Dental Problems in EDS with Dr. Audrey Kershaw

[01:00] Dr. Linda Bluestein: Welcome back, every bendy body, to the Bendy Bodies Podcast with your host and founder, Dr. Linda Bluestein, the Hypermobility MD. I am so excited to chat today with Dr. Audrey Kershaw. Dr. Kershaw and I have been chatting on social media, and I did a presentation with her a few months ago, and she's such an incredible wealth of information. She's an oral surgeon, and she does such fabulous work in the space of people with EDS and HSD.
[01:28] Dr. Audrey Kershaw is the founder of Oral Surgery Scotland. Her career has taken her all over the UK, gaining experience at nationally recognized centers for oral and maxillofacial surgery before settling into an associate specialist post at Dundee Dental Hospital and School in 1998, where she practiced and taught until 2017. Through this, she has been involved in the education of well over 1,000 of Scotland's dentists. Audrey works with the Scottish government's focus groups on rare diseases and the Ehlers-Danlos Society. She has reached over 1,000 clinicians and healthcare professionals with her hereditary connective tissue disorders and EDS teaching sessions.
[02:09] I am really excited about this conversation as I know people have lots of questions about dental problems with EDS and oral surgery with EDS. As always, this information is for educational purposes only and is not a substitute for personalized medical advice. Stick around until the very end so you don't miss any of our special hypermobility hacks. Here we go.
[02:32] Okay, I am so excited to be here with Dr. Kershaw to talk about so many important topics that I feel like are just not talked about often enough. You got into this space in kind of an unusual way, right? Can you tell us — start off by telling us how you got interested in EDS and related conditions?

[02:54] Dr. Audrey Kershaw: Yeah, thanks, Linda. For decades, I knew there was something going on with some of our oral surgery patients. They wouldn't numb up. They were anxious. They definitely were feeling it. A lot of the staff thought, no, they were just anxious, they weren't feeling it. I just knew there was a lot going on. And then back in 2017, I discovered — came across Ehlers-Danlos, and it was like, my goodness, it just opened everything up and I saw exactly what was going on. So that was how I got in.
[03:29] Now, when I first came across it in 2017, Linda, you'll remember back then the Ehlers-Danlos syndromes were 1 in 5,000. And I thought, okay, I've maybe found one, but it's going to be another 7 years at the rate I work before I find another. So I wasn't picking so many up then because I thought, no, no, this can't be right. But now I'm much, much more confident, and I realize it's much more common than we previously thought. There's the Northeast of England study from last year that said 1 in 227, I think it was. And I definitely find more than that. So that was basically how I got into it.

[04:03] Dr. Linda Bluestein: And we're so glad that you did, because this is — thank you. Yeah, you're doing such incredible work, and it's so great to get to have this conversation with you today. I know so many people are going to benefit from it, just like your patients are benefiting from the knowledge that you've gained. So in terms of dental problems that you commonly see in people that lead you to suspect undiagnosed Ehlers-Danlos syndrome, hypermobility spectrum disorder, comorbidities like mast cell activation syndrome, or POTS, what things do you see that make you suspect those conditions?

[04:48] Dr. Audrey Kershaw: So if I just take a little step back there, Linda, we can pick these up from a 3-line referral letter. We are that good at it now. Reception staff, nurses, managers can pick it up when they phone a patient. We just get a little inkling there's something going on here.
[05:05] So, to begin with, I think a big thing is failed local anaesthesia. That is a big question I ask in my history taking. And that sounds quite an easy question to ask — does LA sometimes not work for you? But I find we've got to ask it 3 times now. Some people think they should get a numb lip, and that means it's worked, but they still feel the pain. And I have to explain, no, no, no, that's not the way this is supposed to work. It's supposed to numb you up and you shouldn't feel any pain. Other people, when you say, does local anaesthetic work, they say, the dentist tells me it works. I say, well, I'm not really very interested in what the dentist tells me. What do you feel? I've even had medical students and dentists not realize either what it should mean to have local anaesthetic work. So we make a real point of asking in our history: does local anaesthetic work?
[06:00] There are many, many things that we can pick up, Linda. White spots in the teeth, poorly formed molar teeth, some missing teeth. If the patient comes in — or we quite often pick up staff we work with — bruises on their body. They don't know where they've got the bruises from. They maybe bleed after having a tooth out. Their gums maybe bleed quite easily when they're brushing their teeth. Very anxious, as you know, Linda. The patients are anxious. They want to know, they want to check. Is it okay if they bring some shopping bags with them? Where will they park their car? Lovely, lovely people, but they just want to get it right.
[06:40] They're also the ones that maybe show the signs and symptoms of POTS. So they'll be taking the postures with the arms crossed, the legs crossed over, will maybe be walking round the waiting room. So we are very clued into all these signs and symptoms now.
[06:53] We also had a lady referred to us with 40 years of bad breath, and she was at the end of her tether. I don't know how she found me, but that's another sign and symptom. And it's so satisfying to be able to help these people out.
[07:14] Also, in our medical histories, a thing that's quite often said about medical histories is, tell us any relevant medical history. Now, I always say that word "relevant" needs to go, because everything is relevant. I want to know if you've got reflux, if you've got IBS, if you've had spine surgery. We need to know it all. And I think as dentists, we need to move to a full proper medical history. Tell them we want to know everything. Patients just think, it's a dentist, I'll just make this quick for them.

[07:48] Dr. Linda Bluestein: Yeah, that's really interesting because whether you're a dentist or — I know my husband who's a urologist, they're used to dealing with a very discreet part of the history. So it's very interesting that you're saying that all of the history is relevant. I know for me I feel like that's true, but that's super interesting, and I love that you feel that way.
[08:09] And I'm also curious about the halitosis or bad breath, because I have been told by my husband that I have bad breath. I always thought that was related to sinus problems that I've had for a long, long time. Can you tell us more about that? That's really interesting.

[08:29] Dr. Audrey Kershaw: Well, this lady — who is of the same name as yourself, and she will not mind me talking about her, but I will not give too many details, but hi — she had seen every specialist going. She'd seen GI, ear, nose, and throat, everything. It was affecting her life, 40 years of it. And we think this is coming from the acid in her stomach.
[08:56] So, we're now getting her along to try and get some decent help for this. But as you say, it could be coming from your sinuses. There are about 13 different reasons for having 40 years of bad breath. So we needed to work through each of them and say, we don't think it's that, we don't think it's this. But she very much thinks that we're right. And she's now gone on to be diagnosed with hypermobile EDS.

