jaz]
Very relatable. 

[Audrey]
So that was basically my journey. I had failed LA when I was 47. It was surgery under spinal. And I said, excuse me, because some of us elders done lost patients. We’re very polite. We do have our faults, Jaz, but excuse me. I can actually feel what you’re doing to be told by one of the team? No, no. You’re just feeling pushing. I left it a few minutes longer and I said, excuse me. You just got to laugh, Jaz.

It was horrendous. I said, and excuse me. It’s not just pushing, I do actually feel it very, very sharp and sore, just really to be told. No, you’re making this up. I hope I don’t have a those down. ‘Cause like you said, you wish you don’t have it. So my lower four incisors. Loss vitality.

Huge apical infection. We think it’s because orthodontics, yes, that’s the only source of trauma I had to her teeth. So, loss of vitality, my lower incisors. Fast forward many years. I now have a resin bonded bridge for my lower incisor. One of ’em lost, fractured, and my old principal, Amit, shout out to Amit Mahindra.

He was there removing my retained root of my lower incisor. Now, lower incisor classically an easy area to numb up. Okay? And he’s luxating it, and I can feel everything right. I can feel everything. So a lot of relatable things that you are saying. I don’t know. I haven’t been officially diagnosed, but just connecting all the dots.

[Jaz]
There’s a very good paper as well that you could maybe put up on the link to it. It’s the best. We’ve got, I think it’s a 2019 explaining about local anesthetic. We need so much more research, Jaz, and if any d listening to this, wants to help in any way, wants to get into research with all of this, we need so much more research.

Certain types of LA work. Better than others. It’s all in the paper. So I always knew there was something wrong. Every so often I would find myself sitting in my doctors thinking, what am I here for? I just know there’s something wrong and I now know. So it was when I was 53 years old, a very good friend of mine, joy, who is medically qualified.

Joy, knows everything about me. We have wonderful chats and joy just said in the middle of a conversation, oh Audrey, do you think you’ve got tell, it’s Ehlers-Danlos. I said, you’re talking rubbish, Joy. And then within two or three minutes it was, oh my goodness. Oh my goodness me. So one of the things that’s a little bit confusing, but it didn’t delay me finding out Ehlers-Danlos is I am not overly flexible.

I don’t have the shoulders of pop out Jaz. I am flexible. If you come to a Pilates class or a yoga class with me, you’ll think, my goodness, she’s fairly flexible. That’s good. I used to think it was the rest of the population, Jaz that had issues, they really need to do a bit more exercise ’cause they’re just not all that flexible.

And then the discovered is me. That’s the one that’s just that little bit more so I can’t do the thumb back to the wrist trick, like that doesn’t come up. My elbows are not overly flexible. It’s not easy to see how flexible you are when you’re over 50 or whatever. Or sometimes it’s just not easy at all.

But you know, I was always a little bit more flexible, but I was never overly flexible, and that is one of the things that confuses patients and confuses everybody, these are called hyper mobility syndromes. I don’t like the term because it’s not easy to see if somebody’s hyper mobile. There may be where in the past, but not now.

And some people like myself really, were not overly hyper mobile at all, but we do have Ehlers-Danlos. It’s interesting because that’s worth exploring because what I was taught in the past and what I’ve been doing in clinic as well is yeah, we do the BA score, like a mock version. Can you put your thumb and stuff?

And if they can’t do all that, we think, okay, maybe you’re not a hypermobile and therefore maybe that’s not important in your etiology. But what you’re really saying is just ’cause they don’t have that feature doesn’t mean that they don’t have Ehlers-Danlos. But we’ve been using that as like a yardstick. 

[Audrey]
So we have a specialist in London, Alan Hakeem, who I’ve sent you his details. Alan is an amazing man. Alan is internationally, I think one of the leaders in Ehlers-Danlos. Alan will say, if you have a bait and score high enough, good. And if you don’t have a bait and score high enough, still fine. And the bait and score, I mean that’s only looking at what so many joints out of 300 joints in your body.

And sometimes we have people that had a patient last week, she had very, very bendy was the dislocated and hips, but she wasn’t doing well on the beaten or the Alan and the Hake and Scream score is out of five, and that’s maybe a better one to use for your clinic. But as Alan says, if you score over three on the Hake and scream score, fine.

