Communicating with a Bruxist – PDP011

Jaz’s Introduction: Hello, everyone, and thank you for joining me today. I’m Jaz Gulanti. And this is the protrusive Dental podcast episode 11. I’m joined today by Barry Oulton really excited to have him on because he is someone who lectures all over the country about communicating with patients. And he also lectures about parafunction and parafunction control. So what I decided to do and the reason I approached him was to marry these two together about an episode about how to communicate with Bruxists. It’s a huge topic is something that’s probably born out of frustration, my earlier years when I used to speak to patients and the signs of parafunction are obvious to me at one stage they weren’t when I learned what I was looking for. And we’ll discuss that in this episode, it becomes obvious, you know, patients that exhibit signs of parafunction. When you speak to these patients, invariably, they actually deny the fact that their parafunction, I don’t know, I don’t grind my teeth. And there’s a there’s a way you can approach this so that they can actually take accountability for their parafunction, because ultimately, that has a huge bearing on the longevity, our restorations and their pain levels and whatnot. So I’ve got a great episode with Barry Oulton today, there is a Protrusive Dental pearl within the episode. So I hope you enjoy it. You can listen to it on Spotify, Apple podcast, Google podcasts, Stitcher, wherever you usually listen to it. So thanks so much for joining me. And I hope you enjoy Barry Oulton.

Main Interview:
[Jaz] Let’s just start Barry, thanks so much for joining me on the Protrusive Dental podcast. I was just having speaking to you earlier about how happy I am that I’ve got you to speak on this topic because I think you marry communication and topic of paraunction, occlusion, all that sort of stuff really well. So for those few people who probably don’t know who you are, can you please tell us a little bit about yourself?

[Barry]
Yes, sure. Firstly, Jaz, thanks for having me. I’m delighted to be chatting to you, and sharing some information with anybody that’s listening. So I am Barry Oulton I am a dentist, I owned my own practice in Hazlemere, for 20 years, private practice down in Surrey, I have recently sold it in to the Portland group. So I’ve become an associate, after 20 years of running my own practice, so that I can concentrate a lot more time on delivering my own training courses through the new company, the confident dentist Academy. So my background is qualified in Leeds ’93 did my VT, I then moved down south and I became a vt trainer. So I had five years of being VT trainer. Because I really enjoy teaching, sharing, training, coaching, things like that.

[Jaz]
Yep, that’s very evident from everything I’ve seen from you so far. You’re very generous with your knowledge. And that’s great that you’ve, you know, you’ve obviously had that theme for a long time as a, I didn’t know you’re a VT trainer as well. So

[Barry]
Yeah, I mean, I enjoy interacting with people. And as you know, this can be a bit of a lonely job kind it. So I’m bringing people on, I’ve, you know, so I’ve spent, I must have spent hundreds of thousands on my education over the last 20 years. And I believe that I could download what I’ve learned in 20 years, I could download that to somebody probably in the next three years. And if you can, I think if you can help somebody fast track and improve on what you’re doing, I think that’s something that we all ought to be doing. So I’m very happy to share.

[Jaz]
That’s perfect. And I think that ethos of that we now with the digital age and online presence and able to share so quickly, I feel that now for young dentists particular to be able to stand on the shoulders of giants is you know, so much more accessible now. And it’s great that we have mentors like yourself who are sharing, and just like you said, helping us to fast track and as you know, learning from the mistakes of others and an accelerating your progression is going to be so good. And something that I you know, I invest like you a lot in my education, I spent many thousands of pounds so far and I intend to continue to do so. And I’m hoping that I can learn faster than some of my like mentors like yourself, because I’ve got people like you who are sharing.

[Barry]
Yeah, I’m all for that. And why reinvent the wheel. So. And the other thing is, you know, when I’m sharing what I’ve learned, I always learn when I get the feedback, because just because I’ve honed some of the systems in my practice, you know, I’ve spent maybe 15 years honing some of the business systems and they work brilliantly. I also think that once I am sharing those I get feedback and I’m able to improve upon what I’ve already created. So I think it’s essential, you know, not just in our profession, but particularly in our profession, I think it’s essential that we’re sharing ideas because it makes everything better for everybody, including the end user, which is obviously the patient.

[Jaz]
Brilliant. So what are your interests? I know, obviously communication and helping dentists to communicate better with patients, but also, am I right in saying that parafunction is another one of your interests?

[Barry]
Parafunction is a huge interest of mine. And I’ve learned an awful lot over the last 12 years. And actually, so my training company is in sales and communication. And I was the first dentist in the UK to attend a sales training course. And it was 20 years ago. And then there were certain things that happened in my life that led me down the parafunctional route and the communication sales and NLP routes. And that was about 14 years ago, my wife had an affair, and pretty much the, for me for two years. I didn’t know. For me at the time, my kind of whole world, it felt like my whole world have fallen apart. And so I went and walked on hot coals with a guy called Tony Robbins [Jaz] Anthony Robbins. [Barry] Now I did his course three times. And there were certain things that I learned on that course that just utterly blew me away, in the way that human beings process information, and how we formulate our thoughts, our internal representations. And so, off the back of that I decided to go and learn all about NLP. At the same time, during the breakdown of the marriage and becoming a single father, I was breaking teeth. And a good friend of mine said to me

[Jaz]
Your own teeth or patient’s teeth?

