Stay away from TMD! [SPLINTEMBER] – PDP039

Jaz’s Introduction:
Now if I dived straight into talking about different appliances, different splints without first covering the context of the temporomandibular joint anatomy, the muscles the teeth and there I even say the occlusion and the role that has in it probably lacked a lot of direction and context right? So I’m going to go back to basics. I’m going to talk about anatomy and its relevance to the different so-called temporomandibular disorders that we see and hopefully that will tie in with the future episodes and you can sort of follow along in a more logical manner. So that’s what this is about.

So the reason I pick the title stay away from tmd is because I genuinely mean it like, stay away. Do you really want to get involved in tmd patients unless you genuinely have a passion for it and you have a genuine passion for treating chronic pain now it’s a serious question because it is something that you need to be waking up on Monday morning going to work and you gotta say to yourself okay today I’m excited to go into work today to see my six patients who all have severe chronic pain and they’ve been going from one specialist clinic to another specialist clinic and they’re finally going to see me and I’ll solve all their problems. This is really complex dentistry and it’s very niche density so that’s what I mean by chronic pain and tmd. Do you really want a practice built around that

And of course don’t take my word for it if it’s something you generally want to do then that’s totally cool but what I found is that I molded my practice and the type of care that I provide I don’t advertise on my patient-facing website or in any sort of public-facing YouTube sort of content I make for patients that I like to treat tmd or that sort of stuff it’s something that I don’t advertise myself because I don’t want to be swamped with these patients because they are challenging and complex a lot of these patients are chronic pain patients which is a whole different field. In fact a member of the public or a prospective patient actually commented on the first splintember episode on my YouTube channel and she commented saying ‘hey I’m not a dentist but I’d like to know are you going to be covering the treatment of an anteriorly displaced disc?’ So I sort of said no I’m not going to be covering this it’s quite a niche thing and it’s not something I’m into so I’ll explain a bit more about that and the relevance of that but this is something that I don’t want to be swamped with and maybe nor should you.

Protrusive Dental Pearl
Okay just so before I start talking and delving deeper and deeper into this concept of staying away from tmd, I want to share with you the Protrusive Dental Pearl, it’s a really cool one I’m recommending an app I don’t get paid for this in any way I just think it’s a freaking awesome app. So if you’re a student, you will love this, if you are like me you’re driving and sometimes you want to create content like sometimes when I plan a podcast episode or something like even a long email I want to draft I’m using this app.

It’s basically a transcription app. There’s so many different uses for it even if you wanted to record a lecture with the lecturer’s permission you can use this transcription app and it has been the best transcription app I have found. Okay it’s called otter, O-T-T-E-R. And literally it’s just brilliant you can either upload some audio content that you have and it will transcribe it for you or you can be driving or in a lecture and as it’s sort of listening and recording the audio it’s also transcribing.

Now the thing I like about it is that you can actually add your own words in as part of the dictionary because obviously a lot of the dental terms it won’t understand but you can sort of add those in there but generally with someone who’s got a clear voice and you’re pronouncing things well, it’s actually really accurate. So I would recommend checking out otter.ai, that’s the website otter.ai, oter.ai. I believe that’s the website and you can get this on apple and on android. I have it on my android and it has been just fantastic for transcribing so any scenario you can think of whether you’re a student doing a postgraduate training, recording lectures, or if you want to maybe blog like if you’ve got a practice blog for example and you want to make content and if like me you hate typing on your phone and you hate typing in general and you like speaking then you.

What I tend to do is I sort of speak to my phone and I rely on otter to transcribe things for me and I just do the little corrections and hey presto I have my own text that I need so I think it’s great transcription service so check out otter if you think this will be useful in your life.

Treating temporomandibular disorders is very niche and you have to really love it. It’s not something that you know. It’s not like I don’t enjoy it. It’s very satisfying. It’s very cool to be able to get these patients out of pain but how many of these patients do you actually get like in a new patient examination? How many tell you that I’m really really finding a lot of pain in my ear and my joint? It’s something I’m suffering with a lot. You get the occasional one but it’s not something that you get in a lot of.

I mean maybe I get about one every couple of months who may have this sort of presenting complaint so they’re not very common patients to find it’s not very common issue to find to be honest with you tmd patients are out there but they only seek out those who advertise themselves as tmd dentists if you like. You see I decided that my niche and what I like to do is just good quality, general dentistry and I want my patients to have beautiful healthy smiles well-aligned teeth, treating tooth wear which sort of goes hand in hand with it orthodontics and how that the whole ortho-restorative dentistry I love that side.

