Two ‘TMJ Queens’ in Two Days – another tribute to International Women’s Day last week and what better than having Dr Priya Mistry from USA who has limited her practice to the treatment of Temporo-Mandibular Disorders.
I first discovered Dr Priya Mistry’s fantastic content on YouTube – I really enjoyed her style of content presentation. I quickly saw her grow on this platform and help so many of the public with their TMD concerns.
I realised that a lot of what she has to share is not just helpful for patients, but is really useful and helpful for Dentists, especially as many of us find the TMJ to be a mystical joint! I probe Dr Mistry about her full examination protocol for a typical TMD patient so we can gain insight in to how Dentists limited to TMD get to a diagnosis – arguably the trickiest part!
Some parts of her specialised exam is already familiar to us – the usual palpation and range of motion measuring. Other parts are very different, such as measuring leg-length and really analysing the postural chain. Also, there are a lot of pre-appointment questionnaires that patients need to fill in advance of the appointment.
The main take-home from this episode is to figure out when to treat TMD patients yourself in practice, and when to refer to someone like Dr Mistry. I enjoyed her ‘4 levels of TMD’ which was very easy to follow.
If you enjoyed this episode, do check out the episode with Dr Gurs Sehmi where I probe him for the full protocol examination for his Smile Makeover treatments!
Enrollment for SplintCourse ends on Friday (thanks for all of you who joined from around the world!) I look forward to catching you on the Monthly Live Webinars:
Click here for Full Episode Transcription:Opening Snippet: Yeah what really, excuse my French but what really pisses me off right is when Dental Professionals right like we have this like closed mind and we don't accept that there are other ways there are unknown unknowns and they go by the very poor quality evidence that exists right so i hope when when i commented on your video i hope you didn't feel like i was like disagreeing with you i was just coming at a different angle i kept a very open mind.
Jaz’s Introduction: Hello, Protruserati! It’s Jaz Gulati and welcome to today’s episode all about the perfect TMJ exam. I”m joined today by someone really cool. Her name is Dr Priya Mistry. She’s based in Oregon, USA and I found her on youtube and honestly she is such a cool girl she makes brilliant content for patients actually but i think as dentists we can learn so much. In this episode we cover about what a TMJ examination entails for her. Now, remember a lot of these things we won’t be able to implement in our practices especially for GDPs because she is limited to TMJ. She’s limited to treatment of people with temporomandibular disorders so what she does is way above and beyond what we do including like CBCT scans, a full body examination while they’re laying down so you get to hear her workflow. So what we can learn from this episode is what do these people do that are limited or specialized in the practice of just TMD. We also answer towards the end of the podcast about what is her approach to someone with disc displacement without reduction these are people who used to have clicks and suddenly they’re locked and they cannot open very much so how does she treat this very difficult condition to treat. You see, I’ve been reading the evidence I’ve been checking out and the evidence is very varied. There’s many different ways to approach it so i’d like to listen to her schools of thought and i want you all to keep a very open mind, keep an open mind because a lot of what she teaches is not evidence-base, it’s not taught in dent schools but that doesn’t mean it’s wrong. I’ll tell you why it’s likely not wrong because the three arms of evidence-based sensory, don’t forget we talked about this in the Lincoln Harris episode that the two other arms of evidence-based dentistry aside from the literature is the patient values and the clinician’s expertise, okay? These are two other arms and the the evidence that’s out there in the field, in the entire field of TMD it’s very varied, it’s very biased, it’s very poor quality as a whole. So there are so many unknown unknowns. So just have an open mind when we listen to this yes we talk about posture, yes we talk about the neck and stuff but i think there’s so much we can learn. I’m hoping it’s gonna open your eyes if not anything then to at least the importance of the airway in your diagnosis and trying to get grips with patients who may have sleep disorder breathing, I know I always bang on about this but I’m hoping you’ll gain a lot of value from this. The Protrusive Dental Pearl I have you is when you’re doing the TMJ examination I want to make it obviously relevant, use your pinky fingers to feel inside their ear, by doing so you’re doing an intra-auricular examination of the TMJ which will give you more information. Why? Because you’re going to get closer to the back of the joint and that’s when you can hear a lot of closing clicks and you’ll see Dr Priya discussing that as well and the other reason is when we’re feeling the lateral pole of the TMJ which is basically when they open up and you can feel their condyle that’s we’re touching the lateral pole the condyle that when we’re doing that. That’s not very well innervated doesn’t have a great blood supply there therefore by touching behind joint i.e from the intra-auricular within the ear approach you obviously have to tell your patients you’re doing this beforehand otherwise I think what the hell is this dentist doing. You get to feel a much more innovative and vascular portion of the anatomy and you do gain some more information i.e is there inflammation, is there pain that kind of stuff. So there we are that’s my Protrusive Dental Pearl for you and now let’s join Dr Priya Mistry aka the TMJ doc.