But if you don’t, and another thing Alan will quite often say is they get annoyed because if you don’t score highly enough, if you’re not hypermobile enough, you don’t get let into the party. And we need to let these other people into the party. It was actually Alan that gave me the Ehlers-Danlos label. He saw me in London. Yeah. 

[Jaz]
And how does one get that for myself, but also for patients? Because I had this conversation, like I told you on the phone, I had these conversations with my TMD patients that, look, you are hyper mobile and that could be a sign of a connective tissue disorder. And we talk about it.

But really, I’ll be honest with you. I haven’t found, like no one ever says, okay, can you phone me to a GP? Because then they get lost. Like there’s no clear pathway. So I’m sure we’ll develop into how to do that. But how does one get a label? How does one get a diagnosis? Is it only through genetic testing or how is it done?

[Audrey]
Up in Scotland, I struggled until about two years ago. I got this email out of the blue from Janet Ner and she’s a osteopath now working in cell Daikin fife, and it was one of these emails, I got Jaz. I thought, who is this from? Are they winding me up? No, she wasn’t. She had moved up from Chichester. I think Janet, excuse me, I’ve got that wrong.

And she had come up to Fife to settle and Janet also says on our website that she is also a bendy and I send my patients to Janet. Now, I have completely swamped Janet with patients. If you can see, I found sort of 75 patients last year and 55 or so others. Janet cannot keep up. With the number of cases that I’m finding for her.

So we have to be very, very careful who I now send on to Janet. So I am lucky up here. I I’ve got Janet, you know Janet can diagnose Ehlers-Danlos. Now, I love the way Janet works. Janet’s got a mind probably like mine and yours, Jaz. We don’t just assume, we want to look for all the evidence. I know where my knowledge is lacking.

I think the more you know, the more you realize you don’t know. So it’s very easy just to get a diagnosis of hypermobile e Ds ’cause that’s the most common. There’s another 13, 14, or so different types of Ehlers-Danlos. But they’re very, very rare, supposedly now any type of Ehlers-Danlos, when my friend Joy first said to me was supposed to be one in 5,000 people had it.

So I thought, right, I’m really, really rare. Hey, I’m special. And I thought it’s going to take me 1 77 years at the rate I work, I’m going to find an Ehlers-Danlos case. So when I found my first one, I thought that’s it for seven years or so. I see one in eight of my patients with an undiagnosed connective tissue disorder, one in eight everyday. I’ll say that again.

Speaking to other people, there’s a Welsh study that says one in 500. There’s a Northeast of England study from last year that said one in 227. There’s limitations to these studies because these are only the people that have been diagnosed. So I feel one in eight is maybe a little bit high, but that is what I find in my patients because people suss me out.

They don’t know why they’re sussing me out, but they suss me out and they find me. Yeah, I think it’s maybe more like something, one in 30, one in a hundred, but it’s definitely much, much more than we think. I’ve gone off at a tangent. How do we manage this? I have got Janet up in Scotland for this. Even the patients I see from the north of England, they come and see Janet. People will travel three hours or so to see Janet. It’s very hard if we don’t have a Janet in our lives. Have you seen Jaz, the international consortium of EDS GP checklist? 

[Jaz]
Unless you sent it to me. ‘Cause you sent me some things that I- 

[Audrey]
I can send to you, whatever we need. This is a checklist to see if you fulfill the criteria for having hypermobile Ehlers-Danlos, and it’s in three different sections, you have to have the bait and score, you have to have all the other signs and symptoms. And then the third paragraph is you have to not have other genetic conditions going. It’s okay, but it’s got it’s drawbacks.

I believe that is going to be updated by the International Consortium this year. If you fulfill the criteria for that, great. Fine. You get your diagnosis, but there’s those people that don’t quite fit in. If you have got a rarer sort of Ehlers-Danlos, that’s where I was starting to talk about genetic testing.

The leaflet I sent you, it was talking of the red flags. If you’ve got any of those red flags, you should be able to get genetic testing. We have patients that go to rheumatology, genetic. They get turned away from rheumatology ’cause maybe rightly so. That’s not the right place for them. I personally have been through all of this and it’s very interesting as a experienced clinician sitting in front of someone who will not take you seriously.

And I have come out and I’ve walked around the nearest park. Crying my eyes out in floods of tears because it was so, so difficult. So Janet and I are also picking up many, many more rarer types of Ehlers-Danlos, and they go for genetic testing. It takes time to pass through that national health service.

