Stop taking OPGs/Panoral radiographs for TMD…they have limited benefit! In this episode I discuss the Piper Classification of TMJ with Dr Jim McKee from the Spear faculty. We also cover exactly when and why imaging of the TMJ may be beneficial (MRIs and CBCTs). I have found the Piper classification easy to implement and I hope this episode helps you understand it.
Protrusive Dental Pearl: Observe the patient’s path of opening. If someone’s jaw opening makes a ‘V’ shape, that’s a DEVIATION. If someone’s jaw opens, and then it goes all the way to one side, and it doesn’t go back to the middle, that’s a DEFLECTION.
If you want to Download the PDF version of the Piper Classification of TMJ Infographic we made, click here!
Dr Jim McKee is part of Spear Education – a platform that has taught me so much of my occlusion.
In this episode I asked Dr. Jim McKee:
- What is the Piper Classification of TMJ?
- What are the risks of having to rehabilitate someone where you haven’t the health of the TMJ? (19:22)
- Are there any other useful TMD classifications? (21:01)
- Is there any benefit of taking a Panoral radiograph? (24:48)
- What is the difference between an MRI and CBCT for someone with a TMJ pathology? (26:51)
- What type of imaging is best for TMD? (28:58)
- What additional information can a CBCT provide above an MRI? (33:59)
- How do we decide the most appropriate imaging technique? (35:22)
- Dr McKee’s thoughts on idiopathic condylar resorption in adult patients? (32:58)
- Should we be taking routine MRI/CBCT for TMJ health diagnosis? Or only for patients who have a joint based history? (36:62)
- Is there a clinical way to determine which classifications patients are in (Piper III vs Piper IV)? (39:23)
- Is TMJ disorder always a progressive disorder? (40:51)
- How to manage asymptomatic clicks? (42:17)
- Deviation or Deflection as part of full workup and imaging of the way to get the exact diagnosis? (44:07)
- How does the Piper classification influence Restorative management? (47:12)
If you enjoyed this episode, check out TMJ Physiotherapy – When to Refer and How They can Help
Check out SPEAR EDUCATION, a two-day seminar, where Dr. Jim McKee teaches 25% of the course!
Click here for Full Episode Transcription:Opening Snippet: I used to work in the emergency department of a very large dental hospital. This is like a year and a half out of Dental school and I’ll never forget this one patient I had, right? She came in and it’s an emergency that had never seen before.
Like 99% was like acute pulpitis or an abscess. And you know we were doing extirpations and stuff. Now, this lady came in and she was literally like her mandible was all to one side. She was literally all deranged, she was in agony, she’s pointing to a jaw joint, I forget which side she was pointing on now, but she was in absolute agony and just everything about her bite looked way OFF, right? and I had no idea or the diagnosis was. I didn’t know. I had no idea what to do. So naturally what I did.
The first thing I thought was okay. Looks like it could be something to do with the TMJ. I’m thinking TMD. Therefore, what do we do? Why don’t we get a radiograph? Okay? Because that’s we do with teeth, right? We take a radiograph. So, I suggested again O.P.G. okay? So I sent this lady for an OPG. Okay? Anyway, the OPG/OPT comes back and you can’t really notice anything unusual in it. And I show it to my consultant and my consultant absolutely flips to me. I mean it’s like ‘Jaz, what the hell you take an OPG for?” Right? Because an OPG is not going to show you much when it comes to TMD. Alright?
So that was the lesson number one I had several years ago, and I want to share that with you. And on that topic, I’ve had brought on, someone absolutely amazing today is from the spear faculty. I’ve got huge respect for spear education online and what they achieve and their training facility, which I’d love to go to one day in Scottsdale, Arizona. I’ve got Dr. Jim McKee whose real authority when it comes to imaging for TMD and generally about occlusion, you know, and raising the OVD and treatment planning and all these kind of things. So, it’s great to have him on the podcast today on behalf of spear.
Hello Protruserati, I’m Jaz Gulati. Welcome to new listeners. Really great to have you on. And as usual, all my usual listeners, thanks so much for continued to come back for more nuggets and more gems. Today’s gems are all around the piper classification for TMJ. There’s something I teach on my splint course, but I want to hear from Jim who’s been teaching it for way longer and applying it. I want to find out the clinical applications of the piper classification and I’m sure he will do a great job of explaining it way better than I ever could. So, I’ve got Jim speaking about that also about the clinical relevance of little things like clicks. Well, what about patients with asymptomatic clicks? What’s the best way to manage those patients? So, there’s a lot of real world TMJ and that could be related dilemmas that I’m going to give you answers for today.
Protrusive Dental Pearl:
The Protrusive Dental Pearl Have you today is regarding TMJ diagnosis and examination whenever you’re examining your patients range of motion. When you get the patient to open up, you will observe that they make a nice straight-line path of opening. And what happens if their path of opening isn’t normal and straight, it goes to one side. How do you write that in the notes? Simple thing is you draw it. But now these are all digital. So how can you describe it without having to somehow digitally draw it? Well, if the mandible, okay, does a shimmy.
