I recorded this a few weeks ago and recently finished editing it (always enjoy chatting with Barry G) – I was pretty much ‘shy’ and dare I say ’embarassed’ to post this/make it public because in the grand scheme of things, our world is being rocked by Covid-19 at the moment and we have so much to worry about…
But then two people independently sent me a photo on Instagram of them at home watching my YouTube/IGTV interviews I posted recently telling me they are learning so much from the guests on Protrusive.
If this video or any of my content can get you to chill on your sofa and learn while you #stayathome – then that would be awesome.
Sending my best wishes to all – stay home as much as reasonably possible 🙏🏼
I hope all this will reunite our profession.
In this episode:
– Jaz shares a Parable of the 12 Blind Men relevant to TMD and makes a mess of it!
– We discuss if the role of teeth/occlusion/malocclusion/Restorative really has a role to play in TMD/pain?
– What is macro trauma and micro trauma, and how is it relevant to TMJ pathology?
– What is Barry’s message? What does he mean by ‘Occlusion does not matter unless you’re occluding?’
– Why MIP is pathalogical
– We discuss Confirmation bias in Dentistry
– Can we reliably stop parafunction?
– What adjunctive support therapies are prescribed for complex oro-facial pain patients?
– Can you use an AMPSA with a patient with Degenerative Joint Disease?
– The first 20mm of opening is pure condylar RO- NOT! It’s not pure rotation!
– What is an Enthesis and why is that relevant?
– Can you give an anterior only appliance to someone with clicking?
– Why might a patient say their click has now stopped?
YouTube Link: www.jaz.dental/YouTube
Click below for full episode transcript:Opening Snippet: Welcome to the Protrusive Dental podcast the forward thinking podcast for dental professionals. Join us as we discuss hot topics and dentistry clinical tips, continuing education and adding value to your life and career with your host, Jaz Gulati...
Jaz’s Introduction: Hello, everyone. Welcome to Episode 22 with Dr. Barry Glassman. He likes me to call him Barry, as you’ll see. So this is a my first ever full intro and outro video podcast. And I’m glad to see Barry, he also featured in episode eight, which if you haven’t listened to it, it’s a great episode, I urge you to check it out. Episode eight was all about anterior midpoint stop appliances, and do they cause a OBS. So if you haven’t heard that already, it’s really great. You can hear Barry’s passion in that in what he believes. And I guess I want to give you some context, in terms of what you’re about to watch or listen to if you listen on the podcast between the conversation between myself and Barry. Basically, what Barry teaches and what he’s all about, and I heavily recommend going on one of his courses because it’s a different way to see occlusion and basically the crux of it is, is that it’s not the occlusion, or the malocclusion that causes a lot of problems. Let’s call this let you know whether it’s chipping or things breaking TMD, which is a very loose term. It’s not because of the occlusion per se, it’s because of occluding. And what Barry always says on his courses, nouns don’t hurt people, verbs do. So the occlusion is not as important as the occluding. So if you’ve got someone who’s like a 17 and a half minute a day chewer, then they’re not likely to cause that much problems when in terms of destroying their teeth, or TMD. Because essentially, what we’re talking about is the relationship between parafunction and causing repetitive micro trauma in the temporomandibular joint is quite, we will discuss a fair bit of anatomy at the end. So it’s actually a good revision for that. And I’d actually encourage people to if you’re listening on the audio podcast version, to actually go to the video version, which some of you are watching right now, because Barry actually shows the temporomandibular joint and the disc, and he describes about the lateral pole and the media pole, which is something that’s not very well understood. It took me years to get the hang of that myself. So people might say that ‘Jaz, you know, you’ve just said and you agree with Barry that occlusion doesn’t matter. So why do you, Jaz go on so many different occlusion courses?’ And as you know, I’m a bit of a junkie for learning about occlusion. And I guess the answer I have and I sort of touched on it a little bit on the episode is this, is that yes, occluding is the problem. And the occlusion per se is not as important. But remember that not all of your patients are going to wear appliances, and not all of your patients will adapt to one. And when you have an opportunity to rehabilitate someone, or reorganize their occlusion for whatever reason, then you obviously want to set out for a minimal stress occlusion, which is something I learned from Ian Buckle at the Dawson Academy. So if you’re going to go through the effort of really doing placing lots of restorations, you’d be foolish not to design it for so that when they do parafunction, they parafunction in a more dentally beautiful way as someone recently put it on a Facebook group I saw. So that’s why I continue to learn about occlusion. And it’s good to have that hat on. But also, it’s really good to have Barry’s hat on about and actually occlusion doesn’t matter. It’s the occluding. So I like to marry them both together. I started off the discussion with Barry by introducing a parable that I read about it involves 12 blind men and an elephant and this parable is quite a famous parable in religion obviously, but there is one version of it I read that is very relevant to TMD and if anyone has read this Parable you will know exactly what I’m talking about. If you have read it, can you please send it to me? There’s like a PDF version? And I’ve always remembered it I’ve never been able to find it again online so if you know what I’m talking about, can you please send me that parable? So listen to, I make a bit of a pamphlet but you can listen to it anyway as I share it with Barry. So Barry is an oral facial pain specialist. So I speak to him about how to manage these complex patients, what therapy is he does adjunctively to let’s say an anterior midpoint stop appliance were indicated. Also towards the end of the episode we discuss about anatomy and clicking joints and whether an anterior midpoint stop appliance as some people may argue is contraindicated for someone with clicking joints so you can hear about his view and the anatomy and how it relates to it. So the Protrusive Dental Pearl I want to share with you before we jump straight to the episode with myself and Barry is I’ve had a lot of people ask me because they saw that when the smilefast course and they asked me about the smilefast course. So firstly want to say I have no financial interest with smilefast. I just went on the course. And I have the utmost respect for Thomas Sealey and Mide who were the founders of smilefast, clinical founders. And I have to, you know, give it to them. They’ve set up a fantastic system. So if you’re someone who’s doing or planning composite veneers or rehabs I think it’s a great ROI. Because I think I’m already at the moment spending time and money on digital wax ups, the stents that I usually make myself, and I think the whole package they’ve created is really slick. So I quite like to smilefast. Unfortunately, we’re in the midst of the Coronavirus crisis at the moment. So there’s not going to be much dentistry happening in the next couple of months. But I like to think that I’ll be using it more and more in my daily practice. So the pearl is, if you’re sitting on the fence about smilefast to do it, it’s actually, I actually really enjoyed the course and I think it’s gonna be very clinically applicable, it’s going to save me time and money. So that’s my pearl shared with you. So let’s jump to the episode with Barry and I and I’ll catch you in the outro.
