Dr. Brown graduated from Georgetown dental in 1986 and built a large practice shortly thereafter. He has been working in the area of TMJ disorders for over 25 years and took over the practice of Dr. Brendan Stack about 5 years ago. He has lectured on TMJ disorders in London, Dubai, Seoul, Washington DC, and Oslo. He currently teaches TMJ and sleep treatment modalities in Toronto. He is very experienced in identifying cranial bone distortions and how they relate to the various disorders including migraines, sleep disordered breathing, and even movement disorders like Tourette’s.
http://sleepandtmjtherapy.com/
VIDEO - DUwHF #1055 - Jeffrey Brown
AUDIO - DUwHF #1055 - Jeffrey Brown
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Howard: It is just a huge, huge honor for me today to be podcast interviewing Dr Jeffrey Brown all the way from Falls Church, Virginia, about ten minutes from Washington DC. He graduated from Georgetown Dental in 1986 and built a large practice shortly thereafter. He's been working in the area of TMJ disorders for over twenty five years and took over the practice of Dr Brendan Stack about five years ago. He has lectured on TMJ disorders in London, Dubai, Seoul, Washington DC, and Oslo. He currently teaches TMJ and sleep treatment modalities in Toronto. He is very experienced in identifying cranial bone distortions and how they relate to the various disorders, including migraines, sleep disorder breathing, and even movement disorders like Tourette's. I'm so honored to have you come on this show because this is dentistry uncensored. Let's start with the uncensored part. It seems like the only thing pediatric dentists argue over is like silver diamine fluoride. I still don't know what endodontists argue about. They all seem to be on the same page, but man, when it comes to TMJ, there is more different camps...there's neural muscular. TMJ is a lot more confusing to the young dentists because they hear one guy saying neuromuscular and they see another guy, no you got to do Dawson, Pankey, CR, so shed some light on TMJ for all of our homies today.
Jeffrey: Okay. I've been through it all Howard. I was, I guess I am a neuromuscular dentist from way back the LBI training. However, I learned after about a year or so that it didn't work for me at least. I started studying how cranial bones… if the cranial bones are distorted like this, like if a person's ears are like this, the eyes are like this, the cranial bones internally are all distorted. So I really kind of felt like pulsing and tensing the muscles wouldn't make any difference because you're just simply pulsing to an unstable cranial foundation. It's kind of like if you renovate the kitchen in your beach house, the beach house, the stilts are like this, the house is tipped this way, you're going to renovate the kitchen internally and kind of make it like this, but it won't be level with the rest of the house. So that's my theory on it. I know there's a lot of guys and gals arguing neuromuscular is the next best thing compared to white bread. However, I learned over the years of my osteopath and physical therapy training that I think there's a little better ways to do things, but you're right, it's terribly contemptuous out there that we argue all the time about how TMJ treatment should be done. And I guess because of Brendan, I do an MRI on every single patient that walks in my door. Yes sir, an MRI, magnetic resonance imaging, of the articular discs in the joints.
Howard: Well let me interrupt you right there. It seems like most people are using a cone beam technology in their office because an MRI is a large machine. So you think it's better to treat TMJ/TMD, sending him out for an MRI because you want to see soft tissue as much as hard tissue?
Jeffrey : I most certainly do, and I also get a CBCT of the TM joints when the patient comes back in and various other x rays, to look at the bones, condylar shape and positioning, I check condylar angulation relative to the central axis, but if you don't look at the disc, if you don't know where that disc is, you've lost another measure of how the patient is doing. Because a follow up MRI a year down the road will tell you if you're on the right path. So I like to do a whole gamut. MRI for soft tissue, CBCT of the condyles, then three other standard orthodontic films, and then I have a really good picture and I can track and progress with the patient. A lot of patients want to measure how they're doing. They want measurable quantities. This is how you give it to them.
Howard: I want to read more of your bio because I'm a huge fan of yours. Dr Jeffrey Brown grew up in the state of Maine and went to Bowdoin College where he graduated Magna Cum Laude in '82. He accepted early decision into the Georgetown School of Dentistry and graduated there in '86. While at Georgetown, Dr Brown worked in the neurology department as an assistant on a project that involves studying the regeneration of nerve tissue in the spinal column after major trauma. Upon graduation from Georgetown Dental School, Dr Brown worked for a short time as an associate in the practice in Falls Church, Virginia. From there, he moved on, built his own practice in the Fairlington neighborhood in Arlington, Virginia, creating one of the largest practices ever seen on the east coast. Dr Brown took a short sabbatical to help raise his four young children and to continue his education. It was then he began the process of understanding sleep apnea and how it correlates to TMJ treatment. His knowledge of the combined fields, of TMJ, sleep, and orthodontics has given him a perspective unlike most other practitioners who perform basic dentistry. In addition, Dr Brown has also learned the advanced techniques involved in expanding an airway so that both children and adults can breathe better. His training continued overtime at the famous sleep medicine center near the Emory university hospital. He is also continuing his training with the American Academy of Craniofacial pain and the ALF education institute. In 2013, Dr. Brown met Dr. Brennan Stack and was immediately impressed with the success Dr. Stack had in treating TMJ cases and being able to repair so many damaged lives. For Dr. Brown helping people by dealing with the debilitating TMJ issues became a second calling and they say the rest is history. The only red flag in this bio is you went to Georgetown and you worked in Emory and then they closed both of those dental schools down. Do other dental schools say "Hey, don't come work here, every time you're in a dental school it goes under, it goes down."?
Jeffrey: Well that's a possibility, Howard. But also back then I had hair on my head. I rode a motorcycle too. So things have changed a lot since then.
Howard: So what do you think these kids need to know because they're going to come out of school. I know what they're thinking. They're thinking Dr Brown, I graduated $400,000 in student loans. I feel like we hardly learned anything in TMJ and occlusion. What advice would you give them on their journey to learn TMJ, occlusion, sleep apnea, how they're related.