So I don’t want that to be displaced by a swarm of chronic pain, tmd patients. So be careful what you wish for so in short I like to build things and I like to protect them and that’s where splints come in. Come into it for me really, how can I protect people’s dentitions from getting worse? How can I protect them once I’ve carried out a rehabilitation?

Now one of my mentors Michael Melkers once taught me that the past is prologue. Now what that means is that whatever the patient has done to their dentition in the past so you have these patients who really want things down right and they’re going to come and see you and you’re going to make them look fantastic and obviously you’re going to pay a lot of attention to waxing it up so it’s “functional” you know that’s a quotation marks functional because I’ll tell you why I have a problem with the word functional as well but anyway so everything is working canine guidance, disclussion posteriorly the whole mutually protected occlusion.

Because when you’re doing rehabilitation you want to set them up for success. You want to minimize the stress so it’s called the minimal stress dentition but what the past prologue means is that whatever all the things that they used to do with their teeth before you did the rehab. Your rehab will be subjected to the very same forces to the very same destructive chewing patterns and grinding and that sort of stuff so you have to protect them. It doesn’t mean that once you’ve done the rehabilitation and you’ve improved that occluding scheme that that’s going to be the answer to all their problems because you know fast forward 10, 15, 20 years you’ll also get chipping and wear on your rehab.

And of course you don’t want that after patients, after the patients spend a lot of time and money in your chair to to build a beautiful healthy smile, you want to protect it against the forces that destroyed it in the first place so that’s why I think there is a huge role for splints after rehabilitations. There are some sort of theories out there that once you rehabilitate the patient that you don’t need a splint right? Because you’ve set them up for life with their canine guidance and mutually protected occlusion and smooth excursions and that sort of stuff but really what I’ve learned from my mentors is past is prologue so remember that and that’s why splints have a massive role in your after care of your patients after you do the restorative density to get them where they want to be.

Now if you want to set up a tmd type practice then you can be extremely successful like if you’re in a state in the US or a part of Australia or anywhere in the UK and you sort of advertise yourself as a TMD-based practice and that sort of content you put out, then you get patients coming from miles and miles away to come and see you. You’ll get dentists referring to you. You can easily build a really good reputation for yourself because these patients find it difficult to get the right care. So if you want to do that and that’s your passion I think go with it. Okay this is going to be a fantastic field for you but it’s not for me because I love all the other things that restorative dentistry has to offer for my patients.

So I don’t want that to be displaced by a swarm of tmd patients. As I said before these are chronic pain patients and often they require multidisciplinary care and to give you an example some of these patients may need MRIs to actually have a look at the position of their discs. Now for me to get my patient to spend 800 pounds for an MRI, yes of course it’s more likely if I’m in a specialist type practice doing this type of stuff day in day out and the patient has sort of looked out and has been seeking out for this type of care but the type of referral pathways especially where I am to actually get the patient to have an MRI have it interpreted and sent back to me it just seems like a lot of work for a general, a humble general dentist like myself. So this is where I think if you are going to be a TMD type practice then go for it but make sure you’re working in a sort of multi-disciplinary team to manage these very chronic sorts of patients. So all those reasons above are one half of why I named this episode, stay away from tmd and I genuinely mean it.

Now there is a second reason of why I named this episode stay away from tmd and it’s basically from now on I want you to make me a promise and the promise is that unless you’re going to be talking about in a very broad umbrella term, I want you to stop using the term tmd. So the next time you’ve seen your patient you’ve done your history examination and you’re about to write your diagnoses please do not write tmd because tmd is an umbrella term it’s not actually a diagnosis per se and we’re going to go into the classifications and different sort of diagnoses within it but you just have to appreciate that tmd is a very weak term.

Every time I see someone posting on social media and they say guys my patient has tmd which is the best splint for this patient, they’ve got canine guidance on the right and group function on the left they, have a crown on the upper left seven what splints the best? The whole you know so much wrong about that sort of post but the diagnosis from the beginning is an issue because tmd is an umbrella term. I’ll be using the term tmd now and again very much so as the umbrella term and it contains so much I mean there’s actually so many diagnoses within tmd and I put the whole classification in the Protrusive dental community facebook group so you can download it.

