In this long overdue (sorry, Protruserati!) episode I will go deeper in to Anterior Midpoint Stop Appliances as an occlusal splint for bruxism, myofascial pain and headaches. If you have not already, you must absolutely check out Understanding AMPSA Part 1 as this is the sequel!
Protrusive Dental Pearl 55: Remember at Dental School where they taught us that 3 fingers worth of mouth opening is considered ‘good’ or normal? Well, make sure you remember it’s the patient’s fingers, not your fingers! I showed how to use a range of motion scale and the benefits of checking mouth opening objectively:
I teach what I know, and I know Resin Bonded Bridges and Splints for GDPs as I have devoted my career to their study!
“No amount of canine guidance or posterior disclusion or level of osseointegration of your implants will save you from the destructive forces of Bruxism”Jaz Gulati, PDP055
So here is a recap from AMPSA Part 1:
- Anterior appliances are not as evil as you were taught
- We myth busted the Dahl-concept-type occlusal changes with normal wear of such appliances
- I gave the analogy of the ‘locked-in’ patient, and how when you allow them freedom of movement (reduce the resistance in grinding motions) it is like weight lifting and the weights have been removed
- We looked at some of the contraindications – intra-capsular issues which are rarer – but also those who are just higher risk of anterior open bites
- Remember, sometimes you WANT patients to get an AOB!
In this Episode I summarise:
- What is the difference between these various anterior appliances and is one better than the other?
- Deciding upper arch or lower arch, or sometimes both arches?
- How many of my patients have developed Anterior open bites, which splints caused them, and how to manage such a scenario?
- Why even an AMPSA can be an overkill and which patients may actually benefit from a soft bite guard, for example!
These appliances can bring HUGE solution to a MASSIVE problem for our patients. Many of my patients are pain-free and no longe require painkillers for headaches and jaw pain. My strongest bruxists (whose teeth I have restored) are religious at wearing the appliance (despite a favourable occlusal scheme) and they love it and KNOW that their Dentistry is protected. This is not a cheap piece of plastic. It is a custom made Orthotic Appliance – I charge anywhere from £450 – £1,300 for appliances (simple AMPSAs, complex AMPSAs, Michigan/Tanner appliances – every case is different).
One of my previous delegates from The Splint Course (when it was delivered live) called in to the show and asked ‘I am concerned about charging a high fee for this appliance? What is the appliance does not work?’ – towards the end of this episode we discuss this in full depth!
If you enjoyed this episode, you will like why Michigan Splints are overrated!
Don’t forget to sign up to The Splint Course for an exclusive launch offer.
Click here for Full Episode Transcription:Opening Snippet: And patient number one might be like hey you place these anterior restorations for me and they keep breaking my fillings keep chipping my crowns are chipping i'm not happy versus the patient who's taken ownership of their bruxism and they're the ones who come to you and after they chip something they're like hey i'm so sorry and they're apologizing to you. They're not blaming you. They're blaming themselves. Why? Because they know.
Main: Happy New Year to the Protruserati Welcome back to the show. I covered a lot of stuff regarding splints and occlusal appliances in September. Remember we call it splintember and that was a real fun to record but i felt as though i couldn’t do it justice. I did have more to give and just never got around to making this AMPSA part 2 which i did promise you So it’s finally happening right now AMPSA part 2. Let’s continue from AMPSA part one and finish off the splintember series These solo episodes they really do take it out of me it’s actually really challenging to talk in front of camera, it’s so much easier just to have a chat with someone who you want to learn from but you know it’s great fun to do this Ultimately it is something that really challenges me in fact recently on the Protrusive Dental community Facebook group. I asked you all which was your favorite episode of episode series of 2020 and i listed every single one of the whole 38 or what how many there were throughout the whole year and i was humbled that you guys had chosen the splintember series of all the different episodes So thank you so much and i’m hoping that i will do justice with this episode, you guys really encouraged me so thank you. So we also finished 2020 on quite a high. I won an award, the podcast won an award for the best podcast in occlusion and treatment planning. Thanks to course karma and i’m so grateful to whoever that one person was who voted for me initially and that set off a chain reaction and so many others ended up voting for me like if it wasn’t for you that one first person i wouldn’t or may not have even discovered course karma. It’s such a fantastic resource for dentists around the world to find courses basically. So you know you always wanted that sort of one reference where can i find all these courses we usually end up going on google or asking on facebook but what course karma is trying to do and it’s still you know still got a bit to do to get there but i’m really encouraging Aly. Aly Bhatia name and course karma to really bring all the courses in the world in dentistry and bring them together in one place and that’s what course karma did but thank you so much for all of you who voted for me. Really appreciate it. The podcast did celebrate its second birthday recently it was started at the very end of 2018 early 2019, so it’s been two years the very first guest if you remember was Surinder Arora who was all about moving to singapore as a dentist, so expat dentist Singapore. So i just wanted to thank Surinder for being my very first guest. She’s doing some great things so if you’re interested in yoga or if you like the idea of yoga, she set up a new page on instagram it’s @dentistofyoga so do check out Surinder because she helped me a lot with this podcast so i’d appreciate if you would check out her page. So here’s the Protrusive dental pearl for this episode, remember at dental school where they taught us to use three fingers to assess whether your patient has trismus or not. So remember if you use your three fingers and you check and they can open three fingers then that’s great and if they can open less than two fingers, so you’re making your notes okay one