Main Interview: Dr Priya Mistry, welcome to the Protrusive Dental podcast, how are you? I’m well and thank you for having me how are you doing? I’m great and honestly I’m so excited to speak to you today and for those people in the UK maybe around the world who don’t know yet who you are. I’m going to give my sort of version of an intro and then I want you to do a proper intro Priya, look I came across your content on YouTube I was searching about Aqualizer splints something I’ve been using on and off but then sometimes I deliver it I’m thinking is it supposed to be this flimsy and then y’all. I came across one of your videos and then I saw more videos and I see that on a regular basis nowadays you’ve been creating some wonderful content. So I was in awe of your content and just so everyone knows the content you make is primarily for patients and I have seen you in the last two months grow and grow and grow and it’s been an absolute pleasure to see. So, Priya, tell us a little bit about yourself, what you’re practicing, what got you into this crazy field of TMJ, TMD. Yes, so I’m over here in Portland Oregon and I’m working with my mentor Dr Arthur Parker, who has been doing TMJ work for (gosh) well over 40 years now and he’s just wonderful and he’s really just meeting him sort of changed the course of my life and so i’ve been practicing general dentistry for 13 years and about two years ago i very randomly walked into my mentor’s wife’s jewelry store to get a clasp on a necklace fixed. So my mother-in-law gave me this beautiful necklace but i just wanna i felt like the clasp was a little bit flimsy so i just wanted to change the clasp and i walked in there and luckily my mentor’s wife her name is Debbie. Debbie and i are both pretty chatty and so we got to talking and she told me about the work that her husband does she told me he stopped practicing general dentistry 35 years ago and he opened up his tmj only practice sort of as a hobby but also it’s his passion and so i thought huh tmj only that’s pretty rare because even if you refer to a tmj specialist they’re doing a lot of other things and they’re typically doing a lot of restorative dentistry which we don’t do at all so i thought huh and i remember walking out of that store and i called my husband right away he’s a dentist as well and we had been living in this area for about two years at that point but i have had babies each year so i didn’t really know the dentist in this area so i called my husband i said do you know Dr Arthur Parker he said yes that’s a huge name he’s the tmj guy like he’s a big deal i refer all my tmj patients to him and i said well you know i kind of want to reach out to him and maybe shadow him he said definitely like go back in that jewelry store talk to his wife get his contact info Buy some jewelry. He probably didn’t say that he said talk to her but don’t buy some jewelry. Don’t look at anything just talk to her So i went back in there and you know the rest is history i started shadowing him and i was just fascinated to see what he was doing and so i was shadowing him maybe half a day three times a week and every single time i came in the patients would say are you taking over because Dr Parker saved my life you know and i had one patient say they were about to commit suicide they were in so much pain and Dr Parker saved them and i thought is he arranging for all these patients to come in when I’m here. I thought gosh you know i’m hearing this time and again what is he doing and so you know it turned into a mentorship and then i just actually bought the practice last week and he’s still working, i’m still learning from him. He’s amazing. Congratulations that’s so so so good well done. Thank you. Thank you so much. I can’t believe you’ve been practicing for 13 years though you don’t look like it. Oh yes it’s the haircut. Fantastic Wonderful. Brilliant but what struck you about the fact that you know his wife when you met her she told you that her husband has an interest in tmj but did you already have an interest? What was that connection that you felt that you needed to reach out to him? Yes, so i had taken a course in 2011 about sleep apnea in children and i just remember thinking children with sleep apnea like you know we’re taught in school or at least i was that it’s associated with like very obese older people i didn’t think about children i thought huh so when his wife spoke to me she said that Dr Parker is doing tmj work and he also works with the kids with small airways to help guide their growth and development so there is another aspect to our practice too and so that kind of hooked me but then also the tmj part there’s so many patients i’ve seen in 13 years that came into the office and they could barely open their mouths and i honestly had no clue what to do for them i mean they couldn’t even open enough for me to get impressions even if i wanted to do something so i would put them on muscle relaxants, anti-inflammatories and say come back in a week if you’re feeling a little better then that means we know it’s your tmj and then i would just make a regular flat plain splint and hope. So Priya at that stage i think what you’re describing is a very typical situation for a lot of dentists we don’t see these issues so often when they come we try and think back to our anatomy from dent school we’re like what’s going on so we failed to make a diagnosis maybe you went through that, right? Is that what you felt at the stage that you experienced? Yes definitely and so when she said that he’s been doing tmj work for so long i thought oh my gosh i can finally learn how to do something beyond this because i felt like i would just give them a split and hope for the best and i thought that’s just not good enough for our patients so i need to learn more. So then i thought maybe you know i didn’t know where it was going to go but i knew i definitely wanted to learn if he was open to it and it just developed. Hey it’s Jaz i’m just interfering into this episode to tell you the following if you’re listening to this podcast when it’s released then we’re probably just a few days away from the splintcourse enrollment coming to an end so i only wanted to open the course for two weeks because i want to limit the number of students because i want to focus on monthly mentorship. I’m going to do monthly coaching webinars for all your splint queries for all your patients because i realized when i did a resin bonded bridge course that actually people need opinions, people need mentorship so i’m so excited for those who have joined me on the splint course if you want to learn more about how to treat patients in general dental practice with splints and how you can improve myofascial pain and protect your precious veneers, how to find centric relation better, easier with clever appliances then please do the split course. I’ve worked really hard over the years to make lots of clinical videos. One thing i didn’t have in the resin bonded bridge course by putting in the splint course is so many clinical videos, testimonials from patients, showing you step by step every single technique from tmj diagnosis from muscle examination to the final delivery and adjustment to splint so i really hope you join me just a few days left. If you haven’t already check out splitcourse.com and enroll today. I love that story. I love how it started with the necklace, the jewelry about the clasp this is wonderful amazing well let’s get into the the meat and potatoes of the episode talk you know i’ve seen your content your wonderful way you make content and the your patient mannerism and your education style is brilliant. So i can see because one part of treating patients with tmd is the ability to educate our patients, is the ability to take an empathetic approach with our patients and you definitely have all those fine qualities. So tell us what is your protocol for a tmj exam let’s say a patient comes in and she’s been referred and tell us what percentage are referred and what percentages come to you directly and to be honest with you one thing i did want to explore with you is now with the youtube you messaged me saying ‘hey you have a patient in the UK [exeter] and that kind of stuff and we’ve been emailing i’m sure is blown up how many patients and i’m sure patients want to drive from everywhere because Priya even though i make my content for dentists people have been watching my videos about ipr techniques with an orthodontist and about splints which i make for dentists and they are finding me and