[09:23] Dr. Linda Bluestein: Oh, interesting, interesting. And so that's great that you're picking up on these other things and making referrals for people. How do you approach that when you do suspect that someone is in this category of a connective tissue disorder, maybe mast cell activation syndrome?

[09:43] Dr. Audrey Kershaw: Yeah, so what I do is I make it very clear to them, I'm just the dentist they've come to see. I'm not qualified to be diagnosing. Even if I was qualified, Linda — and I will be if I go to a conference — this is such a complicated field. We need to make sure we're not missing other important things that it could be.
[10:04] So I say to them, have you considered that all your seemingly unconnected signs and symptoms could be connected? And then you see the light bulb going on. And then we discuss. When we've discussed that, they then think, oh well, okay, I didn't bother to tell you this, I didn't answer that question correctly. They need time for all this to process for them. And they quite often message us later to say, forgot to tell you about this — and is this relevant that my sister's got this, my dad's got this? So we'll let them have time to think about it.
[10:40] National Health Service in Britain, very difficult to get help. We don't have good pathways for help. I think you know my colleague, Janet Gravener. Shout out to Janet here. Janet and I work very, very closely together, and I send a lot of my patients to see Janet. And I am so lucky to have Janet. Our patients are so lucky to have Janet. And Janet and I work as a team. But that's only for the sort of private patients I have — I've completely flooded Janet with patients. So I have to be very, very careful who I send. I know Janet has got some other colleagues in Moffat and in Glasgow, and we're trying to sort of send a few that way as well. But it's not easy to get help, as you know.
[11:24] I also would stress to the patients, Linda, that getting a label stuck on you, it's not the be-all and end-all. You know, it doesn't matter what label we're going to put on this at the end of the day. All that matters is I know you're going to be difficult to numb up when I take your wisdom tooth out. You might bleed a lot afterwards. You're anxious. You cannot stand up without falling over. So yes, it would be great to have a label on them to help them with their lives, but that takes time. And that's not the be-all and end-all.

[11:56] Dr. Linda Bluestein: And I know there's a lot of people listening to this thinking, oh my gosh, I wish I could go see Dr. Kershaw. I definitely want to, in the latter part of this conversation, touch on how people can find someone who may be more likely to listen to them. But I want to make sure we dig more first into some of the other problems that people may see, because that's so important. Unfortunately, not only can not everyone get to you, but you couldn't see everyone that you would need to see. And I'm sure you're already really busy.

[11:58] Dr. Audrey Kershaw: Yes.

[12:24] Dr. Linda Bluestein: So let's talk a little bit about gum problems — gum recession, gingivitis, periodontitis. What kind of treatments can be done? What do you see in terms of gum problems in this population?

[12:40] Dr. Audrey Kershaw: So, I think this bit is very poorly known about and managed. Patients with Ehlers-Danlos syndrome, unless it's the periodontal type of EDS, are not more prone to periodontal disease. They're not more prone to gum disease — I'm trying to use layman's terms here as well.
[13:06] If you've got periodontal EDS, which is 1 in 1 million maybe — I think there's only been 134 cases written up — that is very, very rare. You do not get more gum disease if you have Ehlers-Danlos syndrome. There may be more reasons why your gums are giving issues. If you're too tired to brush your teeth, if you're too tired to go to the dentist, if your joints are too sore and you can't get in there to use the cleaning aids we have. Patients with Ehlers-Danlos, they bleed easier, so their gums will bleed easier than other people that don't have Ehlers-Danlos, but we could see that as a bit of an early warning sign that they need to have their oral hygiene 100% or they're going to have some bleeding.
[14:01] So for these patients, we do not have to manage them any differently than we do the general population with gum disease. Other patients with underlying medical issues will have issues cleaning their teeth, using interdental aids, and whatever else. So that is what I think we need to do with that.

[14:23] Dr. Linda Bluestein: And in terms of enamel defects, root anomalies, pulp stones — are those things more common in people with EDS?

[14:32] Dr. Audrey Kershaw: Yes, they are. I think we take a step back as well and say research into EDS and dental issues, we're needing much more done on this. There are our colleagues in Austria, Ines and Ulrike. I'm not sure if you're aware of them — I'm not even going to try and pronounce their second names, but with all respect to them. They've got some things on YouTube and they are quite good things to watch. But they are being very, very honest. They seem absolutely lovely people, being very, very honest and saying we need much more research into all of this.
[15:14] So, we are aware that we can get a condition called molar incisal hypomineralization. That means basically the teeth have white spots on them. So when the patient smiles, you can see white spots in the front teeth maybe, or the molar teeth are poorly formed. That is another way that I pick up these cases. If I get sent an X-ray before I see the patient, I think, ah, the first molars are very badly decayed or they're missing. That could be a sign of Ehlers-Danlos syndrome.
[15:47] Sometimes the first molars are so poorly formed that they might be taken out earlier on in life — maybe even the child is 9 or 10 — to make way for the wisdom teeth if the patient has wisdom teeth, and then the spaces will all close up.
[16:04] You also mentioned about root shapes. That's not so much an issue for us. I know in classical EDS, we can get maybe shorter roots. Very, very occasionally that might mean the teeth could fall out, but that is so rare. I've never seen it. I've not heard reports of that really at all. And in vascular EDS, we can have longer roots on the teeth. So it just gives us maybe a little bit of an idea if we are looking at an X-ray — another little sign that this could be an Ehlers-Danlos syndrome case.
[16:43] With pulp stones, I messaged a colleague of mine last night, Gareth Calvert, restorative consultant, and Gareth said yes, when he is doing root canal treatment on a tooth, yes, they do see pulp stones, but this doesn't really interfere too much with what they're doing. So again, that's more something that I can see on an X-ray. When I take an X-ray for their wisdom teeth, I can see the other teeth — they could have pulp stones — and I think, that's just another little sign there.

[17:10] Dr. Linda Bluestein: So what are pulp stones? Just so we make sure that everyone —

[17:11] Dr. Audrey Kershaw: Pulp stones. So the way the tooth is made, there is the outer harder layers, there's the inner pulp, which is the nerves and the blood vessels. You can get calcified stones in there. They're normally in the higher up part of the root, and we can just take them out if we're doing a root canal treatment.

[17:30] Dr. Linda Bluestein: And you can actually see those on an X-ray then?

[17:36] Dr. Audrey Kershaw: You can very often see those on an X-ray, yes.