finger, two fingers, three fingers but one thing they forgot to tell you is that it’s not your fingers right? It’s the patient’s fingers so for example i remember back in the day i used to use my three fingers and a petite lady would come along and my three fingers had no chance of fitting inside her mouth right? So unless you’re a petite lady then it’s not going to work either. So remember it’s the patient’s three fingers not your three fingers but how can we make this more objective? How can we check the maximum opening more objectively? Well if easy answer is use a ruler right? Use a ruler and sometimes what i like to use is one of these. I’m hoping you can see this. There we are. It’s from great lakes it’s called a range of motion scale. So this is pretty cool thing to use. I’ll put a little video in the background as i’m speaking about how i use this. The other thing you can do which is pretty clever is how about you calibrate your three fingers calibrate your three fingers just get a ruler measure how fat your three fingers are and so you know that hey your three fingers are 38 millimeters or whatever and that can give you some form of a gauge basically. So that’s my protrusive dental pearl when you’re checking for your maximum opening, the objective use the patient’s fingers or at least use a measurement tool like a ruler or this range of motion scale Now when would you want to check the opening range, when is it important? Well before any complex sensory i think it’s important i like to do it as part of my new patient protocol because it will be the difference between me referring that patient for a molar root canal versus me doing myself right? Because remember easy dentistry on a difficult patient is still difficult. So i’ve struggled the most when i’m doing posterior restorations on a rubber dam on people with limited opening so it’s an important factor you should be screening for it i think so it’s a good thing to know but also if you’re doing any splint work then you’ll find that actually when you make patient splints their range of motion can actually improve so typically you can you know it’s not uncommon to get four to five millimeters plus depending on where they started of increased mouth opening. So it’s important to be able to objectively show that because sometimes patients might come back and think you know what i don’t think this is working because maybe they didn’t have that many symptoms to begin with right and you’re giving the appliance for more protective reasons rather than to help them with pain but if you say to the patient hey you know before you were opening at 42 millimeters and now you’re opening at 47 millimeters it’s important it all counts. so that’s my little tip for you today. So as part of making this episode and scripting this episode i listened back to part one so AMPSA part one i listen to that again so hey if you’ve ended up here by accident you’ve just discovered my podcast and thought hey let me click on this latest episode it’d be really cool if you went back to the episodes in september listen to the entire splintember series but particularly AMPSA part one so that today’s episode sort of builds on AMPSA part one and i had to listen again to AMPSA part one to help you recap and i have to apologize guys i think it was complicated. It’s partly because hey it’s a it’s a complex field and i wanted to simplify it but in a matter of 35 40 minutes how long the episode was i really wanted to make it as valuable as possible and give you as much as possible but by doing so it can get more and more complex so i’m so sorry if i lost any of you i am trying to simplify as much as possible which is why i’m super excited to announce that very soon the splint course will be launching. So it’s an online split course it’s www.splintcourse.com and i’m so stoked, it’s four or five years of hard work that i’ve worked on to bring this together to really the mission is to simplify splints for general dental practitioners so i’m super excited to share with you in this course splintcourse.com I’m going to cover not only one or two appliances but about four or five different appliances what the indications are, how to identify who will benefit the most from appliance, who are the true bruxers. It’s fascinating you know because about 10-16% of all your bruxing and para functional patients are destructive bruxers and it’s fascinating research about what they do in their sleep and which phases of sleep they parafunctioning which determines what kind of bruxist they become so there’s a lot of research that i’ve put into this. A lot of reading of the literature which i’ve done for you which is just fascinating i’m so happy to share that because it helps you to make an informed appliance choice He’s so enthusiastic to push the knowledge into your head and i’ve really learned. I’ve been on some quite notable courses based around occlusion before and i’ve really taken an awful lot from a one day course in comparison to a number of days so yeah really really enjoyed it. I talk a lot in the course about helping your patients with myofascial pain and i go really in depth into anterior midpoint stop appliances so something we’ve been talking about in the last episode and this episode but really building on it with more videos with more flow charts and design charts and how to get the most from your laboratory and how to get your patient to wear the damn thing so we go into real detail with that but also how to get your bruxism patients to take ownership of their bruxism like there’s a difference between the patient who you’ve done anterior restoration for and they keep chipping it and patient number one might be like hey you place these anterior restorations for me and they keep breaking my fillings, keep chipping my crowns are chipping, i’m not happy versus the patient who’s taken ownership of their bruxism and they’re the ones who come to you and after they chip something they’re like hey i’m so sorry and they’re apologizing to you. They’re not blaming you, they’re blaming themselves. Why? because they know they have a bruxism issue. You’ve educated them. You’ve pre-warned them that this will happen and you’ve also given an appliance to it to manage that because sometimes no matter how much canine guidance you have, no matter how much posterior disclusion you have they will still destroy things so these true bruxers. They will destroy anything that comes their way that’s why they destroyed their dentition to begin with so super important we protect against the force of parafunction for these patients. Now you might