Jeffrey: It is a long journey, Howard. It's a very tough one. I had a doctor from Toronto called me a couple of years ago. Fresh out of school said, "oh, I see what you do. I want to do what you do. I love what you do." And I said, "What's your training? Have you have you become disgruntled? Have you learned that everything they teach you out there is pretty much questionable." I said, if you're not an unhappy dentist, you've been everywhere, and I'm talking Pankey, Dawson, LVI, you've done it all, FC and everything. Hundreds of hours of orthodontic training. If you haven't done that and become a little bit disgruntled and questioning things then there's nothing we have in common yet. In other words, I tell the young person, you need a lot more experience in failures to get where I'm at. I guess you have to be a little disappointed in the way things are being taught and then you learn from guys like Brendan. Brendan was brilliant. I'm sure you knew Brendan. We met six years ago after...and I did meet him by the way, fifteen, twenty years ago and I said, “Hey, I want to buy your practice and all this.” He told me you were to put it in, what to do with it. That was Brendan for you. Then we hooked up again six years back and he says, I think I'm ready at this point in time. I thought I knew a lot of stuff. I really did. I thought I was really top notch with the field of TMD. When I met Brendan, he beat me down to the ground basically with my knowledge base. I didn't know much of anything I found out and these past six years have been an eyeopener. Now he is retired at this point, but he pushed me along that journey very hard at the beginning and I'll have to admit I learned a hell of a lot from that man.
Howard: You have him come on in the next week. We'll release you then followed by him.
Jeffrey: Okay. Yeah, we can try to arrange it. Brendan just had a medical procedure, so I'll have to see if he can get out and around.
Howard: Okay. So talk about your expertise in the area of TMJD. You have over five hundred hours of training in the amazing ALF appliance, your practice limited to TMJ disorders. You treat migraines, Tourettes, tremors, ADD, OCD, dystonia, and understand the connection between displace, articular disc and these disorders. And you claim an 80 to 90% chance of improving their lives greatly.
Jeffrey: Oh yeah. Tremendously so. My team thinks we're about 90%, however I call it 80%. So we're somewhere in the middle there. We are able to treat the TMJ slipped discs and by getting those displaced discs back on top of the condyle where they belong, you abate so many of the symptoms and my experience has been so far..for example, Tourette's. We see a lot of Tourette's patients. Whether that's fortunate or unfortunate, we're able to help it. I think we're down around 80% with those people. We're 90% or higher with migraines, but the Tourette's patients are the interesting ones. We have a lot of people fly in from all over the world to see me for Tourette's treatment. The problem is we're not treating Tourette's, we're treating the TMJ disorder and I want to be really clear about that. And so far, Howard, in 100% of my cases, the articular discs are tipped medially in Tourette's patients. That's something very astounding, I think. Brendan and I argued on this for many years as far as, should we write a paper about this? Should we talk more about this? But every single Tourettes patient I've ever met has medially slipped discs and to me that's fascinating and astounding information because no one really has a handle on this yet. They all say Tourette's is a genetic disorder, maybe a developmental disorder. They really don't know. Then they put all sorts of labels on it saying it has to be present for a year and all these little ticks have to be present, but to me it's just me medially tipped discs.
Howard: Wow, and how do you treat it?
Jeffrey: With various appliances. Now the MRI is the key factor here. If the medially slipped discs are lodged and do not reduce, their stuck, then I use a lower geld appliance to take the pressure off, I flat plane it to get mobility of the maxilla. Upper ALF. The ALF is the key thing too. The ALF will begin the process of leveling the cranial bones, which are always distorted in these patients. Every single time. I00%.
Howard: It's a wild disease, Tourette's. There's two hundred thousand cases a year in the United States. It's rare in females. It's mostly in males and it starts off about age six and then it's kind of gone by forty. Why do you think it's an males between age six and forty?
Jeffrey: Well, because age six is when the first molar start to come in, that's when you have major changes to the structure itself. Things are really moving around a lot and if there's a predisposition, with that slipped disc it's going to aggravate it even more. Males over females, I don't know exactly why I'm thinking males develop a lot faster at that age maybe, but I don't know. I don't know a lot about the development aspects at that age. Just that the six year molars do come in. And it really doesn't go away. It's just more that as you get older you learn to deal with it. We just finished with a forty year old male who I worked with Jack, and I can say his name because he gave permission, but we worked with Jack for about a year and he has terrible ticks. When he first came to my office, he sat in our dental chair and you know how big those dental chairs are, Howard? Those are heavy duty devices. He did this. And he broke my damn dental chair. He broke the rod or shaft down at the bottom because his ticks were so violent. When you walk up to the guy he scares you when he has a tic like that, you jump back because you're in fear. Well we worked with him, got him 60% better, then discussed the surgical option of going in and placating the discs back on top of the condyles. He did that and a month later comes in, the ticks were still there. We still had hopes and the funny thing is six months later he calls up and says, the ticks are 95% gone. He was all better. He actually joined his son's softball team and became their coach because this is the first time in forty years he could actually walk out the door and not be embarrassed by his behaviour. That was a win.
Howard: And how did you treat it?
Jeffrey: Well, I treated it with the [inaudible 00:13:05] appliance on the lower, ALF on the upper, osteopath work to realign the cervical spine. His whole body was worked upon and realigned and then came a tragic call at about seven months in. I was driving to West Virginia to go to Jay Gerber's classes, the famous orthodontic training program. I'm halfway through up in the mountains and Jack calls me up and says, "Hey Jeff, man, I need to tell you something". His little dog was attacked by two, almost mastiff type things. He intervened, laid on the ground, protecting his dog. The two dogs attacked him. They tore his ear off the side of his head, cut open his jaw, ripped open his shoulder. And Jack called me back and said, hey doc, you know, the ticks are all back again because they tore the ear off and now he's got the ticks back all over again. If you ever wanted to prove positive that the displaced discs caused the Tourette's. There it is right there.
Howard: So tell me more about this ALF appliance.
Jeffrey: Okay. What the ALF does Howard, it's a little device. In fact, I'll show you my ALF. I have two. Here it is. It looks no more than a paperclip. However, when I teach this stuff, I actually teach the dentist to only treat young people for starters. Give the palate, the cranial bones the support they require for growth and development. All credit goes to Derrick Nordstrom out in California. He invented these things forty years ago.
Howard: Can you find that Ryan? ALF appliance. His name's Dr Derek...
Jeffrey: Derek Nordstrom and he's in California.
Howard: Is he a dentist or a lab man?