[Barry]
Yeah, my own teeth. Fortunately, my dentistry didn’t suffer. So I broke a tooth. And a good friend of mine, a guy called Matt Everett said, “I think it might be grinding your teeth, you need a splint.” And I was like, “No, mate, honestly, I’ve been a dentist for 12, 13 years, I would know if I was grinding my teeth.” And so two months later, I broke another tooth. And yeah, again, Matt says, “Look, let me make you a splint.” And I was like, “Mate, there’s no way I’m grinding my teeth.” Another month later, and I fractured beyond repair my upper right five, which I had to have an implant placed. And I phoned up Matt Everett and said, “I think I owe you an apology. I think I might be grinding my teeth.” And he made me an anterior deprogramming splint. By the time they weren’t involved with NTI. And this was a kind of a revolution to me, because number one is obviously I stopped breaking my teeth. And number two, the discomfort in my head and neck that I was having, that I hadn’t really recognized, because it was just an incredibly stressful time. That massively reduced. And so I thought, Blimey, this, you know, there’s something in this. So that was the point that I went away and started to learn a lot more about parafunction. I spent a lot more time more with Matt Everett, and Neil. [Jaz] Great guys. [Barry] Fantastic guys. And they really helped me begin my journey. So I learned about parafunction, I did some training in the States.

[Jaz]
I just wanted to say I was smiling when you’re telling that story towards the end. Because, you know, essentially, the experience that you had, whereby you are in denial about your own parafunction is, you know, we, as dentists face this every single day, okay? And the main thing I want to pick your brains about today, what the main thing we’ll extract from you is, how can we communicate with these patients? So previously, two, three years ago, maybe even four years ago, I say to my patients, “Do you grind your teeth?” I used to ask them, “Do you grind your teeth?” And I realized some years later, that’s a ridiculous question. Because, you know, it’s like telling a diabetic person who doesn’t know they have diabetes. “Are you diabetic?” You know,

[Barry]
Yeah, you’re right. It’s exactly like that.

[Jaz]
That’s how I say it to my patient nowadays. And I instead, I think probably Pav taught me this was, you don’t you don’t ask them, ‘Do you grind your teeth?’ You say, “Are you aware that you grind your teeth?” But can you now just dive right in and tell me, How can we address this issue of the fact that the patient like you were in your own sort of journey, completely unaware, oblivious, and in denial, you know, you were telling Matt No, that can’t be the case until further damages have to happen. So how can we be more influential to our patients? Because we know we can see the signs of it, but the patients are completely unaware and there that creates an issue of trust, or mistrust.

[Barry]
Yeah, let me rewind a little bit because I think firstly, the majority of dentists are not aware that their patients are grinding and clenching to the significant amount that they are.

[Jaz]
Absolutely agreed. Yep.

[Barry]
And the reason for that is that even when I was a young graduate, we were really trained to be problem solvers. And therefore, we became focused on symptoms, not signs. And so if you look at the statistics and the studies, there’s a study done in 2001, UK, Germany, Italy, they had 13,000 patients. And they determined that they out of that cohort, 8.2% of them reported grinding during their sleep, and 6% had pain related to their grinding. Then there’s another study that puts it between 6 and 12%. And then a huge study in Sweden put it around about 6 to 12%. The thing is that these are patients that are actively complaining of the symptoms of parafunctional activity. When we look at patients on a daily basis, I without over exaggerating, I believe 95% of my patients show signs of parafunctional activity.

[Jaz]
Again, 100% agreed. And I feel as though is because over the last few years, like you, Barry, I’m really interested in this topic, I feel like it’s the key to success in our restorative cases. And we can help a lot of patients by diagnosing because I think once I learned to diagnose and actually my journey started when I was perhaps just after my VT, I was doing a part time job in a Saturday clinic. And I used to see patients who were treated by a Prosthodontist. And I’d read in his notes, when he’d seen his patients, he would notice all these wear facets. And in my head, I was thinking what wear facets, I don’t see any wear facets. And when your eyes open to this, that’s when you can start diagnosing and realizing actually, the problem is around about 95% where you can see the signs of it.

[Barry]
Yeah. And so I think there’s a lot, I think it’s the most misdiagnosed thing in dentistry today. I think that, you know, they did another study where they asked people do you grind your teeth? 22% of them said, “Oh, yes, I think I do.” 67% said, “No, there’s absolutely no way I grind my teeth” just like I did 12 years ago. And 11% when “I don’t really know,” then they examined them. And when they examined them, what they found is that 66% of them had moderate to severe occlusal wear. So that’s two thirds, moderate to severe, not even mild, right? And 50% of them had tongue scalloping. So that that’s nearly 100% of people have the signs of parafunctional activity, whereas only 22% had the symptoms. So when I’m lecturing, what I’m trying to do is encourage people to look at the signs because there’s so many things that we’re missing, that I believe are attributable to parafunctional activity. Such as you know, I get somebody in this is I’ve had gum disease, and I look and they’ve got wear facets from parafunction on the lower sixes. And their periodontal disease is only limited to the lower sixes. And what ultimately, I thought was actually that wasn’t a bacterial periodontal disease. That was a parafunctionally driven bone loss that ultimately led the periodontist to think that it was a bacterial disease. And so that’s why this patient presents with something that continued to get worse till we gave him a splint. And it’s now stabilized for the last five years.