We can try that. We can go privately as well. Janet would be better talking at this than I am NHS. If you go to get tested, you don’t get tested for all the other 300 or so connective tissue disorders as it could be. If you go privately, which is about 500 pounds, you can, so it’s not easy. In Scotland, I work with the Ehlers-Danlos support UK, Scotland.

Got a family friend who’s an MP member of the Scottish Parliament. Okay. I got him involved. Mike Mara. Mike has been great and he has been helping us get this through the Scottish Parliament to try and get better care pathways for patients. So the answer, how do we do this, is we say to the patient, you’ve got a few signs and symptoms of a connective tissue disorder.

I am not qualified to diagnose you. I’m not an expert, but I do know something on this. I sent them some links, I think they were maybe the links I sent to you for the Ehlers-Danlos websites and whatever. And also Linda Stein’s, Betty Bo Bendy body podcasts, ’cause I’m finding that so much more useful now than anything else.

‘Cause Linda’s great as I kept saying. So we give them that. We say, do you want us to write to your doctor? I have a standard letter to write to the doctor to say, we’ve met so and so. They’ve got all these signs and symptoms. It may be suggestive of a connective tissue disorder. They’re interested in taking this further.

Some patients get places other patients don’t. So it’s basically very, very hard Jaz. Very, very hard at the moment, and that is what we’re trying to campaign for and push for through the parliaments and the healthcare providers. I’m also trying it in my own way by doing these podcasts and lecturing, going to the Scottish Dental Show.

We have now lectured to about a thousand healthcare professionals, and I now have people who have been on my talks saying they’re now picking up. Undiagnosed Ehlers-Danlos cases or undiagnosed connective tissue disorders. 

[Jaz]
But just to clarify, the main way, therefore, for those who don’t fit in the consortium sort of standard pathway is genetic testing. 

[Audrey]
There is no genetic test for being hypermobile EDS. There is no genetic test at the moment. The Norris lab in the states, they think last year they’ve maybe found four different causes that could be genetic for hypermobile Ehlers-Danlos, but we’re not there yet. So we’re in this no man’s land of, there’s no genetic test.

It’s a clinical diagnosis. You need to find somebody who can clinically diagnose you, that knows what’s going on. GPs should be able to clinically diagnose, but to me the problem is it’s like somebody saying, I’m a dentist. I should be able to diagnose your perio disease. I’m a oral surgeon, Jaz, don’t they asking me to do this?

Yeah. Very hard because as I said before, there’s no place for doctor bashing. These GPs have been taught very little about connective tissue disorders. They’ve been taught that it’s blue sclera, stretchy skin and mobile joints. If you don’t fit into that, that’s not you. I’ve been there with my GP and it’s very, very difficult. You’re told you’re being anxious. You’re depressed. It’s like I don’t get depressed. 

[Jaz]
Interesting. It reminds me of something that James and Spencer in the US taught me, right? He taught me that, and I share this and I always name drop him is TMD patients are NUTS. Okay. I’m sure you know where I’m going with this.

And so it sounds like, these suspected ED patients are nuts. And really what NUTS stands for is not understanding their symptoms. Right? That’s what NUTS stands for. And then that is a whole plethora of consequences, but let’s just connect it all together. One in eight patients that you see, now, is that one in eight of your TMD patients?

[Audrey]
One in eight of all my patients. All of them. 

[Jaz]
Okay. So what about specifically your TMD patients? What percentage or what ratio of those? 

[Audrey]
Almost every TM joint patient I see is an undiagnosed connective tissue disorder. 

[Jaz]
Okay. Let’s go with that then. 

[Audrey]
Yes. 

[Jaz]
Because I see plenty of these as well that individual, what should the dentist be saying to them, because I feel as though the pathways, like you said, aren’t quite clear yet. So what is our role in communicating and screening and helping them? 

[Audrey]
Jaz as I was making up my own template and I had a massive medical history that I would ask everything going, and I would send this to Janet and it would be all over the place, and I couldn’t ask enough. Linda Bluestein, again, has come to the rescue and she has got a sheet on her bendy body’s website, and it’s basically just listing all of the possible signs and symptoms or most of them. So what I do now is I go through this and I just tick them off.