Jeffrey: He's a dentist, but the guy is... he's one of these brilliant, brilliant fellows that does all his own lab work by himself. He's up until two in the morning, three in the morning working in his lab, making things. He's an inventor, absolutely amazing to talk to this fellow. He runs the ALF interface group that I'm a part of and we meet every year, talk about advancements and we studied things like traumatic brain injuries and how the ALF can help with alleviating those concussion cases. How the ALF can gently re-nudge the bones open, getting better CSF flow, better lymphatic drainage, venous drainage is critical too. The ALF is an amazing device for all that. And after literally hundreds of hours of training in this, I finally feel like I have a good handle on what I can do with this. I actually use it to correct class three malocclusions as well. And crossbites of course. So you can do a lot with this little thing.
Howard: Wow. So you make your own ALF appliances or do you have a lab do it?
Jeffrey: Oh Hell no. I'm too lazy for that. I don't do much. I have my lab do them.
Howard: And I wouldn't assume all labs know how to make an ALF appliance.
Jeffrey: We're in the process of working with certain laboratories and getting compliance standards. I don't know if we can pull it off or not. We're trying, but there's a bunch of labs that say they do ALF appliances and they just don't have a handle on it. I use a guy in Canada, at Orthodent’s laboratory, awesome lab, I've used them for years and we go way back when it comes to these things, but they know exactly what I'm looking for. The solder points have to be just right. It takes a lot of finesse, I'll admit, and it's not for everybody, but once you get a handle on this, you really don't go back to the old styles. As an example, I have banned rapid palatal expanders in my office. I haven't done any in twenty years because of this technology. Do you want to hear about that a little bit?
Howard: Absolutely.
Jeffrey: Oh, well, all right. I'll step on a few toes. Let me give you the proper name. Howard Farran is the guy you want to complain to, not me. My name is Bill Smith okay. Because an RPE, the problems with it, it blocks the tongue from proper posturing. If your tongue does not go to the roof of your mouth for a good seal, you are not able to breathe through your nose. Therefore you will not have nitric oxide formation in the paranasal sinuses. Nitric oxide is the molecule of the century according to Time magazine, not according to me, but according to Time magazine. Additionally, if you're an osteopath doctor and you do hands on the patient's skull with an RP in there, there is zero cranial motion, no cranial rhythm, no flowing, no movement like is required. RPE's also slow down lymphatic drainage. Lymphatic drainage was confirmed to exist by University of Virginia Hospital Center a couple of years ago. UVA Hospital Center confirmed there is indeed a lymphatic system in our brains and if that lymph does not drain at nighttime at that directly correlates to ADD OCD, autoimmune disorders and Alzheimer's. Again, not me saying this, this is UVA hospital confirming all these nuances, so if you stick something in there that holds up cranial motion, you're blocking the lymphatics from draining. You might be causing ADD in our children is what I'm telling you. And again, my name is Bill Smith okay? But Howard you've got to realize, you know, going down this path that I've gone down, I really do upset a few people here and there and I'm sorry that I'm doing that, but what I'm asking of people is go back and learn about these things. It's so important to help your patients get better. The kids, the adults that I see every day, most of them are doing so much better and some of them aren't. But hey, for 80% of the time I feel like we're treating everybody. Right.
Howard: So you talked about ADD, OCD, dystonia. Talk about those more. ADD...it seems like so many parents are told from their kid's teacher and at grammar school that you're little boy, he's bouncing off the walls. He has ADD. And in America they want you to start taking a pill. I mean American is about big pharma, United States is about 5% of the nearly eight billion humans on earth and we take half the prescription pills. That should be a red flag. Do you agree?
Jeffrey: Sure as heck yes. It really is. These kids that I see all the time, they come to me and they're just jumping off the walls and jumping all over the chairs. They've got headaches and neck aches and backaches and they're jumping all over. They're hurting. They're not sleeping. That's the biggest issue. I think sleep is the really direct correlator with ADD and OCD, and then what happens is you take the little ALF appliance, you fit it in the maxilla and mandible, now the cranial structures have this support system in place. It's like saying, let me put arch supports onto your arches to help your entire leg and back system feel better and function better. We all get that, right? Well, very few people get the fact that you put an arch support in an upper and lower support and these kids thrive. They function better. And when Derek gets lecturing, he starts getting a little hyperactive in his lecturer saying, what's you're doing is you're allowing the epigenetics to express themselves. You're allowing the child to thrive and I see it all the time in what I do. And the other thing is that these kids are in sympathetic nervous system mode all the time, they're fight or flight, they don't know how to relax or rest or unwind and you lay the ALFs in and you see instantly within reason, excuse me, instantly I call it, but weeks or months later, we see very miraculous things start to happen. Just this week alone, two children came in, brother sister. Their headaches are now gone. They've calmed down tremendously. I take care of a group from Fort Worth, Texas of all places. The Fort Worth contingency, we call them. They fly in, they're all getting better. We're fixing class two malocclusions. We're fixing ADD. The Tourette's has calmed down on another kid from Fort Worth. So the kids that I put the ALFs in, start to sleep better, then the ADD calms down because I think they're sleeping better. So it's all connected.
Howard: So how could that be more preventive? How would you screen children at a younger age to get underneath that so they wouldn't end up there?
Jeffrey: What we do in my office, we see every single young child at no charge for a fairly thorough examination to start a foundation. We start looking at the frenum, pull back the lips. Are they tongue tied? It's so interesting. A lot of them have been screened by their pediatricians yet they're tongue tied. I don't know if you saw the article the other day about dentists are doing frenectomies at an all time record high just to make money while I'm the idiot that doesn't make any money off of it because I refer all my frenectomy cases to an EMT just because if there's a bleeder, I want the MD on top of it. That's just my paranoia, I guess you want to call it that. Trying to be safe with kids, but if you can screen these kids early and I mean two to three years old, look at the frenums, look at the cranial bones. Are they level? Learn to palpate this, learn to take an x ray or two. If they're distorted it internally, then I will often just do what are called bite turbos. Are you familiar with that?
Howard: No.
Jeffrey: Howard. I don't have photos of it here, but I imagine on the lower Es you put a little riser or lifter a few millimeters tall so that now the teeth in front don't touch. So what you do is you're taking a high mandibular plane angle. You put a little turbo or build up here on the mandible and it brings the high mandible down a little bit better. Thus less TMJ symptoms as they grow older. The sixes will come in taller to better support the TM joints, all the teeth forward of the Es supra erupt. So instead of a kid having a super deep bite like that, we do this over time. We gradually open them, open them and open them, and that's probably doing the little tiny people, about three years old, if they're cooperative, if there are too bouncing off the chair and bouncing off the wall, we tell mom and dad, wait and check them in six months.