they’re driving hundreds of miles to come and see me. I bet that’s happening to you as well so give us a flavor of that. Yes, yeah so people are trying to to come from far i mean with Covid there’s a lot of limitations and the tricky part is i really don’t encourage people with actual intracapsular problems to come see me because that can be a four to six month resolution and so i need them nearby, I do jaw manipulation. I can’t do that on somebody that’s coming from a different state you know or they have to travel far so the people that i have encouraged it’s just been a few that have come from far but it’s mostly muscle, myofascial problems and those patients i think a few of them have come one has had great success the other is still struggling but that’s tmj you know there’s often other parts of the body involved and so we’re trying to figure it out i wish you, i wish it was closer because i think we could have probably nailed it by now but it’s very hard to work with people that are far away so i really prefer people close by but it’s been.. but it’s the impact of social media. It’s the impact of creating content and you know it’s just amazing how and i’ve joined these and maybe you should join us as well. I’ve joined this group on facebook with people who are suffering from tmd and you should totally go and share your content there’s like thousands of people. I just want to understand their journey and understand their issues and these people are really desperate and i know you’re going to go into this so tell us about these patients that seek you out or refer to you. What is the typical exact first appointment yeah so typical first appointment takes about an hour and that includes our examination and talking with our office administrator and getting an appointment set up so it’s not super long but it is very thorough so when these patients get referred to us the first thing we do is we have a really comprehensive patient intake form. So it’s a lot of paperwork but it’s for a good reason because the paperwork has very specific questions as to pain. So are they having headaches? Are they having neck pain? Are they having ear pain? Is it sharp? Is it dull? Is it constant? Is it coming and going fleeting? Stuffy ears? It covers so many things along with limited range of motion, noises in the joints blocking incidents there’s a lot in that intake paperwork along with a sleep apnea questionnaire because sleep apnea and tmjd are very much related and then also a a history on any accidents any car accidents, anything that could have caused whiplash and so sometimes people come in and they say oh my gosh this is a lot of paperwork but then when they sit down for the exam they say i didn’t even think that you know my accident two years ago yeah like i did have a really bad whiplash i wouldn’t have put that on there so there’s a good reason for all the questions but it starts with that intake paperwork and then once i get that in my hands i read it very thoroughly like i know everything before i go in there and so there’s that that’s a big aspect to it and then of course when we go in the first thing i do is i just sit down i say you know i read through your paperwork it sounds like your condition started i don’t know two months ago whatever it is and i say tell me your story because people want to tell their story people want to feel as though you’re empathizing with them which i do very much so i you know these people are typically in a lot of pain and so they tell their story i listen i take really detailed notes i want to know everything and i ask questions every now and then i try my best not to interrupt them and then at the end the two questions i always ask if they haven’t covered it in their history is what is your prior orthodontic treatment did have you had any did you have braces? Did you have invisalign and when you had braces? Did you have any permanent teeth extracted tell me and so they tell me about their orthodontic history and then i also ask history of injury to the head, neck or jaw think back even if it happened in your childhood let me know if there was any sort of injury because even though our paperwork covers it they don’t necessarily think to tell us about a really bad accident you know when they were 12 or 13. So i go through that and so once that part is done then we can really get it started with actually physically examining the patients. So that all is part of a very comprehensive history taking which starts with the forms continues on to their story and how much time do you think of that appointment is actually them telling you the story you reading their paperwork just so we get an idea? Depending on how chatty they are maybe 10, 15 minutes i mean you know i kind of guide them because sometimes it’s easy to get lost in explaining your story so i’ll sort of you know nicely interrupt and sort of guide them back on track if they’re getting a little off but yeah usually about 10-15 minutes and also an important part of this is i observe them as they’re talking to me i observe their head posture, i observe if one shoulder’s higher than the other and then right after this exam they actually have to get up from the chair they’re sitting in and then sit down on our exam table so i even observe the way that they walk so this is all i’m getting an idea of their overall body posture because that definitely plays into the mandible and it’s positioning so what are you then examining for? yeah so i’m looking for a lot of these people have cervical misalignment so the cervical spine if they are rotated or these vertebrae if they’re rotated or if they’re tilted at all it’ll show in their head posture like they’re looking off one way and they don’t even realize it right and then discrepancies and shoulder height and then even in [gate] if someone’s walking really straight great but if one leg’s swinging out one way it shows me that there may be some instability in the hips as well so i try you know but be discreet about it Do have like a diagram of the body and you’re sort of making notes about any postural issues or is this something that you just on the side just make a note of? no we noted in our exam form too so there is a point during the exam where we actually lay the patient out on a table so we don’t have a dental chair in that room we actually have a massage therapy table so at that point then i make more notes about it but you know these are just simple observations at the beginning and then i comment on it later on in the exam Sure. Tell us what’s next yes so what’s next is i have the patient take a seat just sitting facing me on the exam table and the next part is a range of motion exam so i use my little range of motion scale and i ask them to open and i basically just say you know do what you can don’t hurt yourself and so i just kind of see what their range of motion is ask them to move side to side and we write that down so there’s an assistant in the room taking all the notes writing it all down on the exam form after the range of motion exam then we.. Just tell the dentists out there because you want to make as educational as possible some young dentist students might be listening. What are the figures that are normal and then which figures are you thinking or there’s a red flag, there’s something going on that we need to investigate further? So 45 to 50 millimeters is normal opening and then 10 to 12 side to side is normal lateral excursions 25 millimeters opening and below can be indicative is usually indicative of the jaw being locked closed meaning the articular disc is displaced without reduction so the jaw is locked somewhere in the 30s can be kind of tricky because there could be an intracapsular problem or it could be all myofascially driven like the muscles are so angry that the patient isn’t able to open more so further evaluation is needed for that. So those are sort of the numbers involved there That’s really helpful. Thank you Good yeah so after the range of motion exam then we do a muscle palpation exam so for the muscle palpation exam i always say i’m gonna be feeling muscles around your head, neck and jaws and when i do so i use about this much pressure and so i put about three pounds of pressure on their like arm or shoulder just to give them an idea of how much pressure i’ll be using and i say if that gives you I personally i put my finger on there on their forehead and i say this is how much pressure i’m pulling because they need something to compare to because if when i didn’t used to do that and i just felt the muscle they were like yeah they don’t have a reference to compare against so it’s so important to give them a sensation they can compare to. I’m really glad you mentioned it It’s so important right and so i say you know it once i’m feeling muscles around your head, neck and jaw if you feel more than pressure i want you to stop and grade it on scale of 1 to 3. 