[17:41] Dr. Linda Bluestein: Interesting. Okay. So with my patients and my clients, I would say if not 100%, it would be probably very close to 100% have jaw pain. Jaw pain, clicking, difficulty with chewing harder foods, difficulty with dental work because of needing to have your mouth open, and that kind of thing. And I have done an episode on TMD specifically, or Temporomandibular Joint Disorder.

[18:12] Dr. Audrey Kershaw: That I've watched, yes. As well as most of the 140 episodes, Linda, yes.

[18:17] Dr. Linda Bluestein: Oh, bless your heart. What is your experience in encountering TMD with this population, and what treatments do you find most effective?

[18:28] Dr. Audrey Kershaw: So we've got to remember, I don't see a routine sample of the population. I work as a specialist in oral surgery, and I get patients that other dentists and healthcare professionals are maybe not managing. So I maybe get the more difficult cases.
[18:47] I see a lot of TMD cases that are referred to me. I had one this week — their dentist had tried for 18 months, didn't manage, and she said, you need to go and see Audrey. So she came to see me, and that is the way I get the TMD patients.
[19:10] I think the figures are TMD occurs in about 25% of the general population, but in the EDS population, it's 75%. So yes, a lot of the EDS population will have issues.
[19:26] What I think is important about all of this, Linda — listening to other people speak and reading stuff — I think it's very important we always take a step back and we see the bigger picture. So there's a very good document that came out last year from the Royal College of Surgeons in England. It's called Get It Right First Time — GIRFT — a TMD document, very easy to Google and find. And that is an amazing document. It has looked at all the papers out there, all the ways, it gives you everything in there. And that is what I follow, and I think we should be following, at least in Britain.
[20:13] What we find is if you have TMD and you go to a restorative dentist, they're likely to give you a splint. If you come to see me, I'm likely to diagnose EDS. If you go to a maxfax surgeon, surgery may be spoken about sooner rather than later. If you go to a physiotherapist, they're going to do physio on you. We need all of these different people, but we need them at the right time.
[20:44] So this document is brilliant. It takes you through everything stage by stage. There is the 92-page document or whatever, there's also a clinician's and then a patient handout. So it is a complete cheat on clinic, because you just get the patient handout, you can work through that, you can give them it to take away. And it has to be very much patient-led as well.
[21:16] So I will very much do self-supported management with them. And we will also discuss whether we go to physio, whether we go to Janet — being the osteopath — and we see what's actually going to work.
[21:34] I also feel with a lot of these, Linda, I have a physiotherapist, Cameron, who I use. We have to see the body holistically, and quite often if Cameron can sort out the head, the shoulder pain, the neck pain, the back pain, we don't even need to look at the TMJ because that'll sort itself. So I'm very much for not concentrating just on the TMD — we're concentrating on the rest of the body.
[22:09] And by the time I speak to my TMD patients, I find most of my TMD cases are actually an undiagnosed connective tissue disorder. And when we get everything else out on the table, all the other things that are wrong with them, we find maybe some of these other things are so much bigger. So we have to tackle everything — not all at the same time, but we have to decide on what we're going to do and where we're going to go with all this.
[22:33] And they're maybe talking to me about their TMD because I'm the only one that's going to listen to them at the moment. They have been to all the other specialists and they're not getting anywhere. So we need to see the body as a whole. So that's just my sort of take on TMD. And the Get It Right First Time RCS document is absolutely brilliant. When we've done this podcast, I'm going to send our link to the guys that wrote this. It's Emma and — I am so sorry, I'm so bad with names. Not Damian, sorry. Can't think at the moment. I know you well, but sorry.

[23:12] Dr. Linda Bluestein: That's okay. I definitely struggle with that myself. And when I started teaching at the medical school, I would ask the students to please wear their name tag every time, because I would teach a class and then I wouldn't come back for a little while. So I totally hear you about the names. I could totally relate to that.
[23:25] So I'm also fascinated because I feel like this is literally exactly what I was struggling with maybe 5 years ago when I was trying to get more care for my TMD. And I'd had it for quite a few years. And I know you've listened to the episode where I talked to my own doctor here in Colorado. I was still in Wisconsin at the time, about 5 years ago, and I was starting to explore who else I could go to. I'd already had physical therapy and my dentist had already fitted me for a splint, and so I was wearing that, but it had gone from being very stable to being a lot more problematic.
[24:07] And it was so interesting because I did realize exactly what you just said — if you go to this person, you're likely to get this; if you go to this other person, you're likely to get something else. Because of course we all offer what we have in our armamentarium. If someone comes to me, I'm not going to offer to take out their wisdom teeth. I have no idea how to do that.
So I'm going to offer the things that I know how to do. And that was one of the real challenges I faced — I would literally call the offices and I would ask, well, what kind of appliances do they use or treatments? Because it is tricky if you have TMD and you get offered surgery before you really need it. That would be something that I think would be really problematic potentially down the road. Any surgery, right? Patient selection is everything — making sure that you're offering surgery to the person who needs it, but that you're not operating on people who might be able to have more conservative care.
[25:09] So if someone is listening to this and they're going to check out the document — which we're going to link in the show notes, all those documents that you mentioned, the patient handout, the clinician handout, the full document, which I did pull up yesterday after you mentioned it to me —

[25:22] Dr. Audrey Kershaw: Oh, great.

[25:24] Dr. Linda Bluestein: And I love that title, Get It Right the First Time, because we should apply that to everything, right? So if someone is trying to figure out who to go to and they're aware of these kinds of differences in approaches, what do you recommend that they do?

[25:44] Dr. Audrey Kershaw: I think it's very difficult for patients, Linda. If they can, read as much as they can on it. Read the 92-page document, read the patient guide.
[25:58] I think what you'll see with Ehlers-Danlos syndromes as well is it's difficult enough finding your way if you are educated, you have the time and the resources to do it. People who maybe don't have a scientific background to be able to understand what they're reading — it is very, very difficult for patients. You need to find somebody who's going to take a very holistic view of it. And that's difficult.
[26:34] I think if they go along for a hospital appointment, they need to make it very clear they want a very holistic view. They don't just want to go to see somebody that does one sort of splint and that works and that's what everyone gets. Yes, they might need that sort of splint, but we need this holistic approach.