But really when you break it down it involves three main sort of global themes. There’s a few more but there’s three main ones right and the first one to consider is not even the most common one but it’s a bony. Let’s think about bones, right? So you’ve got your condyle up against the articular eminence there’s usually a healthy meniscus or a disc between it but sometimes things go wrong and over time you get a degenerative type condition sort of like osteoarthritis so think of the first sort of term or the first broad genre of diagnosis to do with the bone.

A lot of these patients when you palpate their temporomandibular joints, you get to open and close you will get something called crepitus this is like the grating sound that you get and it’s unmistakable the first time you hear it like ah that’s what they meant at dental school, that’s crepitus. It’s completely unmistakable. It’s not like a click or a pop and that’s generally a sign of it but a lot of these patients actually are asymptomatic. It’s a chronic thing and it’s degenerative so it’s something that’s there is sort of built up to that so that’s the first sort of key theme within diagnosis is there something wrong with the bone?

So I wanted to mention that one and really get it out of the way because it’s not that common and something that there are bigger fish to fry when it comes to the umbrella term of tmd and the most common one actually is what we call myofascial pain or myofascial pain dysfunction syndrome and it’s basically something to do with the muscles so that’s the other part of the anatomy right? There’s something not quite right with the muscles, if there’s any sort of muscular you can sort of elude to the fact that is a myofascial pain or muscular in origin okay so it doesn’t get confusing right so far I’ve said it can be bony or it could be muscular and if it’s muscle you can put the term myofascial as a sort of general term for something’s not quite right with the muscles. Which muscles?

It’s of course the muscles of mastication, masseter, temporalis medial and lateral pterygoids. It’s generally these ones, you can get the accessory muscles involved as well but these are the main players when it comes to myofascial pain. These are your headache patients. These are your ‘oh my neck is stiff, my shoulders are sore’ sort of thing these are the sort of referred pain from the masseters.

If you listen to episode 11 communicating with the bruxist, we sort of talked about that with Barry Oulton, the referred pain element. So this is all under the second umbrella term of myofascial pain. Now if you read Dawson’s textbook, the term occlusal muscle is also used right? So occlusal muscle disorders and this is very much myofascial in nature. The reason why occlusal muscle is not the best term in the world is the following: now stay with me I don’t want to confuse anyone. Occlusal muscle sort of implies that the occlusion is at fault right? But the problem is it’s not really the occlusion per se and I’ve talked about this before it’s the occluding right? It’s the fact that this patient is parafunctioning and bruxing in the first place and they are parafunctioning and bruxing on an occlusal scheme or an occluding scheme which is not perfect and what I mean by perfect that is you know what you read in the textbook about the canine guidance, no non-working side interferences and posterior disclusion all these things okay they might not have that.

And if they’re parafunctioning and they’ve got all these interferences involved and it’s not really set up in a minimal stress dentition then they could be having muscle pain hence why the term occlusal muscle. So that’s also within this sort of myofascial pain diagnosis. So of course if the patient wasn’t occluding so much they wouldn’t be having these problems. Their muscles wouldn’t be so sore in the first place and of course their existing occluding scheme may not be helping them. So occlusal muscle is not the best term but it’s commonly used so that’s another term that’s used and that’s totally fine if you want to use that.

Now the next stretch structure and really the third structure we’re going to be looking at is intra-articular okay? Intra-articular, that’s what’s happening within the temporomandibular joint space okay and this is most commonly something like a pathology involving the disc, so for example clicking so internal derangement is a term that’s commonly used and we’ll go into that in future episodes but internal derangement with or without reduction. So let’s just, okay we can cover it now with internal derangement okay with or without reduction what that means basically is that the disc that sat on top of the condyle, the meniscus right? If there’s a derangement, it’s usually the lateral pterygoid that’s sort of pulling the disc forward to the condyle and with the reduction basically means that the disc is able to jump back on and that jumping back on is the click or the pop right?

When the patient has got this disc forward but it never jumps back on. We call that internal arrangement without reduction, so actually reduction in this case is a bit like a fracture of a bone. When orthopedic surgeons or maxillofacial surgeons when they’re reducing a fracture they’re bringing the fracture line back together. They’re bringing the two fragments of bone if you like back together so that fracture is now reduced. So very much in the same way the disc is reduced so it’s internal derangement with reduction if they have the disc jumping back on and that usually manifests itself as a click or a pop.

