Meshel & Tommy Show: Tommy's Appointment

Media item: radio segment

Programme: the Meshel & Tommy show, Melbourne commercial radio

Date broadcast: 19 February 2014

This page records the media item. The audio is the property of the broadcaster and is not reproduced here.

What this page deliberately does not do

No individual's dental history, treatment or clinical information is published here, whatever was broadcast. Health information does not stop being health information because it was said on air, and section 133 of the National Law prohibits testimonials about clinical care in the advertising of a regulated health service. The other segments from the same programme are at Tommy's confession, Moz gets a new tooth and Tommy talks wisdom teeth.

What follows is general information: exactly what happens at a comprehensive dental examination. Knowing the sequence in advance is one of the more effective things for anyone who finds appointments difficult — see Dental Anxiety.

The size of that problem in Australia is documented. In Armfield's analysis of the National Dental Telephone Interview Survey (final study population n = 6,112 Australians aged 16 and over, 7,312 completed interviews, 64.8% participation), 11.9% said they were ‘very' afraid of going to the dentist and a further 5.2% ‘quite' afraid. The fear translated into avoidance: 43.9% of the very afraid had last seen a dentist more than two years ago, against 29.1% of those with no fear (χ² = 62.65, p < 0.001), and 27.6% of the very afraid expected to attend only when they had pain or a problem, against under 17% of everyone else. Fear rose across age groups up to 46 to 64 and then fell among those 65 and over.

What actually happens, in order

1. Medical history — and it is not a formality

The form matters more than almost anything else in the appointment, because several ordinary medical facts change what is safe to do.

The ones that genuinely change treatment:

Anticoagulants and antiplatelet medication — warfarin, apixaban, rivaroxaban, clopidogrel, aspirin. Do not stop them without instruction from the prescriber; the risk of stopping is usually greater than the bleeding risk, and dentistry manages the bleeding.
Bisphosphonates and other antiresorptive drugs, for osteoporosis or cancer — associated with medication-related osteonecrosis of the jaw after extractions and implant surgery. This must be disclosed, including if you took them years ago. See Dental Implants.
Diabetes, and how well controlled it is. It affects healing and gum disease in both directions — see Diabetes and oral health and the two-way street.
Heart valve replacement, previous infective endocarditis, or certain congenital heart conditions, which may require antibiotic prophylaxis before some procedures.
Immunosuppression, chemotherapy, and previous radiotherapy to the head and neck.
Allergies, particularly to antibiotics, latex and local anaesthetic.
Pregnancy. Routine dental care is safe and encouraged in pregnancy; some elective treatment and imaging is deferred. See Is it safe to visit the dentist in pregnancy? and Oral health care while pregnant.
Everything you take, including over-the-counter medicines and supplements. Hundreds of common medications cause dry mouth, which is one of the strongest decay risk factors there is. Bollen and Beikler's review in the International Journal of Oral Science (2012;4(2):55–63) names medication as ‘one of the most prevalent causes of xerostomia', singling out anticholinergics, antihistamines and diuretics, and puts unstimulated flow in a dry mouth at about 0.15 mL per minute against a normal 0.25–0.50 mL per minute. The same review notes that salivary gland function ‘is well preserved in the healthy geriatric population', so dry mouth is not simply a consequence of age. See My mouth is always dry and What causes dry mouth?

Update it every visit. A history taken three years ago is a history of three years ago.

2. What you have noticed

Sensitivity, pain, bleeding gums, a rough edge, clicking, a lump, bad taste, a tooth that feels different. Say all of it, including things you assume are unimportant. See What to do if you suffer from sensitive teeth, What causes bad breath and how can I fix it? and I have a toothache — what could be the cause? Also say if you are anxious, if you have a gag reflex, or if lying flat is difficult.

3. The extraoral examination — the part nobody notices

Before anything goes in your mouth, the practitioner looks at and feels the outside: lymph nodes in the neck, the jaw joints as you open and close, the muscles of mastication, the lips and the facial skin.

This takes under a minute and it is genuinely important. It is part of screening for head and neck cancer, and it picks up jaw joint problems and muscle tenderness from clenching — see TMD and Teeth Grinding, What causes TMJ jaw pain? and Night-time tooth grinding and clenching.

4. The soft tissue examination — oral cancer screening

The practitioner examines the tongue — including lifting it and looking underneath — the floor of the mouth, the cheeks, the palate, the tonsillar area and the gums. The RACGP describes the screen as achievable ‘through a comprehensive oral cavity examination with readily available equipment', which is one reason it belongs in an ordinary check-up rather than a specialist clinic.

This is oral cancer screening, and it is the reason to attend even if you have no teeth at all. See Oral cancer: how a dentist can help with early detection and Oral cancer: signs and risk factors.