Main Interview: [Jaz] Barry, listen, I think we[Barry]
You are having trouble with your mustache you keep playing with it. [Jaz]
Everyone says that. One of my guests they say that so I stopped playing with it. It’s so I don’t know. It’s just a natural thing for me to do you know. Every time I’ve been to a long course the instructor at the end says you know what, there’s a sign like when you’re thinking, when you’re in deep thought or when you’re interacting. Occasionally, you do this [Barry]
then you’re, then I’m in trouble because you’re thinking all the time now. [Jaz]
I generally am, my other trademark is really stroking my beard as well. So this is not one of my professors told me about and they identified that and so it’s definitely a trait of mine. So get used to either or video get used to it. Everyone welcome back to another episode with Dr. Barry Glassman, who’s in sunny Florida right now. And we’ve evolved since episode eight, where we talked about AOBs evolved into video. Neither myself or Dr. Glassman has have had plastic surgery which both our wives recommended. But yet we’re still on video. [Barry] You can call me Barry. [Jaz] Okay, yeah, thank you. Barry, thanks for coming on, again, that episode about AMPAs or anterior midpoint stop appliance and AOBs was very well received. It’s had over 3000 listens, you know, counting on Facebook and on through my podcast platform and stuff. So the message is getting out there. Now if you’re listening to this, and you haven’t heard episode eight of the Protrusive Dental podcast, please listen to it because I see it all the time still on social media, bashing these appliances, anterior only appliances because people still think that the posterior teeth will overerupt. We’re not talking about that today, because we’ve covered that extensively and to a good standard, I’d say Barry on episode eight. So I think we’re way past that. But I want to bring you back to do some more mythbusting with occlusion. [Barry] I’m here. Let’s bust it. [Jaz] So let’s, I wanna, Let’s bust it. Absolutely. So the first thing I’m gonna ask you is, Have you ever heard of a parable with the 12 blind men? Does that ring a bell to 12 blind men? [Barry]
My wife also tell did you here a parable of 12 blind men? 12 blind men? No. [Jaz]
Okay, I’m surprised. I’m surprised. But okay. Let me tell you this and the guests a parable. And then from that parable, I think will lead to our first question I’m doing I’m making a fun thing. Okay. So the parable is, this is set, the parable is set in India, and this is 12 blind men walking through the jungle, I don’t know how like, enter through some guide or something. But anyway, they’re 12 blind men, and they come across an elephant. Now, none of them, none of these guys can see the elephant. So each blind person grabs on to a part of the elephant. So we’re talking about occlusion and TMD. But they’re essentially attacking this elephant. Why in the sense that one person is holding the elephant’s leg and says the elephant is about yay big. And I can feel some hard nails and the elephant is almost like circular in sort of cross reference in cross section. And then the other person’s like, No, I mean, the elephant is really hard. It’s really tough. It’s obviously holding on to the tusk of the elephant. And on the other person’s like, No, no, I mean, elephants got like a long dangly bit and a hairy sort of a tail type thing. And no one can agree what this elephant is, right? And of course, that the elephant is being perceived by each blind person based on the part of the elephant they’re touching, and how can we relate that to TMD and occlusion? Well, if you go to a particular dentist, that dentist might say that TMD and occlusion can be treated by finding an interference, deleting that interference and doing lots of funny things to the teeth to realign their jaws. And suddenly all the problems will go away, right? Another dentist might hold on to a different part of the elephant in this TMD and occlusion type elephant, and might say that actually appliance A or appliance B will sort everything out. Another elephant entirely might say, actually, in other dentists, he might actually say, actually, it’s the combination of the chiropractor and physiotherapy and having Botox in the Masseters is what’s the right thing to do. And the fourth one will do a TMJ surgery. So this is the situation I think, and I think that parable represents the current situation. Well, that actually, depending on which speciality or which dentist or which clinician you go to, you will get completely different opinions and none more so than in the whole topic of TMD and occlusion. So what do you think of that parable in relation to TMD? And occlusion? [Barry]
I think we should keep it in India. No, no I show my wife is saying to me, boy, that’s really good. They look at one part. And where’s the, where they, Think about this. What, where is the problem? The problem with the parable, is that we have an actual physical thing at the end. That’s true. It is an elephant. [Jaz]
Yes. And what the elephant represents is what parafunction? [Barry]
Ah, no, I think the elephant represents, unfortunately, TMD the results of knowledge what we’re trying to find. It’s not the cause. I know we can get the blindness here is the puzzle that the cause, but it’s not the cause that they’re coming up with. It’s the end result. It’s that final thing. What is, they’re trying to identify what this is? And the answer is, it’s not just what you feel in the leg. It’s not just what you feel on the tusk. It’s not what you just feel in the ear. It’s the whole thing. The whole thing represents, therefore, the what we’re trying to identify, which is, “TMD” And the problem is, there is no such thing. So while the para, I get it, because were the parable was really good. Were it’s really good, is that what it’s suggesting is that there are contributing factors, that we can do different things and wind up with a positive result. And then what happens is we assume a mechanism, we assume the mechanism based upon what we did, and then assume that that’s the mechanism that was at play, that caused the result. And assume, therefore, that the next person who shows up, the next elephant that shows up that TMD thing, that I can do the same thing I did. Because it worked before, and that’s going to be there for work again. And if I don’t do it, the way I was taught, and it doesn’t succeed, one of two things happen. Either this person’s psychologically involved, and they can’t get better. Because after all, I did it as well as I could have possibly done it. And I know how good I am. Or I’m insecure. And I think to myself, boy, if only I could have equilibrate, as well as the person who taught me If only I could put it in appliances, as well as Barry does, wouldn’t that be great? And the answer is you probably can. But in this particular complicated case, with its own unique factors, the mechanisms the contributing factors may be different, even though we identified it as an elephant. [Jaz]