So sorry if that bit got a bit confusing and I will sort of break it down in future episodes but really it’s either bone pathology, it’s muscle pathology or it’s something to do with a disc as a broad term. I’m really trying to keep it as simple as possible so that’s generally what tmd involves. The three main structures bone, muscle and what’s happening inside the joint space, which is exactly why I want you to now stay away from the term tmd and wouldn’t it be so much better for our patients, for our profession, for us ourselves when we’re trying to choose the correct treatment treatment modality to actually be able to pinpoint the diagnosis ,is it something to do with the bone? Is it something to do with the muscle very commonly or is it something to do with the joint space as well? Something to do with the disc intra-articular?

Now if I went really deep here and talked about every single little diagnosis within the classification like Retrodiscitis, Capsulitis, Synovitis all these sort of things it can get really deep and really confusing but if you stick to the basics of respecting these three main diagnoses within tmd you can’t really go wrong. It’s a fantastic thing to be able to sort of understand tmd in that way it really helps you to eventually because what I’m telling you is it’s not going to make you a tmd expert I’m not a tmd expert but I respect the anatomy and I know the anatomy and when you start thinking about diagnosis of tmd in this way it really helps you to understand what’s happening. 

You can exhibit that you’re a good practitioner if in the notes you can write if it’s something to do with myofascial pain, if it’s an intra-articular diagnosis or something like osteoarthritis, thankfully that’s not too common. Now the other thing I want to tell you about is something that it’s a theory I really like and I want to share it with you. Now it’s something that I’m not sure if it has enough evidence or not to be honest with you but it’s something that my mentors have always taught me so hear me out and if there’s any evidence to disprove this and I’m totally open to so reading it but I told you already from before the evidence in this sort of area is quite poor unfortunately but this theory is called the weakest link theory.

So far I’ve talked about parafunction, bruxism and how that may affect bone muscle or intra-articular but there are other structures that are also affected by the forces of parafunction, bruxism. Now they are of course the teeth themselves and the periodontium which makes sense right you know the teeth can take a real beating and you’ll see you would obviously see where are the teeth or cracks and of course the periodontium in the Dawson textbook it does of course mention that due to the forces of parafunction someone can get recession, someone can get sensitivity, so in some respect it can also involve the pulp if you like so that we can we can include that within the term of teeth obviously, so teeth and periodontium are also affected by the forces of parafunction.

Now an interesting observation that I was taught by Dr. Pasquale Venuti, an italian dentist I follow and I really respect one of his lectures is that you know those patients that have really worn down their teeth, all their posterior teeth are flattened including the anterior and when you take photo of this patient with their teeth apart like everything is like completely flat everything is like machined flat right? An interesting observation is that these patients, okay yes they have lots of wear but seldom do they come with lots of cracks. They are not the ones that come with cracked teeth whereas those patients that have very steep cuspal inclines, those patients that when you get when you ask them to grind left and right they’re almost locked.

They have this like very well defined interlocking and you get them to grind together and they’re like yeah I’m trying I’m trying and you see no movement of the mandible right? So those places are locked in and actually you may notice that those are the patients that usually come in with the cracks in their teeth. Isn’t that an interesting observation that some of those patients with generalized wear because they’re able to glide across quite freely that the stresses don’t build up in the teeth and the teeth don’t respond with cracks they respond with wear and there’s another group of patients whose teeth don’t wear away but their teeth flex and they crack.

Now as well as cracks and wear the teeth can also become sensitive. I can give you some examples of my own patients where I experienced this in dental school for example. I remember a couple of cases whereby I placed a resin bonded bridge and it was a canine replacing a lateral incisor and it was like a mesial cancellator so you can imagine this sort of bridge design and what I had checked was the occlusion to the degree of my knowledge at the time as a student I got the patient to bite together and I saw that everything was meeting together roughly at the same time and I was happy got the blue dot everywhere done right? Now this patient came back with a main complaint that their tooth was very sensitive so this was something that confused me at the time I was thinking why is this too sensitive? Could it be recurrent carries that has happened in the last two weeks? Could it be some dentine hypersensitivity? Is there some recession? Did I make things work worse by? Did I over etch something?