[Jaz]
And I’ve got patients just like that. In fact, I’m treating a person with orthodontics at the moment who, his occlusion was such that he was only occluding on sevens and central incisors. So his sevens and central incisors only. And when he presented to me as part of my comprehensive assessment, his lower central refilled. And, and I also okay, and he had any trauma, you know, why would they root treat it? He has, “I have no idea. I just went to my dentist” having severe pain and he found his infection, no history of trauma, you know, to me, and you have to look at the signs and whatnot. It’s obvious he’s got these huge masseters, so sevens and centrals taking all the load, the central is going to lose. And that’s why they lost vitality. And the dentist never made that connection previously, from what I can gather from history. So we see, that’s the more extreme end of things, but we can see so much more along the way from these, from no sign to all these extreme sort of late presenters. So a lot of it is a tip of the iceberg. So that full circle, how can we become more influential to these patients because they need need our help to prevent them losing more teeth, having more muscular and joint rated pains? So where do we begin? How do we, how can we approach this conversation? I’m asking you, because I know you’re, you know, you’re probably thought more than anyone else about this because it marries communication and parafunction so well.

[Barry]
Yep. So the reason I went back and rewind a little to talk about signs and symptoms is that the first step for me is to ensure that it is part and parcel of every examination. So it’s part and parcel of your new patient and your existing patient examination protocol. Because when I’ve explained to my patients that I’m looking for it, that’s already sowing the seed that at some point, I’m going to discuss it with them, because I know and, you know, 95% of our patients are going to show signs of parafunctional activity. And so I want to begin that process of communicating with them right at the beginning with an upfront contract to the fact that I’m going to be looking at that. So I, my treatment coordinator explains that, ‘Amongst the examination, some of the things that Barry is going to be doing are..’ and she’ll explain what a BPA is, she will explain, you know, what I’m doing, when I’m looking at the teeth, and so on and so forth. She’ll also explain, he’s going to examine your muscles and feel your muscles of attention and tenderness. And then look at your teeth for any signs of grinding and clenching. Because what we know is that 95% of our patients grind and clench, and not many of them know it. And we give them some reasons of why we want to identify if they’re parafunctioning. Because, you know, we have lots of patients that have had root canal treatments, because their dentist was doing their absolute level best, chasing the pain, not realizing that the pain that the patient was having was referred pain from muscle problems, not from tooth problems. And so again, the first thing I show my patients is a trigger point shot by Travell and Simons Have you got that?

[Jaz]
No, I don’t.

[Barry]
Okay, so if you’re doing any parafunctional treatment for any patients, the first thing I would recommend you do is go to Amazon, I don’t know where else you can get this. But you go to Amazon and you look at Travell and Simons triggerpoint. They have developed a chart of trigger points for the whole body. But section two is the head and neck. And it indicates where the tension is built up from parafunctional activity. And in the muscle, you get a tender area, a trigger point, and then it shows you where the pain is referred to. And so as an undergraduate, I was taught that pain in teeth could be referred from top to bottom. And what I believe, that I discovered and became aware of 12 years ago, is that that’s incorrect. Over the last 12, 13 years, however long it’s been, whenever I’ve had somebody enter my studio now and say, Look, Barry, I’ve got to say but I don’t know whether it’s top or bottom. The overriding presenting pain has always been muscular. And so I palpate, the masseter, I find that trigger point, and it’s that that’s been causing that tooth ache. Now, I also recognized that there could be a problem with a tooth, maybe a pulpitis. And that has invariably caused them to parafunction more during the night. So that then they get the problem with the muscle because I got caught out about 10 years ago, I was really evangelical about this, a patient came in, you know, “I’ve got this pain, I don’t know which tooth it is.” And I was like,”Oh, I know what it is. It’ll be muscle.” And sure enough, they had trigger point problems. And I explained that what we need to do is give them a splint to you know, get the muscles relaxed. And that was sort the pain out. Two months later, they came in, they’d had no pain for two months. And then they came in with a blown up abscess on a tooth. And it made me realize that actually, they did have an underlying problem with their tooth. What that of course, was increased grinding and clenching, which they presented with muscular pain. But I had, at that point, I’d realized that what I hadn’t done is really look at the fact that there was an underlying tooth going on that was actually causing them to parafunctional even more. So now I haven’t made that mistake since. But 10 years ago, you know, getting into this in the early days, that was a mistake that I made. So in terms of communicating to patients, we start right at the beginning, we start in terms of our presentation of what we’re going to be doing in the examination. My examination protocol is very automated in terms of I operate a co pilot operation with my nurse so she will read out what she wants me to look at and I report on it. We develop that again about 15 years ago, because I was providing my examinations almost in silence, you know, looking at everything and then saying, you know, everything’s fine, which meant that my patients weren’t hearing everything that I was doing for them. And so we developed this co pilot system where my nurse says, soft tissues, and I’ll run through each soft tissue, she’ll say, saliva consistency and volume. So we have this whole thing that we run through. And the patient, first time we did it, a patient was like, ‘Wow, you’ve never done that before.’ And I went, ‘You know, I’m embarrassed to say, I’ve been doing that for you, every six months, for the last eight years, I just haven’t been telling you, I’ve been doing it.’