Absolutely. I think I told my story a little bit wrong. I think that in the story, the way I read it, I’ve been trying to find this website where I read this parable initially, and it was on like this TMD type website, but I like the story better in the way I read it because actually, the elephant represented para function. And everyone’s trying to treat a different thing. But it was the story that the author was trying to make the connection was that actually we need, the parafunction and the trauma that results in the anatomy from that be it the muscles that take a hit, the teeth, or the joint is the parafunctions, the main thing that we need to help. So that was that and to what degree do you think is everything is responsible and all the problems that we face is from parafunction and you know, in the dental TMD, occlusion type things that we’re going to be talking about parafunction has a huge role to play [Barry]
In my way of thinking there are those Jaz that don’t agree with us. There’s a big movement in Italy, led by a dear friend of mine, Daniel Manfredini. And they’re spending a lot of time accepting the fact that parafunction may play a role, but don’t really think that appliance therapy has much of a role. And they’re looking more at access tooth, they’re looking more at psychological component, and which blows my mind, because when, you know, most of the damage that the general dentist is looking at isn’t significant pain, it isn’t significant headaches. They’re not the secondary care patients that I saw on a regular basis, the general dentist sees the wear patterns that you see, the general dentists sees the initial joint dysfunction, maybe some limited joint pain, but more clicking or low grade discomfort? This is what the general dentist is seeing. And don’t you know, I’m having a little trouble dealing with someone telling me that this is, these are access to patients. These are psychologically and this is a physically damaged joint. You can identify. And and we can do. And how did it get that way? And what we know is that it got that way always as a result of some sort of trauma and the absolute absence of trauma, these joints, these ligaments, the tendons, joints, that they don’t get damaged. And so they get damaged, not from the forces of function, but the forces of trauma. And that trauma can be micro trauma, which is the parafunction that you’re referring to, or macro trauma, you know, your wife punching you in the mouth on a regular basis that says that awful, [Jaz]
or road traffic accident or [Barry]
A football injury, for goodness sakes, you know, so super, you’re supposed to be impressive. I came up with football rather than soccer. So yeah, I think from a general dental standpoint, parafunctions are incredibly important and so easy, as we’ve learned to control and but that’s what the that’s a greatest frustration. I think, at one point in my life, Jaz, I really thought that I was going to be able to, I noticed outs, I thought I’d be able to help my profession more than I have. And I, in some ways really looked at my career of a somewhat of better, only because I thought I could make the restorative gurus understand that what they were teaching was extremely important. What if we would just add this simple parafunctional control concept? That is, you know, the we have study after study that shows with decreased forces with anterior midpoints, up from Hitori up to the Becker, I mean, it just, it’s over. It’s overwhelming the predominance of the evidence. And why not apply that to protect our patients and the dentistry we do for them. It makes no sense to me, and I thought it was so simple. But it flew in the face of them trying to make this restorative pain dysfunction connection. And they wanted to teach the player a greater role as though the craniomandibular system is dominated by teeth, it’s dominated by teeth, because that’s what we see. That’s what, you know, the chiropractors thinks it’s dominated by your cervical spine. You know, the neural [Jaz]
and the physiotherapist will think something different and these are the people who are, these blind, we are all the blind, you know, men in the parable. [Barry]
In fact that the neurologist thinks it’s all you know, it’s neuromuscular, it’s controlled by the brainstem. And, you know, we, in dentistry, tried to create these mechanisms that we talked about. Neurology doesn’t do that, ask an neurologists the cause of a common headache, and what will they tell you? [Jaz]
I hope they’ll say dehydration. [Barry]
No. Well, the reality is we don’t know you know, it’s dehydration as you’re drinking and I’m drinking coffee at causing increased dehydration but the reality is, is that there are many contributing factors. We’re still battling over what a migraine, the physiology of the actual migraine, it just changed three years ago, we no longer consider it a vascular headache. It’s fascinating, right? So that we all know a lot about science that we don’t know. But there’s very little about dentistry, we don’t know. And so dentistry needs to find answers and it creates the very mechanisms we just explained, because they want to feel good about what they want it, they want to be able to look at a patient says, You have TMD. This is what I do for you, I put Botox, I’s adjust your bite, I’d use flat plane appliances, I’d use a Tanner, I should know because I’m well trained by Dawson. And and I see an increased influence of, of the restorative gurus By the way, in England, which is fascinating to me. And there is a certain I don’t mean to be offensive, but there is a certain arrogance to knowing all the answers, and the day and looks at the rest of us dentistry. Like we’re the stupid ones, we don’t understand what interferences do what and how important your position is and we don’t understand fencing and some really absurd when we look at the science myths. And that’s what we, my goal in my teachings is to truly simplify this for the general but it’s not that complicated. Truly simplify this for the general dentists not so that you treat migraines not so that you wind up treating, you know, advanced headache, any referral patterns in oral facial pain, but that you can look at the you’re at that patient who is starting down that road and you can make a recommendation, it’s so simple. And really help them, really help them and then get to use your brain in a positive way. And but you have to unlearn these things that are being brought across the sea. And the old [Jaz]
Any example to make it tangible to listeners about the most common things, misconceptions that people initially when they come on your course that they have. So what are these common myths? Because there’s a common question I want to ask you about parafunction control. But before we get to that, hat is the most common myth that you’d like to bust? What’s the main message that you want Dentists to get from this episode? [Barry] What do you think it is? [Jaz] I think having been on your course which was a great for changing my mindset is that occlusion doesn’t matter. [Barry]
Watch your occluding [Jaz]