say Jaz look, I don’t want to be making splints all day long, want to be doing beautiful dentistry. I want to be doing the full mouth rehabilitations. Well, I see appliances and splints as a precursor to that i think you can totally use an appliance diagnostically in every patient who’s you can be doing a raising of the ovd on for several reasons you know not you know including relaxing the muscles. Don’t you want your muscles to be in a relaxed state before you start changing the vertical dimension that’s one but also diagnostically to figure out who are those true bruxers and the few protocols which i discuss in the split course which i’m so excited to share with you. So if that’s something that interests you if you found these episodes useful but you just need that one step more to be able to implement it then this course is for you do check out splintcourse.com. The secret is if you actually register and put your email address in, I will inform you about the launch offer which i promise will be worth your while. The last point on that is that all of the education I’ve done, all the courses I’ve done, all the mentors, all the failures that I’ve had, chair side which i’ll share with you in the course they’re all out there like you can totally go and start making your own splints and start trial and error and learn which is fantastic. You can go to these courses. You can speak to some mentors. You can read the literature on this which is vast and a lot of it’s rubbish some of it’s golden but what i offer with the splint course is just to save you time really so it’s all out there everything you need for splints is technically all out there but what i’m offering you is saving you time and saving you tears in terms of failures remakes and lab issues that you might get so I hope you join me for that course and that’s my plug done. Let’s dive into the education of AMPSA part two So in part one we covered about how these appliances are not as evil as dental school first taught you. I sort of busted the myths about the appliances these anterior only appliances acting as a Dahl appliance. We looked into that already in part one, we looked at how these appliances reduce resistance and the analogy i used was that if you’re lifting a really heavy weight doing loads of repetitions and your muscles get tired but then i give you a lighter weight and suddenly your muscles can still lift that load but it’s so much easier compared to that heavy weight. Now the heavy weight is similar to your patient who’s locked in and they’ve got this parafunctional habit due to sleep apnea, stress, ggastroesophageal reflux disease whatever it might be right and they’ve got this parafunctional problem and they’re trying to grind but the muscles are locking them in and what this does it sends their muscles into overdrive so you can just release that then allow them to glide along because it won’t stop their parafunction remember? It’ll just allow them to parafunction in a more dentally beautiful way which is essentially how any of these appliances work so we covered that and we also covered how you should avoid this appliance in people with intracapsular issues who are joint load positive so you do a load test and it’s positive but you know these patients are rare so i find a lot of patients are amenable to AMPSA treatment but it’s also to identify which ones may be high risk of getting anterior open bites remember not because of the Dahl type movements because of other reasons which i touched on and again at the end of this episode i’ll touch on again. In this part two we’re gonna cover about what’s the difference between an NTI an SCI, an MCI, a FOS. Like is one superior than the other so look at the different varieties different branding and it’s essentially just that it’s just branding right? Like b-splint, e-splint What’s the difference? Is there a king of anterior midpoints appliances? I’m also going to cover the some of the decision making that you have to do when it comes to AMPSAs like should i give an upper? Should i give it lower? Should i make sure you make them upper and lower together? When might that be overkill? When that might be the only real option to go for? So we’re gonna cover about some decision making. Now that can be quite complex and i always liken it to arts and crafts of decision making like you know sometimes you have to get out there make these splints and figure out for yourself because there’s only so much i can cover in these episodes but you’ll find out a few of the most common reasons why you might go for one arch over the other. I’ll be talking about which my patients have had anterior open bites after such appliances or any appliance and how we got in that situation? How to solve that situation or rather how to preempt that situation? So it’s not going to be an issue when it happens because why? Because you predicted it, you told the patient this was going to happen so it’s not even like you warned the patient you told the patient sometimes you can tell them with quite a lot of conviction that’s going to happen and remember sometimes you want this to happen. Sometimes you want your patient to relax their mandible so much that they actually seat into centric relation and it gives you all that lovely wonderful space you want anteriorly to rehabilitate them. So that’s one thing we’ll look at as well which is so so key and lastly why an AMPSA might just be overkill and sometimes a patient all they need is a bit of plastic between the teeth. Why? How sometimes by heating and melting the soft bite guard you could actually get a really great even soft bite guard which is just crazy right you’re thinking ‘what the hell Jaz is doing, he’s recommending the most evil appliance of all even more evil than AMPSAs right? The soft bite guards are really regarding dentistry as a terrible appliance and no one should should have this but hey guess what’s the most common appliance in the whole wide world? It’s a soft bite guard. So let’s make it even easier and more successful and we’ll talk about that as well towards the end of this episode. So let’s look at those four things in order the first one i said was is there one AMPSA that’s superior to the others? To put it bluntly no not really. It’s a technology. It’s the scienc. It’s a science of biting on your front teeth that’s furthest away from the tmj that’s the most important everything else is just dentist naming appliances after themselves remember the g-splint remember that g-splint i covered in episode 40 or 39 i think it was. So same thing right? You want the most appropriate