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VIDEO - DUwHF #875 - DeWitt Wilkerson
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AUDIO - DUwHF #875 - DeWitt Wilkerson
Dr. DeWitt “Witt” Wilkerson graduated from the University of Florida, College of Dentistry in 1982, the same year he joined the Dawson private practice group in St. Petersburg, Florida.
- He serves as a Senior Faculty/Lecturer and Director of Dental Medicine,
the Dawson Academy, where he has taught over 600 days of lectures/hands on courses
- President, American Academy for Oral-Systemic Health(AAOSH)
- Adjunct Professor, Graduate Studies, University of Florida, College of Dentistry.
- Past President, AES, (American Equilibration Society, Leaders in Occlusion, TMD, Comprehensive Oral Care)
- Past Associate Faculty and Special Lecturer, L.D. Pankey Institute.
Witt lectures both nationally and internationally on the subjects of Restorative Dentistry, Dental Occlusion, TM Disorders, Airway/Sleep Apnea, and Integrative Dental Medicine.
It has been said that form follows function and deformation follows dysfunction. The future of Dentistry’s role in complete health will center around these two principles. The astute Dentist must correctly answer “why” questions related to malocclusion, muscle soreness, clenching & bruxing, headaches, clicking joints, severe dental wear, acid reflux and inflammation, as specialists in oral medicine. New answers are coming in daily as we recognize the key relationships involved in Integrative Dental Medicine. You will not want to miss this fascinating podcast by one of the leading investigative clinicians in our profession.
Howard: It is such a huge honor today to be podcast interviewing Doctor ‘Witt’ Wilkerson, director of Dental Medicine of the Dawson Academy for Advanced Dental Study, president of the American Academy for Oral Systemic Health, past president of the American Equilibration Society, leaders and occlusion TMD and comprehensive oral care.
I cannot believe it. You graduated from the University of Florida College of Dentistry in 1982, the same year he joined the Dawson Private Practice Group in St. Petersburg Florida. You lectured nationally, internationally on the subjects of restorative dentistry, dental occlusion, TM disorders, air sleep apnea, integrative medicine. I can't believe I got you to come on the show today, thank you so much for coming on the show.
DeWitt: Oh Howard, thank you. It's my honor and privilege to be with you and to just talk about what we're passionate about.
Howard: Well the reason I'm so excited to be on the show is because if I podcast interview and I have like twenty-five different pediatric dentists, they don't disagree about hardly anything. If I brought on twenty-five endodontists, they pretty much all agree. In fact I hate to podcast interview more endodontists because I've already done twenty-five and they really don't say anything that much different. But, my God, when you get to your area.
DeWitt: Yeah. Yeah.
Howard: Occlusion, TMJ, TMD, it's like world religions. I mean my two older sisters went into the Catholic nunnery straight out of high school. I've been a dentist thirty years, my older sister's been a nun for thirty-five years. There is no way I could give her a one day seminar and she'd be Hindu or Buddhist.
Howard: Do you think TMJ is kind of like world religion? I mean it seems like there's all these camps and theories and philosophies. Or do you think it's really, over the last three decades, turned into more of a narrow exact science like endodontics.
DeWitt: Howard I don't think that it's become an exact science as you listen to different people and their opinions and philosophies and approaches. But the interesting thing, as an observer and clinician and someone who's trying to keep up with research, is that you will hear people saying what seem to be nearly literally opposite things, that say they have a great following of successful cases. I have to tell you in the last couple of years I think we may be getting a handle on why that could actually be true, and so that might be something we want to talk about.
Howard: Well let's talk about it, and I also want to tell you that this show is weighted towards millennials.
Howard: Old guys like me like to go to conventions and read textbooks. The millennials they love podcast online CE. Whenever they come out of school they always complain that they didn't learn enough, they didn't place an implant, that didn't do an Invisalign, they didn't learn enough about occlusion.
Howard: It starts off they need to make a decision between like neuromuscular occlusion.
Howard: There's equipment that you buy with that. What would you call your occlusion philosophy? CR?
DeWitt: Centric Relation. Yeah.