Unless you’re occluding so basically those who have been on Barry’s course I strongly suggest going up. That’s not to say that in this my opinion, Barry okay. That’s not to say you shouldn’t learn how to do a full mouth rehabilitation it for those who want to do itin the gold standard way. Because when you’re reconstructing the dentition, you want to set it up so that you have a mechanical advantage within your dentistry in case the patient, all my patient at the end of her reconstruction again, a night guard, wheter an NTI, SCi, FOS whatever, you know all the appliances I use. So they would get an appliance because I know that their parafunction will most likely still continue because we know that putting their jaw into centric relation will not stop there bruxism. Doing fiddling around with all interferences will not stop them from still parafunctioning. So if their parafunction before on their natural dentition, and they destroy the natural dentition. And then when you give them a full mouth rehabilitation, it’s going to continue, right? But the whole reason we learn to do it in that way is that in case they forget to wear the appliance, but things are in a mechanical in aadvantage for you the forces are low. So that’s what you know that’s an important part of it as well, I think for those who are giving the people the dentistry they want. [Barry]
So therefore, the message that you just expounded upon better than I can was that we build occlusions for function as opposed for parafunction so that the [Jaz]
Other way around, right? Other way around, we build the occlusion for parafunction. [Barry]
For parafunction. Not function. I’m sorry. Right. So thank you. So that this concept that I want even context all around to distribute the forces is nonsense. [Jaz] Yep, absolutely. [Barry] That’s the myth. I don’t want forces to exist in the first place. So the first myth is that or an understanding the first big piece that’s really hard to accept is that maximum intercuspation is pathological. Yep, We test tap tap tap, shouldn’t happen. May does a study that shows that there are some form of dental contact in a 24 hour period in a normal patient who may parafunction. 20 minutes out of the 24 hours. Now that dental contact is not MIP, that’s incline to incline that’s the devil touching when you when you do it in some way that you could never ever predict, you know what you check when you check occlusion, You’re not checking in any way shape or form how somebody chews. It’s impossible. [Jaz]
Absolutely. So you know, I learned that on your, Sorry [Barry]
That’s the first myth. [Jaz]
Teeth shouldn’t be touching in the first place. [Barry] That’s not why I want it. [Jaz] Absolutely. In this studies go back to the 1960s, I believe is a Graf, G-R-A-F, that showed that in the classical study that in the way that they found that was like 17 minutes and a half minutes in a day that teeth should be touching and and some studies expand on that, that in your sleep, it should be eight minutes. But Barry, the reality is that I think I see wear patterns in about 90% of the patients. I do I see all the time. And it’s because I’m looking for it. There I see it. So I think for whatever reason we have, you know, the populations that we see our parafunctioning a lot. The issue is that people are keeping the teeth together for longer than the average 17 and a half minutes, that’s the problem. [Barry]
And the reality is that all of the people who claim they were stopped, let’s just say you’ve got a patient who’s got facial pain is and joint clicking, and you do an equilibration. And in three months, they no longer are facial pain or joint clicking. The assumption is therefore what? My patients stop grinding and clenching, because they’re better. And the reality is that when ever that was studied with EMGs, there was no change in the initiation of muscular activity that brought the teeth together, while they should be totally separated at night, as the muscles become more and more relaxed as we go deeper to sleep. So what is it that happened? You change the force vectors, when they in fact did parafunction that got them within their adaptive capacity? [Jaz]
Yeah, absolutely. [Barry]
So and we can create ideal force vectors with anterior midpoint stop. And that’s the end of you know, it’s [Jaz]
You’re right, so you know, the anterior midpoint stop appliance can create the ideal force vector. But the word you use and the or, you know, it’s good that you say is that it’s parafunctional control, right? But I don’t want people to misinterpret that you’re not controlling the parafunction, ie, you’re not stopping the parafunction in most people. Right? You’re controlling the parafunction, you’re managing the parafunction, you’re localizing the parafunction, if anything, and then you’re improving or decreasing the force levels being produced by the muscles switching off, but the parafunction largely still continues. Right? [Barry]
So that’s like, 100%. Right. And I think that points out to me, that I disagree with you. My term of parafunctional control isn’t good. It is problematic, because I never thought about that. I never thought that it would make someone think that I was suggesting we could stop parafunction. Parafunctional control plane, [inaudible] [Jaz]
When I first came across it. It was a Pav teaching. S4S in the UK at the time. And when I came to his lecture that I must have been a student at this time, right? And I literally thought saw the lecture title. And I thought, okay, we’re controlling it, you know, this, there’s going to be finished in a way. So how can we stop the para function? So yeah, but then I learned that, you know, we’re controlling it, we’re managing. [Barry]
We’re controlling the forces as the result from. So I need to rethink that. And when Matt listens to this, I want to change the name of the course. And I’m teaching this weekend I leave tomorrow. For for St. Pete. I’m teaching a two day course with Jim Boyd, who is the creator, the inventor of the NTI. And he came to me said, Well, what do you want to call the course and I said occlusion and parafunctional control for the general dentists. They said, Oh, that’s great. And I gotta be honest with you. There are I have many weaknesses. Some of them I don’t want to discuss right here. But unfortunately, my wife’s not in the room because she will quickly discuss them. So I have I have many weaknesses. No one has no weaknesses greater than my inability to properly entitle a course. I just suck at that I just I could never come up with good titles. And the one I thought I had, thank you very much because they pointed out to me that it’s not so good. [Jaz]
That was not my intention. That was not my intention that was just in case any young dentist out there thinking, Okay, this appliance is going to stop someone’s para function. No, it’s not we’re just in your way controlling it, we’re reducing the forces, we’re changing the force vectors, were then creating an environment whereby the patient can start feeling better if they are symptomatic. Or if they’re not symptomatic, then they can be protecting, depending on the reason that you’re using the appliance. [Barry]