1 is a little tender, 3 is painful. 2 in between and i say if you just feel pressure we’ll keep going to the next spot but if you feel more interrupt me. Grade it on that scale and let me know if it’s your right side your left side or both and so they’re usually good with that and we start at the temples and we just go through the whole muscle exam so i have a video on my youtube called muscle palpation exam and there’s even a i think there’s a form that you can download afterwards if you want to incorporate that into your paperwork . – Amazing i’ll link that on so my producer will put that on so everyone can access that i’ll also put it on the blog on protrusive.co.uk so people can find easy access to this video because i think it’s so important to be able to do that correctly as part of your record taking Yes, it is important to do that correctly and you know the muscles can give us so much information as to what’s going on with the patient and sometimes what’s interesting is when i palpate the lateral pterygoid at the end of the exam i do that right after the muscle palpation exam i then put my fingers over the joints and asked the patient to open and close and i’m feeling for pops and clicks but what i often see is patients who are limited in range of motion not locked but limited in range of motion they can open more after i’ve palpated and released that lateral pterygoid it’s so interesting but i see it time and again they’re able to open a little bit more so if you see that if you observe that. That’s telling you that this might be more muscular driven than an intracapsular issue so i see that a lot so the next step i guess which leads me into is I check I just want to ask on that point actually just want to because a great point you mentioned there now. This is a very controversial area whether you can or cannot palpate lateral pterygoid. A lot of people think you can’t, I mean I appreciate your expertise in this as well because you’ve you know got a mentor and you’ve limited your practice so but we need to appreciate that there’s both sides so some people from cadaver studies say that okay it’s it’s not possible whereas what you have experienced and what you feel is like a myofacial release these patients are able to open more so you know we have to be open-minded and consider that actually we don’t know exactly if it’s possible but I love hearing your experience I love getting different viewpoints on the podcast so that’s it so we’ve got one point for yes we can palpate it and i’ve also seen the video of you doing the release on yourself in that live video you did which which is fantastic so that’s good to know. – Right so next what i do is I tell the patients that i’m going to place my fingers over their jaw joints and i’ll watch and feel as they open and close a few times so here i’m looking to see if their range of motion increased i’m also feeling for any pops or clicks or crepitus and you can feel for that pretty easily and i’m watching for any deviation off to one side or an s pattern deviation even on the way back up i’m just watching for all of that so watching feeling and letting my assistant know what to write down and so that’s sort of the next part then i ask the patient to lie down and say ‘are you comfortable being on your back?’ So then they actually lie down on their back and i tell them we do a little bit of a postural exam here and i say i’m going to start by checking leg length and then i’ll place my hands on your head and finish up my exam so i do i just go to the end of the table i check their leg length and most people have some discrepancy and so i make note of that because if there’s a discrepancy in the leg length that usually correlates with the discrepancy in the hip height and so once there’s discrepancies along the postural chain it’ll feed up and back down and with the mandible being suspended in a sling of muscle it’s very responsive to those changes in the postural chain so when i say postural chain i mean the mandible i mean the spine itself the shoulders, the hips and the feet so looking at all of that -This is really fascinating because we don’t get taught any of this at dental school i don’t know what your experience was about the extent they went into this. Did you get taught any of this at dental school? -No I got taught none of this at dental school no and i would never have even thought to look at leg lengths when i’m doing a tmj exam right like when i first started shadowing my mentor here i could not figure out why he was checking leg length and Dr Parker is amazing but he is a man of few words and so i always poke him and ask him a lot of questions and so after the first couple observational sessions that i had with him i just said you know i don’t get it let’s sit down and talk and that’s when he explained the postural chain the same way i just did and i said that makes sense and so that’s that’s another indication as to whether i know we’re going to touch on this later whether to get a body worker, a physical therapist, a chiropractor involved at a later stage so it’s just sort of giving me more pieces of the puzzle – Brilliant fantastic you explain that really well fantastic so you’ve laid them down you’ve done the leg length what happens next? yes so then i do leg length and then i actually sit down and i say i’m gonna put my fingers in your ears i know that sounds funny but when i do that i can feel inside your jaw joints so i just use my little pinkies and i place them in the ears and i put just a little bit of pressure going anteriorly and i ask them to open and close and this is the part of the exam where you can actually feel closing clicks really well opening clicks are often like you can feel them from here but the closing clicks you can’t always they’re just softer they’re just quieter so here you can feel that you can feel crepitus really well and and so that’s just sort of gives you confirmation as to what you felt from here and it gives you more information oftentimes too so i do that That area is much better innovated than the lateral poles and that’s why another reason gives you so much information so if you felt the lateral poles and then sometimes they’re they’re not feeling any pain sometimes i’m sure you found intraorically that actually reveals the there might be some inflammation, some pain is that what you found? -Yes, I have i found the exact same thing and so that part of the exam is pretty quick and then the last part i say i’m just going to take a look inside your mouth now so when i look inside their mouth i’m looking for a lot of things really. I’m looking for scalloping on the lateral borders of the tongue that scalloping on those lateral borders is telling me that you know there’s probably not enough room in their mouth for their tongue or they’re using their tongue as sort of a soft night guard or it’s just it shouldn’t be there essentially and so when i see that scalloping i know that tongue isn’t always in the proper position up against the roof of the mouth with the light suction it’s doing a little bit more than it should so i look for that scalloping on the lateral borders of the tongue. I look for tori, palatal tori, mandibular tori, a narrow arched palate i’m looking at that i’m looking at molar classification, looking for deep bites, i’m looking for cross bites, looking for signs of clenching and grinding clear signs like wear on the teeth, recession, abfraction, craze line so like vertical fractures in the enamel gives us lots of clues i’m looking at how much space the tongue takes up in their mouth so we call it Mallampati score here i’m not sure if you call it that there but i asked – The same yeah as well yeah Okay so stick their tongue out i’m looking at what i can see in the back so i’m looking for the Mallampati score There’s a lot that i’m looking at and the whole time my assistant’s taking notes i’m looking for missing teeth. So i’m looking for a lot in that part just to kind of give us more clues as to maybe how they got there and so those class two div two patients. The majority of our tmj patients that class two div two just sort of doesn’t allow the mandible to