Did this for a patient yesterday. I just go through it. So do you have acid reflux issues. Do you have irritable bowel syndrome? Do you get anxious? Do you have poor sleep? Do you this or that? We just go through it. It doesn’t give you a score or anything, but it just has the patient opening up.

Just to go back to what you said about TMD, what I feel sometimes throughout my career on TMD was we just see the TM joints. We don’t think the TM joint is connected to the rest of the body, and I do remember whether it was, what, 20 or so years ago, 30 years ago. It was said people with TMD were more likely to have GI issues.

One thing that you had said in a podcast, a TMD podcast, because I’ve listened to so many of yours when I’m traveling, so thank you for keeping me company on that. You had mentioned that you can only see a certain number of TMD cases because they exhaust you. For want of a better word. They are so demanding is not emotionally.

[Jaz]
Emotionally, no, yeah. Not in a bad way for them, but like as a clinician, like, therapists need a therapist. It is draining mentally and emotionally. And concentration. 

[Audrey]
Absolutely. And that wrong, true for me when I was listening to it, and I so appreciate you being so honest in these podcasts. ‘Cause I find it because I’m highly sensitive with my elders Danlos. It may be difficult to, to find people that can understand and talk to about this. What I find about my Ehlers-Danlos cases is, I so want to be there. But I have to give so much a consultation telling somebody who came in thinking they were fit and well saying, do you think your unconnected signs and symptoms are connected?

I think you might have this. The supporting them through it, we absolutely want to be there. My job wouldn’t be the same if I didn’t, but it really does take it outta us, and we have to be so, so careful to look after ourselves when we’re doing these things. Some cases are much more draining for want of a better word than others. I mean, I will be drained by any day. I’ll give as much as I have. Some are more draining than others. All of them are so rewarding. 

[Jaz]
Rewarding is a huge element and that that balances out and it’s so great to do that. But you know, TMD patients, it’s a category of chronic pain and they are just like any sort of medical issue, dental issue, once they have it, once they’re prone to have ebbs and flows, right? And so flareups are normal course of TMD, it’s not like a straight line goes up and down, up and down and it varies depending on so many factors. So I’ll give you an example, right?

The other day I opened my email inbox and a patient who I’d seen who travels hundreds of miles, see me. She saw me and she was having a flare up, and I’d just read her email and I started to get palpitations. Now, I haven’t done anything wrong here. I helped her big time. She was in a really bad way.

Some conservative care. Later she was feeling amazing. A year later I see an email, and now she didn’t mean to upset me. It was me that I got upset. I’m not upset, but like I started getting palpitations. Just reading that she was getting a flare up and it affected, it is like it really affected me. Cut me. And so this is how, just a peripheral. Drainage that can happen as well on the side when you feel everything your patient feels. 

[Audrey]
Yes, and I think the T MDs and the Ehlers-Danlos centers, we’ve gotta be so, so careful that we keep our energy levels up so we’ve got enough to be able to give these patients. Because I think if I didn’t have Ehlers-Danlos patients to pick up, I don’t know if I would still be a working because it is so rewarding. And I think another thing I meant to see was I feel very humbled that I have discovered about Ehlers-Danlos syndromes, and I am in a position to be able to help so many people, and that is not supposed to sound bigheaded whatsoever. I am so humbled to be able to do this, and as I said before- 

[Jaz]
Even a major facilitator. 

[Audrey]
Yes, it is not just me that can do this. I have taught others to do this and before I stop working, I dunno how many years next year, five, six years, seven years, I need to have left enough dentists to be able to pick up all these cases and to help them. And it is such an honor to be able to do that Jaz. I think you u of D can get that as well. 

[Jaz]
The famous study, the opera study- 

[Audrey]
And that is so well known about these days. If you listen to Tara Renton, go on about TMD these days. TMD is related to sleep disorders, headaches, migraines. There are papers to say migraine sufferers and Janet knows this paper are 95% chance of having an undiagnosed connective tissue disorder. So if I see on a patient’s record reflux headaches and migraines, you are just, it’s like, oh my goodness. There’s another one. So this is one of the things I’ve got in my list to speak to you about here, Jaz.

We need a better dental flow chart for how we manage this. Until very, very recently, Jaz was very alone with this because I was stepping outside of what all my other colleagues did and I was willing to do it because I’m in my sixties. An outlier. 