Like I was confused at the time as to why this patient was getting sensitivity then my tutor came along and this tutor was very switched on and she told me that actually it could be something to do with the occlusion or the occluding, right and what I didn’t check as I told you was the excursions. I didn’t check the dynamic occlusion and when we checked it at that appointment on the review visit I found that I had lots of excursive load on the pontic. Now what this does is excursive load on a cantilever bridge it really amplifies the talking force in the abutment tooth and this is how a tooth can respond with sensitivity with pulpitis so what I had done is I adjusted the pontic to get rid of that harmful excursive contact and when I reviewed the patient again in four weeks all the symptoms had gone so this is an example a common scenario where maybe you’ve been thrown up, thrown away or thrown out and you didn’t realize you didn’t check as thoroughly as you could have. The excursive movements and the patient have come back with some sensitivity. So that’s another way that the forces of parafunction bruxism can exhibit in your patients sensitivity when you have when you place a new restoration and you haven’t checked the excursive guidance.

Now I also did this embarrassingly a few years ago on a patient who has extremely worn teeth, I can show you a photo of that patient now, actually it’s on the screen now and on this patient I replaced I believe is the upper left second premolar crown again I cemented it I thought I’d check the occlusion but I didn’t check the excursion as well as I should have because I’ve got a phone call from this patient saying that every time they’re eating now and again they’re knocking into this tooth and they’ve also told me that they’re getting a lot of sensitivity from this tooth so what’s happening here? So same as that other patient with the resin bonded bridge. This patient was getting sensitivity because all that excursive load was now on this very steep cuspal incline of a new crown which was not harmonious with the rest of his wear facets.

So one thing I mentioned in instagram live recently I did with Allen Smith from precision dental was that the best technicians in the world. What they will do is they will always check the wear facets on the adjacent teeth and try to match them up. This is to make sure that everything is harmonious when you’re checking the occlusion. Now this is a mistake made by me and the technician and the patient suffered with sensitivity. Now as soon as the patient came back and I adjusted that very steep cuspal incline which didn’t suit this patient I made it flatter or the sensitivity went away.

So these are two examples of how parafunction and bruxism and a clinical mistake in terms of checking the occlusion resulted in sensitivity. So one thing I can tell you about both those patients I mentioned is that both those patients were parafunctional bruxist patients. What I’m trying to say is that sometimes you can make a mistake in your restoration and I guarantee it happens all the time and a lot of these patients will never complain they won’t get sensitivity they won’t get any problems and you’ll never hear about it why is that right?

If your patient only brings their teeth together for 17 half minutes a day which is a classic sort of Graf study I believe in 1964 and again I’ll put that in the protrusive dental community, then they won’t have an issue but if their patients parafunction with some force and for some time and they’re rubbing their teeth together and they’re sort of amplifying that your clinical mistake, they’re the ones who are going to get above the threshold of pain and those are the ones that you’ll hear about or the restoration will fracture or something will crack and something will give right? So this is a really interesting theory that actually you can get away with a lot in occlusion and you probably have with your patients right you can jack things open you can give have complete disregard for the occlusion you do a rehab arbitrarily and you don’t get the perfect guidance that you intended and you send them home and they come back and guess what? Nothing’s broken, nothing sensitive so don’t you think it could have something to do with their parafunctional status or how long they keep their teeth together for?

If they’re the classic sentient half minute chewers and they don’t really exhibit that much force then they’re probably not going to have many issues interesting theory though and this is something I actually share with my patients as well those patients who are parafunctioning and I find evidence of this I sometimes find it very useful to tell the patient ‘hey did you know that our teeth should only touch for about 17 minutes a day?’ and most patients and actually most dentists in my experience are shocked by this. They think whoa that’s interesting and when they come back to see you a few weeks later or at the next recall those positively parafunctional patients with all the signs and sometimes the symptoms they will suddenly tell you after you told me about the 17 minutes of touching I’ve noticed my teeth touching so many more times and I think you’re right doc I think I am grinding I think I am clenching and something that I’m now so much more aware of compared to before when I didn’t know this.

So it’s a great thing to tell your patients who sometimes may not be 100% convinced of their parafunctional status just tell them did you know our teeth should only meet for 17 minutes a day and just give them that information and let them sit on it and when they come back they will give you that feedback that actually they have noticed that their teeth are touching sometimes it’s all to do with having that awareness and of course the way you’ve communicated with this patient all along is that you would have showed them their photos you would have shown them their wear facets meeting up together like we discussed with the the episode with dr Barry Oulton and you may have told the patient like what we learned from episode 21 with Dr Manrina Rhode was that you’re chewing your own enamel I really like that term that Dr Manrina used you are chewing your own enamel the other term I like describing to patients is something I learned from Dr Steven Phelan which is damaged enamel.