[26:53] Dr. Linda Bluestein: Yeah, and we're asking patients to do more and more as things have gotten more and more complicated. They are the common thread between their specialists. And I don't know about you, but I use an EMR that doesn't connect with other EMRs because I'm in solo practice, so I don't have the ability to afford something like Epic that has care everywhere. And you probably have completely different systems where you are. So we are asking patients to do more and more, which I feel very badly about, because if they're already sick and they're dealing with these complex illnesses, it's even harder. They've got brain fog, and —

[27:30] Dr. Audrey Kershaw: Even for the best of them, it's very, very hard. Yeah.

[27:39] Dr. Linda Bluestein: We are going to take a quick break and when we come back, we are going to talk about oral ulcers, tori, how to find a dentist that might be a good fit for you. We will be right back.
[29:12] Okay, we're back with Dr. Kershaw and talking about so many great topics related to dentistry and her expertise in oral surgery. I had a patient the other day who has oral ulcers, and she has had them for many, many years, but they've been particularly bad lately. And I had some different things in my differential diagnosis, but I would love to hear how often you see that and if you have any thoughts on oral ulcers.

[29:40] Dr. Audrey Kershaw: Yeah, this is another way, Linda, that we pick up some Ehlers-Danlos cases. They come into us with oral ulcers.
[29:45] With your medical background, I'm sure you know a fair bit about this. In my sort of career, I did a lot of oral surgery hospital jobs, some oral medicine jobs. I'm very much not an oral medicine specialist, but while doing oral surgery jobs you have to see oral medicine patients because there's not enough oral medicine consultants.
[30:11] So we have the British and Irish Society of Oral Medicine, and they again help me cheat in my job, and they've got wonderful leaflets on a lot of oral medicine things, and they've got very good leaflets on recurrent oral ulcers. So if somebody comes in to see me with oral ulcers, you would want to take a really good history.
[30:36] Some of the reasons for having oral ulcers would be low iron. So what we do is we do a full blood count, ferritin, folate, B12, blood glucose, a celiac screen, and vitamin D screen. And if patients are low in any of these things, they can get oral ulcers. So that's fine maybe to discover somebody's low in B12 or low in folate, but as you know, we then need to think, well, why is the patient low in, say, folate? Being low in folate could be from celiac disease. And I think the figures are something like 70% of people with celiac haven't been picked up.

[31:24] Dr. Linda Bluestein: I think I've seen a similar statistic.

[31:25] Dr. Audrey Kershaw: There are papers out there to say that. So we can pick these patients up on clinic. And people with Ehlers-Danlos are more likely to have celiac disease and Crohn's disease and all of this. So it just starts us off in a little bit of detective work there, to see what we can find.
[31:49] And I think it's also very important to get in here: when we find one thing wrong with somebody, we shouldn't just stop there. If we can put a label of celiac on somebody, that doesn't mean they don't also have Crohn's disease, or they don't also have Ehlers-Danlos syndrome in there as well. I'm not going to let anything pass me, Linda, that I could stop from passing me.

[32:18] Dr. Linda Bluestein: Yeah, that's amazing. I do think that is something that is very important for people who have EDS — to remember that you can also get other problems. Don't attribute everything to EDS because you could miss some really important things. And while EDS can cause — and HSD can cause — a lot of other problems, and mast cell activation syndrome of course, we know the overlap there. There's a saying, I don't know if you've heard this or if you've heard me say this before — people are entitled to as many diseases as they damn well please.

[33:00] Dr. Audrey Kershaw: And I agree. I always say that. And I think patients need to know this as well. Just because they've already given us a great big story about their type 1 diabetes, it doesn't mean everything is to do with their type 1 diabetes. There could be other things.
[33:17] So that's it about ulcers. I think as well, patients don't maybe feel they should say to their dentist that they keep getting ulcers every so often. We really want them to tell us as much as they can.
[33:30] Another thing — at least in Britain, I qualified 37 years ago, Linda, there was a big divide between dentists and doctors. I think as the decades are going on, we need to value every single member of the healthcare team. We need the physios, we need the osteopaths, we need the dentists, and we need to see that all of us can pick things up and then should be able to take them along to whoever is looking after the patient's care. So we as dentists have got a big, big role to play in managing the patient's healthcare.
[34:14] And we're in the very lucky position that, well, as a general dentist, they would be seeing a patient maybe every 6 months, every year. Whereas you might go decades before you go and see your GP.

[34:28] Dr. Linda Bluestein: Those are excellent points. And speaking of oral surgery things, I have had multiple surgeries for tori.

[34:35] Dr. Audrey Kershaw: Ah. That's where that question came from.

[34:39] Dr. Linda Bluestein: Yes. I try to sneak in some of my own personal questions. But I did also, when I asked for people to give me questions that they wanted me to pose to you, a couple of people did also ask about tori. So can you tell us what tori are, if you happen to think that those are more common with EDS or HSD, and also is surgical excision the only option?

[35:07] Dr. Audrey Kershaw: So we're into a private consultation for you here then, Linda. Tori are little lumps of bone, which are normal in most people. We quite often see them on the inside of the lower jaw, or we can see them on the roof of the mouth. Could I ask where yours are, Linda?

[35:31] Dr. Linda Bluestein: I did have some that were excised. The inside of my lower jaw, and then I had some that were very, very big. The skin — or the mucosa — was getting very, very thin.

[35:45] Dr. Audrey Kershaw: Very thin, I think.

[35:46] Dr. Linda Bluestein: Yes.

[35:48] Dr. Audrey Kershaw: We do see cases like this. I take it they were sent away to be looked at under the microscope?

[35:55] Dr. Linda Bluestein: I would think so. This was a number of years ago, but I would think so, yeah.

[36:02] Dr. Audrey Kershaw: So this is not something that I was aware of was related to Ehlers-Danlos syndrome. I think it's worth keeping in mind though.
[36:16] What can we do with them? All we can do is take them off, and make sure they're not down to some other reason — for example, something like fibrous dysplasia, one of those other sorts of conditions.
[36:31] The time where I have removed tori recently — I've only maybe done it 3 times in the past 7 or so years — it's when on the inside of the lower jaw they've been too big for a patient to be able to wear a denture easily.
[36:49] We quite often get patients coming in terrified they're dying of cancer because they've noticed these great big lumps on the inside, like the place you had them. And we have to say, you've had these at every single checkup for the past 20 years, and you've now just noticed them. There's nothing to worry about. And that's just why it's good when we're doing a checkup that we write everything in the notes. Even if I'm doing just an oral surgery, I will always put in the notes if there's tori there, because patients suddenly realize they're there.
[37:25] Really, most of the time they're nothing to worry about. If they were very fast growing, or if you had several in different areas of your mouth that seemed to be growing, we would want to be sending them off to be looked at.