appliance for that patient and it could be an NTI. It could be an SCI. So forget about the brands i mean there is one reason why i like the FOS, the F-O-S, the flexi orthotic splint, it’s because of the chemistry behind it is that the acrylic will actually bond to the polyester copolymer. Now you can’t stick acrylic to NTI, SCI when i call it but there is no chemical bond. It will stick but the material science is completely different to polyester copolymer so that’s the main advantage. That’s why i switched to FOS. I find that to have a monoblock so the acrylic joined to the FOS blank is a stronger appliance and so far the patient’s done very well over the years with that. So use any appliance you want. Speak to the lab which is your local lab which is the a good lab that you know that is going to make these appliances. Two labs that i can tell you in the UK right now is PDS as Precision dental studio in Thatcham. There’s a subset within there called bite they make great splints. So do s4s who have supported me a lot over the years as well so these are two labs i can tell you straight away that gonna be able to help you and guide you on your anterior midpoint stop appliances and in the US i’m sure there are loads. In Australia. So find a lab. Find a technician who’s made loads and who can guide you. The main thing is for any anterior midpoint stop appliance especially the ones that get the smaller they get is that make sure it’s tight enough that they’re unable to dislodge it with their lip or their tongue. So every patient, every fit, every recall, I always get the patients to bring their splint inside because not it’s not a wham-bam thank you ma’am kind of appliance right? You gotta keep following it up. Keep training them to bring their appliance in every time and tell them remember if you can remove this appliance with your tongue or your lips like that then it’s time to contact me let’s re-line it let’s make you a new one that means this end of its life or you know just simply realigning with acrylic. It’s another benefit of using acrylic actually so you gotta train your patients to make sure it’s tight enough and they should only be able to remove it with their hand. So remove the hand completely cool. Remove with their lip or their tongue uncool and of course make sure no back teeth are hitting on clenching and or grinding and sometimes you might think they’re not hitting but as their muscles deprogram just like on a michigan appliance you see their jaw go pak pak pak it can happen on an appliance as well and sometimes i love to or i always color these appliances in and what they come back with is they come back with this like chevron right they come up this like little v-shape in fact i’ll put a little photo up right now one of these appliances that they make a pattern in and that shows you where their centric relation is and that’s the furthest back their mandible can go. So it’s great for diagnostic. It’s great for patient communication but it also shows you their range of movement as well. So it’s interesting actually how the para functional range of movement is often higher than what they can achieve during the day so if you get their range of motion during the day to be around about 10 millimeters you might find that in their appliance at night time they’re going 12 millimeters or more so it’s really fascinating with the studies behind what you’re doing in your sleep. Let’s look at the second point which is what kind of design is appropriate in terms of which arch should you choose for AMPSA. Should you choose the upper arch lower arch sometimes both? Well the easy way to think about it is and some things to consider in quick decision making is if your upper arch has delicate restorations let’s say veneers wouldn’t it be good to get an appliance to completely cover those veneers or delicate restorations so that in parafunction they’re not taking any load at all because if you put the appliance on the lower incisors in that scenario then even the upper incisal edge let’s say that’s a veneer is still taking load right? It’s still putting flexure and shear stress inside that luting cement so it’s sometimes good to incorporate your restorations within the splint so whether those restorations are upper arch quite commonly or lower arch consider that. How about crowding? If the lower arch is crowded you must have had this right where the upper arch is completely aligned and the lower arch has lower incisor crowding so common and what you do is you make an appliance for the top and you find that because you’ve got crowding on the lower, you’re always just hitting on one tooth and then you adjust that tooth and then you’re hitting on the other tooth that’s crowded and suddenly you’re spending ages a long time grinding it to get the even contacts and then suddenly in grinding you find that it’s just one tooth taking all the loads again. So wouldn’t it make sense to make the appliance on the crowded arch so that it’s now up against the aligned flat opposing teeth whichever it may be? So that’s another sort of thing to consider in decision making upper lower and sometimes you might have to go for a dual. A dual arch like a top and a bottom arch is good for those really hypertrophic muscles you really strong grinders because it gives them plastic to plastic and plastic to plastic will always wear less than teeth to plastic for example. So that’s one thing that i like about that and also if you’ve got upper and lower crowding and the patient won’t have orthodontics then go for you know a dual arch sort of AMPSA so that way the crowded arch is is negated and the upper crowded arch is negated and you’ve just got plastic to plastic meeting at the front and you get all the benefits of an AMPSA which we discussed in episode one. It’s also worthwhile using a dual arch design when you’ve got retention concerns because if you’ve got small teeth that are really worn and the patient doesn’t want a rehabilitation and you’re just putting them in a holding pattern. You’re trying to you know figure out where the muscles want to go so at that point. You might find if you’re making a small AMPSA? It ain’t going to work right? if you want to extend that now to involve more teeth top and bottom as well it will give you more retention so some for example in one arch if you’ve got small upper teeth instead of covering two to two extend that AMPSA, six to six, eight to eight whatever you need to do to get it to grip onto more teeth to improve your retention. So that’s another factor to consider. So each of those designs i just mentioned whether it’s