[Jaz]
That’s amazing. It’s just building values. And it’s the same reason why I also do the same, Barry, as someone called Zak Kara, a friend of mine, taught me to be more proud of the way I examine and actually make it more vocal, I’m now checking for your muscles just like you do. When you’re in the video, I saw your muscle exam video, which I can direct people to that if that’s okay with you. Is to I also say, I’m now screening for mouth cancer, something that trying to think who taught me that a James taught me that to actually tell patients I’m now screening for mouth cancer. And they go away thing Oh, yeah, this dentist, he actually cares. He’s looking for mouth cancer, even though we all do it. Unless you mentioned that you don’t actually communicate that to the patient. So that’s a great point you’ve raised.

[Barry]
Yeah, I mean, it’s, it’s something that I think is essential. And if we can get all dentists during that, it means patients then value the professional because they understand that we’re not just you know, having a quick look flicking around, we are actually being very comprehensive in what we’re doing. We’re just at time, some of us are failing to highlight how comprehensive and how good we actually are. So it’s part of our exam protocol that starts the whole ball rolling in terms of communicating with patients about parafunction. And then there are patients that take time to appreciate that they’re parafunctioning and the ramifications of it, just like it took me time. And so I’m, I don’t jump up and down and start beating on the drum, I sow seeds, I talk to them, we take 23 photos anyway. So we’re able to demonstrate that, you know, you’ve got a fraction, you’ve got some gum recession, you’ve got some sensitivity, you’ve got some wear you’ve got some chipping, you’ve got this than the other, we also take a position because I call it dental gymnastics, you know what people do in bed at night with their mouths is phenomenal. And, you know, you can see there wear patterns, if they do parafunctional anteriorly, it fits like a glove, there’s multiple little jigsaw puzzles. So we get them, I get them to go into that position. Almost always the like, Oh, that’s really uncomfortable. I don’t do that. When we get them into that position, we take a photograph, so that we can demonstrate why their teeth have got little notches in or V shapes in the upper interiors, or whatever it is, we’re able to demonstrate. And, you know, some people take longer to appreciate that. And I’m in no rush. You know, I want my patients eventually come in saying, “Look, I think you might be right, I’d like to, you know, take your recommendation.” Many people just jump on board because we explained it so well.

[Jaz]
That’s another amazing tip I want to highlight. So this is out there to take photos of people in their sort of wear facet positions where the central notches and the where the lower incisors match up. Even on the canines, they can match up quite well sometimes. So take those photos and show your patients. And some patients, like you said might take more time to come around to it. And that’s completely okay.

[Barry]
Yes, it is. And the other thing that when we’re case presenting, if a patient, which is well within their right, declines to have an SCi, we will get them to sign a disclaimer. And the disclaimer, which is you know, not heavily worded, it’s a nice disclaimer just basically says I’ve been advised that I grind and clench. And therefore, my porcelain units or anything like that are not guaranteed. Because you know, very often you get people that have wear and tear on their teeth. And if they’re going to wear their teeth, they’re going to smash up the porcelain. So if they elect not to have a splint, then we get them to sign a disclaimer And that, again, adds quite a bit of weight to how important we as clinicians think it is that they as patients follow our advice and were in SCi to protect them from parafunctional at night.

[Jaz]
Absolutely, because a lot of these patients who come in needing rehabilitation of their anterior teeth is because of parafunction. And if we’re not, if we just restore them and leave them to it, they’re gonna break our restorations. So yeah, in my practice, absolutely. We do have Have guarantees for indirect work and direct work different years. But all of that is void and null if they don’t actually have an appliance or if they fail to maintain to wear an appliance.

[Payman]
Yeah, absolutely. I’m glad you and I are on this on the same page, really I am, just want to encourage anybody that’s listening to consider implementing that into their practice. Because if we don’t talk about that with patients, and something does break, invariably, it’s our fault, isn’t it? Patients don’t come back and say, “Oh, my new crown broke because I was grinding on it,” they come back and say, “Well, this was a faulty crown.” And actually, you know, it wasn’t, it’s just that may be

[Jaz]
And in a patient’s perspective. I mean, if it hadn’t been explained, or the dentist hasn’t looked for the signs of wear and parafunction, then and if they don’t know themselves, which in most cases they don’t, then it’s normal behavior for someone to say, “Hang on, this is broken, it shouldn’t have broken, it must have been something faulty with the product.”

[Barry]
Yep, exactly right. I mean, I had it, you know, 20 years ago, whereas I have VT. So 25 years ago, whenever it was, before I really knew what I know now, I had a patient who I thought had a chipped, upper right lateral. So I restored it with composite, that composite came off four times. And at the end of the day, the patient just thought that I was a crappy dentist. And I was disappointed, I thought I was a crappy dentist because this incisal edge composite kept coming off. Now, you know, I was wet behind the years, I’d only just come out of uni, I was in my vt, I didn’t realize that it wasn’t a chip, it was a wear pattern. And they were parafunctioning. And I was just repairing replacing the tooth that was missing, that they’d spent 10 years wearing away. And because I’d lengthened it, they were then taking 10 minutes to ping it off. And so it was you know, you don’t know what you don’t know. And so until you start to really know and understand that you’re looking for signs, not symptoms, you can’t misdiagnose things. And that’s I was guilty of that 20, 25 years ago, I less guilty of it now, obviously. Because fundamentally, I’m looking for this on absolutely every patient that walks through my door.