[37:40] Dr. Linda Bluestein: Okay. And what about wisdom teeth extraction? If you could maybe refresh our memory a little bit about local anaesthetics and how those might act differently in people with EDS, and if there are other considerations for wisdom teeth extraction for people with EDS and HSD and the comorbidities.

[38:00] Dr. Audrey Kershaw: Okay. So most of my work is probably removing wisdom teeth. And there are many, many things with Ehlers-Danlos that can make this a little bit more difficult. So there are many chances for me to find an Ehlers-Danlos case.
[38:22] So the patient is anxious and stressed because anxiety goes with having Ehlers-Danlos. And since I discovered about Ehlers-Danlos, Linda, I see being anxious totally differently now. I don't know if it was the way I was brought up, but if you were anxious, it was just, well, you pull yourself together, will you stop being so stupid, nobody else is getting worked up about this.
[38:43] Being anxious is built in. It is a very good early warning system. It's maybe the way that you're made. Anxiety will be worse if your POTS is worse, your blood pressure issues are worse. So we have to keep that in mind as well.
[39:03] So we've got an anxious patient to begin with. The local anaesthetic may not work. And that is quite a big thing. In my history, Linda, I always ask about LA not working, and I ask 3 times, and I sometimes literally pin the patient against the wall and say, "You will tell me the truth."
[39:30] A lot of patients don't realize — and I've actually had a final year medical student and a dentist who I had to explain this to, which is just crazy. Some people think if the dentist tells them they're numb, they must be numb. And I have to say, I'm not interested in what your dentist thinks. I'm interested: does it feel sore to yourself? Yes, it feels sore. But the dentist tells me I'm numb. No, no, no, that doesn't count.
[39:58] Some other people think because their lip goes numb — they feel their lip's numb, but they still feel pain when the dentist's working on the tooth. I say, I'm sorry, this does not make sense. This was not the point of it. Yes, your lips should go numb, and that suggests the nerve we were trying to get numb is numb, but you shouldn't be feeling anything in the tooth.
[40:21] So we need to make a real, real point of getting this out of them because they have been told they're just being silly, it's pushing, it's pressure, it can't be sore. And it just makes our treatment so much harder. We need to say to them, I actually believe you that you're not numb, and let's work on this together. That then reduces the anxiety, the stress, and it's so much, so much easier.
[40:45] I think later on we'll talk about local anaesthetic in more detail, because that's a different question we've got. But going back to wisdom teeth, we've got the patient anxious, local anaesthetic maybe not working, they can bleed easily. So if I know the patient's got Ehlers-Danlos, or I think they might be, we'll put in some special gauze to stop the bleeding. And they can bruise easily.
[41:16] So it's important — because I work in so many different practices — once I had a patient come in with bruising down to their chest. From oral surgery. This was an easy wisdom tooth I did, and I hadn't long started at that practice. And I had to say, this patient has got a bleeding problem. They have got Ehlers-Danlos. And this isn't anything wrong that we've done. So there are all these little things that can just uncover a case.
[41:48] I know, Linda, a lot of the time when I put my number 15 scalpel blade onto the lining of the mouth, it's fragile. The mucosa breaks up, it's fragile. It doesn't suture back well. Your suture needle sometimes just pulls out. That's Ehlers-Danlos for you. My nurse also sees it when I do it.
[42:17] Another thing as well, just thinking about it, is sometimes when I try to numb up the patient, it is very, very sore. Now, I know I'm being gentle. Ehlers-Danlos patients — correct me if I'm wrong, but they feel pain earlier than other people. And they can maybe put up with more pain, but they definitely feel the pain much, much earlier. And so that's another early sign and symptom. And I have to say to them, I know this is all a great big learning curve coming in to see me, but I know that you're feeling that, I know it's very sore. You are feeling it more than anybody else will, and I'll try and be as gentle as I possibly can.
[42:56] When I'm taking out wisdom teeth, patients think their TMJ might be an issue, because they think they have to open very, very wide. So if anybody's thinking of having their wisdom teeth out and you open wide — I'll say to you, would you mind not opening wide? Because that's making it difficult for me. If you open wide, your cheek gets taut. I can't get in there. So I don't actually need a lot of room to get the wisdom tooth out. What I say to them is, you just open to where it feels comfortable, to where the muscles are not either open or closed, your jaw's just hanging. And if you're not doing it right for me, I will tell you.
[43:37] I think it's maybe different if you're going along to have fillings done or whatever. And there are some wisdom teeth where the TMJ can be an issue, but normally I just have to explain to them it's maybe not going to be so much of an issue.
[43:55] Now, you'll be good to speak to about this one, Linda. Over the past 7 or 8 years that I've known about Ehlers-Danlos, we're seeing that healing can be delayed in patients with Ehlers-Danlos.
[44:12] We actually had a man, and I'll call him Stephen. Stephen, if you're listening to this, I know you won't mind me speaking about you because nobody will know who you are. Now, you know it's much harder to pick up Ehlers-Danlos cases in men than in ladies. Last year I picked up 120 possible Ehlers-Danlos cases.

[44:34] Dr. Linda Bluestein: Wow.

[44:34] Dr. Audrey Kershaw: They have all gone on to be diagnosed or are being diagnosed. Only 3 of those were men.

[44:41] Dr. Linda Bluestein: Really? Wow.

[44:42] Dr. Audrey Kershaw: So anyway, Stephen came in. Now, I don't know if you agree, Linda, but I find Ehlers-Danlos characters — some of them, oh my goodness, they're just gorgeous. This man — I was 15 minutes late to see him. He was so reassuring. "That's not a problem. You just take your time. I'm very happy to sit." "No, no, that's not a problem. I know you're so busy." And he came in, local anaesthetic didn't work, and it hadn't worked in the past. He had a couple of little things in his medical history, and he took the best part of a month to heal.

[45:17] Dr. Linda Bluestein: Oh wow.