come down and forward where it usually wants to be where the muscles joints and ligaments are the happiest and so we see that a lot the class you div two especially with our patients that are As a restorative dentist they’re also the patients that just give us so much trouble in terms of destructive treatment planning, longevity or restorations, the amount of resistance they put on restoration so yeah no one likes these class two div two patients sorry if you’re class two div two but you give us a lot of hard work. – He does a lot of hard work Brilliant Yes absolutely carry on – Yeah so that’s it i mean once we do the occlusal exam i say you know you can sit up and have a seat back in your original spot and then i just go over everything with them and i always start with you know we talk a lot about tmj and we talk about tmd at our practice and i said tmj i always say tmj is not it’s not a diagnosis it just means temporomandibular joints but if there’s a problem within those joints it will manifest as clicking, popping, crackling noises or episodes of the jaw locking so if they have any of those i say clearly there’s an issue there and then i say tmd which is temporomandibular disorder or dysfunction it recognizes that there’s a group of muscles that work together to guide and support the jaw if or when those muscles become dysfunctional usually due to chronic clenching chronic grinding sometimes even just the way the teeth fit together. Unilateral crossbites can be very dysfunctional for the joints. So i say sometimes even just the way the teeth fit together or imbalances along the postural chain can make these muscles dysfunctional they can get trapped in a chronic pain and spasm cycle and when that happens it can lead to a lot of different symptoms with number one being headache closely followed by ear and neck related concerns, jaw pain, tingling in the jaw, in the extremities. There’s just so many things that go along with it that tmd is often called the great imposter disease because there’s just so many different things that can come along with it and so depending on which one they have more of or if they have both i just explain everything and then how we treat it and how we can help them. – But the most amazing thing is that i don’t think the literature on tmd will ever reveal the truth because there are so many confounding factors right including the fact that the current accepted model in literature is the the biopsychosocial model of disease so we know there’s more to it than just trauma like there’s so many patients that have really severe signs of bruxism but they will never manifest Never. as having pain or tmd and when you have these other people who don’t have as much history of micro or macro trauma but then they suffer so much more so i don’t think the evidence will ever be able to find the truth in that whatever the truth may be because it’s just impossible to study, it’s impossible to get the end numbers, it’s impossible to get the sleep studies, it’s impossible to account for every single factor that can be contributing. So where do you think because that’s what we can discuss theories and opinions because that’s the best we have because the other arms of evidence-based dentistry are clinical expertise and the patient experience and patient values and we have to remember that those two make up the three arms of evidence-based dentistry. So tell me your theories on the most common reasons that someone will turn up to you with tmd and while others who also may be chronic clenchers grinders they won’t get tmd what’s your take on that? – Yeah, so my opinion is you know and i know i’ve been talking a lot about this but it goes back to the postural dynamics, it goes back to the history, so i had one patient who’s class one molar occlusion overall her occlusion was beautiful, right? She had two fillings replaced and boom suddenly her whole right side began hurting especially just right up in here felt like her scalp was on fire, it felt like somebody was hitting her in the head with a 2×4, her jaw was constantly aching, her whole life changed because of those two fillings and she said what happened here. So we got her in i made her the orthotics, i started treating her and with her history what came out is she had suffered four really severe whiplash incidents in car accidents over a matter of like five years and so her cervical vertebrae were totally not in alignment and when that happens the muscles that attach, there they start compensating everything starts compensating and eventually something gives you can only compensate for so long if it’s very extreme compensation, right? And so it was staying open for those two minor fillings i mean they were class two fillings they were tiny. They weren’t anywhere near the nerve but just staying open it just triggered everything and all these symptoms came on and now we’ve got her back to like 90% of those symptoms are gone maybe 95% i think last time i spoke to her but i mean it took a toll on her life she had two young kids. She was just crying all the time you know, she was debilitated so i guess what i’m trying to say is those incidents that of whiplash even if you think you’ve recovered or you’re okay but your neck is just a little stiff or a little painful sometimes they can come back to haunt you later and so these people that have had multiple accidents it’s usually very active people too snowboarders, skiers, we see a lot of musicians, violinists that are holding their necks in a certain way i think that plays into a lot of it and like you said there’s not a lot of research on that. – Zero because i’ve been really delved deep into literature in fact one of my comments on your youtube videos some while ago was discussing literature and stuff as you may remember but you know i have to admit i know nothing or very little about the postural chain and i would like to learn more about that i’ll probably be watching your videos more and more did learn more about that but yeah i know nothing about that so i’m the first to say that so in my view of the world i think the reason why some people switch and get the signs or the symptoms they complain of tmd issues is adaptive capacity. Is that something that you’re familiar with the adaptive capacity theory? – Well go ahead and tell me. Sure so the adaptive capacity theory is that in a way also interlinks with the weakest link theory that so we you know there’s the teeth, there’s the periodontium, there’s the muscles and somewhere along that sort of system in the masticatory system something is the weak point that for example some patients will get a myofascial pain but not so much intracapsular and the teeth will not wear down so much whereas other people they will destroy their teeth but the adaptive capacity ie the ability for that system to heal or how resilient that system is above the threshold of them getting pain and again we don’t have the evidence to prove this so it’s just one of those theories and one of those things which i like discussing with clever people like you because there’s not enough tmj geeks out there and it’s nice to have that so if you don’t mind i won’t just want to because i know dentists are thinking this while they’re listening to this is that specific patient that you mentioned who had those two restorations and it maybe it was her mouth staying open for that long or you know a change in occlusion that affected her either the postural chain or her adaptive capacity in whatever way how just give us a flavor of how you treated her Yeah sure so we got her into my tmj practice and we did our full workup and so we always take a cbct scan and so that gives us information about the bony components of the joints, it shows us we take a good look at the upper cervical vertebrae and we’re looking for rotations in them we look at airway we look at a lot of things in that and so we got the cbct and then what we do right after that is we get of course molds of the teeth if they’re able to open enough and after the molds then we use a tens unit a muscle stimulator and it gets the muscles in the head, neck and jaw nice and relaxed and so we use that to deprogram those muscles so they go to their correct resting length and then we record that position with a very sophisticated jaw tracking technology that’s precise down to tenths of a millimeter so it’s telling us exactly where to position the mandible so that the muscles are in their most relaxed position so for her it was all myofascial. There were no joint issues at all