[Jaz]
Brilliant. And that’s so true. And I think we’ve all had that patient, I think every one of us can think immediately when you describe that scenario, and name of a patient popped into everyone’s head, and they sort of remember Oh, yeah, that was definitely the case on that patient.

[Barry]
Yeah, but it’s like the first time you prep a lower left seven, you got a nice millimeter clearance, and then you take the bite and think “Hang on a minute. It’s an occlusion again.” We’ve all been there as well. Right? When you realize that actually the there are certain things that you weren’t aware of in dentistry, or maybe you didn’t pick up at uni. So yeah, it’s a learning curve. It’s then the I think the idea is then to not make the same mistake twice.

[Jaz]
Absolutely. Last tooth in the art syndrome. And I think that could deserve its own episode in itself, basically, in terms of management and whatnot, but fine. What other tips can you share when communicating with our patients with parafunction or wear? Because one thing I found actually is that I’m sure I’m in fact, I’m definitely I’m positive that Barry, that when you are explaining to your patients about the signs that they exhibit of parafunction, and wear is that you’re probably the first person in majority of cases that discusses with them?

[Barry]
Yes, always.

[Jaz]
Yeah, exactly. And it’s always easier in the few times that I have been the second or third dentist. It’s just so much easier as

[Barry]
Well, it’s interesting, because I when I get patients that come in, and they’ve got a lot of wear, and I say, “Okay, so does anybody ever chatted to you about the grinding, clenching?” And they go, “Yes. Oh, my last dentist told me I grind my teeth.” And I said, “Okay, and what else?” “Well, that was it. They told me, they told me I grind my teeth” Full stop. No advice. No discussion about an appliance or anything like that. So it hasn’t always made it easier. They just are aware that they’ve grind their teeth. And so

[Jaz]
Yeah, of course. So the awareness aspect is what I meant, but whether they’re not, whether they have been explained that, you know, the rationale of how to take things forward, either in terms of protection or rehabilitation is obviously something that, you know, may or may not be discussed, but I find the awareness and the acceptability of the, you know, the trust, is there just a few notches higher when you’re the second or third person, but in the most cases or majority of cases, when you are the first person that people listen to for the first time. People are telling their patients actually, you know, did you know that you know, you actually do grind your teeth and here’s the evidence, and that’s always the trickiest bit and everyone will handle that differently.

[Barry]
Yeah, So in my communications training, one of the things when I learned so I master hypnotherapist as well. And one of the things we learn in hypnotherapy is the art of telling stories. people relate to stories and analogies. And so when I talk about parafunction to a patient, I don’t really talk about parafunction. I talk about garden fences. Do you want to hear my analogy?

[Jaz]
I love analogies and please, please shoot away.

[Barry]
Okay. So I was chatting my patient and say, “Look, do you have a garden?” And only once or somebody said, “No, I live in a flat.” And I’m like, “Oh, damn it. Do you know anybody that has a garden?” And the patient went, “Yeah, of course.” I was like, “Great. Do they have a fence?” And they go, “Yeah” “Okay, so let me explain grinding and clenching. In terms of your fence in your garden. It’s like me, creeping into your garden at night and rocking a fence post. Every night that you’re grinding and clenching, you’re rocking the fence posts, and they’re your teeth, and so I need you to picture me creeping into your garden bit weird, I know. But I want you to picture me creeping into your garden at night, and rocking a fence post. Now, if that fence post is made of concrete, and it’s set in the ground into concrete, then when I’m rocking that fence post, the energy that I’m using, is has to go somewhere, right? It was Einstein that said it or was it Newton, it was Newton. So that energy has to go somewhere. And basically, if it’s a concrete post in the concrete ground, it’s going to go into my muscles. And I’m going to have some muscle tension probably the following day. If that post is concrete, and it’s set in the soil, and every night I creep in and rock that fence post, over a period of time, whether it’s six months or a year, eventually what’s going to happen? It’ the soil is going to reduce around the base of the post. And that’s where we can get some bone loss and some gum recession. And that’s ultimately where teeth might be able to become loose from grinding, clenching. I said, Now, what I want you to picture is that fence post is made of wood. And the fence post is made of wood, and it’s set into concrete. And I come along and rock it and what happens is at the base of that post, it starts to splinter, you then come along with your garden strimmer. And you take away those splinters. And that’s where you get things called abfraction and I demonstrate are my teeth, I clicked them. Because I’ve got abfraction from parafunctioning years ago. And I said that’s where you get these abfraction and this bit of gum recession. The other thing that can happen to those posts is they can break. And I said and I’ve broken three of my posts, I lost two teeth, I had to have an implant, or you can chip and break the top of them. And so when I’m going to be looking at your teeth, what I’m going to be looking at is any of those signs, whether there’s some chipping at the base of your posts, whether there’s some groundwork that’s gone, I’m going to look at your muscles as well, because most patients have signs of all three of those aspects. And some patients have the signs and actually some patients have increased symptoms, where their muscles are sore and they present with headaches, neck ache, shoulder pain, migraines, all sorts of things. So I explained that as my opening gambit to a patient so that they can understand that there’s a variance in what can happen when you parafunctioning based on quality, a bone, you know, what the grinding on, what the teeth are, like, you know, all sorts of different things and they get it, it makes perfect sense to