Howard: It kind of sounds like the new technique, the meaw. I noticed in like Taiwan and Japan and Europe, a lot of orthodontists are really more concerned with the angle, whereas a lot of the Americans do a lot of orthognathic surgery. They change the angle. But again, why do you not use the RP, the rapid palatal expander, which is used so much in the orthodontists and the pediatric dentists in America.
Jeffrey: Again, just the basic cranial motion is stopped dead in its tracks. Tongue cannot posture properly. You cannot get a proper swallow. All these are factors that are so important and you're just blocking the children's development when you do these things. You might as well put a vice grip on their maxilla. And I know that's going to stir up a lot of controversy out there. And I'm sorry for that, but it's just the way it is. Once you start with this and you start learning what the ALF can do, you start to realize that maybe like yesterday I told the patient, yeah, if you want to do jaw surgery, you can, but I'm not going to be part of it because you'll be back in my chair a year later when you're hurting. Do you want to do a DNA or something like that? I don't do that. I banned all such heavy, heavy items in my practice. No mara's, no twin blocks, unless they're an ALF twinlock. We don't want to slow down development.
Howard: And who is your favorite orthodontic instructor? Because the one thing the orthodontists have done in America has kept orthodontic education out of the dental schools. When you're in a dental school, the endodontists have no problem teaching molar endo. The oral surgeons love to teach you extractions. The pediatric...every one of the nine specialties will do anything and everything to teach you how to do what they do. Knowing the eighty twenty rule, you'll do 80% they’ll do twenty, until you come to orthodontics. And then in every dental school the say, “Well, if you were to learn ortho, you should go to ortho school.” And whenever an orthodontist starts teaching American general dentist orthodontics, they're amazingly blackballed from the orthodontic society. Take Richard Lead. He's the only board certified orthodontist. He was the teacher at University of California, San Francisco. Then he moved over to Detroit and hell, he's never asked to speak anywhere. His name is dirt because he's just low life. So what low life was teaching you, a mere general dentist about ortho. And who do you recommend for that?
Jeffrey: I give a lot of credit to Brock Ron Dahl up in Toronto. Awesome, awesome man. He teaches incredibly excellent orthodontic techniques. The only thing is what I have attended his courses over the years. He says, look, you know, Jeff, you're the outlier. You do ALFs. You don't do mara's, TBs, all these different positioners. I don't do any of that. And he readily acknowledges that. Then I also would recommend Jay Gerber at the straight wire orthodontic studies group. Jay another, he's again, a general dentist that learned heavy duty orthodontic techniques, brilliant man who teaches this to the general dentist population. So I've done all the training with these guys imaginable. I really thank them for my orthodontic abilities and I must admit I have to do orthodontic work every day. I don't really want to though, Howard, but I have to for severe TMJ cases. I have to. I've had to learn how to lift bicuspids and molars and canines sometimes as high as twenty millimeters, which we hear that can't be done. At least that's what I'm told by orthodontists. We do it every day.
Howard: How does TMD relate to sleep apnea?
Jeffrey: Okay. When I palpate a patient's head and neck region, I can reach in and grab the lateral pterygoid, which is way by the second roller, and if that's in spasm, then internally they're like this. They're tight as a drum. Their throat is constricting, so that's one of the factors. The other thing that I see almost three fourths of the time is a calcified stylohyoid ligament running from the mastoid down to the hyoid bone, roughly, and when that thing is calcified, it looks sometimes like my finger does, but it's all bone in the neck that's closing down the airway in the throat too. That's from again postural problems. The patient is often forward head posture like this, and because they're discs are out of place they feel better hanging their head forward. It's so much more comfortable. So then the neck is irritated stylohyoids calcify, more and more throat problems. Swallowing problems, reading problems, again, all connected to those slipped discs.
Howard: You mentioned that that is running all the way down to the hyoid bone. That's why the cheetah can't roar because the cheetah's the cat without a hyoid bone, so all the other cats can roar. But the Cheetah, the fastest running of all the cats, seventy miles an hour, it can just purr like a kitty cat because it doesn't have a hyoid bone. Isn't that bizarre?
Jeffrey: That's crazy.
Howard: That is crazy. You know when you and I were little, you got in 86, I was 87, the oral surgeons were doing a lot of flap surgery on TMJs. I mean it was a common thing and remember it was University of Louisville. No, it was New Orleans where they had that really famous oral surgeon putting in a lot of artificial disc and then those disc disintegrated, they were finding macrophages eating parts of that disc in knee caps and all that kind of stuff. Are you seeing much TMJ surgeries anymore or artificial condyle joints, or is that kind of a bygone era?
Jeffrey: Well, a lot of it is a bygone era. The arthrocentesis for example, where you shoot the needle in on the high side and flush it out and low side. I've talked to my surgeon, Eugene Gregory, wonderful, wonderful guy who does my surgeries, actually almost every week he does surgeries for me. So yeah, we do surgeries. When you're an arthrocentesis, you generally will perforate the disc, with that first needle or the second, so you're damaging the joint anyway. The better approach is go in one inch incision right there at the crease of the air. He picks up the disc, placates it back where is belongs fourteen, fifteen stitches front and back to hold it where it belongs. Success rate is 94% of the time and almost every single patient that comes out, I had three this week that just were post op checks, they all said the same thing: I wish I had done this twenty years ago. All the pain is gone.
Howard: Who's your ortho doing that?
Jeffrey: His name is Eugene Gregory in Falls Church, Virginia. He goes way back with me and Dr. Stack, he knew Brendan back forty years ago. The unfortunate thing is Eugene is retiring at some point in the near future, so I'm trying to negotiate a replacement for him. Hopefully we'll find somebody and we're working on it now.
Howard: Does Eugene Gregory have any referrals for that?
Jeffrey: To replace him?
Howard: Yeah.