When you have got severe wear sets I show the patients their photos and I tell them this is damaged enamel because that’s such a powerful term and patients really understand that this isn’t normal, they’ve chewed their enamel and now it’s damaged so these are all communication hacks I’m giving you so tell them that our teeth should only touch for 17 minutes a day and even then with not that much force only when we’re swallowing maybe that’s too much detail but you sort of gauge what the patient wants to hear. You tell them or you show them they’re damaged enamel and tell them you don’t want them to chew that enamel away and all these things are very powerful as well as telling them that they’re dentine and obviously you show them the photo, their photo of the exposed dentine and you tell them that their dentine is six times softer than the enamel and it wears away quicker.

These are all great things for the patient to know medical legally you’ve covered yourself and eventually when they do come back and they realize they’ve been parafunctioning they’ll have so much trust in you because quite a lot of times you’ll be the first dentist to tell them and don’t be disheartened if they don’t fully understand or they don’t fully trust you at that point because no one’s ever told them before.

Okay so we talked about the joints, muscles ,bone periodontium and the teeth when they can be sensitive and which patients they’re more likely to be sensitive so let’s go back full circle now and I was talking about the weakest link theory right? So why is it that some patients that parafunction they have painful jaws whereas other patients who parafunction have pain has painful muscles, they have headaches, they have spasms in their muscle, they have neck pain, shoulder ache all these sorts of things and other patients they don’t have any symptoms in fact most patients I’d say that have signs of parafunction on their teeth and periodontium and whatnot they don’t have symptoms they don’t hurt, they don’t have painful especially for males they don’t come complaining of headaches for example.

So why is it that some patients don’t have any of those symptoms but all they exhibit is worn teeth or maybe they have cracked teeth or maybe they just have other signs in the periodontium, sensitivity, referred pain. Why does parafunction have different sort of signs and symptoms in different patients?

Well maybe this is something to do with the weakest link like what is your patient’s weakest link? And I love this theory because it helps me to sort of figure out a little bit about the patient for example sometimes you get a patient in and you can tell they’ve got these massive massive masseter muscles and they’ve got generalized wear posteriorly and you know that they’ve been parafunctioning all the way offsets match up one of those patients and these patients have no signs of pain or problems from their joints or from their muscles. And actually their periodontium is amazing even though they’re all hygiene may not be amazing but their periodontium is thick, it’s thick and strong and they may even have lingual tori and all these exostoses because one of the theories is that the body lays down more bone in response to all this sort of additional force that it’s absorbing.

So these patients have these big strong thick gums and they’re almost immune to periodontal disease, they’re the ones whose biggest problem will be wear, whereas you have these ladies coming in who don’t have much signs of tooth wear and they have thin delicate gums with recession and maybe they’re the ones who are complaining of a clicking painful jaw joint and really their weakest link is the joint, whereas you have other patients whose weakest link may be the joint and the muscle so sometimes it’s to do with what is the weakest link, is it the teeth? Is it the joint or is it the muscle or any one or a combination? So the weakest link for any patient could be determined by genetics biology anatomy all these sort of things and to me occlusion has a role but really it depends on what is their occluding scheme and the magnitude and the vectors of the parafunctional forces.

Now don’t worry if that’s really confusing I will put on some diagrams in the future to explain that but as long as you understand that tmd is an umbrella term and I want to stay away from that umbrella term and really if you want to make a practice and living from treating these chronic pain tmd patients then go for it you’ll be very successful but if like me you just want to do your bread and butter general and cosmetic dentistry then maybe that’s not the best area for you to go into. So I hope this episode gave you some food for thought.

I wanted to make it like quite a broad thing so it sort of sets us up for future episodes to talk about different appliances because I wanted to put in some communication hacks in there. I wanted to put in some diagnosis in there so you sort of know what’s going on because when I talk about the different appliances in future episodes you sort of have some background about what is tmd that’s an umbrella term and why some patients may be affected more, why some patients due to the weakest link theory might have this funneling type bone loss and mobility around certain teeth whereas others will come with jaw pain and popping, whereas others will have headaches and some people all they’ll ever have is cracked teeth and that’s all and and that is something that will hopefully be helpful in designing the correct appliance for your patient. So catch you for the rest of splintember. Really appreciate you listening all the way to the end. Thank you so much.