We reduce, we often many. And this also upsets a lot of people because I don’t think is, you know, keep in mind my practice, Jaz, my practice was truly secondary care, severe pain patterns, oral facial pain, migraine patients that were reconstituted to a board of and preventive therapy. Very, very complex, complicated patients. And a great number of them got significantly better. We are there. Not all of them and not. [Jaz]
And by your therapy, you mean usually like an appliance, right? Like, [Barry]
Almost. That’s absolutely fascinating. So when you look at a history of mine, like someone like me, that was that’s an old codger and started doing, started looking into paint therapy for dentists as the dentist in the late 70s. So in the late 70s, we really didn’t know much and we were taking every job. We were shoving them back guys with Niles cache, and we were taking the jaw and deprogramming it and then shoving it back to we heard a clunk, putting the condyle in the external auditory meatus and then and adjusting the bites. And some of our patients got better. When I met Harold Gelb, Harold Gelb said to me, no, no, you know, you can’t, you’re putting the condyles in the wrong place. And he made mincemeat of me at a lecture at Temple University in Philadelphia. And they met me afterwards, they took me to dinner, and he said, Barry, you’ve got potential. And I worked with him for seven years in his office. And then when I realized that what he was doing wasn’t quite as successful as he claimed, he was [Jaz]
Because the Gelb appliance is literally the opposite appliance of [Barry]
So yeah, and then I started studying with neuro muscular people, I was tensing people and making them you know, AM, but when I was with the people, when I was with the, and then with everybody else I was using, at that point, we were learning, teaching deprogrammer 6 to 11, which is opera three, opera three to three. And we’ll put those appliances in and then then it came back and said, Oh, we got to take these appliance out, they’re going to cause trouble. And I said, Okay, and I took the appliances out. And in my private practice, what I found was all my patients started that pain again. So without telling them I start putting appliance back in this is about when I meet Jim Boyd, and Jim Boyd’s going, Oh, my God, this, this, this, and then you have to do this, you have to do this. And I met afterwards, after his lecture. I said, Oh, my God, it’s amazing. He said, Well, did you find that you have to, for example, you can’t let the canines touch. I never thought about that. But I lied. And I said, Oh, yeah, you can’t let the canine flex and then I went home back to my practices. No canine contact. And lo and behold, what I then all of a sudden, I make this realization as we’ve learned all this stuff. I mean, I’ve learned how to diagnose, I do blood studies, we do all the things you’re supposed to do. We know when you’re supposed to do imaging, we don’t because these are advanced patients. But when the simple ones that the beginning it gets so many simple cases was the click, was with a degenerative joint disease, there was some oral facial pain, some style of mandibular insertion, gnosis, some referred pain patterns from sprained ligaments, these were easy to fix. I would give these long treatment plans, and it started with an appliance and then come back three weeks later and said, Okay, now we’re going to start the supportive therapy and the patient would say why? As we want to make it sound better. [Jaz]
So it’s what in the US a lot of dentist called phase two, right? So Phase One is the appliance, and phase two would be a six figure. [Barry]
This is still phase one. And so this was supportive therapy. I never ever did phase two where I told people you got to you’re now in a new job position. That’s then neuromuscular concepts and I knew all while I never ever recommend that. So having said that, but but even in phase one was more complicated. And then I was it suddenly struck me it. These patients didn’t need me. They didn’t need the background I had. They need the training, I had in sleep and pain. They didn’t need that. They needed a dentist who understood parafunctional control. And if a general dentist could do that, then they could send it to me for the supportive therapy that they wouldn’t need, but they would already have been started with the appliance therapy that for the most part, got them all better. [Jaz]
So for the most patients, for the simple patients, they would get better with the appliance with their dentist. And what I want to know now is what kind of support therapy adjunctively do you think well? [Barry]
Okay, so [Jaz]
I mean, that might be a complicated question, because it really depends on the exact diagnosis. [Barry]
So I’m not going to go into our patients with Ms or MSIS patients or patients with more complicated altered autonomic system responses, I’m not going to go into that, I’m just going to talk about that patient with a degenerative joint disease. So the patient with degenerative joint disease, there’s no better way to treat them, interestingly enough, than with an anterior midpoint stop appliance even though one of the big messes we have to fight is that you can never use an anterior midpoint stop applaiance in a patient with a joint problem, because you’ll compress the joints. Well, the study after study we showed us in the course shows that that’s not the case, that we don’t compress this concept of taking the condyle with no posterior support. And that, and therefore, allowing the condyles to move up and back into the retro discal tissue doesn’t happen. And we have tomographic proof of that. [Jaz]
And because I’m a real geek, I respect and I agree with that. But the I like to find out why and the you know, the nitty gritty of each bit. And the way I rationalize that was the function of the anterior temporalis a vector that does actually doesn’t allow it to go all the way back. [Barry]
So the anterior temporalis is a little more vertical. But the masseter temporalis is extremely anterior. Remember, the origins is the inferior [Jaz] Yup, the zygomatic [Barry] the zygoma and it’s hatching. So the attachment is really, so so when you combine, you add the force vectors, your physics, finally physics, [Jaz]
All the physics A-level everything. [Barry]
So but when you combine the force vectors, it’s Furthermore, remember what we were taught another myth is the first 20 millimeters of opening as pure? [Jaz]
Rotation? It’s not. It’s translation. And, you know, I think MRI has shown that right? [Barry]
Translates immediately. Yeah. And it makes sense, because the lateral pterygoid is in contracts at the same time that the other. And so if when it contracts, the only thing the condyle can do is move forward. Well, as it’s moving forward, how in the world is it going up and back? Because it’s move forward, because there’s something between the teeth, you’re not allowed into full closure. [Jaz]