So, what I mean is let’s say someone’s opening up, moving their mandible to the right and then back to the left and down to the middle again, okay, Because the path or the trajectory that if you draw a line from the chin going down as they open their mouth and it makes a little V Shape, think of deviation. So, if someone’s jaw shimmies to one side, it comes back, that’s a deviation.
Okay, now if someone’s jaw opens and then it goes all the way to one side and it doesn’t go back to the middle. Again, that’s a deflection, so that’s how you differentiate between a deviation. The deviation has a V, and therefore there’s a V shape in its path, and deflection doesn’t have V in it, it’s a sort of down straight and then off to one side, and it stays there deflects to one side. That’s a cool little tip to remember in terms of deviation, deflection. and that’s something you should write in your notes in terms of management and stuff. I hope you enjoy this one, guys and I’ll see you in the outro.
Dr. Jim Mckee, welcome to Protrusive Dental podcast, how are you?
I’m awesome. it’s great to be here.
It’s so great to have you on because I’ve been having a look at your presence on spear and the kinds of group as a collective, spear EDUCATION has meant so much to me in my journey. I’m afraid, I’ve never been able to come over to Scottsdale, Arizona yet. But the amount of sort of articles I read on the website, the online membership, all the videos I watched from Frank Spear, Gary Dewood and now being able to speak to YOU. I mean you guys have had a huge influence to me, so thank you so much for making time to come on the podcast today.
Well, it is truly my pleasure to be here. Thank you for having me. It’s truly an honor.
Please tell us for those who don’t know who you are. Dr McKee a little bit about yourself and who you work with. I mean, we were just speaking earlier, obviously there are some huge names, including yourself in the spare faculty. Obviously, I think Jason Smithson from the UK has recently joined your team as well. So, you know you guys got some superstars but tell us about you, tell us about you Dr. McKee.
Well, it’s kind of an interesting story, you know, I graduated from dental school in 1984. And really didn’t know what I was going to do. And there was a woman who was in practice in Downers Grove, which is about 45 minutes Southwest of Chicago, typical Chicago suburb. And she wanted transition or practice because she wanted to spend more time with her children, and I needed to practice. So that’s how it started. But it was a really, really small practice.
First day in practice, I did a root canal or did amalgam build up on number, it would be 37 in the international numbering system. And that was at 8:00 AM, at 4:00. I did a root canal on number 27, and I said, I’m proud to say the amalgam build up patient still the patient in the practice and the Endo patient is why don’t you do endo.
Sounds like me.
But a very small practice and gradually for the first four or five years, I just kind of felt my way through it. Kind of getting my feet underneath me. But I was starting to see cases that were making me uncomfortable. Wear cases SPECIFICALLY. clicking and popping joints specifically. I didn’t know how to treat those because my experience I think is similar to many done this that I’ve talked to are training in occlusion and TMD and Dental School doesn’t lead to a lot of confidence when we get out of school.
So, I ended up, Pete Dawson is a name. Pete was a huge name in occlusion, and I got a seminar, a flyer for seminar that Pete was doing in Chicago, and I took the train downtown to hear him. And I had been out 4.5 years and it was the first time that it made sense to me. From there, I started going down and hearing what Pete had to say and I would take his courses.
A year later I met an oral surgeon that Pete worked with. His name was Mark Piper. And Mark and I became very good friends. So, it was kind of interesting if you go back and look at a lot of dentist, how they got trained in Occlusion. They learned the Occlusion side first and then later they learned the giant part. I was really fortunate because I kind of was able to learn both of those together from working with Pete and with working with Mark. So, in terms of my thought process, I’ve always thought about the joints and the teeth is almost one unit just on different parts of the system.
So, from there I just started basically doing as much CE/CPD as I could in terms of occlusion in TMD. I learned how to image again from Mark early in the 1990s. So, I took my first MRI in 1991 and I started seeing a lot of patients who had these types of problems. I also started a local study club in our community because there were a lot of dentists at that time either going to hear Pete Dawson or going to the Pankey Institute and we were trying to implement those concepts into our practice. So, I started the study club and then eventually the Dawson Academy asked me if I would come down and teach with them. So that’s how I started teaching.
So, I taught at the Pankey Institute, I taught with Pete Dawson for 13 or 14 years, I taught with Mark Piper for 10 years, we ran a study club program and I’ve been in spear for about five years now, I think. So, it’s really been, I never thought I’d be doing teaching or lecturing. It’s been so much fun. I met so many wonderful people and I’ve had a great time doing it. So, I feel really, really fortunate. So recently I have another dentist in the practice, now a wonderful woman who joined us Dr. Courtney.
So right now what I do is I practice 8 days a month and then I’m part of the occlusion seminar. It’s spear education with Frank Spear and Greg Kinzer. And then I teach the advanced occlusion workshop with Gary Dewood. that’s the workshop that’s kind of focused on patients who do have joint problems. And how do you manage those in the regular world? Because we see those patients everyday. So that’s a little bit about me.
As you were talking and you’re mentioning all these giants, in occlusion, in dentistry. Honestly, every time you mention one these guys, I get like a little bit excited. So, one thing to learn about me as I get very excited when it comes to these exact topic. So it’s so, so amazing to have you on Dr McKee because I know we’re going to learn so much from you regarding exactly what you’re talking about. The confusions that we have in general practice about the TMJ anatomy and the diagnosis we can make and how to manage these cases.