upper arch lower arch or dual arch there are some compromises and some considerations that you should have for each one That is sort of going beyond the scope of an episode because i want to cover a lot more things but bear in mind that for every advantage there’s you know some degree of disadvantage for using each arch, whether it relates to patient comfort or a chance of an interference posteriorly or raising the OVD too much and those kind of things that you should be looking out for as well. So how many of my patients have had anterior openbites after giving these types of naughty evil appliances?Well around about 2,3 patients have had their anterior open bites from anterior only appliances and one from a posterior-only appliance which i didn’t prescribe but i just wanted to share that with you and in fact show a photo of it now for those watching the podcast. Those listening just imagine a posterior appliance only on the molars which you can easily just buy on amazon right but then you think wait Jaz you just said a posterior only appliance shouldn’t that cause posterior intrusion like yeah it should right but it caused an anterior open bite so you know how often i’ve seen in the past on facebook and stuff people post an anterior only appliance and they say this appliance caused my patients AOB These are evil appliances stay away. Well i can show you cases of AOBs from michigan splints from tanner appliances from essix retainers from the posterior only appliance like who would have thought right? So there are other mechanisms that action there’s usually the muscles relaxing. So the muscles can relax in any situation including a posterior only appliance so isn’t that interesting? Now with the anterior only appliance that i gave every one of those with the confidence i had with the mentors i had and with the education that i’ve sort of delved into splints more and more and more i was in a position that with every one of those patients i was able to tell them before they even had the anterior open bite that hey you know what with this appliance you will get an anterior open bite and this is what you will look like and so when it happens they’re like yeah you know what you said has happened but guess what every time their symptoms went away, their muscle issues went away and they weren’t so concerned because no one smiles with their teeth together and remember the whole thing about our teeth shouldn’t be touching You know lips together, teeth apart. That’s the mantra. So a lot of these times it’s not an issue at all so what does it boil down to? Well it boils down to communication. Did you spot that they were high risk and how was your communication beforehand and afterwards like if someone comes with an aob from appliance and you completely freak out and you call the police then obviously the patient’s gonna think oh my god you know something’s wrong my bite you know everything’s going wrong. The world’s on fire kind of thing but whereas sometimes patients come in from other dentists who’ve given anterior appliances and they come in and they’ve got an aob i’m like oh okay you know your front teeth used to meet now they don’t? How’s that going for you, everything okay? They’re like yeah everything’s fine no issues i’m like yeah that’s what i expect don’t worry about it just keep wearing appliances it’s a good thing and as long as it’s not an aesthetic issue or a massive functional issue then it’s okay like you know sometimes you have to warn these patients ahead of time that you may not be able to bite cellotapes. Use these tangible examples don’t say you will get an anterior open bite that means nothing to no one. Tell them you may not be able to bite your nails again which is kind of a good thing i wish i can’t i think i need an aob for that but you won’t be able to bite your nails. You may not be able to buy sellotape anymore and just give them these really tangible examples so what are you thinking well you’re thinking okay Jaz fair enough but what are these high risk features. Well i’m about to share with you the secret to figuring out who is at high risk There’s lots of factors okay but if i was to give you three main ones right it’s the following. It’s the patient okay who has got a minimal overbite to start with like they’ve got a one millimeter overbite, they’ve got like a two percent overbite or a five percent overbite right? So if their jaw just shuffles back a teensy weensy bit guess what they have an aob right? They lose their coupling of the anterior teeth. So if you start off with a minimal overbite then you are higher risk of getting an anterior open bite like you never ever get a deep bite patient and expect to give an appliance and for them to have an aob it’s extremely rare like whoa like that’s a unicorn right there. So these minimal overbite is number one Number two is those who’ve got posterior instability so instead of you know posterior instabilities when they bite they bite together everything just fits like a puzzle you know everything fits together at the back nicely but you know that’s patients who everything is just like flat like they can bite in four or five different positions right? So in that patient don’t you think that if their muscles relax that they may actually forget to bite that suddenly bite that they usually have there that might change? Well i think so right? So it depends on how well the teeth mesh together at the back and the last one is they’ve got a significant slide between their centric relation contact point and their maximum intercuspal position. Someone said again their centric relation contact point a large slide until their maximum intercuspal position then surely if they were to relax their muscles change their bite in any way along that path something that the muscles might enjoy a bit more and that will result in a change in bite and a change in potential the overbite into an anterior open bite so hope that wasn’t too confusing because i’m trying to i know i’m trying to whiz through here but i’m trying to jam pack as much as i can because i’ve got some communication bits coming up as well. So finally point number four of the main things i want to cover in this episode about AMPSA part 2 is what if an AMPSA is overkill? What i mean by overkill is we make AMPSAs to help people’s muscles relax right and there are some side effects of doing that which i mentioned exhaustively and you know thankfully most of our patients will not suffer these consequences but any appliance that any appliance you make has its own risks right? So sometimes when you’ve got a patient who’s