Howard: She's 25 years old, she's commuting an hour to work and her first question is should I turn right and go down neuromuscular LVI Biotech scan? Or should I go left and go the CR camp? How would you explain that?
DeWitt: All right. Well the first thing we want to do is look at the physiology of the people that we're treating. I know every camp would say ‘well that's exactly right and that's what we do’. But the simplest way I can explain it, because this is how we explain to patients is we want to know what your muscles are doing, we want to know what your joints are doing. We want to know how the bite fits into that normally speaking.
So if we understand that joints are seated by muscles that pull across joints, and whatever direction those muscles are pulling that's the direction those joints are going to be seated. So if we're closing our mouths and you've got your masseters and your medial pterygoids and your temporalis muscles primarily firing. Then they’re going to take those joints up that slippery slope until it hits bottom. In this case hits top and that would be the highest point that the joints can go against the articular eminence, which would be traditionally a spot that would be called centric relations.
So that's a bottoming out point of seating other joints by muscle regardless of occlusion. It's before the teeth come together. You remember, Howard, some of the work that was done by Lundeen and Gibbs back in the 80s, where they were looking at chewing strokes and joint position and muscle activity. What they found was that at the end of normal chewing strokes the joints were fully seated on both sides. So we take that as the natural physiologic position to start. Another way of looking at it be like a door on its hinges. So if you've got a door on its hinges and then you close the door, you don't want to run into the frame. The door on its hinges would be the joint seated by muscles and then closing into the bite touching evenly together, would be sort of the second half of that equation.
There was a well-known prosthodontist back in the 20s and 30s, and he described occlusion as like an inverted tripod where you had a three legged stool. He said occlusion is the two legs which are the joints fully seated, and then the third leg which is the bite fully seated at the same time. So that's what we're always seeking for and a static bite relationship is all the teeth bit, and touch evenly when the joints are fully seated.
Howard: These kids are coming out of school $350,000 in student loans, and a lot of them specifically asked ‘if I wanted to really become an expert in this like you, do I really need to upgrade the practice I bought from a 2D pano to $100,000 CBCT?’ Could you do what you do today with a two dimensional pano or is 3D imaging really standard of care now in this orofacial pain.
DeWitt: No, I think you could do it with a pano and a good apenex. It depends, of course, if you're going to get into implants and things like that but that's a different reason. You're talking about occlusion and excellent dentistry and you can get excellent results using plain imaging, and we did for many, many, many, years before 3D imaging came along. So yes, that's possible. Sure.
Howard: There was a very interesting article on Tops University's Web site orofacial pain fact and fiction, where they were saying many dentists web sites contain inaccurate information about treating temporomandibular disorders. Their conclusion was that oral facial pain should really be a specialty, and that the ADA should recognize oral facial pain as a specialty. What are your thoughts on all that?
DeWitt: I think that every dentist should be knowledgeable about temporomandibular joints, their anatomy, what goes wrong with them, how they relate to the muscles, and the bite, and the masticatory system. So to me the temporomandibular joints are just part of dentistry, I don't think that you should have to be a specialist to treat that. Unfortunately very few really know how to diagnose and treat it well but that is not because it needs to be a specialty, I don't think Howard.
Howard: Interesting. Back on the money, in so many decisions money is the answer. What's the question? Again they have a big debt load. They're also wondering there's a lot of expensive equipment to buy like tech scans things like that. What other type of equipment do you need to do what you do? Do you use these electronic occlusal devices measurements?
DeWitt: Yes, I do use the T-scan and I think that it's a valuable tool if you're going to be working with occlusion on a daily basis which really is dentistry. But I don't think that you have to have a T-scan to be an excellent restorative or occlusal oriented dentist, again for many years before we had that we were able to get excellent results. So I don't think that is the only way, let's put it that way, even though it's super helpful particularly the T-scan I'm referring to, because of the fact that you can really quantify occlusal contacts better than you can with articulating paper where you're looking, and you really can't get hard numbers from that.