Jeffrey: Not right now, no. Gene is thinking of... at first when he knew Brendan and then he didn't know I was coming on board, he was ready to retire six years ago and just say that's it, I've had enough, but because of me he stuck around and he may stick around a few more years is what we're hoping for because he's got the knowledge base. He's done thousands of joints and he's written papers and he's done such a great job with these people and it's quite a finesse to do TMJ surgery. You will hear mostly negative things on the Internet about this type of surgery. The people just don't know enough about it and the experience just is not there. As a good example, I had a patient about a year ago, one of our state department patients needed surgery. She could only open ten, twelve millimeters. That was it. Locked, couldn't move. Months on end. We tried an appliance and we knew she needed surgery, so she said, “Look, I'm not paying Dr Gregory's fee, which is out of network for insurance. I'm going to find my own surgeon.” So she calls Blue Cross, they got a list of eighteen TMJ surgeons is what they gave her, a list of eighteen doctors. She called every single one of them. One them said he had done ten meniscectomies, which is removal of discs. All the others basically said, haven't heard about it, don't know what you're talking about, don't have any experience, and this is the list of TMJ surgeons that was provided to this patient. So she was disgusted. She ended up having Dr. Gregory do the surgery and she said, “Yeah, best thing in the world. I should have done it thirty years ago.” So that's our typical story on surgery.
Howard: Wow. You say you treat TMJ when people who have movement disorders like Tourette's. A far more common movement disorder is Parkinson's?
Jeffrey: Yes.
Howard: What are your thoughts on that?
Jeffrey: I think it's the same thing. I think Parkinson's is just for folks that are a bit older and the same thing is going on. Every time I do my MRI, movement disorders show up that the articular disc are tipped in medially or inward, and that's the typical thing that we see. Whether you're six years old or sixty five years old, it's about the same thing to me. Now the problem with that is as we get older and older, those discs...I wrote a blog on this one, Howard, it was called something about the case of the french fry that was stuck. So if you think about, you're in the driver's seat of your car, then there's a console to your right where you rest your arm. Well between the chair and the console is this tiny space. Imagine if you drop your french fry down in there. It is stuck, it is jammed down in there. Well, if you're young and pliable you can really reach down in there and pick up the french fry, like the medial slipped disc. But if it's stuck down in there for fifty years, odds are it's calcified and may have adhered. Things like that happen. There is what I see happening with Parkinson's, the medially slipped disc is literally jammed down in there between the chair and the console. And to get it out is darn near impossible. So therefore Parkinson's doesn't work as well with our treatments.
Howard: Wow, that's a lot.
Jeffrey: Yeah. But I see it all the time unfortunately and when I tell the patient, look, your seventy or eighty year old parent hands are like this. I think the disc is jammed down in there and the MRI tends to show that almost every time or it's eroded away. So my theory on Parkinson's and for what you all want to take it for whatever it's worth, I think that articular disc is jammed down medially between the condyle and all of that tissue. It's been down there eroding for years upon years sending aberrant signals to the brain through the auriculotemporal nerve or whatever bundles of nerves are getting hit and it's just stuck and there is no way anyone in the world can get the whole thing back up there again, which is why Parkinson's, excuse me, is so damn difficult to deal with and get a success with. And when I explain this to the patients, they're like, “Oh, I should've done this forty years ago.” And I say, “Yeah, yes indeed. But you're here now.” We do try, but the success rate is so much lower as we get older as with anything.
Howard: Now, the most common would be headaches and migraines. How do you think TMD can treat headaches and migraines?
Jeffrey: Most of those have anterior or laterally displaced discs almost all the time. And again, we do the MRI. I've got a bunch of videos on YouTube if you look for them. You'll see there's Carrie out there that talks about severe migraines. She was on Tegretol, Topamax, all these other terrible drugs for years on end and we just simply made her appliances and we're now finishing up her case, orthodontically. We're lifting her teeth to long term support those TM joints. And a lot of cases are done like that, but migraines aren't that hard to work with.
Howard: So you can successfully treat migraines with orthodontic appliance and orthodontics?
Jeffrey: I don't call them orthodontic. I call them orthopedic appliances. Orthodontics refers to just the tooth itself and we only manipulate the teeth after we get the discs in place and as Dr. Stack used to say once the discs are good, then bring up the pretty little white things to support what you just did. And it's so true. Yeah, that's Brendan's way of describing it.
Howard: So what would you tell a young child who's twenty five years old, she just graduated from dental school and she says she wants to learn more about this. She wants to learn more about sleep apnea. And the other thing that concerns me about this, and I want you to address this, it seems like dentistry is, in a way it's going in the wrong direction, because it seems like a very popular dental practicing model is to be a jack of all trades. They want to do their molar endo and place implants, and do sleep apnea, and do Invisalign. It's like gosh, in 1900 there were no specialties and healthcare was 1% of the GDP. At the end of the century it was 14% of the GDP with fifteen specialties in medicine and nine in dentistry. Now we're at 2018 and healthcare is 17% of the economy and can you really master ortho, TMJ, sleep apnea, molar endo, placing implants, bone grafting, veneers, cosmetic bleed. I mean, can you really be a jack of all trades? When someone says to me, Howard, I want to get into sleep medicine, my first question is, okay, what are you going to give up? I mean, when are you going to start referring? And they're like, no. I'm like dude, it's a full time job to stay on top of sleep apnea, on TMJ, on molar endo. I mean, look at implants. Just bone grafting. That field is moving so fast. So what do you tell a twenty five year old kid who thinks she's going to play every single instrument in the orchestra?