completely asymptomatic with minimal signs of muscle issues and dysfunction, healthy temporomandinular joints and you just want to give them something just so they don’t bash into things and they have this low grade para functional issue which just above your threshold or you’ve detected that there’s a level of wear at which point you think it’s inappropriate for their age So it’s pathological we’re not physiological and i go and go over in another series but it’s sometimes overkill to give him an AMPSA. So why don’t we just give him some plastic between the teeth like people are so quick to dismiss soft bite splints or the dual laminates so soft on the inside hard on the outside. Take it from me loads of my patients get these because i don’t feel that they can justify the time the expense and and maybe the patients themselves they haven’t taken ownership right so if the patient hasn’t taken ownership of their problem and they really have put it like low in the value because i charge a significant amount for my AMPSA and they’re not ready to commit to that sometimes instead of them going away with nothing you can explain to that hey you know what i’m gonna make you some passive fitting essix retainers like we all can give that right something what i mean a passive fitting is that they must be comfortable to wear because what you don’t want to do is give a patient who’s never worn an appliance before some really orthodontically tight. Essix retainers right? Thermo plastic retainers. You want to give something really easy to take on and off because the chance of them swallowing or inhaling a large essix retainer is more than any bridge or restoration that they have right So just give them that but then just tell them you know what this is doing nothing for your joints, this is doing nothing for your muscles. It’s just when you rub your teeth together the plastic will take the hit let’s see how long it takes you to destroy this let’s see if you get any headaches or muscle issues at which point we know that it’s just tipping you above that threshold and then we can make you something that although you know it’s going to be more investment. It’s something that’s going to be really better for your joints and muscles how do you feel about that Mr Smith because usually the blokes who don’t who don’t go along with this kind of treatment because they don’t have any symptoms or any issues basically so that’s another hack i want to give you that hey you know what don’t dismiss soft bite guys i mean interestingly i think it was 1987 until 1989 where Jeff Oxen had that famous landmark study which proved that soft bite guards were terrible and then they’ll turn your asymptomatic patients into symptomatic patients and many of them will get worse and whatnot but when you read that paper it had an n number of ten right? Had an n number of 10 and everyone did well with the hard appliance and about five people got a little bit worse but i think if that’s the basis of what all the decisions we make in dentistry now then you know we need more than that and actually there’s a randomized control trial that was done some years after i might put in the protrusive dental community actually where actually what they did in this study was they instead of giving them just a soft bite guard like in the Oxen protocol and not doing any adjustments because in the Oxen protocol it said we didn’t bother with any adjustments of this soft bite guard because it’s near on impossible and it used that word impossible right but then some years later rct which i’ll share on the protrusive dental community they gave the soft bite guard but they heated it or you can get an air you know a blow torch something melt it get them to patient to bite into it and grind a little bit left and right so now they’ve at least at least got some degree of balance right and it’s not just like hitting in one area and it actually gets the anterior to touch just a slight amount so can’t you imagine that this might be biomechanically a superior way to deliver a soft bite guard than just a plug and play one? So that’s an interesting one i’ll share that paper on the protrusive dental community. So I hope you enjoyed that little reflection there about you know what sometimes AMPSAs are overkill and i go over various different types of other appliances which may be all more appropriate on splint course. Now one last thing to end with is a communication one. Now as you know i’ve been doing some group functions which is where we come together as a protruserati to answer questions and i had Gurpreet on, he was supposed to be group function number two but Zak Kara came along and stole his thunder but i’m still gonna use his entry because he asked a really cool question. I’ve been mentoring a little bit and we talked about these anterior midpoint stop appliances and he sent me some photos of a case and i sort of said okay make an upper or lower here for this reason and this is what you tell the patient, this is how you screen and stuff like that so he said to me what if it doesn’t work like you’re charging you know 450 pounds which i told him to charge initially he said what if it doesn’t work i said wow okay this is something we can totally tackle in a group function So i’m gonna put that now coming next is group function straight after this but what about these appliances and you charge a certain amount of money like for me personally AMPSAs can cost anywhere from a very simple one to an easy patient or you know repeat appliance for someone who broke theirs or whatever lost their it’s 450 pounds to 850 pounds usually and a michigan or a tanner appliance is anywhere from 700 pounds to 1100 pounds depending on the patient as well basically because there are some more complex features and some features of their personality or their malocclusion whatever that makes it easier so that’s the sort of range. So then it’s common to start making appliances and having a feeling that oh my gosh i’m charging so much money for it but think about how much chair time, how much expertise it takes so you have to charge appropriately. So listen to this next episode. So i’m going to say goodbye and i’ll catch you in the next episode but then now i’m going to catch myself speaking with Gurpreet on a group function about hey what if i charge my patient for this appliance and it’s not working. Hi guys i’m live i’m live on youtube this feels pretty cool i could have gone on facebook but this is a new software that i’m trying at the moment so because of that i wanted to just try out on youtube and this is a new arm of the podcast