[Jaz]
An outlier- 

[Audrey]
And it’s like, I know there’s still a lot of people out there thinking, what is she up to? Don’t care, Jaz, don’t care. I feel we are just having a chat together. We’ve gotta remember so many other people going to be listening. I want and I need help to get something sorted. Last year I listened to a talk, Tara Renton did, and it was a TMD one, I think to do with sleep apnea and oh. Tds and everything else.

It was a great talk, as in all Tara’s talks are, and I thought, I’m going to email this woman. I’m emailing her a as I do a lot of people, I thought, I don’t expect her to answer. And she wrote back saying, dearest Audrey, count me in or something. And it was like, Tara, I love you. And so Tara has also had her eyes opened to Ehlers-Danlos syndromes.

So that was the start of me feeling I was getting somewhere. I was so pleased to hear from you as well, Jaz. I need people to join with and we need to sort this out for our dentists to be able to take this forward. We basically need to go over the medical history. Tara says as well, lot of medical history says relevant medical history.

I get so annoyed about that. Tara gets so annoyed about that. I want to know everything. I want to know if your shoulders pop out. I want to know if you’ve had a collapsed lung. I want to know things that don’t seem to tie in, because all this is very relevant. When we do go through the medical history with the patients with the Linda Bluestein sheet, they’re just so funny.

They’re just so funny because you say, do you have any acid reflux issues? Well, I don’t really listen, want a yes. I don’t, no. Do you or don’t you? Because throughout their whole life they have, and this is me as well, the normalized it. It’s just, oh, this doesn’t matter. This is just ’cause I’m being silly.

It’s because I’ve eaten the wrong thing. It’s because I’ve done yoga too soon. We had a very interesting patient, Beth, who appears on the talks with me and Beth is great, and she’s so funny. Beth says, she just always knew. She had to eat a few more veggies and do a few more yoga classes and she would be okay.

And she came in to see me to have a wisdom tooth out. And we just laugh about this now. We knew before she came in from Poppa’s in her medical history, she’s going to be another Ehlers-Danlos case. 

[Jaz]
And so let’s talk about her, if that’s okay. ‘Cause she obviously comes on with you with these talks. How did she in this individual came to you for a wisdom tooth distraction. You noticed these things and then how did she end up as a case study, get her diagnosis. 

[Audrey]
I also wanted just to say, Jaz, how would you like to do another podcast with four or so of my dental patients that I’ve picked up? I’ve been looking for somebody to help me with podcast Jaz, and I was so delighted to hear from you.

I’ve got great patients that would come on and tell their stories, and I think it would be great for your listeners to hear. So, when Beth came along, she needed a wisdom tooth out. Her medical history had a few little bits in it. Maybe like reflux anxiety. There wasn’t a lot in it, but I work in about eight or nine different places, Jaz throughout Scotland.

The reception team, my treatment coordinator. The nurses, they pick them up before I do. Now they pick them up the same way as I sort of wondered about you. We just need a little hint and we’ve picked them up. So most of the time we know before these patients come in. So Beth, thank you so much for letting us share your story seriously.

So Beth came in, she had horrendous wisdom teeth. She was very anxious. Absolutely lovely girl. We’ve been for dog walks on Ti Ferry Beach together. Patients with Ehlers-Danlos can also Jaz, have a very similar personality and that was one of the things that made me write you that message on the Sunday morning.

You are very sensitive, you’re very caring, you’re very kind, you’re very in touch with your feelings. And we can pick this up with patients, you know that patient, that sort of phones a couple of times before they come to ask. Would it be okay if they come 15 minutes early? Where are they going to park their car?

Blah, blah. It’s like, ah, we think they’re s done lost, we can pick them up. So Beth, we suspected it. Wisdom teeth were horrible. I told Beth, there’s no way I’m doing those wisdom teeth for you, Beth, because you’re so anxious and you need to get Beth on because she gives a really good story.

Beth knew what I was saying was right. Beth knew that she could trust me. This is very, very humbling, Jaz. And these patients know when they can trust you because we listen to them. We don’t tell them they’re talking rubbish. We listen to everything nobody’s ever listened to before. So in the end, Beth ended up in tears and said, there’s nobody I’m going to trust apart from you, Audrey.