At the same time, we have worked through developing clinical skills whereby both through using your hands to guide the mandible, using articulating paper, getting feedback from the patients, and being very careful. You can get outstanding results using methods that have been tried and true that are not involving thousands and thousands of dollars.
Howard: The difference between a twenty-five year old and a fifty-five year old is they're so bright eyed and bushy tailed, they know what they know but they don't know what they don't know. If you assume that you're mostly talking to kids today under thirty. What do you think they don't know that they need to know, and more specifically how do they stay out of trouble?
DeWitt: Yeah, that's a great question. Well one of the things that none of us learned very well in school was about occlusion, or about temporomandibular joints, or about airway issues which of course is a brand new frontier in our work. So I think every young dentist needs to be aware of the fact that there are many issues that can come up with occlusion, whereby whenever we're doing aesthetic dentistry or cosmetic dentistry we're affecting the dynamic of the system.
We have to make sure that we not only do no harm but they were actually solving problems. So you have a patient with wear on their teeth there's a reason for that and the answer to that is not veneers that's going to make everything go away. So we have to understand the dynamic of the masticatory system that we're looking at a system not just at teeth, and that we need to understand the system that is the joints, the muscles, the bite relationships and how they have to be synchronized.
Now we're adding to that an understanding of the impact of breathing disorders and how important that can be. So we're learning that young children that can't breathe well through their nose, and breathe through their mouths will develop malocclusions and this can be a source of malocclusion. So therefore if that's a potential, we need to be looking at that as well. Is the patient breathing well? Is the patient sleeping well? Why do people have parafunctional habits like clenching and grinding.
If you listen to some in the scientific world like Doctor Christian G. Mignon who is the head of the Sleep Center at Stanford University in California, as he describes upper airway resistance syndrome where you can't breathe well through your nose. The signs and symptoms of that are exactly what we would call TMD. So poor sleep, waking up tired, clenching and grinding, sore muscles, morning headaches. All of these would be things that we classically would say ‘well you've got a TMD problem’.
If you talk to Doctor G. Mignon at the sleep center at Stanford University, who's a physician PhD he'd say ‘well that's classic for upper airway resistance syndrome where you can't breathe well, and you're struggling during sleep to get enough oxygen, and you end up with exactly the same symptoms’. So what we're learning is there's overlap with these things and we want to understand those. So to answer your question about the young dentist, I think we need to understand occlusion.
I think we need to understand what can go wrong in the jaw joint, including internal derangements, disc problems, off the disc inflammation because a cardinal rule of thumb for us would be this, if the joints aren't stable the bites are not going to be stable either, and you can go in and correct the bite but it's not going to be stable. It's going to continue to change if the joints are changing, and I would say airway is a subject that relates to that as well. So if we have unresolved airway problems the patient can't sleep while they're not breathing, they're clenching, they're grinding, their sympathetic nervous system is excited during sleep.
They're experiencing fight or flight type symptoms and they're stressed there, then that can translate into clenching, grinding, moving the mandible trying to open the airway, episode at the end of an apneic event where we haven't been breathing and we gasp, or clench, or brucks, see all these things overlap and that's what we need to understand.
Howard: So the overlap is part of those psychological factors. Or do you think it's more purely mechanical factors?
DeWitt: Well I wouldn’t stop at mechanical. But I don't think it's primarily psychological either, and I've seen probably several thousand TMJ patients and I would say I've seen a handful where it was primarily psychological, emotional or psychosocial. But I've seen an awful lot of patients come in who had physical changes and issues going on, that had to do with the system either not being in sync or stressed. As a result of that having all kinds of problems and once those were addressed they were miraculously better.
Howard: So you've taught over six hundred days of classes at the Pankey Institute hands-on courses. But when you go into the field United States has two hundred and twelve thousand Americans have a license to practice dentistry, and the eighty twenty rule, eighty percent of the offices if you walk in there and they see a bunch of abfractions and non-carious lesion abfraction. Their treatment plan is just to fill them in with composite.
Howard: If you claim that you have TMJ, or grinding, or headaches, or whatever. They simply take an upper and lower algen and send it to the lab and make a bite splint. So they fill in six or eight abfractions and give them a night guard. What do you think of that treatment plan overall?