[45:17] Dr. Audrey Kershaw: We got him in 4 weeks afterwards, and that was when I then really pushed him on his medical history. He was 39 years old. He looked about 29, because — I don't know if your audience know — people with Ehlers-Danlos can look much, much younger. So we pushed Stephen nicely. Stephen said, "No, please, please ask me all these questions." The more and more we pushed, he said, "I'm sorry I didn't put that in my medical history. I didn't think you needed to know it." And then it was, "My dad has had a collapsed lung. Could that be anything to do with it?" So by the end of it, we had Stephen seeing that all of his unconnected signs and symptoms that he didn't think I needed to know about were probably connected. And he is taking time to think about it, and we're going to send him on to Janet.
[46:11] So we're seeing more and more cases of delayed healing, and I'm now saying to the patients more and more, you've got Ehlers-Danlos, this might just take a long time to settle.
[46:23] We've also got to think as well, Linda — and you are the best one to talk about this — post-op long-term pain. Patients with Ehlers-Danlos are more likely to have long-term issues with pain, even just from being numbed up. Janet and I have seen a few — because Janet's great at getting these things out of people — where just numbing somebody up to have a filling done, they can have years of long-term pain from that. We need much better resources on this. But yeah, that's all there as well. It's not the patient's fault, it's not my fault, it's one of those things. But we need to be very, very sure before we do surgery on these patients that they're aware of what the consequences could be. Does that make sense to you, Linda?

[47:13] Dr. Linda Bluestein: Yeah, absolutely makes sense to me. And as you were talking about this, I don't know if you noticed that I shifted my headphones. And if anyone watches regularly on YouTube, they'll see about halfway through most interviews I do that — because it's funny that you mentioned about being more sensitive to pain at the same time that people with EDS, including myself, are used to living with low levels of pain that other people probably don't have.
[47:39] So I know for sure that my nervous system is sensitized, and probably most people can wear headphones for hours and they're fine, but it really starts to hurt the top of my head. So I have to shift so that I don't have that pressure on the top of my head anymore.
[47:55] And so we know that people who have central sensitization or nociplastic pain develop allodynia and hyperalgesia — those are two things that we see that let us know that the nervous system is altered in how it's processing the pain signals. Allodynia being something that's normally not painful is painful, and hyperalgesia being something that is normally a little bit painful but is a lot more painful. So I would call this allodynia — most people can have headphones on for a long time, they're padded, but I have this problem.
[48:31] So it's definitely really important for people to be aware of, because you're exactly right. At the same time that we are dealing with so many problems and pain and we cope — I think in some ways, like you're saying about Stephen — the people that I take care of are lovely, lovely people and incredibly resilient because they've been dealing with all of these different things. But at the same time, we can end up reacting even more than other people to certain things. So it's kind of confusing to people who don't specialize in these conditions, because they don't understand how you can have a higher pain tolerance for chronic things, yet there are other things that make you more sore.
And the post-op pain thing is really, really important for people to be aware of. And I'm so glad that you're working with a team so that you can really address those things. Because you're right, it's not anything that you did or can necessarily do differently.
[49:36] What about sedation options for people with EDS, MCAS, or POTS? Are there different things that you might do for that population, especially when it comes to wisdom teeth?

[49:48] Dr. Audrey Kershaw: Yes, that's a very good topic, that one, Linda.
[49:52] So, I have been qualified for 37 years. I've done a lot of different jobs. I've been everywhere, I've done everything, mainly oral surgery and maxillofacial — children's dentistry, loads of different stuff, but mainly oral surgery for the 37 years. About 7 years ago, I left the hospital service and I went to work privately, peripatetically throughout Scotland.
[50:19] So, I'm spoiled, Linda. I can choose where I work, I can choose who I work with, and I can choose how I set up my clinics. I am absolutely spoiled with the people I've got working with me. I work with nurses who completely understand what I'm doing with my patients, and how I want it to be very patient-centered. It is not one size fits all. It is not a production line. We see everything right.
[51:05] So, we can take out wisdom teeth just by numbing them up. We can do oral pre-med — some tablets to make them feel a little drowsy. We can do IV sedation into a vein, or we can put them off to sleep. These days, at least in Britain, we don't put many people off to sleep to have their wisdom teeth out or things like that, because of the risks involved.
[51:30] For sedation into a vein, when I first left the hospital side, I started an IV sedation service. It's really been a complete flop, Linda, because we get patients referred to us for IV sedation, and we call them up beforehand, we have a chat on the phone, we have it all lovely set up in the clinic. I go out and greet them, I shake their hands, I bring them in, we have a good chat about life, and I say, these are your options. If you want sedation, we can do the sedation pre-op workup, but you'll have to come back for the sedation, because that's it. And they just go, get on with it. So we just numb them up and we get on with it.
[52:18] I think if you've got a really good setting, we do not need sedation. So what I find is I can still do sedation, but I do not do sedation because we've got such a lovely setup.
[52:33] What I would say about Ehlers-Danlos patients and sedation is I've done a few Ehlers-Danlos cases that were not diagnosed, under sedation, but they needed very, very huge doses of the drugs we use. And it was not feasible to sedate them — they were not getting sedated with the amount of drugs we could give them.
[53:02] So I don't feel that I need sedation with the setup we've got. I saw a TMD patient this week — won't say where she was referred from — but she came in saying she'd tried everything else for 18 months, and her dentist said, you need to see Audrey because Audrey's going to do amazing things for you. The pressure was on. And anybody listening, I don't necessarily need you to say that to people, but this patient came along believing in what we might be able to do for them. We need that — it is so, so helpful for somebody to say, listen, Audrey and our team will do whatever is possible to make this easy for you.
[53:57] I think it's really important to have a lovely clinic set up, and this will be the same for your clinic. If you're going to get people's deepest, darkest secrets out of them, their full medical history, if they're going to remember back to their childhood, you've got to have them relaxed and happy to be able to do that.
[54:15] I think it's also really important that when the patient comes in, they can feel the nurse and the oral surgeon just have a really good setup between them. And I've got Kim, I've got Caitlin, I've got Corey, I've got Sophie. Sorry, whoever's names I've forgotten here, but I can't remember names. But I am really absolutely lucky to have what I've got there. So I don't need sedation, but that is an option for our patients.

[54:56] Dr. Linda Bluestein: Yeah, I totally agree with you. From my experience working for over 2 decades in the operating room, the way that we treat people is going to set the tone right from the very beginning. And we don't need to give anywhere near as much sedation — if we're doing a general anesthetic, oftentimes you'd give a little Versed before you roll down the OR hallway. But it makes a huge difference if you are making somebody more anxious or if you're making them more comfortable. It makes a huge difference in how things are going to go and what you need to do.
[55:33] So that makes perfectly good sense. And I want to just circle back, because we're going to need to wrap up soon. I want to circle back to local anaesthetics and what you do if somebody does have local anaesthetic resistance. How do you address that if you're going to be working on them?