So, my treatment coordinator wondered what I was up to and we brought her back later on. But Beth trusted me. Beth, I said, I say to some of my patients, you need to see Janet. Beth went to see Janet. Beth found Janet. So, so helpful. And Beth and Janet have got on and Beth got her Ehlers-Danlos hypermobile diagnosis from Janet. Beth will tell you how their lives have been changed.

It is utterly life changing. Now, it’s not just me that can do this. It’s any dentist listening. It is utterly life changing. I know how life changing it is, Jaz, because when I discovered what I had completely changed me as a character and changed my life. 

[Jaz]
And let’s talk about that. In what ways? Because it may not be obvious to someone who hasn’t had any health issues before. Because ultimately there’s no treatment. There’s no cure, there’s no, what is it that you gain from that label and how important that is. 

[Audrey]
A lot of doctors and gps will ever say, there’s no point in knowing about this ’cause, nothing we can do. We cannot cure it ’cause it’s a collagen defect. But if we take the POTS for example, there are so many different things you can do to make that better. I go to little because the cues are shorter. If I go to Tesco, I feel so ill, I can’t go into Tesco. ‘Cause of the bright lights, the heat, and the standing in cues, you don’t stand around. You move from food to food.

You have a chair in clinic, you have to drink plenty of fluids. That was a way that a colleague discovered I was, I had Ehlers-Danlos syndrome because I’d agreed the great. Big water bottle. You have to increase your salt intake. You need to get very, very fit. You have to exercise. There was a German study that showed most of the symptoms of pots could go if you had a really good exercise regime.

That’s not what it’s like for every day, and that’s an interesting study in good on them. But you have your fluids, your salt, your exercise, your sleep. But we’ve also got to remember with all this Jaz, and it’s the same for TMD, you cannot see one thing in isolation. Everything is tied in.

If your POTS is worse, that’s going to make you more anxious. If your anxiety’s worse, that’s gonna affect your sleep. If your anxiety’s worse, you’re not gonna be able to cook so well and everything. And then if you’re not eating so well, it’s just everything is so tied up. So one lady I found.

She said that what her son always said to her was that she is always living on a knife’s edge. And that’s how I sometimes feel. We have to be so, so careful to do everything we need to do. And you’ve had a podcast, I think with Simon about this and that was a really interesting podcast ’cause he was saying about the really important things, and this really goes for patients with Ehlers-Danlos syndromes.

The fluid, the diet, the exercise. He had some letters that said about it. Sorry Simon, I can’t remember what they were. And that is so, so important. So there are very much things we can do, but what it matters. Getting the label is you don’t doubt yourself anymore. You don’t let people put you down.

Oh, why are you being so difficult? Or why you’re always so cold? Or, why do you have to do that? Why do you have to sit with your arms crossed? We can now say to people, yes, I know. It’s funny. I always sit with my arms crossed. But this is me trying to keep my blood pressure up. So can we just laugh about it and get on?

Can you just remember I’m one of these funny people? For example, you were saying Jaz about not remembering people’s names. I was in one job. Where I got such a hard time for not being able to remember people’s names. And that was before I even knew about Ehlers-Danlos. And I would say, listen, it’s just something about me.

I cannot do names. I don’t even do my children’s names nowadays, when it’s on about names. I can address these people with much more confidence and eloquence. I say thank you so much for bearing with me. I don’t even give my own names, my own children’s names. This is something just to do with the brain fog, with the low blood pressure, and it’s just easier. Rather than people saying, you’re just being stupid, Audrey. 

[Jaz]
I totally get that. I think it’s to understand a lot more about yourself and when you stand about yourself, you can then live a life more purposefully, more optimized for you. And then when things just make sense in your life, then you can actually proceed with be your best foot forward. I think that’s the main benefit. 

[Audrey]
I think just being allowed to own our own issues, like I luckily don’t really get sore joints because I’m not allowing myself to have sore joints. But a few years ago I got really sore joints. I had to stop learning Spanish on my phone because moving my fingers hurt my elbows.

Sometimes I have to get rid of my big herbal tea cup because that was hurting me. Just to understand that we’re not being silly and think I need to exercise, I need to do more weights, I need to do more Pilates, rather than just I’m just being stupid and go away in a corner and hide away. What I would say though, Jaz is, a lot of people are striving to get a diagnosis.

A diagnosis is not a be all and end all. And I would say to patients, if we get a diagnosis, fine, good. But what I say to them is, I’m not telling you anything you don’t know, but all I’m saying is do you think all your seemingly unconnected signs and symptoms are actually connected?