so it’s called group function and it’s sort of like an ask me anything but we’re sort of working together more like a group so the protrusive dental community if you like working together to come up with the answers the first couple i’m taking but then as the questions come in i’m gonna pitch them to previous guests and future guests so today on the show to cover a topic about splints is a really good question that was asked by Gurpreet and i really thought a lot of people would benefit from discussing this so I’m going to invite the group who’s called into the show now let’s invite him on so you can ask this question and let’s see if we can have a chat about how i would approach that situation and see if we can get some value out of that so i’m gonna accept Gurpreet, his question is what if my splint doesn’t work and i’ll set some background in a moment because Gurpreet i have had a chat about this already so let’s get Gurpreet to jump in. I’m just going to check my youtube tap am i live yeah looks like i’m live at the moment. Hey buddy, how you doing? How are you i’m very well thank you thank you for coming on agreeing to thank you for having me on uh i’m looking forward to something finding your views no so tell me just set the scene set the scene about the patient you told me about and what is the initial sort of dilemma if you like so a patient’s come in she’s been seen by multiple different dentists in the past complaining of tenderness in her lower left 3 area in the past has been under the care of a hospital and has had a mouth guard a full mouth guard which has worked temporarily but she’s grinded through it then she was given a mouth guide. -Do you know if it was soft or hard do you know have you seen the mouth guard and then my god i’m not as being a thin mouth guard which is what was different to what the last dentist prescribed which seemed to be a slightly thicker one that she just didn’t get on with and she’s not wearing it recently she’s had a had a baby she was off work and recently started working so she said stress i was thinking that she may benefit from an anterior midstop appliance and that leads me to the question so i asked you for your advice and to follow on from that my question was what if it doesn’t work because these appliances are quite expensive and if i’m charging the patient quite a lot of money for these appliances how can i be sure that it’s justifiable? Okay really really important themes and i’m so glad you are sitting up in that way as well because it actually adds another dimension onto it so what i want to do is i want you to mute your mic for a moment because i’m hearing some echo see if you can mute your mic i’ll see if i can do it if you there we are i’ve muted you so you can still hear me right okay i’ve muted you so basically can you give me a thumbs up repeat that you can hear me yeah quite sweet so first you talked about patient the first thing that i sort of thought to myself was this patient has probably got obvious signs of parafunction because the previous two dentists gave a night guard okay so nowadays the most commonly under diagnosed thing dentistry is its para function so if the patient has a night guard. Two things have happened one a dentist has diagnosed that something’s happening para function okay and it’s probably been significant enough and everyone’s got a different threshold and a lot of people wait until we got loads of dentine exposure before prescribing a splint and two is that the patient’s probably now come to terms the fact that hey you know what i para function okay so that’s the first thing i gathered the second thing i want to address is that whenever you get a splint history one of the easiest things to find out from your patient is hey was it rubbery was it could you bend it is it soft or is it hard because that sort of helps you to know what they’ve had previously and of course in the future you can get them to bring it in again. Now for those of you who are joining this group function and you’ve never heard of an AMPSA as you said Gurpreet an anterior midpoint stop appliance. Listen back to a few episodes we talked about you know in splintember series all the different types of splints but essentially a splint that sits on your front teeth and to sort of cut a long story short me and gGurpreet already had a bit of a preamble bit of a chat about this patient and we think that the reason why this lower left canine is hurting is and did you say there was some muscle issues as well i’ve unmuted you yeah so the patient has had tmj problems and that’s why she was under the care of the hospital since then things have got a lot better so she’s been taken away from the carigo hospital but the patient still reports having tenderness around her lower left three headaches yep occasional headaches patient reports bilaterally – You did ask about muscle tension check the muscles there wasn’t anything significant in terms of the size of the muscles but yes headaches was definitely part of the history that she gave me okay so we’re thinking a diagnosis of a myofascial pain and also the fact that actually the canine the reason her canine could be hurting is could be and i don’t like say could be due to the occlusion but it could be due to a parafunction and if you’re parafunctioning on a dodgy occlusion then that could lead to it so anterior midpoint stop appliance. Have two benefits in this scenario okay one is that it can be diagnostic is it the parafunction that’s causing that pain or not now if you give this up by applying so patient and the pain’s still there then we know that it’s probably not the parafunction okay so that’s one the second thing that we’re doing here is helping the muscles to relax and hoping if the muscles are or the parafunction is contributing to her tension and headaches then that will get better so it’s very much diagnostic potentially protective as well and the other thing you mentioned was that there was no real muscle tension if you when you palpated there was nothing obvious and quite often you will find that okay it’s not that common to find tension but also you’ve got to make sure you’re palpating in the origin and the insertion for example it’s one of those sort observations now we i agree with you that i think an anterior midpoint appliance would sort of do the three things that we want protect the teeth, find out if the lower left three is hurting due to the para function and see if the headaches will get better so it fulfills the function okay but then you mention absolute fantastic things same mistake i’ve made before as well