DeWitt: Well I would call that treatment plan an effort to manage the problem, but that is different than resolving the problem. Does that makes sense? So if you walked in, Howard, and I was a physician and we evaluated you and found out you had type 2 diabetes. I've got a couple of choices that we understand now in medicine, and that is I can give you prescriptions and you can try to keep a lid on it with prescriptions, and we'll continue to monitor your blood work.
Or we could understand that ninety percent of people with type 2 diabetes can reverse it with lifestyle changes, and get their blood sugar levels back down to normal without medications. Now we're going to have to talk about your diet. We're going to talk about other factors that could elevate your insulin resistance etcetera. It's the same idea in dentistry as we look at signs of destruction, if you will, I call that occlusal disease. If you've got notching in the roots of your teeth, and wear on the occlusal surfaces, and wear facets, and flat spots, and you've got cupped out, scooped out areas where there's erosion that may be the cause of acidity in your mouth.
So those are all signs and symptoms of what we might call occlusal disease. Now we can go in there and patch up the occlusal disease, and we can try to protect you from making it worse by wearing a splint. But we haven't really resolve the problem, and probably haven't even diagnosed the cause of why we're seeing these effects. So our goal would be if we want a really comprehensive problem solvers and physicians of the masticatory system, and dealing with oral medicine then we're going to be asking different questions. That is not what composite do I use to patch and repair that and cover it up, but what's causing it.
Let me give you just a really stunning example of how important this is medically, because there's a lot more that we're doing that relates to medicine and sometimes we realize. So there was a study done up at the University of Montreal and Jules Levy, who's the dean up there and probably the best known dentist in the area of dentals sleep medicine and has done lots of research on it.
They did a pilot study and they took ten patients who were bruxers, and who had sleep apnea and snoring and then they they gave them an upper nightguard just like you're describing.
They wore that for a week and then after they had initially done a polysomnogram in the hospital to measure their sleep and sleep apnea etcetera. They were all diagnosed positive. They had them where an upper nightguard for a week and then they came back and repeated the overnight sleep study wearing the nightguard. What they found was five out of the ten subjects, their sleep apnea AHI Apnea-Hypopnoea Index went up by more than fifty percent. In other words their sleep apnea, half the time, out of ten subjects got worse as a result of wearing the CR nightguard that I’ve made hundreds of through the years for people with brucks.
We know that bruxing and sleep apnea are often closely associated, so what that would say is if you have somebody who has wear on their teeth and you're concerned about that. What you don't want to do is make them a CR nightguard without first screening to find out if they could have an airway problem, because you actually could make it worse. What's driving their bruxing could be an airway problem at night and now when we put our nightguard in to protect them from bruxing or protect the teeth. We actually may be making their airway, which could be life threatening concern, actually worse. So that's why the more we learn now the more we're responsible for.
So we have to understand these relationships and cause and effect is what we want to understand, and so that's that's the direction we're moving in and in the future, Howard. I think if this information becomes general knowledge then dentists can actually get in trouble for making a nightguard without a complete diagnosis. If the risk is that it could make something like an airway problem worse.
Howard: Do you think dentistry kind of went the wrong direction 1840 when they created the first dental school in the world, University of Baltimore, Maryland. Basically the legend has it that the reason they started different dental schools, because the hospital needed beds where you lay down. The dentist needed chairs where you sat up so they kind of parted ways in 1840.
Howard: Now we're at 2017 and everybody's talking about the oral health connection, integrative dental medicine. Do you think that was a mistake not to have dentistry in 1840 be just another branch? Like physicians they become Ob Gyn, cardiologists, dermatologists, ear nose and throat. Do you think the ear nose and throat, they should have done like the Soviet Union where you're a stomatologist but it's a branch of the med school instead of separating a totally different school. Do you think that was a wrong decision in 1840? Do you see some day the MD’s and the DDS getting back together somehow?
DeWitt: I do think that was a mistake, because I think that as this has evolved it's as if dentistry is not part of medicine, and I think even dentists think of themselves in some cases as ‘well I didn't go to medical school but I did go to dental school’. The fact is that we can probably save more lives through dentistry than any other profession in the healthcare field, because we spend more time with our patients than anyone else.