I didn’t think about that. So that really scratches that itch your head in a really good way. So that’s brilliant. So not only is the vectors of the muscle, which I already sort of had in my head, it’s also the fact that actually the lateral pterygoid is already activated, because you’re slightly open. So it’s actually giving that sort of anterior position of the condyle. [Barry]
Right. I’m not sure the turbos activate it, but it’s not allowed. [Jaz]
It doesn’t allow it to go all the way back. Yeah. [Barry]
It can’t go back. And we see that we, when we take someone with a just as a deprogrammer, just I’ve just an NTI or SCI, we put it we take a picture of it, the condyle’s down and forward. We didn’t bring them forward. No. So the answer is that of that. So with the general cases, we now what else do we want to do? Well do we want to go on, if it’s severe pain with a general case, we want to put them on steroids for a short period of time, we want to put them on AdSense for a short period of time, do we actually want to we use a process called iontophoresis that uses electrical current and the process that is the concept that likes repel, so it goes two phases, the positive and the negative phase and the positive phase forces the lidocaine, which is a positive charge, local anesthetic through the tissue into that and then negative forces, negatively charged which would be the steroids and so we can get steriod into the joint without an injection. So we can treat them with six sessions of iontophoresis. Put them on. Again, the splint therapy which everyone will think oh my god, you’re crushing the joint and degenerative disease gets now under control. And with less pain and less dysfunction. [Jaz]
Now what about the role of massage and physio? [Barry]
Okay, so it’s interesting. Don’t get me wrong physio can be very, very helpful in some cases, I personally have found and teach that muscles are overrated, ligament insertions are underrated. So, muscles tend to be the ones that are doing the pushing. They don’t tend to get hurt. We don’t even understand muscle pain very well, we know that there’s an increase in glutamate, for example, in patients with muscle pain, but we don’t really understand much about how muscles and why muscles hurt. And to be honest with you, there aren’t many people when I palpate, the masseter, despite pain, reported pain words that are hurt here. When I palpate the masseter and what do they say? ‘A can feel little bit more that what my grandmother does. They love that.’ [Jaz]
Temporalis, oh, that was really good. What’s your hourly rate? they say. [Barry]
That’s exactly it. You know, I don’t worry if you find a source like that’s why they’re getting into your temporalis. No, anterior temporal headaches are not sore anterior temporal muscles. And so I think muscles are overrated. And muscles are the ones that you know, if you’re standing at the edge of the cliff, and someone pushes you, the object now wouldn’t be to fix the pusher. It’s the treat the damage that’s done as a result of the pushing. We tend to look at the pusher. I don’t think the pushers are the issues. [Jaz] Interesting [Barry] though, is the and again, so physiotherapy can really be helpful in patients where we’ve reached our limit, then we want to increase the range of motion. Physical therapy can be really helpful because some dentists don’t want to do the iontophoresis, do the ligament insertion injuries where we do a lot of injection therapy on those patients. And we really, you know, I used to show those extra those clips of me doing these [inaudible] or ligament insertions and masseter insertion, insertion injections, but I don’t show them anymore because I, the legal world’s gotten kind of interesting. And he I don’t want anybody getting in trouble because of what I taught them. And the use of extra oral injections in some in the states and some, I just tried to defend some really good practitioners in Sydney, Australia, because they were doing trigger point injections. Now, I’m not even talking about trigger point injections. I think they are really overrated. And I may think that because I may not be as good at them, as some other people, I just wasn’t. Personally I couldn’t find the trigger points as readily as some people claim they could. [Jaz] Interesting. [Barry] Let’s say they didn’t, I’m saying, I’m not talking about them, I’m talking about me. And I didn’t get as positive response from doing trigger, as I did from ligament insertion injections. So we look at [inaudible] mandibular, the masseter insertion. And the major insertions in the posterior cervical. A lot of our patients that wake up in the morning and they say, did you wake up with a headache, is it? Oh, yeah. Where is it? At that point right here, their point right to the attachment to the end of the line. And it’s fascinating because when Lavigne’s group, Kato did a study what they showed was right before, these muscles contract, the temporalis master contract, right before that happens, the depressors contract almost as in an attempt, careful, I don’t try to predict why God or Darwin’s doing what they’re doing. But almost as though to protect the structure so that you don’t slam. It raises the mandible for the masseters and temporalis when they suddenly contract at the same time. Thus, posterior cervical muscles contract. And they stay contracted in what we call isometric co contractions during the clenching activity. Well, when you’re pulling like that constant contraction, where’s the injury likely to take place in the muscle itself? no. We’re the at the enthesis, where the muscle attaches to the end for nickel wine, [Jaz]
and I believe whenever I’m doing a muscle examination, you know, I’m not expecting to find a positive result when I’m actually massaging the meat of the muscle is always at the origin and the insertion where you know, you’d get a positive if there is a true positive response, right? [Barry]
Exactly. So we palpate the origin of that the deep cervical capitus. Here we showed people how to do that, and that injury is the most common one to improve with parafunctional control. [Jaz]
I’m actually learning a lot even though I already thought you know what I’m getting the hang of it, then you throw new things out there. So yeah, muscles are important. But ligaments may be even more as what you showed showed that and ligaments and PCs. And so that’s very interesting. [Barry]
I think of all the things we talked about today, I think the thing that I would like, if someone said to me what was a message that you are hoping that someone watching this is getting? And what that message is, is that we as dentists shouldn’t be afraid of unlearning, and learning about occlusion, that it’s not as complicated. It’s not as complicated. The answer is, we don’t want people occluding, and we’ll show you how to protect people from doing that. And sometimes a flat plane appliance is the right appliance. Sometimes a Tanner appliance might be the right appliance, more often than not, anterior midpoint stop is appropriate. And we show you why and how, and to understand that this is not for the pain specialist. This is not for the guy that wants to treat migraines, though, would be awfully nice if some of your patients migraines, decrease in intensity and frequency as a result of your therapy. But I would never make that promise or may never make that diagnosis as a dentist. Those bruxism, nocturnal parafunction. [Jaz]