Why the timing matters so much: the RACGP records that oral cancer ‘has a relatively low five-year survival rate, at around 50%, mostly due to diagnostic delays'. Oral Health Victoria attributes the low survival to the same cause — delayed presentation or diagnosis — and it is why the Victorian Government's 2016–20 Cancer Plan established an Oral Cancer Screening and Prevention Program.

Oral cancer is strongly associated with smoking and alcohol, particularly together, and with HPV for oropharyngeal cancers. The RACGP's own list of risk factors is age over 45 (especially in men), tobacco use, alcohol consumption, areca (betel) nut chewing and limited access to dental care — and it flags a further trend worth knowing: ‘an emerging subgroup of non-smoking and non-drinking middle-aged women with tongue cancers'. The absence of the usual risk factors is not reassurance. It also notes the cruel shape of the problem: the people at highest risk ‘tend to have irregular dental attendance'. See What are the causes, symptoms and treatment of mouth cancer?

For scale, Cancer Council Victoria recorded 1,226 oral and oropharyngeal cancer diagnoses in Victoria in 2023 — 883 in males (72%) and 343 in females (28%) — an age-standardised rate of 23 per 100,000 males and 8 per 100,000 females, with a median age at diagnosis of 64 in males and 67 in females. Together they accounted for 3.1% of all cancers diagnosed and 2.6% of all cancer-related deaths in the state that year.

The rule worth remembering: any ulcer, white patch, red patch or lump that has not healed in two to three weeks needs examining. That is the RACGP's threshold — anyone ‘reporting any unexplained and/or non-healing changes or symptoms in the mouth for more than two to three weeks (eg a persistent ulcer, red patches, lumps, a sore throat, or erythematous or speckled lesions) should have an oral cancer screen'. Not next year — a fortnight to three weeks. On the ordinary kind, see The cause of mouth ulcers and their usual treatments.

5. The teeth

Each tooth is examined for decay, cracks, wear, and the condition of existing restorations. Wear patterns are read for grinding, and erosion patterns for acid — dietary or reflux. See The stages of dental decay, Chipped and Cracked Teeth, Why does a cracked tooth hurt so much? and What is acid wear and how can I avoid it?

6. The gums — periodontal charting

A small blunt probe measures the depth of the crevice between gum and tooth at multiple points around each tooth. This is measurement, not poking, and it is the only way to detect gum disease, which is painless until advanced. See What is periodontal disease? and Do I need a deeper cleaning?

Healthy is generally 1–3 mm without bleeding. Deeper pockets, bleeding on probing, recession and mobility are recorded so that the next visit can be compared to this one.

Bleeding gums are not normal. They are the earliest and most reliable sign of a disease that destroys bone which does not grow back, and which is the leading cause of adult tooth loss. See Bleeding Gums and Periodontists.

7. Radiographs — if, and only if, justified

X-rays are taken because they will change a decision, not on a schedule. That principle is called justification: the exposure has to be earned by what it will add to your care, rather than taken to a calendar. See How safe are dental X-rays? and When do safe dental X-rays become unsafe?

The common views: bitewings, which show decay between back teeth and bone levels; periapicals, showing a whole tooth and its root; OPG (panoramic), showing all the jaws, used for wisdom teeth and broad assessment. The International Atomic Energy Agency's published typical effective doses put the scale of each: intraoral imaging 1–8 μSv, panoramic examinations 4–30 μSv, cephalometric 2–3 μSv, and cone beam CT 50 μSv or below for small or medium scanning volumes, around 100 μSv for large volumes.

Cone beam CT therefore delivers substantially more dose and should be reserved for cases where it genuinely changes management — implant planning, complex endodontics, impacted teeth. There is trial evidence on exactly that point for lower wisdom teeth: a 2022 systematic review in BMC Oral Health, pooling seven randomised trials, concluded that ‘CBCT should not be used routinely to assess MTMs, and it is unlikely to reduce risk of nerve injury even in most high-risk cases', and that the decision ‘should therefore be carefully justified' against the added radiation and cost. The authors place CBCT where three-dimensional imaging has the potential to change the decision or the surgical technique — not as a default. The equipment is described under Technology.

Dental radiographs are low dose, but the appropriate interval depends on your risk, not a calendar. You can ask for copies of your radiographs, and it is worth taking them when you change practices — see the Privacy Policy.

8. The discussion

A good treatment plan tells you:

What is urgent, what can be monitored, and what is optional
What happens if you do nothing — every option should have this stated
The alternatives, including the least invasive one
The cost, itemised, with ASDS item numbers so you can compare it and check your health fund — see the Price Guide and Understanding Your Treatment
Your risk-based recall interval. Six months is a convention, not evidence; some people need three, some are safe at twelve or eighteen — see How often should I go to the dentist?