Jeffrey: I have those discussions frequently actually, and I tell them, please do not be a jack of all trades. Do not do what I do. I think that's one of the best bits of advice you can get out of the seminar today. Don't do what I do, but learn how to screen for it and identify it. Number one, you check range of motion. You palpate a few bones. Have your hygienists do that. That's fine, but put it in the chart range of motion. Twenty eight millimeters, patient advised. But that's the best thing you can do right now. The thing is, if you go down this path...Howard, I'll be very blunt, I'm in my office seven days a week right now. I'm here at zero five hundred hours Monday through Friday, studying MRIs, looking at my frontal and lateral [inaudible 00:39:35], comparing things, writing notes. There's no other way to do this kind of practice otherwise. You can't just walk in the room and say, oh Joe, you have a cracked tooth. We need a crown. You can't do that. You have to present the patient about a forty five minute dissertation on their entire condition. Some of them two or three times this week, I had women in tears. They came here saying, I don't know what's wrong with me. My doctor says it's all in my head. I heard all the time, been to the neurologist, been to the ENT had been here, had been there. I look at them and you can instantly tell cranial bones are twisted. It's instant. Then you do the MRI. That's a further back up on what you already believed. Then knew do the frontal cephalometric to further confirm what you already know, you pile the information on. Then you present it to the patient. You can't go down the hall and cut a crown prep and then run back in and do a forty five minute consult and this actually happened yesterday. I had a new patient in who went to a local TMJ person she said and she said he rushed her in and out of there in five minutes, told her wear an appliance do this, do that, and she had no idea what was going on. They never took the time to explain the MRI or explain the x rays and I understand if you're in a busy GP practice, you cannot do such things. You can't just take the time. I think I've got the luxury of that I was retired for awhile and I just came back in because I wanted to really help people get better and I think if you're doing a lot of other stuff, you're not able to focus in on the cranial bones and all the little things like working on different things everyday of the week. We're inventing a frenum reduction appliance right now and you know, if I was busy cutting crowns all day, I wouldn't have time for that.
Howard: So how much are you focused on sleep medicine, sleep apnea?
Jeffrey: Well, every single patient that I have has an apneic problem. So it's all intertwined like this. This is out of place. They don't sleep well, vice versa. So it's all connected. So we're treating the whole picture all at the same time. And I will totally admit when a new patient comes in, they've got an order for a sleep appliance, I say, that's fine, I will do that if that's all you wish. Allow me to diagnose what's going on first. Every one of them has an underlying TMJ problem, every single one of them. So if they want to narval or whatever they want, I will do it and call it a bandaid. It's a temporary thing. However it will slow down cranial rhythm it will cause other problems later on. Imagine if the articular discs are anteriorly displaced and you put it in a device, it brings a jaw down, shoves it forward, you're going to potentially damage those discs. So it may create a TMJ problem. So thinking back, well gee, that's why I took an MRI to understand what I'm dealing with. It's all cyclical thinking, Howard, you know, it's a slipped discs do you want to put in a device, that will jam the jaw forward and bang those discs even further and exacerbate the TMD problem.
Howard: What percent of people who use a CPAP in America do you think had an MRI?
Jeffrey: None.
Howard: And what percent of the people using a CPAP today, do you think if they had an MRI, would show some type of TMD disorder?
Jeffrey: Probably 80% or so, maybe 90%.
Howard: That is amazing.
Jeffrey: Yeah. I have to every single patient that's come here for sleep therapy, except for one out of maybe five hundred of the past five years. One I did not do an MRI on because there was no indicator whatsoever, but every single other one of them has slipped discs.
Howard: And give us more demographics. We talked about Tourette's was mostly males between six and forty. What about TMD?
Jeffrey: I'm not sure what's more prevalent in females. I actually had an interview this morning at seven am with a facebook group called dearly and they asked me why is it mostly women seem to have TMD issues? One, women are more sensitive in general. I don't know if that's the nurturing effect taking care of the children being more sensitive. Second reason women are smarter. That's just the way it is. Women deal with things. Men put things off. Men are more likely to say, oh, I'll take an advil because I'm hurting or I'll suck down some alcohol to kill the pain. Women are more likely to deal with issues. And I do think that ties into the nurturing aspect of being female and therefore it makes them smarter and they're going to deal with it more than a male would.
Howard: Oh, absolutely. Every epidemiologist I've ever talked to you said, you know, women, when they have a problem, they raise their hand and they go get help. And then I had lunch yesterday with an emergency room physician in Phoenix, Arizona. And we were laughing because every time I talked to an emergency room physician, they say things like, you know, grandpa will come in and he'll, have passed out in the grocery store and it turns out he's had black diarrhea for two years. And of course at that point ulcerated colon, he's got to have surgery, he's got to have half his colon taken out. Well, women after they've had black diarrhea for a week, they think, you know, something's not right. But your average life expectancy in America for a male is seventy four women is seventy nine. Women live five years longer because they raise their hand and get help. So I would assume that every disease would, like TMD, would have a higher incidence of women because women will go ask about their condition whereas men don't want to be. It's so bizarre and I know it's corny and cliché, but they won't even ask for directions. I mean, you know, older men without GPS and you're like, you know, could we stop at a gas station or can we find...before they had smartphones. I noticed that all the time, all the women would stop at the gas station and ask for directions and the men would just drive around aimlessly last forever because they're the men.
Jeffrey: It is so true. It is so true. Yes. You know, one thing I do want to point out too, that we all should be aware of, dental extractions, the problems that they cause. When you yank a tooth out of a person's head. I see every day of the week, my new patients coming in, they've had the four on the floor, we're all familiar with that expression and has taken the upper and lower jaw and done this to it. There's an airway problem ready to happen. You can only survive so many years if they yank out four bicuspids, they retract your maxilla and mandible to make the orthodontic work easy. I see these patients all the time. They're all compressed back. They can't breathe, it eventually catches up with everybody. I'll go on my theory of wisdom teeth. When my own daughter, I guess three, four years ago, had her wisdom teeth pulled out. I put ALFs for her to give cranial support for the cranial bones. She went to the oral surgeon on a Friday at twelve noon, had four wisdoms out, kept her ALFs place all weekend, went to Myrtle beach with her girlfriends, had a wonderful time. No pain, no swelling whatsoever, because when you pull wisdom teeth out, you have the four teeth out. You have major holes in your head at that point. Sixteen square centimeters, by the way of big holes, everything will collapse and that will cause major cranial disruption and other problems. So what I'm trying to do nowadays, I'm actually trying to invent a cheap, cheap ALF for surgical cases. So when the wisdom teeth come out, keep that cranial support in place. The problem is ALFs are not cheap. They are thousands of dollars.
Howard: An ALF is thousands of dollars?
Jeffrey: Yeah, about three thousand or so. They're like any other like an orthodontic case would be basically so it's like, upper lowers six thousand plus and it's a lot of work involved in making these things and they are quite expensive but that's normally the normal fee I guess for all over the U. S for those people that do them. But I would like to invent a cheap version of that to give the support for during the time a patient has wisdom teeth out. So we're kind of working on with some ideas on that too. imagine just a cheap, a valplast framework or something to hold things in place during the six weeks of healing.