Now, we could have gone in any direction in terms of what to speak about, what something I haven’t spoken about yet in this podcast is imaging and how that can relate to classifications and how that can relate to the person in front of you in the chair. So I’m hoping to give us a little bit of tour, a little bit of flavor on that. So my first question to start that off and it’s so great to hear about your history with Mark Piper is obviously some of us who may or may not have heard of the piper classification. It’s something that I’m quite familiar with.
I use it, but I want to know if you just don’t mind just summarizing for the dentist listening all over the world what is the piper classification? And then maybe give us a flavor of if there are any other classifications that use and if they are superior, inferior, just your general viewpoint on that?
For sure. Well, let’s start out with the piper classification. You know, it’s funny Mark Piper is known as an oral surgeon. But honestly, I have to say, I think Mark’s greatest contribution to dentistry has been his piper classification because there’s a restorative dentist what it allows me to do almost instantly is to assess the level of risk that I have in the restorative patients sitting in my chair.
And I’ll get an idea whether I have to worry about potential pain issues in the future or whether I’ll have to worry about potential occlusion issues in the future. So the piper classification is really easy to work with. Here is the easiest way to think about it. If we think about the condyle, there’s a medial pole and there is a lateral pole and there is a disc that attaches to the medial and the lateral pole basically like a bucket handle. There was a ligament attachment at the lateral aspect and there’s a ligament attachment at the medial aspect.
The reason why I like Mark’s classification system in the restorative world and I’ll talk about a couple other ones that are out there too, is because the medial pole for me really becomes an important discussion point because if you look at joint anatomy, the joint socket on the medial aspect offers dense thick bone that’s ideal for dissipating the bite forces that we generate when we function or para function. So, if we can have the loading forces passed through the medial pole, and if we can have soft tissue at the medial pole, most of the time, those cases are going to be very predictable. So, in terms of piper classification, Mark has different classifications.
There’s a piper 1. A piper 2. A piper 3A, 3B. And then there’s 4A, 4B, 5A, and 5B. So, let’s go 1-3B first. 4 separate classifications or 4 separate stages, 1, 2, 3a. and 3b. All those share one common characteristic, the soft tissue is covering the medial pole. So if that’s the case, those cases tend to be very low risk cases for restorative patients and dentists doing restorative dentistry. Because if we have the disc at the medial pole generally, we can dissipate the load very efficiently. And the disc maintains the position of the condyle.
We don’t think about the disc in that way but I really think as a restorative dentist what the disc is and this is a time that I heard Mark say, it’s the holding contact in the joint. Pete Dawson talked about holding contacts at the tooth level so you can maintain a stable occlusion. But that’s basically what the disc does at the joint level. It’s the holding contact with a condyle functions against. So as long as the disc is at the medial pole, those are really predictable cases.
So, a piper stage 1 disc covered at the medial disc covered at the lateral, if you look from the top, the bones completely protected. Normal joint. Easy case. Piper stage 2, beginning laxity at the lateral pole, medial pole is still intact. This might be the patient was an intermittent click. They wake up in the morning, they click for 10 or 15 minutes, and it goes away. Typically, not a lot of pain, not a lot of bite changes. Okay, let’s move the piper 3s.
This is where it gets very interesting because people, often my issue with the piper classification is just like you said, I think it’s really simple, but people, when they first look at, oh my God, there’s, you know, four or five different classifications and they look at the numbers and they look at the diagram and they don’t just pause for a second and just appreciate.
Actually it’s really simple and what you’ve done already is really massively simplified it by saying that stages 1-3 and the definition with the medial pole and the medial surface. That really helps already. So, I think anyone who’s listening and watching the moment can really easily follow along so far, so don’t get confused or don’t let this worry or confuse you because actually it’s a really simple classification. It just gets a little bit exciting here.
Well, okay, so the 3s are related to the lateral pole. So again, everything up 1, 2, 3A and 3B. Medial pole is all intact. 3a, we’ve got a lateral pole CLICK a typical disc displacement with reduction at the lateral pole. 3B is a disc displacement without reduction. So, we don’t click anymore at the lateral pole. That’s it. So that’s 1-3B.
Just before we go to 4 and 5, Dr. McKee because we have a lot of young audience, we have a lot of international audience as well. So can you just clarify for them. What do you mean by disc displacement with reduction? And disc displacement without reduction? Because a lot of people, a lot of young dentists may have not heard this term before. So, if you just briefly describe that as well?
So, a disc displacement with reduction is when the disc is forward and the condyle opens and moves back underneath it. Now in order for that to happen, the disc has to maintain its shape and as long as the disc maintains its shape, then that condyle can get back underneath that disc when a disc comes off the condyle, although it’s important to understand HOW a disc gets its nutrition.