“Watch and monitor” is a legitimate clinical decision. Early enamel decay can remineralise — see Can you reverse tooth decay? Do I need a filling? and The benefits of fluoride — and a practitioner who fills every early lesion on sight is not being more thorough.

What you can reasonably ask for, throughout

To stop at any time. Agree a raised-hand signal at the start.
To ask what the practitioner is finding, as they find it.
To see it. Intraoral cameras exist; ask to be shown the tooth being discussed.
To a written plan and quote before agreeing to anything.
To take that plan for a second opinion, with your records and radiographs — see Second Opinions and Corrective Dentistry.
To decline any treatment. Consent is a decision you make, not a form you sign.

Common questions

It has been years since I last went and I am embarrassed. What happens at that appointment?

An examination, a conversation and a written plan — and nothing has to be done on the day. It is worth saying at the point of booking that it has been a long time and that you are anxious, because that changes how the appointment is set up rather than how you are treated in it.

The Victorian Department of Health names the trap you are in: it calls this “the ‘vicious cycle of dental anxiety'”, and points out that avoidance “prevents people from ‘extinguishing' the anxious or fearful state as a result of non-traumatic dental experiences.” In other words, staying away removes the only thing that could disprove the fear — which is the strongest argument available for making the appointment you least want to make.

Several things need doing and I cannot afford them all at once. How is the order decided?

Infection and pain come first, because they do not wait and because the alternative does not work. The RACGP is blunt about the common shortcut: “Antibiotic treatment without dental treatment to remove the cause always fails.” After that the sequence normally runs: stabilise active decay and gum disease, then restore, then anything elective. Cosmetic work on an unstable foundation is money spent twice.

It is entirely reasonable to ask for the plan in stages, with a cost against each stage and a note of what deteriorates if a stage waits. Two figures give the scale of leaving it: the Australian Institute of Health and Welfare counted about 88,600 potentially preventable hospital admissions for dental conditions in 2023–24 — roughly 3 in every 1,000 Australians — defined as hospital stays “considered avoidable with timely non-hospital care.”

I find even a check-up difficult. Can it be done under sedation?

Sometimes, and it is worth knowing the vocabulary because the marketing terms do not match the rules. The ADA's Policy Statement 6.17 sets out four levels. Minimal sedation is “a drug-induced state of diminished anxiety, during which patients are conscious and respond purposefully”, covering “a single low dose oral medication or inhalation of gases” — this is what “happy gas” is. Moderate sedation is deeper and “includes the use of intravenous sedation”. Then deep sedation, and then general anaesthesia.

Who may provide which is not a matter of preference. The ADA's position is that “Dentists with sufficient training and experience may utilise minimal sedation techniques”, while moderate sedation requires a practitioner “endorsed” by the Dental Board of Australia, and an applicant for that endorsement “should have completed a mandatory two-year period as a dentist in general practice.” The same statement says plainly that “Both general anaesthesia and conscious sedation procedures encompass risk” — so for an examination, the behavioural approach above is usually tried first. See Sleep Dentistry.

My tablets give me a dry mouth. Should I stop them, and what can I use?

Do not stop a prescribed medicine to protect your teeth — that is a decision for the prescriber, and dentistry manages the consequence rather than the other way round. Bring the list and say which one started when the dryness did.

Two practical points that are easy to get wrong. First, dry mouth is not simply ageing: Bollen and Beikler record that almost 25% of older people have a dry mouth, but that salivary gland function “is well preserved in the healthy geriatric population”, so it is “probably a condition of systemic or extrinsic origin” — usually medication. Second, the obvious remedy can make it worse. Australian Prescriber states that essential-oil mouthwashes “are not recommended for patients suffering from xerostomia” because of “possible ethanol-induced mucosal irritation and dryness”, and instead notes that a plain sodium bicarbonate rinse — one teaspoon in a glass of water — “is recommended in patients suffering from xerostomia or erosion”, because it raises salivary pH and does not irritate the lining of the mouth.

Practical details

Smile Solutions, Level 1, 220 Collins Street, Manchester Unity Building, Melbourne VIC 3000. Phone 13 13 96, or theteam@smilesolutions.com.au. Monday–Friday 8.00am–6.00pm, Saturday 8.30am–1.30pm, Sunday by appointment. See also Our Location and Contact Us.

Every practitioner's registration can be verified free on the AHPRA public register at ahpra.gov.au.

This page records a broadcast and its date, with general information. It is not a diagnosis or a treatment plan, and it does not replace an examination. No individual's clinical information is published here. Third-party broadcast content is not reproduced.

Smile Solutions trades under ABN 28 193 514 103.