[Jaz]
That’s a really lovely analogy. And obviously it sends home that message that sometimes it’s the muscles that take the hit, sometimes it’s just a teeth, it can be abfraction, obviously, sometimes it could be the TMJ as well. So that that’s a great way to explain to patients. In terms of now that we’ve talked a little bit about communicating with our patients and looking for the signs and whatnot. Can you briefly describe your splint protocols? Does everyone your patients always get an SCi? Or are there certain indications where you might prescribe a different type of appliance?

[Barry]
I would say that 99.9% of the time, my patients get an SCi Now, it might be a slightly different designed SCi, it could be an upper or lower. If they’ve got a deep bite, it’ll be a deep bite SCi where the discluded element begins within the palate, because I don’t want to open them up too much. But invariably, almost all my patients I provide with an SCi The rationale behind that is effectively it is as we know, an anterior deprogrammer. It’s separating the posterior teeth and providing disclusion during parafunctional activity. We know from the EMG test results that by wearing an SCi, it reduces the contraction of temporalis by upwards of 80 85% and masseter by 50%. And I believe that I mean, I haven’t done a full arch splint now for 15 years. I have done all of my Dawson Academy training. And so I am fully aware of providing the idealized occlusion if I was going to be reconstructing somebody’s full mouth, I want, you know, and dots in the back and lines in the front, I still give them an SCi. Because I believe that even with what some people would call a perfect occlusion, if you’re a clencher, the occlusion is virtually irrelevant, right? Because you’re still going to be firing off the muscles. And if you follow Robert Kern Steens belief with T scan, is that in order to minimize any damage and muscular problems, you need to have you, if you’re aiming for canine guidance, you need posterior disclusion in under 0.2 per second. Well, you know, I’ve got T scan and I’m not even going to measure that I can get posterior disclusion in 0.2 per second because I’m just going to protect my patient with an SCi. So, almost entirely, it’s an SCi. The things that might counter that is going to be periodontal involved anterior teeth, which, to be honest, I really don’t see and if they have periodontally, I’ve got some patients with periodontally involved lower anteriors. So I will make the SCi on the lower anteriors. If I have a concern about certain teeth, then I might make them a B splint. Now the B splints I will use which is basically a full arch splint with an anterior deprogrammer built into it. I will provide B splints for any orthodontic patients and any of my younger patients so kind of late teens, because I know from all of our research that there are no occlusal changes from wearing an SCi. But number one is if they’ve had orthodontics I want them to wear essix retainers anyway. So I will invariably make them a B splint, not an SCi. And then if I am concerned maybe that there’s still some growth or this potential of any occlusal changes through normal natural processes, I will then make them a B splint as well.

[Jaz]
Brilliant, and it’s great to discuss these protocols. And a lot of people listening might be at various stages of their journey in learning about these sorts of appliances. In the previous episode, or episode eight, I spoke to Dr. Barry Glassman, and we dispel some of the myths about anterior midpoint stop appliances. So if anyone wants to listen to that, please go ahead and you can listen more about you know whether in, whether they do or not cause a AOBs and that sort of beyond this podcast, more covering that one.

[Barry]
Yeah, can I just say if you haven’t listened to it, please go and listen to him. He is brilliant.

[Jaz]
It’s absolute sensational. He really changed the way I thought about a lot of the concepts and it’s essential listening, anyone can get to one of his courses or at least start off by listen to a podcast and go from there. But it’s interesting you mentioned about orthodontic retention. One of my favorite devices to prescribe for those who’ve had orthodontics is an SCi with essix retainers built into it. So

[Barry]
That’s a B split.

[Jaz]
Yeah, so I guess so the way that s4s sort of send it to me. Yeah, essentially that you know, there’s you know, B splint, E splint, U bank Splint, so many different names and whatnot. Essentially, the mechanics behind it is the same. And yeah, it’s the essix retainer built into it. So that can give you your orthodontic retention as well. And one thing that I found really helpful and again, this comes to the communication aspect back full circle is I don’t know if you do this, Barry, but I color my splints that I prescribed with a Sharpie pen black one, three coatings. And then when the patients come back for the review, is it I’ve never had a patient not grind in a wear pattern, it’s usually left to right sometimes anteroprotrusive and that then just really sends home the message that oh my god, I Yes, you’re right. I do grind my teeth. And I encourage my patients to email me and take photos daily of their sort of wear patterns being formed on their splint and I get loads of emails now saying, “oh, Jaz, you’re right. Here’s what I found and patients get involved in this journey. So is that something you’ve you ever do?

[Barry]
That is absolute stroke of genius and no I don’t and I will be starting tomorrow

[Jaz]
Amazing. Honestly, I think

[Barry]
It’s a great idea.