Typically, a disc will get its nutrition from lubrication fluid or synovial fluid being compressed into it. It wouldn’t make sense to have a blood vessel there because you compress the blood vessel when we compress the condyle pushing into the disc, so it gets its nutrition from lubrication fluid. If the disc is not in the correct position to have lubrication fluid would compressed into it, that disc can start to change shape. And if it starts to change shape, those are the cases where the condyle can’t get back underneath it. Reducing is kind of a confusing term.
I agree with you. I don’t like the term, but it’s typically what’s used in the literature. So that’s why I try to tie that because some people will be you know, familiar with that. So here is the easiest way to think about it with reduction means it clicks. Without reduction means it doesn’t click. That’s I think that’s how I think about it. The easiest way.
One thing that helped me as well to understand it is like the term reduces like when you reduce a fracture, you put it together so when the disc is reducing its going back where it belongs on the condyle. So that’s another great way. That’s helped me in the past. Thanks so much for covering that. You’re just about to come on to number 4, I think.
Well now that we understand 3s. Let’s talk about 4A and 4B. Because it’s the same principal, but instead of 3s being at the lateral pole, 4s are at the medial pole. So, a 4a would be a disc displacement with reduction or disc that clicks now at the medial pole, whereas 4B would be a disc displacement without reduction or the condyle cannot get back under the disc at the medial pole. Okay, so similar thought process 3a and 3B relates to lateral pole. 4A And 4B relates to medial pole. And the last are the 5s.
There’s a 5A And 5B. And with 5s just think this. It’s perforated all the way through. So, it’s bone against bone. 5a is acute. 5b is chronic. So that’s really the piper classification in my mind, I think. Is it structurally intact? Which is a 1 or 2. Is it structurally altered at the lateral pole? Which is 3a or 3b. Or is it structurally altered at the lateral pole in medial pole?
Which would be a 4a 4b or 5a 5b. And once I do that, that’s kind of how I think about it, structurally intact. Piper 1 and 2 have low risk factors. Piper 3A and 3B has low to moderate, typically low risk factors, and piper 4A. 4B, 5A. And 5B typically have a higher risk factor because that’s where the medial pole isn’t covered. So as a result, we tend to see an increase in pain or potential bite instability.
Just to make it really tangible for the young Dentists listening is that, what you mean by risk is exactly how you mentioned there.
Like if you rehabilitate someone and you haven’t identified which piper classification or the health of the joint itself, then you’re constantly chasing a moving target so there is a lack of stability and then you get constant supposed bite changes. Is that one of the worries about treating someone or rehabilitating someone who is at a higher number in terms of piper classification?
I think that’s always the concern now, having said that you can work on patients who have medial pole problems. I don’t want people to think that you can’t work on people and I’m going to say something real. Clearly not everyone needs surgery for as a 4 or 5 because that’s one of the common misconceptions as well. All this does is to be able to articulate the risk so you can communicate it to the patient. That’s really what I’m thinking about it for.
And basically, risk generally develops in one of two ways. Either bite instability as you mentioned because the gasket or the disc isn’t there to position the condyle or we’ve got pain that occurs because we’ve got loading uninjured tissues. I mean, that’s the easiest way to think about it.
I absolutely love it. That’s going to really help clarify that.
I think we’ve made occlusion in TMD too complicated because we didn’t understand it because we never saw the anatomy. Once you see the anatomy with imaging, it really takes all the concern away because you finally have a good idea.
Before we touch on imaging, just tell us, are there any other useful classifications that we should consider reading up on?
You know, the two other ones you typically hear about? A research diagnostic criteria that was developed by the American Academy of Oro facial pain. And it’s an excellent classification system in my experience, many times the dentist to use that tend to have an oral facial pain practice. That’s not what I have.
I’m a restorative dentist and I see patients who will have some pain issues, but primarily my referral bases general dentists with either joint cases that are more complex than they want to handle. Or restorative cases that are more complex than they want to handle. I never tried to develop a facial pain practice that was not my intention. So, I know a lot of the people that will use that classification system tend to focus more on facial pain. So, I don’t use that.
I like the piper 1 because I think it relates more to the restorative world. The Wilke’s classification system is the other big classification system, Clyde Wilkes was a fabulous oral surgeon out of Minnesota, and he developed the surgical, he was an oral surgeon and his many times is very popular with oral surgeons because a lot of times it has a surgical approach to it. So, it all depends kind of on what type of practice you have for restorative dentists. And probably most of the people who will be listening to this podcast. I think the piper classification is a really easy way for the restorative dentist to organize their thoughts to be able to communicate not only with patients with other colleagues that they work with as well.
I’m going to make an infographic for everyone to download based on everything. The beautiful way that Dr. Jim McKee explained things. will make infographic.
So, I’m going to help you to remember and maybe stick it up on your practice wall courtesy of Spear and Protrusive Dental Podcast. You’ll always have that, and you know, one or two times you learn it, you’ll always get it.
Hey guys, it’s just Jaz and I’m interfering with this little update because I know how much you guys love to download, how much you guys find these infographics very helpful, like following on from the massive success of the deep margin elevation infographic that we made after the episode with David Gerdolle, which by the way you can find on the Facebook, you can DM us on Instagram @protrusivedental and we will send that to you. But this one I’m going to make it really easy download.
