Sunday, December 27, 2015

The DTR occlusal revolution

Most dentists have been laboring  extensively and struggling with their patients' bite issues ever since dental school, where our training was either abysmal or opaque, and we graduated with almost no idea of what people did with their jaws or what they were supposed to do, and what might go wrong, if we weren't able to recognize and address a problem. We were undertrained to do something that is complicated and often difficult. 

The truth is, that getting the correct bite is about the most important thing you can do, for some patients, and for others, it is almost secondary. And you won't know which patients who need the most discriminating diagnostic right off the bat. It can be a real conundrum.

Here is my story, only applicable to me.

I graduated from Dental School in 1972, thinking I was pretty smart about most things dental, and was smart enough to not try to get too fancy with treating people with TMJ issues, or headaches, joint noises and so on. Just refer them to the oral surgeon or somebody else.

In 1976, I had heard of Pete Dawson, so I started his series of course, in St. Petersburg, Florida. I learned a lot, and his teaching helped me to formulate some basic ideas about the working of the joint and the interrelationship with the bite. I wasn't so sure about the jaw manipulation, but I chalked that up to my just not having hands like Pete had, and my lack of skill and caring was why some patients never got better. I felt guilty at not being as good as Pete.

In 1980, I started Pankey, and while it was a fun four weeks over the next few years, it was pretty much the same thinking about the TMJ and a very similar approach. But making the Tanner appliances was a bust for me, and another source of guilt that I somehow just didn't do it right, because the patients just didn't respond like I wanted. I also never wanted to admit that I could not see one damn thing on those TMJ radiographs that were supposed to be so diagnostic! Now I realize they were incredibly crude, anyway.

As time went on, though, I realized that those referrals to the oral surgeons often came back with joints that had been operated on, and were worse off now than they had been. That really bothered me, especially after several patients had those awful Teflon type joints placed in the 1980's, when Farrar and McCarthy were lecturing on joint surgery as a panacea for joint pain. Big mistake, huge, in fact.

Some of my patients did seem to get better, some of whom I had done some occlusal work, and some of whom I just left alone, and when I heard Jim Boyd talk about his NTI appliance, it made sense to me. If a person's muscles and joints were painful because of overactive muscles, then the NTI, which seem to really calm them down with overnight wear, made perfect sense. And we had a lot of success over the years with NTI and even other types of bite splints. But I could never figure out which patient was going to be a success! It felt like I just kept throwing things up against the wall to see what stuck.

Of course, during all of these years, I would occasionally go to meetings and listen to lectures by John Kois, John Cranham (been to several of his seminars), spent a week at LVI for Occlusion 1, and heard various talks by John Nasedkin, Niles Guichet, Prabu Raman, and Clayton Chan, among others.
I also spent a significant amount of time and money learning NM dentistry from Brad Durham, and Curtis Westersund- good friends to this day! Bought a K7, and then got terribly frustrated with using it, and the lack of support from the company. Neuromuscular dentistry is a great restorative system, I think, but there are times when you just can't do a full mouth case, or even a full arch, and the NM seems to almost posit that is the default "correct way" to treat a mouth with wear and broken fillings or what we might call "a bad bite".

I had some exposure to the T-Scan along the way, but I never got much training on it, so it stayed in a a drawer somewhere, too valuable to throw away, but not integral to my day to day practice of cosmetic and restorative type care. But as I listened and learned from people I respected, I came to the realization that since every single restorative process I completed had the capacity to affect that patient's bite, I really needed to know what was actually happening, and I began to distrust what I was getting from my articulating paper.  I needed to know what was happening on both sides of the mouth, and I became aware of some studies that showed a great deal of inaccuracies inherent in it use.

About 2 years ago, I really got to thinking about the T-scan, and once I got my handle and software upgraded, and started using it often, it became more and more valuable to me- in balancing splints, getting a denture bite correct, after delivering a big restorative case. What I realized was that while articulating paper really isn't enough to assure a good bite, the COMBINATION of the T-Scan and articulating paper works great. We really got in the habit of using the T-Scan frequently and got to where we really trusted what we were getting. It felt really good.

Then about a year ago, I went to Dallas to hear Dr. Robert Kerstein talk about the next phase, what he called DTR, for Disclusion Time Reduction, and although Robert is pretty much a typical prosthodontist, emphasizing the science behind what he was finding, it was not hard for me to get excited to hear how the COMBINATION of the T-Scan and the BioEMG (from Bioresearch) was giving him and several other doctors across the country some really amazing results with patients. People with lifelong issues with headache, TMD issues, sensitive teeth- the whole gamut of muscle driven pain and dysfunction, were being cured, quickly and permanently! Dr. Ben Sutter, Dr. Nick Yiannos and Dr. Kerstein have all published patient testimonials and treatment explanations on YouTube- available to everyone!

I am not going to delve too deeply into the physiology here, but the gist of this treatment is Dr. Kerstein's observations that it is not an imbalance in a person's MIP or centric occlusion that seems to be the issue, but rather the interferences in the working side excursions that caused the most issues, and that was detected by looking at the EMG readings of the muscles involved (primarily the anterior temporalis and masseter muscles). By bridging between the T-Scan software and the EMG software, the dentist is able to see in real time, what contacts seem to be triggering abnormal muscle activity, and then when those contacts are smoothed down, how the muscle is able to calm down. Immediately, not a week or two later!  Balancing side contacts are also important to remove, but the big "AHA" moment was in seeing how working interferences triggered the most muscle hyperactivity. I believe this is the first time in dentistry that you are able to get such instant feedback on muscle activity as it relates to the bite.

Think for a moment about all of the patients you might have seen over your career, and how many of them experienced hypersensitive teeth, or extreme wear, or  broken teeth or broken restorations, things where you couldn't understand the etiology. But if the interferences in the bite are triggering the hyper function, and we can actually SEE which interferences are triggering which muscles, we have a huge leg up on dealing with this problem!

Although Dr. Kerstein has been doing this treatment for twenty five years, his calls for more investigation and his papers on the technique have been ignored, perhaps because they were out of the mainstream, or lack institutional support. But Truth will out, and the tide is turning, I believe. We have a technique and system for measurement and treatment that doesn't require a full mouth of crowns, doesn't portend surgical need, and doesn't obligate a person to wear a piece of plastic for the rest of their lives. Other methods for treatment and restoration will always be needed, but what DTR represents is a conservative, relatively inexpensive approach to a vexing problem for which dentistry really hasn't had good answers, yet. 

For further information I would advise  the videos that Dr. Yiannos, Dr. Sutter or Dr. Kerstein have up on You Tube. They are an amazing source of information.