I think it’s important to communicate in the correct way as dentists to our patients because we’re not here legally, we should we can’t be treating these these migraines, so we should be very much say Look. It’s interesting, that get these migraines, I wanted to help treat your reduce your forces, because I don’t want you to hurt your teeth and hurt your jaw anymore. Let’s see how that goes. Some patients help some patient doesn’t. But I’m not treating you specifically for that I’m treating other things.’ [Barry]
The good news is that while we protect your teeth and your jaws and your joint, a lot of our patients with migraines tell us they significantly decreased in intensity and frequency. Let’s keep our fingers crossed. Wouldn’t that be great? Hello? [Jaz]
That’s a good way to put it. There’s actually so many questions, but I have to cut it short because we’re already coming up to the almost 50-minute mark. It’s very easy chatting to you, Barry. So I’m going okay, so you touched on the occlusion course stuff. So I’m hoping to come see you in Glasgow in June for the part two because I’ve done your part one, but I’m gonna do the part two as well in June. I think you’re in Glasgow and in London? [Barry]
Yes. So we’re in Glasgow, I don’t have the dates right in front of me. You could have them. But the day [Jaz] I’ll put them on. [Barry] That’s great. And the dates are. So there’s a two day in Glasgow, where it’s a one day the lecture and then the second day is the hands on. And then we move the follow, that’s a Friday and a Saturday. And then we move to London the very next week and we’re in London doing the exact same thing Thursday and Friday at the BDA [Jaz]
Brilliant, so then I’ll make sure the details are there. So one more question. I thought of it that some people say that you shouldn’t prescribe an anterior midpoint stop appliance for someone who’s got clicking. So anatomically, I can see where they’re coming from, because that is disc displacement. So the disc is now a usually a bit more anterior. Not always because it’s a bit more complicated than that, because it could be lateral pole and the medial pole could be fine, then Henceforth, an anterior midpoint stop appliance should not be contraindicated. I know over a video even podcast episode. For those who are new to this and learning about this and anatomy. They’re like, what the hell am I saying, and I’ve been there, but I think want to learn more about this. The Anatomy, I think once you learn the TMJ anatomy, you can really visualize it better, but in that same scenario where you have anterior disc displacement, and you do get some degree of seating just from the lateral pterygoid relaxing, right? With the anterior midpoint midpoint stop appliance, there is a potential that it could be impinging on retro discal tissue. My thinking and please correct me if I’m wrong, Barry, my thinking is that a lot of times because the muscles themselves are reducing in force, that doesn’t seem to be a significant issue. [Barry]
I don’t even know where to start. I have to unpack that. Okay, so let’s go back. This disc is fibrocartilage. Very bony like, and it’s attached. If I can show you it’s attached. This is my condyle. It’s attached on the media pole and a lateral pole. It’s attached anteriorly by the superior head of the lateral pterygoid, right? And posteriorly what’s called a retro discal lamina, we used to call it a posterior ligament but that’s not really ligament and is irrelevant right now. And then when I this thing is well tethered. Wherever it goes, there’s a if your compartment, the superior compartment and it stays well tethered, and it stays interposed between the condyle and the glenoid fossa. And it’s smooth and as the temporomandibular joint ligament around it, [Jaz]
And the lateral collateral ligament. [Barry]
And this is similar other synovial fluid. There’s a lot there’s a temporal mandibular joint ligament around the whole thing. This is a lateral collateral ligament, this the medial collateral ligament, okay, so that attaches it at the lateral pole, and the medial pole. Okay, lateral pole and the medial. Lateral pole. Medial pole. Now, the superior head of the lateral pterygoid runs medially, because it attaches that the lateral pterygoid [inaudible] sphenoid bone, which is closer to the midline. So when it contracts, it tends to do damage to more often a lateral pole. And when it does damage to the lateral pole, the tethering is now altered, it’s weakened. And here’s the thing about ligament damage, it tends to be permanent. It doesn’t heal. So now [Jaz]
It doesn’t heal, and also the only way south I mean, it can only really throughout someone’s lifespan over the next decades, decades, decades, the eventual and I’ve heard some people say this eventual pathophysiology is that eventually, if the forces aren’t controlled, and the micro trauma continues, then it can only get worse and worse and worse [Barry]
And just keep in mind that a third of our patients who are adults without symptoms, have internal injuries that are significant. So I don’t want to overstate the need to stop this from happening. And there’s, we go through, in the course we go through how to make a decision whether or not someone needs to be treated. And it’s simply because they’re clicking. It’s just not that simple. So now this disc tends to be anterior and medial just tends to be that way, because the lateral pole is been compromised. And if it gets that way enough, there’s a big thick poster rim. And then when you open, the click is the reduction, the rim coming back over the condyle. That’s what makes that click. Now, how did it get that way? Well, it got that way through some sort of trauma to this lateral pole. You’re right. If we don’t stop that trauma. Will this get worse? And the answer is? I don’t know. [Jaz]
Back to episode eight. Well, you know, I don’t know. Yeah, that was a revelation. Absolutely. It’s not. [Barry]
I don’t know, I can’t say. Is the patient still grinding? Clenching? I don’t know. Because they’ve got wear patterns on their teeth, does that mean they’re grinding and clenching? No, that means they grind it and clenched it, but it’s not time stamped? I don’t know. So now the patient’s reported, you know, lately, the click is getting worse. All right. Now, I don’t care where this disc is, what’s causing the click? Forces. What do I think? I think they’re grinding and clenching. Where are the forces greater? More disruptive. During eating or drink dysfunction, during parafunction, so if I can control the parafunctional forces, that patient may be able, it’s fascinating, maybe they believe I very rarely need to tell a TMD patient with joint pain, you need to eat soft foods. It’s very rare. Because most of the time, those aren’t the forces that hurt them. Now, if they’re damaged enough, until they get better. Sometimes that’s necessary. It’s often usually not. That if I can, so wherever that I don’t care what condyle, it could be medial, it could be, If I can decrease the forces, I go into anterior midpoint stop. [Jaz]