So, this is an infographic, a pdf download with a visual aid and a description basically summarizes this episode with Dr Mckee in a way that is presented quite nicely in the pdf with the piper classification and the clinical implications. So, it’s easy for you to follow along in practice. So, if you want to download this infographic, just head to protrusive.co.uk/tmj and you’ll be able to get your copy for free. Thanks so much for listening, guys. I will return back to Dr Mckee.
And I think it’s wonderful how you can relate it to restorative dentistry. And the best gem there, just to really highlight it is how you can prompt you to communicate risk and you’re so right that, you know, just because someone has a piper 4 doesn’t mean that you can’t treat them. You know, there’s so many more factors. And I love that you said that.
Let’s talk about imaging because it’s so much we can cover this podcast. I want to keep it going. So, let’s talk about imaging. In the intro I recorded just for speaking to you, I mentioned about the story of a lady or I saw when I was like a year out of dental school, she came in and she was completely like an acute pain. Her mandible was completely to one side. She couldn’t get her teeth together. She was in a terrific pain. And at the time I didn’t really know what I was doing.
So, I requested an OPG and then my consultant was like what the hell? OPD shows nothing in this scenario and that’s how I learned at the time. So can you tell us. Is there any value at all or is it a waste of time? Because I know there are different camps in having an OPG or should we always skip that and then opt for other forms of imaging?
There’s something you can learn from any image. So, I want to make sure that we say that right up front. For an OPG, primarily what I would look for in terms of jaw joints is I would look at the ramus length. I think that’s the best thing I can tell at an OPG.
And generally, I can tell us one ramus length is shorter or longer than the other. One almost universally, if we have one shorter one longer, it’s almost the one that’s shorter that didn’t develop as opposed to the one that’s longer that grew more. So, it’s almost always a lack of growth. So panorex’s themselves though in terms of being able to diagnose the condition of the joint.
I don’t have a lot of faith in. Because basically it’s a two-dimensional x ray and any time we work with a two-dimensional X ray, we have to understand that if we take a panoRex and take a look at the condyle, right, let’s say at the lateral pole, all of a sudden this is the only view we’re seeing. The condyle may be very different at the medial pole. So that’s why I think today, I think two-dimensional imaging has some really significant limitations and diagnosis for jaw joints and problems. And today I think that really if we have a patient that we decide would benefit from imaging, then I think we want to look at 3-dimensional imaging, such as an MRI.
Tell us the difference then between an MRI and what information it gives you for someone with a TMJ pathology, which we can discuss and so and why you may offer an MRI versus a CBCT and what additional information that might give you that MRI can’t? And then how do you decide or is it a matter of some patients will need both.
Let’s talk about MRI first, because that’s what I learned first. I learned that from Mark in 1991 like I said. So MRI is basically will show disc position. And if we have a normal disc, if you put it on a clock face, the posterior attachment, that’s going to be approximately 1 o’clock. Now, if you look at the literature, it’s going to say 12 o’clock. But if you really read the literature, what it says is 12 o’clock plus or minus 10 degrees in 1990. When the paper was originally written by [drase] If you look at 1997, it says 12 o’clock plus or minus 30 degrees written by Rammelsberg.
And when you see that type of variation, what it really means is we don’t know what normal is. Well, 2011, Provenzano wrote a really nice article and I think you started to see more people build on that in the literature that when we look at disc position, we really should be looking at the load bearing part of the disc, which is the thin part of the bow tie. If that’s in a normal position, that’s going to be about 11 o’clock because that’s going to allow us to load against that.
That’s going to put our attachment at about 1 o’clock. So 1 o’clock will be normal. 12 o’clock is mild displacement, 11 o’clock some moderate displacement. 10 o’clock is an advanced displacement. So we can tell disc position. We can also tell disc condition. Is it a normal sized disc as the disc started to change shape because it’s not getting proper nutrition? Is it swollen? So those are the main things. The other thing we can see is we can also look at the condition of the marrow space because many times what we’ll see is we’ll see swelling in the marrow space or we’ll see swelling outside the condyle around the disc as well.
So, MRI is going to show. it’s going to emphasize soft tissue from looking a disc position, disc condition and marrow condition. For a CT scan, I’m going to get a better look at the bone. One of the main things I’m going to look at the bone is what’s the size of the bone. Did the bone grow properly? Normal Ramus length. We mentioned that before. It should grow approximately to 65 millimeters ballpark. And again, this is all the concepts that I learned from Mark Piper and also what you should have is a condyle full size that it’s approximately 8 millimeters, anterior to posterior and then 20 millimeters medial to lateral.
So, we can start to gauge our condyle condition. We can also gauge our condyle position because interestingly enough, if a disc comes off and is displaced many times what the soft tissue does is displaced the condyle posteriorly. We many times calling an anteriorly displaced disc. It could also be called the posteriorly displaced condyle because basically what happens is the disc and the bone are fighting for the same space. If the disc comes off and moves forward and the condyle moves back, here’s my question for the restorative dentist, how does that influence the position of the lower incisal edge?
It’s going to make you more class two or open your bite and you’re going to be having an anterior open bite of some degree.