[55:53] Dr. Audrey Kershaw: So I made a few notes here. What do I do if they've got issues with LA?
[56:05] So, to begin with, we have a really lovely setup. There was that very good paper from 2019 — Alan Hakim was one of the authors — and that was saying approximately 88% of patients with Ehlers-Danlos had issues being numbed up at the dentist. You asked me in an email earlier on what percentage of my patients with Ehlers-Danlos I thought there was an issue, and I wrote, before I remembered what the paper said, I wrote between 80 and 90%. So yes, a lot of patients have issues.
[56:43] To begin with, as I said, I ask them 3 times, do they go numb? I need to know, and they need to know that I know, and we all need to know we're working on the same team here.
[56:53] And if they don't go numb, we will try our very best. The paper from 2019 lists the different local anaesthetics that work the best. I don't quite know what you guys use over in the States a lot, but we use lidocaine a lot, and that is the least successful one. I think that works in something like 8% of cases. There are a few things with that study — it's great to have it, but we need to go on and do much, much more research.
[57:28] So we need to use some of the local anaesthetics that work better. One of those is articaine, so we can try and use that. We can use a variety of local anaesthetics; we've got them in the drawer. We can also use many ways of giving anaesthetics. We can give a nerve block. We can just put it to the side of the tooth. We can open up the tooth and put it inside the tooth. We can give it down the side of the tooth.
[57:53] Now, I discuss issues with local anaesthetic a lot, and I discuss it with my nurses a lot, and we have a lot of people come on clinic to watch us. And in these talks, we always talk about this. I almost always get my patients numb and we don't know why.
[58:10] So, I think we need to take a step back, Linda. We need to say, why is it not working? And could it be a mast cell issue? And if it is, what you were talking about a few minutes ago was getting the patient relaxed and not anxious. That is going to reduce your MCAS side effects. So is it MCAS? And does it help that from the waiting room to coming in, I get the patient set up?
[58:40] I don't know how it works for me. I've got a patient, Deborah, who works in Dundee, and Deborah is wonderful and we work so, so well and closely together, and she's now started picking up Ehlers-Danlos patients. And she emails me every so often to say, "How do you do it, Audrey? I still can't get this patient numb." I say, "I don't know, Deborah, I'm not hiding anything."
[59:04] So we just try to reduce the stress. We don't overpromise. We say we're all on the same team and we're here to help, and please help us — you tell us whatever it is you're feeling.
[59:16] One thing we discussed the other day, Linda, and I know this sounds crazy, but we're clutching at straws here. We have a lot of laughing on our clinic. Once a few weeks ago, the manager came in because she thought the patient was crying her eyes out. No, we were just having a good old laugh. Could it be that having a laugh makes local anaesthetic work better? I don't know. I do not know. So some patients will not numb up well, but luckily so far we get most patients okay. But we need much more research into all of this.

[1:00:02] Dr. Linda Bluestein: And I wonder if part of that is the onset time. Once you inject the lidocaine or whatever local anaesthetic you're using, you need to give it a little time to work. So I wonder if maybe it takes longer, maybe it will work in a lot of patients if you give it more time.

[1:00:38] Dr. Audrey Kershaw: I think in some patients we need longer, but I tend not to give it maybe as long as other people would and it works. So I think in some people, if you leave it too long, it's already begun to wear off.

[1:00:52] Dr. Linda Bluestein: Especially lidocaine. Yeah, for sure.

[1:00:53] Dr. Audrey Kershaw: But anything is worth a try. And sometimes when we're working through all these different solutions and different ways of giving it, we don't actually know what's going to work — whether it's the solution, the way we've given it, or the length of time we've waited, because we've been trying it in all these different ways. So we need much, much more research done into all this.

[1:01:14] Dr. Linda Bluestein: Yeah, definitely. And I'm going to try to roll these last questions kind of all into one in the interest of time. Some people asked about being shamed by their dental professional — whether it was their dentist or their hygienist — because they didn't really understand that they really were trying their best with their oral health. So in terms of what patients can do on their own for their dental health, besides the normal things — things that would be more EDS-specific, things that they can do in interacting with their hygienist or their dentist, and choosing a dentist that might be able to better understand their circumstances — what do you recommend to people?

[1:02:05] Dr. Audrey Kershaw: Well, Linda, I would recommend a very good Bendy Bodies podcast. There was one podcast you did that I thought was amazing. It was a podcast on how to interact with your healthcare professionals — when you go in, you try and see if they've had a busy day, and you talk nicely to them. I thought that podcast was amazing. That was basically you telling the patients to get on the same side as their team, have compassion, understanding, realize it's not their fault they don't know things, don't go in blaming. I would direct people to that podcast.
[1:02:49] What I would say here is, you and I both know, Linda, we are both healthcare professionals. You were not diagnosed, I think, until you were 47. You had decades not knowing what was going on. I had decades of not knowing what was going on. This is all down to how we're taught. And we need to be patient with people and get on the same side and try and help healthcare professionals understand what's going on here. The same way as the things we don't know today, Linda, we would like people to come in and say, listen, we maybe just need you to think about this in a different way, or there's this new stuff out. But it's very hard.
[1:03:30] I think a lot of the individuals who feel they're being shamed are being shamed. And I've seen a lot of mothers who have had children with their first molars, as we said, not properly formed, so they decay. They've been shamed. And I have to say to them, I don't think that was your fault. I think these teeth were poorly formed. And then they have a completely different view on it. But that's not right. The patient is being shamed, but that was the dentist and the dental team doing the very best they thought. It's very difficult, but it is so rewarding to be able to say to these people, I'm going to explain this to you in a different way. And we know you were doing your very best to look after your child's teeth.

[1:04:16] Dr. Linda Bluestein: Yeah, that makes a lot of sense. And as you know, because you've listened to the podcast, we always end with a hypermobility hack. Do you have a hypermobility hack to share with us?

[1:04:30] Dr. Audrey Kershaw: I think for the patients with Ehlers-Danlos, get on the same side as your healthcare team. Get on the same side as your doctor or your dentist. I know it's frustrating, I know it's very, very difficult, but try to get on the same side. Don't blame them, it's not their fault.
[1:04:56] I would also urge every patient with Ehlers-Danlos, try and help us spread the word. What I would like is every patient in Britain here — I have shared on the Facebook pages a 2-page write-up we did in Scottish Dental Magazine. "If you can't connect the issues, then connect the tissues." And it just gives a brief summary. If you could take this to your dentist, if we could get this article to every dentist in Britain, the world — we can share it on there. Take this to them, print it out, get them to stick it on a notice board.
[1:05:45] Also, if people can listen to our talk here, if they can listen to the talk we did back in December — help us to spread the word, and we are on your side.