Yep. So yeah, that’s sort of what I thought but you explained it so much better. So it’s basically we’re decreasing the forces. And that in itself, will mean that the sort of what’s happening in the anatomy, which is, you know, we know, like we said, right, the beginning of this episode, that actually, there’s only a defined position, the condyle can go, it won’t go all the way back. [Barry]
And this is interesting. Jaz, what happens now in two months, when the patient says, Dr. Barry, I don’t have pain, and I stopped clicking. Okay, what happened? [Jaz]
So one of two things could have happened. One of a lot more than two things. Okay. So disc could have come back unlikely, I think because like you said, [Barry] Let’s throw that out. Okay? Go. [Jaz] Okay. So yeah. The disc won’t come back. The other thing is that the posterior band has thinned a bit. So maybe it’s changed morphology so that the click is much more subtle. So it’s not audible to the patient as much. [Barry]
That is really good. So the number of people that would have come up with that I have to tell you is real. So for those that are listening, what Jaz need said the posterior band, what he’s referring to, is the posterior rim of the disc, The posterior rim of the disc, which was responsible for that clicking because it was so thick. That is if you decrease the forces, and now they’re no longer destructive, but they’re within the patient’s ability to adapt. Part of that adaptation becomes remodeling of the posterior rim from the pressure, instead of doing damage to the ligament, it now is altering that disc that change the direction forces, and now that this is recovering, but with less veracity, and now no noise, really good, really good. Some people would say all now it’s disc displacement without reduction. And you’d say No, because there’s been no change in range [Jaz] opening. Exactly. [Barry] There wouldn’t be a change in range of motion, suddenly, as a young professional and a younger person. [Jaz]
You know, as much as I don’t want to be known as a TMD guy, but the more I spend time with you, it’s like my inner geek coming out. But it is one of those really interesting joints. It’s one of most fascinating joints, the body and I can’t stop learning about it. So it’s great, and to help our patients with parafunctional control, which I believe is the biggest source of consistent trauma to the joint, is a great thing to be part of. [Barry]
Yep. Very good. All good. Always is. [Jaz]
Barry, thanks so much for coming on this, on my show again. I’m have to bring you back again, because the next time because I had some questions about sleep and airway, and I had so much with time is of the essence, my friend, [Barry]
Can I tell you that we really should do that, because there’s an awful lot of myths out there. And people making a big deal about something that can be very, very important. But like everything else, there’s that knee jerk reaction to make it more important and more difficult or complicated than it really is. [Jaz]
Well, let’s make that happen. And I’m just going to leave a three words, that’s going to make you probably feel sick inside, I imagine, okay. And it’s an airway, websites, orthodontic practice marketing themselves as providing airway friendly orthodontics. [Barry]
It’s sad, it’s really, really sad and please don’t underestimate the incredible value of understanding the role of functional therapy in our younger patients, and the potential that it has. So I don’t mean to underestimate that in any way, shape, or form. But it’s our professionals habit, to take some good information and put it, take it out of perspective and make it a bigger deal because you can sell a course with it or you can or you believe in it. People often ask me, do I What do I believe in? And what’s my response to that? You know that, What do you care? I’m the, Who am I? You know what do I mean, but it’s not a matter of what I believe. You know, I went through all that when I went through camp after camp after camp and what and suddenly I realized that belief means religion and religion is cultish. And it has nothing to do with the science. What, if you asked me what the predominance of the evidence is? I’m very happy to tell you. If he asked me what I believe, what do you care? And unfortunately, they walk into these things. They want to know what is the belief and the people creating their own belief systems and the role models and their own techniques and their own you know, it’s very disturbing. [Jaz]
Well, we have to come back to cover this sort of topic one day. It could be very very good to do so. Enjoy Florida, and I think I’ve done quite well. I don’t think I touched my moustache. [Barry] Is that why you are [inaudible] [Jaz] I don’t know what that mean. I don’t know. I don’t know what that means. [Barry]
It’s good. Oh please I hope to see, if anybody’s actually listening to this. [Jaz]
You made it this far through our TMJ mumbo jumbo then well done firstly. [Barry]
We were very excited about this London trip has been just exciting to me. I really enjoyed initially when I first came to London, Jasneet, I will tell you that I think my style was at that point was 10 years ago was kind of difficult. They weren’t used to my presentation style, which was you know. And either Londoners have changed, the UK, The world has changed or you’ve been watching the parliament too much and I seem calm. I don’t know. But it’s, I so enjoy coming when people are so eager to learn and I am so appreciative of the difficult world in which you exist. I know the preference of the National Health System, I appreciate that. And my goal is to make your lives better, safely. [Jaz]
I hope to see you in June, myself and I can’t do the London date, but I probably can do the Glasgow one. So I’m gonna take a flight to Glasgow, to you. So I’ll see you then. Barry, it’s nice catch up over a drink. And again, I’m going to bring you back. [Barry] I would love that [Jaz] Brilliant, but we’ll have to bring you back for an airway episode. [Barry]
Jaz’s Outro: Thank you so much for watching or listening all the way to the end. I really appreciate it. Please share it far and wide to your dental colleagues if you enjoyed it, and I’ll catch you in the next episode. Like I said before, I’ve got so many recordings lined up that I’m really excited to get them out. Some really great pediatric stuff, a really revolutionary episode about how to look after your back as a dental professional, which is going to shock you I kid you not. So I look forward to getting all that out there. And thanks so much for supporting my podcast by listening to it and I’ll catch you in the next one.