EXACTLY. Any time we see a loss of dimension at the joint level. Either because the condyle moves up or moves back, it’s almost always going to relate to a class two bite shift. Unless one thing happens, unless the teeth adapt. The teeth wear, the teeth move.
But most of the time if we see a change in joint dimension, we end up with a change in the occlusion. That’s why, you know, we’ve made TMD about pain. TMD is really about occlusion almost universally. You will see a bite change before a patient has pain. We’re just not used to calling those class two bites problems that started the joint level. So anyway, back to the CBCT.
So, we look at condyle size, we’ll look at bone size and ramus line and then I’m also going to look at the cortical plate of the condyle because that’s a really important discussion point in the growing patient, we want that to be open so the bone can continue to grow. in the adult patient, we want that to be closed or corticated. So we know we have stable bone. If we think about it the other way, if we see a cortical plate in a 12-year-old that’s already corticated that means they’re done growing.
That’s almost always in response to having an early disc displacement because the disc in the growing patient is there to protect the bone as it grows. And if the disc comes off in a growing patient many times growth will slow down or arrest itself. And as a result, now, those are when we see many of the facially asymmetries, the retrognathic mandible cases we talk about. So that’s where the discussion becomes important in the growing patient. And in the adult patient, as I said before, if you’ve got a condyle that isn’t corticated, those are the patients in my experience a tend to have an increase in pain.
Is that something that would typically be termed as an idiopathic condylar resorption? And therefore, you have this, you know, middle aged lady coming in and she’s developing an anterior open bite which wasn’t there before and she’s getting pain because that’s the kind of stuff that I’ve seen a few emergency settings in secondary care. Is that the kind of thing that you would expect in that kind of a population?
You know, it’s interesting emerging idiopathic condylar resorption in my view is really early onset joint disease. And I think many of those resorption cases are cases that never grew. We just didn’t know because we’re not used to imaging young kids. I mean since I started imaging young kids, I can’t believe how many patients have joint based problems far earlier than we think.
You know again Mark Piper talked about two types of joint problems developmental and degenerative. And I think as a profession, we think that the majority of the problems that occur are degenerative in nature where people grow completely and then break down. I’ve really changed my thinking. I think that many of the cases that we see our developmental and start far earlier in life than we think, and the patient just never grows completely.
By the time we image it we just saw the problem. So, we thought it was resorption. But I don’t think they ever got there. I want to go back to CTs For one second because we talked about the things we could look at. So, I’m going to look at bones. I’m going to look at condyle condition and position. Same thing. I’m going to look at the airway because I want to see nasal airway again. I’m amazed at how many deviated septums we have. I’m amazed at how many compressed pharyngeal airway.
How much compressed pharyngeal airway anatomy there is. And the last time I looked at the upper cervical spine that’s an area that is dentist we can do a great job screening for. And there’s a lot of people who have had neck pain that’s coming from upper cervical spine misalignments that we think maybe it’s coming from the occlusion of the joints. So, in terms of what you get from imaging. Those are the things. So, for MRI disc position, disc condition and marrow space. For CBCT Condyle position, Condyle condition, airway, upper cervical spine.
And to follow up on that, most of the time when I am going to request imaging. I’m going to get both. And the reason is because if I don’t have the MRI then I’m guessing at the soft tissue. And If I don’t have the C.T. scan, then I’m guessing at the hard tissue. And I did that when I was younger. I don’t want to do that now. I mean patients I’ve learned over the years come to you for two things. They want answers and they want options. I can’t give them answers if I only have half the story and I really can’t give them good treatment options either.
So that’s why when I see a new patient my first examination with them is going to be taking a history and doing a clinical exam. And once I’ve done that then we’ll figure out what diagnostic records we need. So, the second appointment will be diagnostic records and then the third appointment will be consultation. My case acceptance increased dramatically after I went to that format because I found if I did everything in one appointment it was overwhelming the patient, I was giving them too much information.
That’s a really great insight and I love how you broke down the MRI vs the CBCT and how you feel that you know they should get both because otherwise you’re missing half a picture. Now you just mentioned about the point about in your practice when you see a patient you have a history examination and then you have your diagnostics and the consultation. Are you routinely taking an MRI and CBCT scan for every new patient? Or is this the patient who specifically has a joint based history or joint based complaint and or has been referred to for a joint issue or a rehabilitation? Give us a flavor of that.
I do not image every patient. So, I want to say that straight up front. Let’s tie that back to the piper classification because that really relates to one image. So generally, if after my history and my exam, my tentative piper diagnosis is of 4A. 4B. 5A. Or 5B. That’s usually want to recommend imaging. So, if I think it’s a 1 to 3b. Then usually I’ll just get mounted study casts and digital photography and do any type of sleep screening. We may need to. But if I think if it’s a 4a to 5b that’s when I’ll go ahead and get the MRI and the CBCT.
That’s very useful.