Howard: Well, the cheapest way to treat it would be to prevent it. I mean it's not even the orthodontists or they oral surgeons. It's the anthropologists that have been telling dentistry for about five years. Look man, we have hominid fossils going back a long time. I mean at Arizona State University is where they have Lucy who's one point six million years old and they're saying all these malocclusions they just showed up in the last century. What went wrong? And what went wrong is they were nursing for several years and they were chewing grit off a mastodon bone and now the minute baby has any difficulty nursing they switch to some gallon guzzle bottle from Costco with a big old sippy cup. So there's no forces on the face. And they feed them baby goo, that's all mush out of a jar. So the baby doesn't fight nursing, doesn't chew anything hard, no forces on its face all through the development. And then people wonder why that thirty two teeth don't fit in comfortably.
Jeffrey: Yeah. And again, this goes back to my ALF, treatment with our patients. I now advise my patients to take those ALFs out in the afternoon. Gnash on nuts, peanuts and pistachios. Almost twenty minutes everyday. Just a little handful is all it takes and all children should be doing this every single day. We tell kids, do not eat with your ALFs in place. That's just my way of doing things. Everybody's different. But when you take these out, eat hard, gnarly foods, stimulate some development. And we also use things called mild munchies to help with that too. But that's a whole other discussion on different appliances.
Howard: So you basically are TMD, sleep apnea, ALF appliances, Do you do root canals, fillings, crowns, hygiene department? Tell us about everything else?
Jeffrey: My initial consultations with my patients, Howard. I sit in a bar stool, they sit in a bar stool. We face each other like this. I look at the patient, the general dentist goes around the chair and comes around like this and says, hey Mr Smith, how you doing? You can't see your patient when you're doing that. So we pull back the hair, look at the eyes, look at the shape of everything, look at the shoulders. If they're like this, they have an internal problem with a cervical spine, the whole back is out of place. So I don't have needles in my office. I don't have any regular drill bits, burrs, that type of stuff. No forceps, no endodontic equipment. I mean nothing like that. My days are spent putting acrylic on appliances to lift the condyles out of the sockets or wire benders to bend ALFs and I only bend these things one fourth of a millimeter, a quarter of a millimeter at every visit. It's ever so subtle.
Howard: How often would you see them to adjust it?
Jeffrey: Four to six weeks usually.
Howard: Four to six weeks. So what do you do when they have a cavity or a filling or they need general family dentistry done.
Jeffrey: They have to keep up with her general dentist at all times. Cleanings, exams the fillings, if anyone needs a crown we try to get all the crowns out of the way before we treat, but that can get in my way too. So, this past week, I ordered, I don't know how many patients that have stainless steel crowns. I ordered those off and put into plastic temporary crowns for the children. The adults are very similar too. I want that patient into a lab fab temporary crown made of acrylic that I can grip onto with my orthodontic appliance, my ALF appliance, my whatever I need or put a ledge there to hold something. So that's the kind of treatment that I would ask of the general dentist is please provide me with something I can work with. I don't want beautiful finished crowns at this time.
Howard: And are most of these patients referred to you by the general dentist or do they come to you directly to you? Are you getting B-to-C referrals business to consumer or more B-to-B business to business from other dentists in the community?
Jeffrey: We check our stats on a regular basis, which I recommend all of you guys do. Check your stats every month, but years ago we were 90% internet referral based by Google. Now we're 51% physician and general dentist referrals. So that's gone up and up and up as time has gone by and it works out pretty well. Yesterday I called a gentleman who referred two patients this week already and I told the patient, you know, you do have a TMJ disorder, call your GP dentist back and say, Hey doc, good call. You send them to the right place. And that gives support for the general dentist to realize that he or she made the right referral and then I send the information to them through what's called dental writer. And that's the program that I use.
Howard: Is it with a w, dental writer with a w?
Jeffrey: Correct. Yeah, spelled properly. Brendan actually developed the program with Rose Nierman many years ago. I see Rose and her people at the different meetings and we talk and say hi and ask how Brendan's doing of course. So we keep in touch with these folks. We use their program literally two, three, four times a day on the new patients, but the issue is that it does not integrate into dentrix or open dental or whatever your platform is. So you have to keep everything separate. Another unfortunate thing is the x rays do not integrate or bridge. So I run three or four separate programs at any one time on every single patient. Try managing that as a general dentist. That is very difficult to do.
Howard: And that's why you really want to have systems that are open because there's a lot of closed systems, [inaudible 00:54:28] that's notoriously a closed system. And so that's why these are important. So when you were 90% internet, tell us your marketing on the Internet that was so successful.
Jeffrey: Well, it all started off way back when I met Brendan. I got on Facebook mostly out of frustration. I would be seeing these - I'll be very blunt - dumbass comments. This week's dumbass comment was surgery first. It is a group that does, I think what they do is they do a maxilla advancement. They do a Le Fort sliding osteotomy on the mandible. They do that before doing anything else for these patients, lock them in tight braces, sealed shut, and I'm thinking that's about as idiotic as against because you're totally changing of the relationship of the condyle to the articular discs. No analysis of the TM joint is being done with these cases. So once again, I got on my podium and they're responded back to us. Somebody was asking me about this. My response to doing that kind of surgery was, hell no, you're stupid if you do it. And Brendan would have said it in much more harsh words as you're now I'm being as nice as I possibly can. And trying to explain the, I'm sorry, it doesn't make a lot of sense. You shouldn't be doing that. And literally three hours ago another patient was here. He's thinking, of having his class three malocclusion corrected surgically. We had a good talk about it. He has crepitus in his left joint. That sounds like potato chips crunching up in there. So we have a seriously blown disc. Do you want to run that maxilla forward with a seriously blown out desk? It doesn't work. So when he heard that as well, I went to all these other doctors last months or so. No one told me about any of this and that currently is the state of the art, I'm afraid. No one had ordered an MRI. That's when he came over here.
Howard: And how much does an MRI usually cost?
Jeffrey: Well, it's $1,690 billed to insurance. If you do not have insurance and you call our imaging center, they knock $1,100 off that. So cash crisis like $495.
Howard: Wow. Does their medical insurance usually paid for that?
Jeffrey: Yeah most of the time.