[Jaz]
A lot of things I say are not original, I learned that from Michael Melkers. But you know, this is great to do with patients. And you know, it underpins everything we discussed about in this episode so far about communicating to our patients. So sometimes we do have these patients who trust us enough to go ahead with a splint and still doubtful but when you color in I’ve never had a patient including myself when I gave myself a do large SCi with sliders and I have this from day one I had left to right wear I wish I knew I would do already and my canines I knew I was parafunctioning. But then you know, to wear it myself. And then when I woke up in the morning after one night of wear, and I saw that clean swipe left and right and everything else black, that’s like this is it, this is what’s good, my patients are going to see as well. And this is going to send such a powerful message.

[Barry]
I think that’s a brilliant I love that. And if you don’t mind going to nick it and I’m going to share it

[Jaz]
Oh, please do. Share it far and wide. And you know, this is what it’s all about in this podcast, to share little gems to help dentists and help patients because ultimately, the patients benefit, the dentist benefit. And it’s a great thing to do.

[Barry]
Yeah, that’s a really neat idea. I’ll be doing that. Three, three coats of Sharpie, right?

[Jaz]
That’s it three kinds of Sharpie. And yeah, it’s great definitely has to be Sharpie. I’ve used a different brand over, let’s call it a black permanent fat marker. And my patient came in. And she told me a week later that her lips went completely black. And I was so embarrassed and apologetic. And then I went to the shops, and I bought like a 12 pack of Sharpies. And I’ve always only ever use Sharpies, and then they work. I don’t use any other brands.

[Barry]
Other brands are available, but don’t use them.

[Jaz]
Absolutely. [Barry] Yeah, that’s really great. [Jaz] What I think we’ve got- Thank you very much. Any other last gems that you’d like to share?

[Barry]
Yes, okay. I would encourage everybody, when they’re communicating with patients, I would like you to learn how to build rapport. And, particularly if you’re dealing with a patient who is resistant to your recommendation or resistance as I was, their understanding that they’re parafunctioning, if you’re in rapport with your patient, you have a much better chance of your patient accepting your recommendations. So what we’re talking about parafunction and how we’re communicating. I think one of the biggest skills I ever learned in a, which improves my communication inside and outside of work was building rapport. So that’s something I would genuinely want people to work on and get better at, because it has a massive impact.

[Jaz]
The other thing, just couple of questions I want to ask, I asked a lot of guests this question is, did you know the difference between, a lot of people have different, parafunction and bruxism? Are they essentially same thing? Are there any nuances? Because dentists use these terms interchangeably.

[Barry]
To me, they are one and the same. Parafunction basically, by definition, is outside of normal function, isn’t it? Because it’s para-function. When I do my training courses for s4s, we do a full day, I asked the question, what is normal function? Because I show a picture of a mild wear? And I say, Is this normal? And everybody says yes. And I say Okay, so let’s think about this. What is normal function? Normal function in the masticatory system is eating, talking, swallowing, drinking. And so I throw out bags of Haribos. Other brands are available, by the way. So I started mixing Haribos and say, right, let’s do some normal functions together. get everybody to eat some sweets, while they’re eating. I say, right. This is normal function. How much are your teeth meeting? And unanimously, the answer is they’re not. And I said, that’s my point. During normal function, teeth don’t meet, there is a maybe a slight touch of teeth. When you swallow, teeth don’t meet

[Jaz]
A lots of near misses. That’s what Barry Glassman thought us, lots of near misses. And occasionally, they do touch in there, but nothing significant

[Barry]
Nothing significant. So then I share the photograph and say, Is this normal? And the answer is no. It’s not normal. It’s common. And it’s not through normal function. It’s outside of normal function. It’s therefore parafunction. So even though it’s mild wear and I said it’s also age dependent, because if that patient I’m showing them is 76, she might go, do you know what, that’s not too bad. But if that patient is 14 years old, I’m concerned where they’re going to be in 20 years time. So I’m keen that we are aware of what parafunction is. And basically, it’s anything outside of normal function. And it’s the same whether it’s, I don’t mind whether people classify as grinding, clenching, bruxism or whatever, it’s all the same, kind of outside of normal functional activity.

[Jaz]
Brilliant. And one thing I’m gonna ask you only because I, you know, you’ve got a lot of wealth of experience. And I’ve asked a lot of people who are like me, and you geeks of occlusion and wear and parafunction and stuff, and you get different answers. People who represent Dawson, people who represent Kois and Pankey, everyone’s got a different opinion about this. So let’s talk about a constricted envelope of function. Okay. So if anyone who’s listening out there is essentially people, for example, with a deep bite, and you see the lower incisors are really worn, and maybe the palatal of the upper is quite worn, and it’s basically as soon as they thrust their mandible forward, it’s all anteriorly guided, it’s a lot of forces anteriorly and when they’re chewing, the theory is that actually the lower teeth, and the upper front teeth are sort of in the way of their functions. Typically, do you think I’ve described that okay, as a constricted envelope of function?

[Barry]
Yeah, I think that’s a pretty good description of it.