So that’s how I determine my image. And basically, really from the exam, I think the most two important aspects of the exam are the history in terms of what’s happened at the joint? What type of treatment have they had? What’s your pain history and what’s your trauma history? So those are the four histories that I’ll take. And then really, I’m going to look at the bite. You know again Mark Piper taught me this a long time ago to read the bite. And if we check the bite with the joints in the socket, the thickness of the disc is about two millimeters. If the anterior teeth are uncoupled greater than the thickness of the disc, I’m beginning to think that I’ve lost the disc and the bites uncoupled.
That’s really interesting. I think nowadays when now that we have intraoral scanners, I think it’s going to be great hopefully in the future to be able to not only just rely on photos but scan people’s arches and bites routinely, even if there’s nothing to do with the piper beyond three. But in the future when we know it’s a change and how much more will be able to finally realize that are something has changed. The teeth are the same. So, what’s happened at the joint level?
I completely agree with you. I completely agree. 100%. And you know, we have a trios scanner we’ve been using it for five years now.
It’s likewise. Thank you for all that wonderful information. I think you really explain these terms really well. So, I’m going to really make it extremely clinical and tangible now and there’s only so much we can cover in this sort of podcast format. So, I’ll ask you at the end, where can dentists learn more about this from you. But in terms of actually making, it clinically relevant, here’s some tricky questions I’m going to ask you. And these are tricky not because I’m being awkward, but these are tricky real-world questions that we may or may not have answers to.
So, for example, if you have someone with a 3A. So, everyone remember 3A. That’s when they have a lateral pole. Perhaps that’s with reduction. Okay? And you have someone with a 4a and that’s when your medial pole is involved. But it’s a disc displacement with reduction. Is it possible to clinically diagnosed because they both may present with a click to a varying degree and they’re both with displacement. So, is there a clinical way to determine whether they are 3A Or 4A?
No. That’s part of the confusion because, you know, occlusion at the tooth level is easy because we can see it. Occlusion at the joint level, we can’t see it. So, we have to do our best guess from what we find for the exam. So, if it’s a 3a. I would expect to hear not a lot of pain, not a lot of headaches, not a lot of Jaw locking. Someone who may do pretty well with this. If it’s a 4A and they say they’ve got more pain, they’ve got more jaw locking. Their bite feels more uneven.
That tips me in thinking that it’s a 4a as opposed to a 3a but that’s an awesome question because, you know, for years that question comes up, is there a way to know definitively without seeing? And there really isn’t. So, you just kind of have to go by feel in which case is you think you need to get the additional information.
Is there any evidence or do you know from your history of practicing in this area whereby if you see someone with a piper 2 or a piper 3a that when you follow these patients up, will they remain stuck on that? Or is it always a progressive disorder?
I’m glad you asked that question. It is not always a progressive disorder. You can have patients stay a 3a their entire life. So, I’m glad you asked that. Many times, the classification system is misunderstood as a progressive disorder, but If I have someone who’s a 3a and stable. most of the time, if they don’t have another joint injury, they’ll stay that way their whole life usually.
So, I’ve changed my thinking over the years. I used to think that the bite caused the disc to displace because that’s what I was taught. I really think now that it tends to have more of an injury that impacts the ligament attachment of the disc to the bone. I don’t think the bite causes the disc to come off the way I was taught when I was younger, the old saying was a bad bite would cause a bad joint,
Very good now. So that’s a very good way to think about it actually. So essentially you said there that someone may stay on the 3A their entire life and as long as they’re stable, that’s okay to make that clinically tangible. That’s our patients who many in a 20% or whatever have asymptomatic clicking right?
So, some dentists get very phase and worried about these clicks and then and when they diagnose them and then patients start to worry about their clicks. So sometimes we have a huge role in just reassuring a patient and doing a wider history, wider examination, taking a note of their range of motion and then monitoring these things over time to then help you decide whether it is progressing or is it staying still? Is that a fair way to think about it?
I completely agree with that. You know I see a lot of patients with asymptomatic clicks and dentists get really concerned about it. When you ask the patient they’ve been clicking for 20 years and they don’t have any bite problems. In a case like that I’m going to monitor it. There is a asymptomatic click though that I would say that we should pay more attention to and that’s in the growing female. If there is a 12 year old, 13 year old, 14 year old girl with an asymptomatic click, that doesn’t hurt yet. To me that warrants further investigation.
Only because many times pain won’t develop to the mid to late teen years and many times those patients are patients that have displaced discs and aren’t growing. And if we could re-establish that condyle disc interface with maybe some type of functional orthodontic appliance, we may be label a positively influenced growth. So, if since it is an asymptomatic click in.
That’s very useful to know. That’s fantastic. Next question because I can’t believe how fast time has gone Jim. The next question I have is deviations and deflections. Some patients have deviations, and some patients have deflection. The way I was taught, was a deviation is when they make a V Shape and the deflection is when they just go off to one side. Imagine area of concern and if someone has a deviation or deflection, is that when you are now thinking of having your full work up and imaging as part of the way to get the exact diagnosis?
Well, any type of deviation or deflection is typically because the disc isn’t in the right place. I mean, if you really think about it, deviations are typically where you’re going to open, let’s say you open to the to the right, usually that’s because you’re right, condyle isn’t moving, it’s not translating forward. So, I probably would want to take a look at that if the patient understands there is a problem, because I think we really have to be careful here.