and so just getting those muscles relaxed was super important when we used the muscle stimulator the tens machine i also put an aqualizer in her mouth i wanted to disclude her teeth, i wanted to get those muscles as deprogrammed as possible and so even when i took the aqualizer out to measure that really relaxed position i said don’t touch your teeth together. Don’t touch your teeth together at all and we’ll kind of go from here so then once i got the information i needed we made her a daytime orthotic and a nighttime one. With the orthotics with the daytime one we always ask our patients to take it out when they eat or drink anything but water and then eventually we wean them off of that daytime one as their symptoms get better and better so we give them the orthotics and then we see our patients once a week for our own therapy in our office so we have several rooms with those massage tables that i mentioned earlier and what i do is i do kind of like a subtle head and neck massage a release of these muscles right at the base of the occiput and then i do a little bit more work extra orally and then intraorally i go in and i release those lateral pterygoids that is not a fun thing for these patients those muscles are very hot a lot of patients sort of tear up when i do this and i just say there’s a good reason for this we’re bringing fresh blood flow, fresh oxygen to those muscles and promoting lymphatic drainage it doesn’t feel great but it helps a lot and so again like i said a lot of these patients i see an increase in range of motion, she wasn’t one of those, her range of motion was fine but once we got her into therapy she noticed that her symptoms improved by 85% within a month it was very fast i mean she felt relief within a week that 85% was within a month and i said what what are we missing what can we do to get you to 90%, 95%, 100% so we went back to those whiplashes and i just said i still think this is playing a role and she was seeing a chiropractor at the time and i said you know you’ve seen this chiropractor a number of times and i hate and i don’t ever do this really because i don’t like stepping on toes and i just said ‘would you perhaps just because you’re in so much, you were in so much pain be open to seeing someone that I recommend’ and so i really work well with these upper cervical chiropractors so here we call them Nucca Chiropractors National Upper Cervical Chiropractic association or atlas orthogonal chiropractors, they do things the same way, they diagnose the same way but nucca treats with their hand and atlas orthogonal treats with like a percussion instrument but the adjustments that they do are not forceful or cracking or jerky it’s very very light pressure applied to the atlas c1 to help it get back into alignment followed up with other things and so they do a lot with the upper cervical vertebrae particularly c1 and so she said she was open to that and once she started seeing the nucca chiropractor I told her i said the first three visits with that chiropractor i want you to come back and see me within 24 hours of your adjustment because these adjustments change the head posture which can change the bite against my splint, my orthotic, we want everything working together right so i don’t want my splint holding her back from progress with this new adjustment she’s had so those first two or three adjustments are the ones that make the biggest difference typically so that’s why i say for the first two or three come back and see me so once she started seeing the nucca chiropractor that got her to 95% so she’s still not at 100% but her quality of life is so improved and i’m still working with her i’m not going to give up i want to get her to 100% but she’s thrilled Brilliant. Well. the geek inside me has to ask you we’ll cover this quickly because a few more things to cover but difference between a daytime and nighttime orthotic just simply but also are you familiar with Jankelson’s orthotic is that what you’re referring to? Yeah, so the Jankelson’s orthotic i don’t know about that but we use his method, the neuromuscular scan, yeah. I think it’s that it’s just to be using the tens machine to find out the corrected length of the muscle and then building the appliance to that lens so yeah fantastic so you and that is that going to be applied to both the daytime and the nighttime or just give us a flavor of the difference. -Yes so it’s the same prescription built into both appliances one different thing that we do from Jankelson’s method is we also look at the cbct and the position of the condyles we take that scan when people are in centric occlusion and so it shows us where the condyles are when their teeth are together and if they’re too far posterior what we usually see is Jankelson’s method is actually asking us to move them anterior. I’ve never really seen it yeah so but if it’s not anterior enough i’ve done this now long enough to sometimes i don’t go exactly with Jankelson’s. Sometimes i go a little bit anterior to it or a little bit i’ll kind of fudge it a little bit to where i know they’re going to have a better result so that’s kind of how we do it and with the daytime. – It’s that mostly with the airway in mind? Airway in mind and position of the condyle because if it’s too far back it’s impinging on that retro-distal tissue so both and i do encourage sleep tests for a lot of my patients as well not all of them wanna do it they’re like i’m here to get out of pain just get me out of pain but i i you know i tell them what i see and then the difference between daytime and nighttime orthotic same prescription built into both. The daytime one is made out of an orthodontic invisalign type material but what we do is we build up pads of triad on the posterior aspects and even on the canines so canines back we build up pads of triad with indentations bite indexes to guide their upper teeth where to rest putting the jaw in the three-dimensional rest position and then the nighttime appliance is a lot thicker essentially because it’s a lot more force can be generated at night and so we don’t want it to break so it’s quite a bit thicker but same prescription built into both. Brilliant. Fantastic. You covered that really well as well what percentage of your patients is a, quick fire around, what percentage of your patients do you think have the signs of bruxism? 95? Yep, I concur. What percentage of patients that you send for a sleep test come back with a positive diagnosis or high enough H.I index that you know they actually are diagnosed with sleep apnea? oh 95. Really high. – Isn’t it just amazing it’s just fascinating how it’s like this really this elephant in the room is something that we need to as a healthcare profession as dentists we need to be screening more of this and i’m on a real mission here to I don’t, i can’t teach stuff because there are people out there especially in the UK where i am who can teach us better but in the uk we don’t have enough clear pathways to get patients help when i send these patients to a GP. The GP was the doctor was never taught about airway in the medical school so it’s a real lack of clear referral pathways i’m a very frustrated dentist for that reason i think in the US do you have better pathways in place i feel ? We do and we have an institute called The Breathe Institute in southern california that is all about this and so really what i see with a lot of my patients too is that low tongue posture, the small airway, they have to breathe through their mouths and so i did a video called Tongue-tied airway and tmj disorders and i feel like that would you know again my channel is more for people looking for answers for themselves but i feel like dentists can learn a lot too it’s just not that technically. – We can learn so much, Priya, honestly guys you if you listen to this and you like what Priya’s saying and in the sense that her style is so good it’s very educational hese videos that she makes for patients i guarantee you’re going to learn so much so please do check out her channel Priya Mistry, the tmj doc. It’s absolutely phenomenal i’ve learned so much from it as well i think it’s great and you know what the problem, Priya look problem with us, UK dentists and i’m you know i say this that we sometimes we’re very much like oh the evidence the evidence the evidence whereas what i want to do with my podcast i want to bring differing opinions so a lot of people will listen to this podcast thing whoa what you’re saying about the the posture because we weren’t taught it then