[Jaz]
Fine. So some dentists believe, or some camps believe that actually, you can have a deep bite, or a constricted envelope of function, but really, in the absence of parafunction, that’s still not going to cause the wear, and whereas other camps are, quite strongly suggested with that actually, even if you have this constricted pattern of wear, you know, you’re all that’s the reason for the wear, rather than any parafunction, do you see what I mean? I mean, also, clinically, it doesn’t matter, because you have to treat that anyway, in one way or another. But did you see what I mean in terms of what the etiology of that wear is? A geeky question. I know. So do you have a philosophy opinion? Do you see what I mean?

[Barry]
I do see what you mean, it’s kind of chicken and egg, isn’t it? You know, I’m talking about what comes first, because you can see somebody that has a deep bite, with no wear. And clearly, there’s no parafunction, you can see somebody that has a deep bite with lots of wear. And you could diagnose the fact that there is a restricted envelope of function. But to be honest, if you release that envelope of function, if you were able to correct that, does that mean they’re not going to parafunction? And I would say, not necessarily. I’m a big proponent now of doing as little dentistry as possible. And so the first thing I do is to get any patient with any signs a parafunctional activity into an SCi, so that their dentistry is a choice rather than a necessity. Because if they aren’t struggling functionally, and it is para function, then the SI is going to solve it for them. And if not, it’s certainly going to protect them at night so that then we can have a discussion about whether we’re going to do dentistry further down the line. I don’t believe that dentistry should be done in order to treat parafunction. I think it should be done once we’ve protected people from parafunction. So that that dentistry is a choice rather than a necessity, if that makes sense. Do I make? Am I making that?

[Jaz]
No, no, that makes sense. Absolutely.

[Barry]
So I am not really often I don’t believe presented with restricted envelope of function issues that I then need to look at by doing any restorative work, because generally speaking, when I’ve used SCi for patients for nocturnal parafunction, their problems go away. And there are the odd cases where we will then sit and talk about doing some dentistry. But that’s not very often now, Jaz. Most mostly, I want my patients to be having the dentistry because they want it not because they need it.

[Jaz]
Brilliant, and we’ve talked a lot about the SCi appliance. So anyone out there who’d like to learn more about this s4s have some great courses along with yourself, Barry, can you just give them, people information about how they can come onto those?

[Barry]
Oh, yeah, absolutely. We run them. London and Birmingham, and we’ve done some in Sheffield. They are a day long. It gives you a lot of background about parafunction. You get a free Haribo. What can I say? We talk about, I talk about different splints. You know, there’s the odd occasion that I’ll use a different sort of splint if there’s some problems with the joints. But really, it’s focused on SCi, we show you how to manufacture a chair side SCi. We’ll give you a demo of doing that and just talk you through the whole protocol. And he had a huge discount actually on the chair side SCi so it’s well worth coming along for the day, you get the discount on the SCi as you go away, and you start making them. All of my staff, where Sci at night, and everybody benefits from it. So it’s a really good interactive fun day. And if you go to the s4s website, they’ll be able to list the dates as well. And I must highly recommend for a much more in depth training from a much more knowledgeable man than me is the other Barry. If you’ve not seen Barry Glassman lecture, he’s an absolute delight. And well worth seeing him as well. So please go to the s4s website and check out the courses that are available.

[Jaz]
Brilliant, I want to echo that as well. And I’m a big fan of using lots of different types of anterior midpoint stop appliances and there’s loads out there. There’s you know that the b splint, the eubank splint, the E splint, that I use something called the Flexi orthotic splits, there’s loads out there but I think in the UK s4s are certainly the the leaders in educating people about different types of splints and midpoint stop appliances. So as a starting point, I’d encourage anyone to learn the theory in the background from Barry Oulton and the s4s. And then from there, look into different other types of appliances. But if you’ve asked s4s, it’s been a great lab and I have no sponsorship from them or anything like that. But I just want credit where credits due, s4s is a great lab for any sort of, or appliance I prescribe. I use them exclusively for appliances, and they run great courses as well. So Barry, with that, thank you so much. We really appreciate you joining me today. Lots of great gems there. And I’ll put some links out there for the comfort dentist and s4s courses, anything else you’d like to share? And really great knowledge you gave me. You taught me about the, was it the pain map on Amazon?

[Barry]
Yeah, the trigger point by Trevell and Simons.

[Jaz]
I’m going to get that straight away because I think it’s so relevant because I’m looking for these signs and I never knew about these trigger points. So that’s my first purchase. Thank you

[Barry]
Alright, Jaz, thank you for having me. And I’m off to order a 12 pack of Sharpies.

[Jaz]
Lovely.

Jaz’s Outro: Thank you very much for listening right to the end. That was Barry Oulton, thanks so much for coming on. I realized Barry is the first time actually spoke to them over voice if you like and I really liked him so I booked on to his course in December in London. So if you’re coming to the December course London please do say hello. As always if you’ve enjoyed the content, go on my Facebook page Protrusive Dental podcast Like it, share it. Subscribe on my website, jaz.dental for episode updates and blog posts and whatnot. And thanks again and the next episode is with the implant ninja. Someone called implant ninja find out who he is, what he’s about. He’s got great Instagram profile. And I was asking him about occlusion relevant to implants and also how to get a good work life balance. So it’s a really special episode actually. So I look forward to joining for Episode 12 out in a few weeks. Thanks so much. Bye!