and you talked about expensive you use the word expensive right you say expensive but the word expensive has negative connotations because you know why do people buy 3000 pounds handbags right like why do people buy 30 000 pound cabinets okay because they’re looking for a solution and the solution comes with a lot of value so you’re not providing a expensive solution at all you’re providing a valuable solution to that patient so if the patient’s problem is big enough then then she that for 400 pounds 700 pounds whatever 1200 pounds or whatever you’re going to charge it doesn’t matter it’s about what value can you bring to the patient the value that you can bring to this patient Gurpreet is that a you’re actually potentially help going to help her with a muscle issue you’re going to help her preventing further tooth surface loss and also it’s a diagnostic you know is this lower left 3 that’s obviously bothering her enough to be able to come and see you as a dentist is it going to be fixed or not so the money in this situation is regardless but what you mentioned was very a good thing that you mentioned hey you know what i’m giving the splint what if it doesn’t work okay it’s a bit like when you go for some i don’t know to a doctor a cardiothoracic a cardiovascular doctor and he puts a stent inside and the stent has partially worked but it’s not partially worked are you gonna get your imagine work in a private country are you gonna get your money back well i think it’s a lot to do with communication and you have to communicate to the patient that hey you know what i’m doing this on a diagnostic basis okay this is a diagnostic appliance i can guarantee that if you wear the splint every night your teeth will not wear away and it’ll be very minimal difference in years to come between your teeth now and your teeth and years to come because you can guarantee that from any splint okay so that should be your fail safe that should be something that a guarantee that you can always give okay whether or not the muscles are gonna get better or not whether or not her headache’s gonna get better okay the video’s been disabled good people listen up so whether or not the muscles are gonna get better it sort of depends on whether if the parafunction was actually contributing to the headaches or not and and whether or not her muscle tension will get better will also depend on the parafunction now my guess is yes because two dentists have already thought that she para functions and she’ll probably benefit from a splint but the way you say to patients that hey you know what i’m trying to help you i can guarantee that if you wear this and you get along with it your teeth will not get worn down anymore but let’s see if we can get rid of your headaches and let’s see if we can get rid of this pain from your lower left three and if it doesn’t then we know that we need to you know bark up a different tree so really it’s two things there one is a value you’re providing something so much more than just a splint okay and it’s not expensive it’s very valuable to a patient so that’s what you should keep in mind and and definitely you can’t over promise you have to under promise and over deliver with everything we do in density especially with splints because some people will just not tolerate and get along with certain splints if you get the diagnosis right which i think you have done here we think it’s myofacial and i think there is a good chance it will work but it’s how you frame it to the patient and if you you have to dissociate yourself from if the patient accepts a treatment or not okay that’s up to the patient but you’ve done your hard work you’ve thought about you’ve been to the splint course you came to my splint course You spent time and money away from family away from the practice to come and learn about this you are ready to implement this and you can really help a lot of patients but it’s about your mindset it’s about how you pitch it to the patient what do you think about that go brut yeah i think i think the day we had the conversation it was quite quite an important one i think it’s all about not having these limiting factors for yourself and thinking about the bigger picture for me thinking about splints the expensive side of things but obviously for somebody who’s been having these symptoms the chance of becoming asymptomatic not having these headaches is of high value so i think definitely it’s the way weight’s being pitched to the patient makes a really big difference you are going to provide a valuable service for this patient and it’s going to be diagnostic and protective so don’t worry too much about that but definitely communication is important and you sort of have to be confident in your approach that hey you know what i i’ve seen these two other appliances and i can tell you don’t get along with them what do you want to do. Do you want to just wear nothing and then bear the consequences of wearing no appliance on a parafunctional patient or do you want to have lots of dentistry to give you all this you know canine guidance and all that sort of stuff you know you can spend a lot of money there maybe the patient’s not ready for that but maybe by going through your approach you’ll get the benefit of of having a splint that she can tolerate and be actually achieving all those aims that we said so I hope that helped the sort of the way that you approach it and i hope those who are listening have found is a group function the second one even though it’s the first one going live but it’s the second group function that will probably go on the podcast soon Thank you so much for being my second victim -No thank you very much okay sweet buddy you can see i’m trying this new software i have no idea how you can end that so how do leave can you leave room i’m gonna give you a remove guest ah there we are i managed to remove Gurpreet so i’m learning this new software it’s pretty cool actually how i can go live at the same time people can call in and we can take questions like that so i hope you guys found that useful and i’ll be sticking this up on the podcast as a group function number two and guys if you ever have any questions for past guests, future guests part the protrusive dental community then we’ll be able to to tackle those together. Once again thanks to Gurpreet for coming on and asking a very pertinent splint question that what if my split doesn’t work Well it’s about how you approach that problem. How you pitch it to the patient. What promises you do make. You have to be very mindful for that. So over and out guys thank you so much.