school they’re like wait what’s going on what’s going on but i always encourage my listeners to keep an open mind there’s so much so many unknown unknowns so i’m loving the direction that went in. Another quick fire question is when your patients come back with a positive diagnosis of obstructing sleep apnea, do you change your appliance now to a mandibular advancement splint? – If it’s mild or moderate sleep apnea, yes. if it’s severe then i just say you know cpap and use what we give you because most of the time we move them anteriorly anyway so it opens their airway a bit but to really know what our appliance is doing they have to take a sleep test without it and with it and most people don’t want to do that i mean these sleep tests can be very expensive they’re not always covered by insurance and that’s why i’m super excited about the breathe institute they’ve actually set up a way to ship my patient a sleep test they take it and their ENT, their medical doctor, their ENT actually looks at the results gives us the diagnosis and their sleep test is really really great too because they have a lot of questions that come along with it they’re trying to determine not just sleep apnea but upper airway resistance syndrome whether this person is a mouth breather and so i haven’t incorporated that into my practice yet but i’m looking forward to doing it because it’s a way for me to offer these sleep tests but they’re still read by an MD because as dentists we can’t diagnose sleep apnea there’s a way to do it that’s cheaper for the patients where it’s like we don’t have they don’t have to spend two thousand dollars on a sleep test we can do it for a couple hundred dollars here you know so i’m trying to incorporate all that but i haven’t done it quite yet Fantastic and it’s far more than we’re doing at the moment and too far i’m also looking for a good home test solution so if anyone’s listening to the podcast and can help me with that in the UK but especially i’d love to hear from you guys. The next one i’m going to ask you then is at which point you think GDPs, general dentists, should be referring to someone like you who’s limited their practice to the treatment of tmd i guess the way we look at our patients is i always say there’s we look at our cases based upon degree of difficulty with four levels four being, four levels four being the highest so fourth the highest level is a locked jaw that’s the most difficult thing to treat jaw locked closed and then the third level is some myofascial concerns as well as some joint involvement, clicking, popping especially clicking at the end of opening that indicates the disc is more displaced than at the beginning of opening so that’s kind of our level three, level two and one are really no joint involvement it’s all myofascial so what i would say is level two, level one anything myofascial without joint involvement try to treat it at your practice you may be surprised at the success that you have i would just make them a nighttime appliance with an aqualizer bite and i again i have a video on that i’m not trying to plug my channel every five minutes but it’s way easier to have you watch my videos. I want to plug it i think you should see it and it’s a video that i found you on a fantastic video and I so i’ve got loads of these aqualizers in the fridge and i like to give them for so people coming to acute pain and stuff but your video so i don’t do because. Here’s the different opinions of what not I do. A lot of midpoint stop appliances but the downside of that is that yes the airway impacts having whereas i think the with the the tens approach that you take i think it puts them in a better position for the airway so i do like your approach as well and i’ve got a couple of patients i’ve identified would be beneficial for that but going back to your point the advice you gave there was to give it a go, try it because myofacial pain is the most common, thankfully, diagnosis and people in that level one area there’s more of them than, thank goodness, for people in level four classification is really helpful and really to ask. Start asking every single patient if they have headaches, if they have neck pain, if they have jaw pain they won’t necessarily think to tell their dentist about their headaches or their neck pain right of course jaw pains are going to tell you but they don’t think and you’ll be surprised at how many people say yeah i have headaches all the time or i you know i’ve had migraines for 20 years or whatever you may hear you can lessen those headaches drastically with these appliances if they’re made correctly if you’re putting their muscles in their happiness -Amen sister. And it’s amazing to do that for someone they look forward to seeing you they’re not coming in for something they’re dreading they’re like you made me feel better i mean it’s so gratifying it’s wonderful You’re so right on the money there because look i love doing my restorative dentistry. I love doing teeth straightening and stuff and i get that perfect onlay on i’m happy but you know what none of this compares to when i have that patient that young lady who’s been taking painkillers for headaches and i’m the first dentist to ask her about headaches and i just make an appliance and i give her some patient education and then suddenly her headaches are gone and then i get a thank you. That means so much and i absolutely love that but you know what i i’ve explored already our approaches are different which is amazing, right? We have two different approaches. I do a lot of anterior only appliances and then you do the way that you describe but they both work so there is a lot of crossover in terms of how we can get our the muscles of the patient relax in a better state and i think as a profession we can learn more through research and stuff in the future i don’t know if we’ll ever get that high quality evidence that we need but it’s just the beauty of it and i think we just have to accept that there’s no unified theory and that’s the beauty of it instead of getting frustrated by it. I’m very mindful of the time but yes carry on. -Sorry just to add to that i mean there’s so many causes of tmjd. There are a lot of solutions too i mean it would make sense that there’s not just one right approach and with tmjd keeping an open mind continuing to learn is so important it’s not as simple as doing a class one filling like we’re all taught to do that the same way but tmjd can be a whole body issue for some of these people and so just keeping an open mind like you said palpating the lateral pterygoid i had somebody already multiple people approach me that’s not even possible. Well i think it is, so you know it is what it is yeah, what, really excuse my French but what really pisses me off right is when dentalprofessionals right like we have this like closed mind and we don’t accept that there are other ways there are unknown unknowns and they go by the very poor quality evidence that exists, right? So i hope when i commented on your video i hope you didn’t feel like i was like disagreeing with you i was just coming at a different angle i kept a very open mind because exactly what you said we don’t know the answers and we need to keep an open mind and appreciate there are other ways to think about this. So I would encourage all dentists to think more openly and i don’t see the point of saying that’s not possible just because someone says it is we don’t know we i don’t i think there’s a lot of unknown unknowns. No don’t stop making content for that reason keep going. -You were really kind in your comments. I’ve had people come after me i’ve had i’ve been called a [ moron ] people are very mean online so your comment was totally great and gracious Above board. Good good and that’s the way we should approach it we should we should be approaching a healthy discussion and whatnot and wanting to learn from each other and i appreciate your reply as well and wanting to learn my perspective as well which is really wonderful so thank you for that. My last question then is when do you involve so you talked about the nucca chiropractors already when do you involve physical therapists or physiotherapists as we know in the UK and also do you ever involve like psychological interventions like cognitive behavioral therapy do you ever get those specialities involved? I usually get the nucca chiropractors, the physical therapists and i have i’ve talked to patients about the cognitive behavioral therapy but a lot of them don’t want to go that route i had one