[1:06:01] Dr. Linda Bluestein: I think those are great, great points. And for people who want to learn more about your work and the fabulous things that you're doing, where would they find you?

[1:06:11] Dr. Audrey Kershaw: So, they can find me on Facebook. I think there can't be many people of my name on Facebook. I've also got a website, Oral Surgery Scotland. You can go on there as well, and you can email me through there. I don't do a lot of social media, Linda. But they can get me on all of that.

[1:06:35] Dr. Linda Bluestein: Yeah, it's wonderful the education that you've been doing because it's so, so important. Like you said, each discipline really can make such a huge difference. So it's so wonderful the work that you've been doing. And I so appreciate you taking the time to chat with me today. This has been such a fun conversation. You were talking about laughing in your clinic — we've done plenty of laughing, starting with taking off our socks at the very beginning.

[1:07:04] Dr. Audrey Kershaw: Yeah, we should maybe tell people that Linda said, would you just give me a minute, Audrey? I want to take my socks off. And I said, Linda, I'm just taking my socks off as well.

[1:07:15] Dr. Linda Bluestein: Yeah, maybe neither of us can regulate our temperature that great, but I can't get too overheated.

[1:07:21] Dr. Audrey Kershaw: So I think Linda, I don't really want to say too much here, but I think for the people that know about EDS and have been listening here, I think they've maybe seen quite a few signs of EDS — things like having to take off your socks, not being able to remember people's names, and maybe looking younger than both of us are, Linda, because I think both of us are the same age. You can quite often pick Ehlers-Danlos cases up by looking at somebody.
[1:07:46] And what I always say, Linda, is this is not about me, what I do, spreading the word on Ehlers-Danlos. It is not about my health. It's very much about helping the patients.

[1:08:09] Dr. Linda Bluestein: And it's so wonderful. And it is very interesting that you say that because I do feel like at the same time, you know, we call these invisible disorders, but there are definitely signs. If you know what to look for, you can definitely — at least have a suspicion — and then you need to do the proper evaluation to actually confirm or come to a proper conclusion.

[1:08:33] Dr. Audrey Kershaw: I have got my hairdresser educated and now able to pick up cases. If I can get Katie — my hairdresser, who's asked to see this — if she can pick up cases, when you've got your eyes open, it's easy. And that's what we're wanting to do with healthcare professionals.
[1:08:51] I think the last thing, if I can say it, is a friend of mine, Lincoln. Lincoln is an artist, nothing to do with this. Lincoln is also picking up cases in his local pub. Just before he was about to say something to the lady serving behind the counter, she actually came out and told him, but he knew. So anyway, Lincoln very nicely put it: I am doing my work upstream. I'm trying to pick up cases before they are in such a bad state of health, before they come downstream to you guys in your clinics where you're trying to sort out all the issues. And I think if we can pick them up upstream so much earlier on, we cut down all the hospital appointments by 50% or whatever. We reduce morbidity, mortality, suicide rate, everything.
[1:09:45] If people say, why are you trying to do this? We can make such a big, big difference.

[1:09:51] Dr. Linda Bluestein: Absolutely. All the physical and psychological sequelae that can happen — we can reduce that by so much when we acknowledge and properly diagnose people and provide them with resources, instead of gaslighting them and having them go from appointment to appointment to appointment, just being told there's nothing wrong with you.

[1:10:11] Dr. Audrey Kershaw: And the toll that takes on everyday life, emotionally, financially, marriages, families, children, work situations. Yeah.

[1:10:22] Dr. Linda Bluestein: Well, that's why I do the podcast, as you know, to provide that information to people and give something where people can easily share a link to an episode.

[1:10:34] Dr. Audrey Kershaw: If I can just say, I'm sorry — people with Ehlers-Danlos, we just have to say things, emotions. I feel you've done more than probably anybody else for Ehlers-Danlos with those 140 podcasts and your website. I have a standard email I give to my patients, and you feature so, so heavily in this. I now don't send them to other websites. I say, if you want to know anything, Linda has a podcast on it. Go on there and they're so easy to find. I am not just being kind, I'm being honest, Linda. And I love what you do and what you've done is just astounding. I really mean it. And some of my patients have you as their poster girl and they are just so pleased that I'm on here with you. You are held in such high regard.

[1:11:30] Dr. Linda Bluestein: Oh, that's so, so sweet. I'm really, really touched. Thank you.

[1:11:33] Dr. Audrey Kershaw: It's true, and I'm sure the audience will completely agree. It's just amazing what you're doing. And thank you. Thank you for giving me all this to read. Yeah, of course.

[1:11:46] Dr. Linda Bluestein: Absolutely. And thank you for your incredible generosity with your time today and sharing your expertise. I'm so glad we finally got to do this. We've been wanting to do it for a while. So thank you. And we'll see you next time. Thank you.

[1:12:01] Dr. Audrey Kershaw: Take care.

[1:12:04] Dr. Linda Bluestein: Well, that was a super fun conversation with Dr. Kershaw. And I feel very confident that you will have found that as helpful as I did. Thank you so much for listening to this week's episode of the Bendy Bodies with the Hypermobility MD podcast. You can help us spread the word about joint hypermobility and related disorders by leaving a review and sharing the podcast. This really helps raise awareness about these complex conditions.
[1:12:29] If you would like to dig deeper, you can meet with me one-on-one. Check out the available options on the services page of my website at hypermobilitymd.com. You can also find me, Dr. Linda Bluestein, on Instagram, Facebook, TikTok, Twitter, or LinkedIn @hypermobilitymd. You can find Human Content, my producing team, @humancontentpods on TikTok and Instagram. You can also find full video episodes every week on YouTube at Bendy Bodies Podcast.
[1:12:56] To learn about the Bendy Bodies Program disclaimer and ethics policy, submission verification and licensing terms, and HIPAA release terms, or to reach out with any questions, please visit bendybodypodcast.com. Bendy Bodies Podcast is a Human Content production. Thank you for being a part of our community, and we'll catch you next time on the Bendy Bodies Podcast.