We're looking at the gateway of the whole body which is the oral cavity and there’s a lot that passes through there starting with, of course, food which can be a tremendous source of inflammation if it's the wrong food, toxins, and also the home of oral bacteria that can now we know be pathogens in both the bloodstream and the GI tract. So to me dentistry is a specialty of medicine and we're kind of hitting it from the back door as it were. Now some of us that are really engaged in the medical component of inflammation, oral asystemic connection, airway and breathing and how it relates to malocclusion and all of these things, Howard. But I would totally agree with the thought that dentistry is medicine and it should be a specialty of medicine no different than being an ophthalmologist.
Howard: Well everything that came in and out of this country on a ship. Those workers were all the longshoremen's, and it was them who negotiated to have dental coverage in 1948. Which started the first one which later turned into Delta Dental, and I think it's very bizarre that they don't even cover an oral cancer screening. Can you imagine what women would say if we stopped taking cervical cancer screenings, pap smears, and didn't cover it? They would claim outrage.
Howard: Yet you go to the mouth, oral cancer’s not covered. When they look at people who die each year from the flu, it's between eight and forty-eight thousand a year. They say ‘when did this person last enter the healthcare arena?’ The dental office or getting their teeth cleaned is always in the top three and only one state, Tennessee, allows the dental office to give a flu shot. When forty-nine out of fifty states won't let me give a flu shot because I'm a dentist, but they would if I was a dermatologist or an ENT. That's kind of bizarre and weird.
DeWitt: Yeah. It is. It is, and there's so many of these chronic type illnesses that we can pick up on first, I give you the classic example is on gastric reflux. So there's a whole segment of those that suffer from gastric reflux that don't know it, and they call it silent reflux. Those are people that if you ask them all the questions about sore throat etcetera, they say ‘no, I don't think so’ but you look at their teeth and what do you see?
You see huge destruction from acids in the mouth and the dentist looks in there and sees it and says ‘something’s really going on here’. Low pH and the vast majority of those people have gastric reflux. The fastest growing cancer in the United States is esophageal cancer. It's like eight hundred percent higher incidence now than it was twenty or thirty years ago, and there's reasons for it. But it's largely completely undiagnosed, and probably the number one quickest way to screen it would be to look at people's teeth, and see what's going on on the occlusal surfaces and smooth surfaces of the teeth.
When you see that erosion going on that’s chemical in nature, you almost certainly have a situation of a gastric reflux type change and that acidity, and what goes on with that coming up from the stomach is leading toward barrett's esophagus and esophageal cancer and just the epidemic of that. Yet the vast majority of those cases are totally undiagnosed. I saw a classic case the other day, Howard, that literally broke my heart. A gentleman came in to see me as a new patient. I live in Florida. He had moved here from California recently. He was an executive with I think it was CBS, and he had to stop his career prematurely because he developed esophageal cancer.
He ended up having his whole esophagus removed, and what they do is they stretch your stomach all the way up to your throat and tie them together, and eliminate that whole esophageal track. And it's just horrible. He is living on narcotics, he can’t eat many foods, his stomach and everything is upset all the time. But here's what's significant about it is, his history is this that for thirty years he had sleep apnea, he had gastric reflux, he nearly destroyed all of his teeth, he had his teeth restored because of the severe wear on his teeth. For thirty years he complained of all these things but nothing was ever done.
Then he was diagnosed with esophageal cancer about three years ago in New York City at Cornell, and they told him the reason you have esophageal cancer is because of gastric reflux, and very well may be related to your sleep apnea. But no one was diagnosing and that could happen today. My commitment and my dental practice is that we screen every single patient for breathing and sleep disorders, and we screen every single patient for gastric reflux and it's very easy to do. You can use a seven or eight question questionnaire and give it to every patient walking in your door and get a very good idea. Plus just the signs that you see when you're doing your examination. So to me this is dental medicine, this is integrative dental medicine, and we have a tremendous responsibility and opportunity to be right on the frontlines changing lives.