Go away and live with that. It doesn’t really matter at the moment, the label we’re slapping on it. Yes, it would be nice to get a label at the end of the day, but let’s just work with what we’ve got and let’s get you off to the exercise classes. Let’s get you increasing your fluid, improving your diet, improving your sleep. Yeah, that’s what I feel. I love that. 

[Jaz]
I mean, it is a total health message and so as we come to the last 10 minutes of the show. Patients, I know you see so many TMD patients as an oral surgeon for the general dentist listening, what other things that do you want them to know to look out for, for example, anesthetic.

That doesn’t work. Okay. We know, I remember from dental school that s dentist was linked to periodontal disease. Okay. I remember that, but not much more in terms of relevance. It has to- 

[Audrey]
What I do is direct your listeners to my lecture that is on YouTube channel. I think I’ve sent that to you already, but I’m very happy to send it all on again.

[Jaz]
Yes, I’ll put that one. 

[Audrey]
Have a look at that, because that is really the dental implications of EDS. So local anesthetic doesn’t work. They can have white spots on their teeth. Molar incisal, o hypo mineralization. I’m on only a neural surgeon. So I don’t know when something is hypo mineralization or a white spot.

So I just call it a white spot because I don’t wanna get in trouble with anybody. So patient I saw this week, even before we said very much, I could see the white spots on her teeth. I made a little list just to remind me because I knew there was so much to talk about. So failed local. When you give the local, these are the ones that don’t like adrenaline in it because they get palpitations.

MIH. These are the patients that are anxious because anxiety and depression goes with Ehlers-Danlos. So they’re anxious. But Jaz, if you listen to these people, if you’re on the right side of them, if your receptionist gets them sorted. They will trust you to the moon and back. And they will not be anxious.

They just need to know. So the anxious ones, they have a narrow V-shaped palette. Orthodontics works faster than usual. They have pulp stones. So they are the big ones that I find. I think that’s about all of them. 

[Jaz]
Great. And then, so what’s the main message that from that lecture that you did, for example, what’s the main takeaway that you want dentists who have enjoyed the listening to your journey, but also how we can look out for things in our patients, how we can support them, and how the saying when you can’t connect the issue, think connected tissue. What’s the main message that you want to give to the general dentist? 

[Audrey]
All the medical history is relevant. If we are aware of connective tissue disorders, we can make our lives much easier. ‘Cause we know those patients are gonna need a couple of minutes more chat on the phone before they come in to get them less anxious.

We can make it much easier for us when we’re doing the local, we might pick up that it’s not going to work, it’s just gonna make our lives much easier. If we know we are also going to make the patient’s life’s much easier and those patients are gonna be so delighted, so loyal, we’re just gonna make it so much better.

We also have to remember, Jaz, I have had many, many of our, let’s call them practice staff come to me after watching my clinics and say, Audrey, I think I’ve got this. I was trying to figure out how many practice staff I’ve picked up. We’re probably talking about 50 or so people who come to my lectures.

There’s always people afterwards that contact me saying, Audrey, this is me. So we need to see everything is relevant. It was last week I had a 26-year-old man in with really hypoplastic sixes. That’s very likely Ehlers-Danlos, he was anxious, he was depressed and he had gastric reflux. Now, if somebody had picks up those, I dunno why anybody hadn’t sorted those hypoplastic sixes, but I was taking one of them out.

He was educated, he was at whatever else, but nobody had said. Listen, I think maybe something’s going on here. Luckily the local anesthetic worked, so I think it’s just be aware and if we can, I’m not saying everybody needs to pick up every case, but this is gonna be life changing. All these patients, I see it’s absolutely life changing. 

[Jaz]
I think it’s important because before dentists used to be very much tunnel vision, the tooth, and we’ve grown so much as a profession away from that. And so now we are incorporating sleep disorder breathing. And screening for that, we’re a stop back and in generally steep, in general, we helping to manage patient’s anxieties and this is one facet of it, right?

Looking a reminder, a really helpful reminder today to look at the patient as a whole and connecting the systems together and helping to speak about health. A wonderful thing to speak about health ’cause who’s not speaking about health to patients? The general, the GPs, because they’re seeing when the patient has a problem, they’re speaking about that problem or one or two problems. We have a great opportunity in dentistry to speak about their health in general, and you know what? I think that makes our career more fulfilling.