that is doing transcendental meditation and it helped her so that’s one but a lot of people don’t even want to go that route i almost wish i could just say can you just do it and then tell me how you feel but you know if they don’t want to do it they don’t want to do it so a lot of them are open to seeing the physical therapists and we have some great tmj physical therapists just very close by to my office here and they have a biofeedback machine so it’s showing you which muscles are firing in different postures and so they actually have you do different postures and they kind of train you to when you feel stress or anxiety coming on to assume these postures that bring the muscles back down to a calmer level so they give you kind of tools that you can use at home they they do a lot of myofascial release they show a lot of exercises that bring relief to our patients and so i do utilize the tmj physical therapists i adore them the ones that we work with the nucca chiropractors and like i said i wish more would do the cognitive behavioral therapy but a lot of them just don’t want to go that route for whatever reason Brilliant and for these complex cases is definitely a team approach i found so last question is i’ve been doing a fair amount of research on what is the best way to treat someone with a disc displacement without reduction okay and the literature is very much we don’t know because so many different ways actually work so i want to hear Priya’s view. What’s doctor Priya Mistry’s most successful intervention or recommended intervention for someone with a disc displacement without reduction? Yes so what we do at my office is we actually say you know if they’re not even open enough for us to get impressions we’ve got to get them open more, right? So we’ve got to get get that disc reduced or at least the muscles calm down a little bit more so that they have a more a better range of motion. So what we do is we say we call them emergency appointments which sounds a lot scarier than it is but we just say it’s about an hour long we have the patient come in and we use the tens with an aqualizer in the mouth for 45 minutes once that’s done we turn the tens off we take the aqualizer out and like i said we do that muscle release at the base of the occiput we do a little bit more extra oral work but the intraoral work is really what’s unique in this in terms of getting the jaw more open so we do that myofascial release with the lateral pterygoid, the temporalis tendon insertion, that area and for a lot of these people it’s quite a bit of pressure you have to put in that area to get those muscles to kind of let go because the lateral pterygoid attaches to the disc, right? So the superior head does and so once we’ve done the myofascial release on both sides a couple times then what we do really that’s really unique is we actually do osteopathic manual jaw manipulation so my mentor, Dr Parker, he studied with osteopaths, tmj physical therapists, naturopaths, he’s traveled the world i mean he’s been around before google and he’s worked with some of the best people but he’s a big believer in osteopathic work hands-on manual therapy and so he with all of that he’s developed a method to actually manipulate the jaw so we do one side at a time and then both together and manipulating the jaw so that we can get the condyle and the disc back in the proper relationship and so it does not always work at that first emergency appointment so typically we’ll see the patient once or twice a week and we can get them unlocked usually the second or third time and as soon as they’re unlocked we take impressions because as soon as they leave they can lock up again so tmj work is often two steps forward one step back two steps forward one step back and it can be frustrating for everybody involved but i always make sure to tell my patients that like it’s not gonna be it. Took you a long time to get here it’s not going to be fixed overnight and some of these people with jaws that are locked some of them totally get it and other people just they just want to be fixed right away and it’s really hard it’s it’s hard emotionally for them it’s kind of draining for me a little bit too but i would imagine it’s hard to have your mouth stuck you know so where you can’t open you can’t eat and you know quality of life goes down a lot and so that’s how we treat it. Priya, I just want to ask you i mean it’s great you mentioned that it’s amazing that by third appointment you can get that result but i just want to explain for the dentists who perhaps have no insight into what happens during this once you’ve got the disc to recapture onto the condyle that’s gonna change their occlusion. So how do you manage that and where does a potential prosthodontic or restorative work come into the future? Is that always necessary? That’s a good question yeah so when they actually lock that’s when they notice ‘hey my bite feels a little bit off’ and so if it’s a little bit off if we can get them unlocked and get it stable we see how they are after four to six months oftentimes we can regain the bite it’s not an issue but there are some times that we cannot and so there was one patient that came in locked and her bite was so off and she was fixated on it. ‘Will my bite come back? Will my bite come back?’ And finally Dr Parker and i just said we don’t know it probably won’t you know and so we didn’t want to guarantee that and it didn’t. So we sent her to an orthodontist after we got her joints stable. So the way we like to describe it is sort of like the two joints and the teeth coming together fitting together like cogs on a gear it’s like a tripod effect and what happens when you cut off one leg of a tripod the whole system goes out of balance so if the disc is completely displaced and the jaw is locked of course the bite’s going to be a little bit off right? And if we can get the disc back in alignment there’s a chance we can recapture that bite but what if the bite becomes totally off, right? Because the patient’s been compensating for so long and she was a patient with the bicuspid extraction retraction orthodontia it was clear she had been trying to grind her way out of that position for years and years and years, she’s in her 60s and her teeth were just beat up from all of that so it’s like you know we think of another way to describe it too is like a door with the two hinges and you know the opening and closing portion of it if every time you close the door you have to kind of shove it by the doorknob to get it to lock eventually the hinges give out. So you replace the hinges but you didn’t fix the original problem so same sort of thing and so she finally accepted it and she went to go get orthodontia once we got her joint stable so you can’t always recapture that bite. Amazing! Priya, you’ve answered all my questions and you gave so much value today and we discussed interesting theories some controversial stuff and that’s the beauty of it and i think you were so humble the way that you delivered that and you were so accepting the fact that you know what some dentists may disagree and that’s fine but i just want everyone to play nice you know let’s let’s all listen to the different theories and share together but i definitely think what you’re doing on youtube is such a great thing if not for dentists but for patients i can see the comments that you’re getting on youtube it’s just phenomenal how much your content is helping so please do continue that and thank you so much for coming on the podcast. Yes, thank you for having me it was so much fun thank you.
Jaz’s Outro: There we have it i hope you enjoy that perspective the varying opinions like you know i don’t believe that we can palpate the lateral pterygoid but Dr Priya Mistry and many other great clinician feel you can. So there’s a beauty in this. There’s a beauty in varied perspectives It’s just the way dentistry is we’re never gonna have this unified theory when i had Villa Pancho on the podcast the physiotherapist she had her own views and there’s a lot of overlap but there’s a lot of difference as well so let’s appreciate the beauty of it all. So i hope you’ll join me same time same place next week when we join another episode of your favorite dental podcast please do leave a review write a review. I love reading them so if you’re listening on apple don’t just give me five stars or how many stars you want to actually write a review i read every single one i really appreciate it. Thanks so much guys for tuning in. I’ll see you next time you.