My new favorite saying, Howard, is on a great day we save a smile, on an amazing day we save a life. We've had a chance to do that on a number of occasions where people believe that we did save their lives, and I think we just might have. That should be happening all over the world through dentistry. All over the world our reputation should be rising right to the top as tremendous screener's, and diagnosticians, and sleuths of medical issues that are causing people to be ill, and even dying prematurely that are just slipping by because of the fact that most people never get a physical. My understanding is the average physician spends seven minutes every two years with their patients.
DeWitt: So that says a lot. It says a lot about our opportunity in dentistry, it's time for dentistry to get on board and say ‘hey we are physicians of oral health and we can jump in there and be on the frontlines and we don't have to take a backseat to anybody. We can learn this stuff, it's not that complicated’.
Howard: Well you were talking earlier about when someone's coming down with type 2 diabetes, do you really want to just take a pill or a hypoglycemic medication, or do you want to change your lifestyle and switch from Mountain Dew, beer and vodka to water and lose weight and exercise. That esophageal cancer has changed so much because after World War 2 half of Americans smoked. Now it's under twenty percent so the old esophageal asquemall cell cancer from alcohol and tobacco has been going down, and the new adenocarcinoma.
You're right they're saying that they think it's caused by Barrett's Esophagus caused by acid reflux. When you go into the dental school, would you agree with this statement that they teach mostly about carious disease and periodontal disease, but very little on occlusal disease? Do you think occlusal is under educated at the expense of caries and periodontal?
DeWitt: Well I think caries and periodontal are critical obviously. But I do think that occlusal disease is rarely addressed, and I don't know the reason why other than maybe there's a lack of confidence in teaching the subject. I had a young dentist who came to study with us recently, who said he went to one of his professors and asked ‘when are we going to really learn about occlusion?’ The professor said ‘oh you'll have to do a prosthodontic residency if you really want to learn about occlusion’. To me occlusions should be the first month of dental school. I mean everything we do is occlusion that we don't touch a tooth without affecting occlusion. So that to me is just not an acceptable answer but it's not an unusual one.
Howard: Well this is dentistry uncensored. So I'm going to ask you a couple of questions that probably are more born in the barn hillbilly than what you're used to hearing at the Pankey Institute, because that's a very advanced type of student and questions. But a lot of general dentists, especially the young ones, say ‘hey, come on if occlusion mattered, the teeth never touch how could occlusion matter?’ Then they also go on to say if all the occlusion and the guidance, I mean look at orthodontist they take all these people and canine guidance and blow out their curve of spee, curve of wells and they take them from canine guidance to group function that teeth never touch. What would you say about those two things that you hear some dentists just flippantly say. I mean you probably don't hear that at the (inaudible 32:39).
DeWitt: Yeah. We do. We do. But I would say that in our studies what we've found is that there's two things we can talk about, we could talk about occlusion which is how your teeth touch, and we could talk about occluding which is what you do with your teeth. There are some people who have horrible malocclusions by our standards, where when they close they only touch on their second molars and that's it. They just get along great, those are the people that never touch their teeth. They swallow and their tongue goes between their teeth, their teeth may go farther apart when they swallow because of tongue inhabits and those intervening.
But the other side of that equation is that we have seen hundreds and hundreds of patients through the years who come in, who's occlusions don't look that bad. But because they occlude meaning they actually bring their teeth together for prolong periods of time, clenching or bruxing, then everything about their occlusion is important because of the fact that we're trying to, not only harmonize what may be a source of reason for clenching and grinding which can be a malocclusion, and those that bring their teeth together. But also we're trying to protect the teeth by having them only guide off of teeth when they move left right and forward and not banging into back teeth which were never designed for that.
All the studies have shown that when you touch back teeth in excursions away from just pure closing motion or contact, then you to turn on the elevator muscles, you turn on the muscles of mastication and actually create more forces and more energy there on the teeth and damage as a result of that. So occlusion is very, very, very important and those that occlude and a lot of people do. If you see someone coming into the practice and they're saying ‘I'm in pain’, either my teeth are hurting, or they're sore, they're sensitive, or my muscles are sore, I've got headaches in the morning, they've got wear on their teeth, they're touching their teeth. There's no doubt, and they're doing it for extended periods of time. So the occlusions very, very important in that case.