[Audrey]
What I would say about the GPS is. As somebody that works privately, I can have as long as I want for a patient. I’ve heard you say before you have 75 minutes for a TMD patient. If a GP is listening to this they are wondering, how can they manage on a 10 minute appointment, so I really, really feel for the GPs, but I listen to the talk from the very nice per girl who, I can’t remember her name, obviously. 

[Jaz]
Rena? 

[Audrey]
Rena. She has bought a, was it a hba one C meter?

[Jaz]
Yes. 

[Audrey]
How wonderful is this? Because all of these things tie in with everything we’re doing, you know? I’ve started asking for hba one Cs whenever I can for patients because it is also relevant, whether it’s a burning mouth or, and also vitamin D levels as well. And I know this has said a lot in your podcasts, Jaz, we’re all thinking along the same lines and I’m so glad you contacted me, jaz, and I am so glad we’ve got a chance to spread the message and a chance for all those guys to get to know each other and maybe work together. 

[Jaz]
Well, thanks for joining the community on Protrusive Guidance. It’s been great to have your contributions on there already. And also thanks for making us all vulnerable today in this episode. Honestly, thank you for doing that. That really is- 

[Audrey]
I appreciate that. 

[Jaz]
A real, real pleasure to to hear your story. Thank you for sharing that with us. ‘Cause it’s gonna inspire so many of us and I think to continue to pedal that health message. I think this podcast has been so good and eye-opening. And this might then trigger a chain of events to help us help, get that health message across to our patients. Talk more about health to our patients. Do some further learning for me, I mean, you’ve been incredibly helpful in terms of getting me to think more about my own health. And what’s more precious, valuable than that. Right. So, hoping everyone enjoyed that. And Audrey, I appreciate your time. 

[Audrey]
Pleasure, Jaz. A pleasure to come on and chat to you. 

[Jaz]
I will put all the resources in the show notes, so your video, any links. So basically if you just send me a mega bundle and so I just don’t miss anything and I’ll put it in the show notes. So in Spotify they scroll down, YouTube rather. They can find your lecture, they can find any goodies that you think will help dentists. That will be one. 

[Audrey]
I want to say to any of your listeners if they have any questions, whether they’re personal or work related, please my email is hello@oralsurgery.scot, if you just Google me, Audrey Kershaw, you’ll find me. Please, we’re here- 

[Jaz]
Also on Protrusive Guidance so you can DM you as well and that’d be great. 

[Audrey]
So pleasure guys. 

[Jaz]
Thanks so much all appreciate you. 

[Audrey]
Take care. 

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. Slightly different theme of the podcast. So for some of you who love the clinical details. You may have not loved this episode as much and that’s, that’s totally cool, right? But I think the vast majority of you really would’ve loved Audrey’s journey because this is an oral surgeon, really, she wears her heart on her sleeve and she really made herself vulnerable and shared so much.

So thank you so much again, Audrey. And dentists were humans first, then dentists. And you may be able to recognize things about your journey, about your life and your health. Anytime we can talk more about health that conversation that we have with yourself about looking after your health or the conversations we have about health with our patients.

It can only be for the better. So if you’re watching or listening to this episode on the app right now, scroll down. You could download the premium notes, you could download the transcript. You can download all the goodies that Audrey promised, and of course, answer the quiz. Get 80% and you get your CPD certificate, like you’ve done all the hard work, you’ve listened all the way.

Why not get that certificate now to prove you’ve learned something? It also gives you opportunity to reflect, which is important for your personal development plan. Yes, all this requires a subscription, but I think it’s genuinely one of the most valuable subscriptions going in dentistry, especially if you listen to every single episode.

Or most episodes, it just becomes cost effective for you and you help to support this podcast and help it grow. So if you wanna join our best plan, that’s the Ultimate Education plan. You’ve got all our masterclasses as well. The easy link for that is protrusive.co.uk/ultimate, and that’ll take you to the right page.

Thank you once again for listening all the way to the end. Catch you same time, same place next week. Bye for now. Oh, and of course, thank you to Team Protrusive. Without the team, I would be lost and I would’ve quit podcasting four or five years ago. So thanks so much for Team Protrusive and of course, thank you, the listener for helping spread the word and helping us to make dentistry tangible.