We really have to do a good job with patient education because so many times dentists get more upset about the problem than it really is because the patients really doing quite well and the patient may need diagnosis, but they may not understand why they need diagnosis. So that’s why I would say just be careful and create the value for the diagnostic. So, the patients, they will understand what the problem is. In terms of some type of deflection. Usually they’re coming forward, the disc is in the way and they’re having to go around it. So again, many times imaging would help. But again, patients have to understand what the problem is.
Brilliant. You’re so right in terms of the patient must be able to have enough value, have enough understanding and the importance in their own sort of anatomical terms as to why this could be an issue in the future if unaddressed and therefore that then builds value into the actual diagnostics which is an important thing to convey to the patient. So, I completely agree with you on that and this going to be the final question because there’s so much we can do. I have to invite you back for a part two because being probably useful. I think there’s been excellent.
You have to appreciate that guys Dr Mckee right now is on vacation in a beautiful part of the world and he’s getting up some time to record today. So again, thank you so much. You’re very kind. So, the next question then let me get my list. Okay, so because every patient is unique. Every joint. MRI, CBCT will come back with a unique proposition, but just as a sweeping statement, if possible, for a generic average case, if they have someone who’s getting, let’s say with a piper 3B.
So that’s when they have a disc displacement without reduction and it’s affecting the lateral pole and maybe they’re also presenting with deviations and or deflections. What is your typical regimen in terms of what kind of treatment and they may be looking at? i.e. are you actually looking to change the shape of the teeth? Change the occlusion a way to better accommodate the joint? Or are you generally going to be at that point involving an orthodontist or is it usually something in a removable appliance that you want to get things corrected in first before committing to anything a bit more invasive?
It depends on what they present with. If they have problems, my typical first approach would be some type of an appliance. I do a lot of flat plane appliances. With a piper 3b You could also do an anterior deprogram as well. So that’s the situation. So, it would be easy to do that as well. I tend to do more flat plane appliances for joints though because I tend to have better success having support all the way around.
Generally, if they’re not having any problems and they’re just clicking a lot of times, I’m just going to monitor it to be honest with you. I mean I might do an equilibration if the teeth present with that because what I’m trying to do is to try and maintain and protect the teeth. So, if I could change the low distribution at the tooth level and that would benefit them, I would do that. But I may not do that necessarily simply to treat the joint.
I know there was a really unfair question tricky question cause there’s so much to it and this is why I enjoy this area so much because it’s very fascinating and something that’s really skimmed over in dental school. So Dr Mckee, tell us more, where can we learn more about this? Do you have any seminars that you run specifically about this? Because a lot of people listen this podcast, they often really resonate with the speaker. They really like speaker and I’m always flooded with questions usually on my Instagram saying, hey, that guest you had on, how can I learn more about that? So please do tell us where we can learn more from you.
Well, I would say the best place now is spear education. the occlusion seminar is a two day seminar and I teach 25% of their course Frank Spear. If you’ve not heard Frank Spear, go hear Frank Spear.
Everyone on this podcast is listening has definitely heard of Frank Spear, I guarantee that.
Yeah, he’s fantastic to listen to Frank explains things so well and Greg Kinzer is just such a talented Dentist. I really enjoy teaching that and then the advanced conclusion workshop as well. I also do study club programs for different study clubs, and I’ve lectured, like I say, I’ve been really fortunate, lectured all over the world, so I do a lot of study programs. I do national meetings, I have a little bit more time now, so I’m looking to put together something a little bit more structured so I’ll have more information for you that in upcoming podcast. Please do.
And you know, you can always send it to me, and I’ll be happy to share it with the Protruserati. So, the name given to the listeners is PROTRUSERATI and they’re always like the geekiest bunch and they always want more and more knowledge and they love guests like you who break down a very complex topics. I’m hoping everyone, there’s no excuse if you listen to the end of this podcast and you cannot now recite the entire piper classification as clinical connotations, then you, it’s impossible.
You’ve definitely got that nail. So, Dr Jim Mckee, thank you so much for giving your time on vacation to cover this really complex topic, but broken it down in such a simple and beautiful to understand the way. I appreciate it. It was such a treat, Jaz.
I can’t thank you enough for having me and I’d love to come back any time that works for you.
We’re going to definitely have you back. Thank you so much. Well, there we are guys. I told you you’d be able to gain so much from this. So, by now you must know the piper classification, you know, a few other classifications out there, you know, now the value of an MRI and a CBCT and maybe not so much an OPG. But now, you know why that’s not going to give you as much information as you need. And hopefully now when you have your patient that has these clicks, you’re able to really close your eyes and think, okay, which piper classification is this? How might this affect what I will say to the patient in terms of their risk going forward.
So, I hope you enjoy this. I’m definitely bring Jim back in the future because I just love talking about topics like these. Thank you so much for joining all the way to the end. I really appreciate it. Do check out the protrusive dental podcast Instagram @protrusivedental if you enjoy this episode, please, would you consider leaving a review on Apple podcasts. We listen on Apple and if you leave a few comments, I love reading them. Thank you so much and I’ll catch you in the next episode. Same time. Same place!