Howard: Can the dentist who diagnosed that and get the medical insurance to pay for the MRI or do you
send them to the physician to order it? How does that work?
Jeffrey: I write the orders myself. I know what I want. I order a very specific MRI in Tesla coil, dedicated tesla coil. In addition, we look for hemorrhagic anomalies, brain bleeds, concussions. Very, very important I think. One of the final things I order is the condylar angulation to the central access. So if you're contemplating a surgical case for this patient and their condyles, that should be like this and one's like this, it's like saying the front end alignment of your car is so far off we dare not put new tires on. So we never do surgery on cases like that. And even after a year of doing conservative therapy, if the condyles are so far out of angulation with each other, you know that the discs won't run on top like this. One's running like this one's running this way and the patient will function that way. You'll rub the disc right off in a couple of years. So you inform the patient and you do the best you can with sometimes what you have. That's it.
Howard: Now would you call yourself a holistic dentist?
Jeffrey: No.
Howard: If you're against surgery, I know it's a very broad term [inaudible 00:58:20] but it's kind of bizarre because like dentists, their knee jerk reaction is, I don't like holistic dentists, naturopaths, I don't want anything to do with them. But then when they go to the doctor and the doctor says, “Oh dude, you have high blood pressure, you need to take a pill.” They're like, “No.” “You have high cholesterol, you need to take a stat.” And they're like, “No, I'll pass.” “You have erectile dysfunction. You need to get pill.” “Oh, I'll pass.” The dentist is all against it until it happens to him. Then he's like, “Dude, I need to change my diet. I need to start exercising. I need to join a gym.” And I'm like, “Whoa, whoa, whoa. You're sounding like one of those holistic, alternative dentist still.” So when you say that you're not surgery first, the consumers would call that kind of holistic. It goes all the way back to the medicine man. For the last two million years, every time you had an ache or a pain, you go to the medicine man and he’d either make a lotion or potion and do a dance or take a knife and cut something off and cutting something off surgery and a lotion or potion, polyphagia is still going on even though you had geniuses like Thomas Edison said the ultimate medicine was the food that you ate and so when you try to treat things by diet and exercise, you're kind of holistic.
And I want to say one thing in marketing that if you're a dentist out there, you might think all that's witchcraft. But dentists who add the words holistic on their website, they swear by it. Hell, there's one dentist in San Francisco that all he did was got his dental office off the grid with solar power. And he has people driving an hour away across San Francisco, burning petroleum, to go to his office because they just figure that's a doctor they can relate with and you can do that, and well we can actually do it in Arizona. I don’t know why I just haven't done it because in Arizona I can pay more for my electricity from the solar farms so I could actually start advertising that today's dental is ran 100% off solar because I was going to get solar panels on the roof because we're in the desert. But when the solar guy came out, he said, I don't recommend solar panels because you haven't done one thing right on the inside. Like when you leave the room, the lights should automatically come off. He says, I had the wrong light bulbs. He said I would take all that solar money and redo what's right because right now you're using so much electricity. Your four thousand square foot buildings roof couldn't capture enough solar to even run it. So if you spent that money down underneath the roof, you could cut your consumption in half and then solar panel would work. But again, the question, if you're not surgery first, are you holistic? Are you a naturopath?
Jeffrey: I only can argue that and this is so funny you mention this. This happened yesterday, this new family said, “Are you a holistic doctor?” I said, “Not really, because all I'm doing is I'm spotting that you have a slipped disc. I'm identifying it, I've proven it. It's not just my thoughts. It is my radiologist confirming this too.” So I'm like, the guy that says, “Ma'am, you've got a broken bone here. Why don't we set it with a cast.” It's logical, it's documentable and as I say, there's not much holistic stuff here that we're talking about. This is reality and fact. So if I want to talk holistic, I would be talking about, well maybe that slipped disc is pinching this nerve or interrupting the vertebral artery flow at C1 level. Maybe that's what the holistic guy would say. But I'm just saying, “Hey, you've got a slipped disc.” I'm kind of simple. You know, Howard, I'm not the smartest stick in the bunch as far as I'm concerned. I just kind of know what I'm doing with this stuff and I see slipped discs. I see distorted bones that are bent bones. I show that to the patients. They see it, I see it, we fix it. Real simple approach really.
Howard: Well our brand is an hour. We're already at an hour and seven minutes. It’s so fun to talk to you. I love technology. I love the fact that I can't believe you're outside of Washington DC. I'm inside of Phoenix where it takes me four hours to fly to where you're at this just an amazing technology. Were there any questions I wasn't smart enough to ask?
Jeffrey: No sir. I think you've done a great job in asking the questions. This is such a misunderstood field. You seem to have a really good handle on what's going on and the confusions out there, so I appreciate it.
Howard: Well, it's Dentistry Uncensored. I don't want to talk about anything anyone agrees on. There's plenty of places to go learn about stuff that no one disagrees on. I like to get to the heart of the story and the heart of the story is, why are the same diseases treated differently? For instance, again, orthognathic surgery, why did the Taiwanese use tilting the maxilla and the mandible? Whereas the Americans are first to do a LeFort osteotomy surgery. So let's talk about that. I love TMD because there's so many different camps. It's pretty boring to do a podcast on a GV black prep. But I want to thank you. I know you're a busy man. You get to work every morning at 5:00 AM and you actually gave me an hour of your time, an hour of your life. I really, really appreciate it, Jeffrey. Thank you so much for coming on the show today and talking to my homies.
Jeffrey: You're very, very welcome. Thank you. I appreciate it
Howard: And I hope you have a great weekend.
Jeffrey: Thank you. You too. Enjoy the sun. We don't have much sun here, as you can see in my background it's been like this all week.
Howard: Well that's a beautiful background. It looks like you're in the Amazon rainforest.
Jeffrey: Well actually if I turn left, I'm looking at interstate four ninety five, the beltway around DC. One of these days I'm hoping I can be a weather forecaster too and just report from my office.
Howard: Well actually if you want to be a weather forecaster, anybody can do it in Phoenix because it's just clear skies and sunny about three hundred and ninety five days a year. I don't even know if you'd have to go to school to be a meteorologist in Arizona. It's nothing for them to give a ten day forecast and be right, but on that note, have a great weekend.
Jeffrey: You too. Thank you very much.