I would add today that we would also pay very close attention to the airway, they could be stimulating sympathetic nervous system response, which means that we have a fight or flight response going on while we're asleep. That is we're choking to death here, we're not getting enough oxygen. So you turn on the sympathetic system, you release cortisone in your bloodstream, you speed up your heart rate, and you respond through being aroused or waking up to some degree, and part of that can even be to clench or grind or jut your jaw abrucks, these sorts of things. So occlusion is very, very important. Now the other side of it is, Howard, let's say you take somebody and you're going to be doing some dentistry on them.
I don't care if it's cosmetic dentistry, aesthetic dentistry or they split a tooth on a on a hamburger that had a bone in it and now you got to restore it. How are you going to do that? Does it matter? It does matter because now you're influencing the system and how things are fitting together. So we always want to move in the direction of more ideal and never causing problems. A fair percentage of the patients we see in our practice here, working with Doctor Dawson for thirty-five years we have patients coming in from all over the world.
I would say the number one source of referral would be severe wear, people who’re wearing down their front teeth, and back teeth, and chipping and breaking teeth, and so there's a sign there of a cause and effect relationship that we need to resolve. Whether you're doing veneers, or covering teeth that have broken fillings, or whatever it is. There's something going on there in the system that needs to be addressed and idealized in every case so that would definitely be our perspective on that and we've seen a lot.
Howard: Again every time I ask my homies I'll say I don't know who’s listening to this on iTunes, it just gives me a number of how many and what country they're from. Shoot me an email Howard@dentaltown.com. Tell me how old you are. I was really surprised by that, so many of these e-mails are coming in and they're saying I'm applying to dental school. I'm D1, D2, D3, I can't believe how of these kids are dental students. So again that might explain a lot of the questions I'm asking you. But help her with verbiage, the patient comes in and a lot of times they say ‘I have a click in my jaw’.
Howard: What should she be thinking, saying, doing, diagnosing, when the patient’s saying ‘hey doc, I have a click in my jaw’, or ‘my jaw is locking’.
DeWitt: Right. Okay, well if we understand the very very basic anatomy of the joint, then we all remember and in studying anatomy, at least little bit, that you've got a condyle with a disc on top and that disk is attached on the inside and outside corner, we call that the collateral ligament attachment. So it's like a bucket handle that's rotating around the top of the condyle or the ball in the socket. Behind those two ligaments on the sides is a ligament that goes to the back wall of the condyle, we call that the posterior ligament. That ligament is like a tether, it prevents the disc from coming forward or slipping forward.
Then up in that behind the disc area is a tissue that we call the retrodiscal or the superior strata tissue, which is like a sponge that engorges with blood when you open your mouth wide, and the condyle goes down and forward and glides down and forward in the socket. It doesn't leave a vacuum behind but it engorges with blood, and that blood filled vascular innervated tissue is right behind the disk. So when you have someone come in and they say it's clinking, typically what that means is as a minimum the disk where it's attached on the outside corner, the lateral corner, is probably either lax, or torn, or stretched in such a way that the disk is slipping forward. When you open and click you're clicking back underneath that corner of the disk, and when you're close you may hear a reciprocal click where it clicks again and it's slipping back forward.
That's the most common click and about a third of our patients that are adults may have a click on one or both sides, so this isn’t rare to have some type of change going on inside of a jaw joint. Fortunately the majority of people that have a click it's a lateral pull off the outside corner, slip just a little bit, and you're criss crossing on that corner and it may never get worse. So people may say it's been doing that for five years, ten years, fifteen years. It doesn't bother me, it's not hurting.
Maybe they had an injury there in the past and that affected the integrity of the disk on top of the condyle. We had that criss crossing on opening and closing, so in the presence of no symptoms and no changes it can be something that's innocent, and will not require necessarily any treatment at all, Howard. But in many cases particularly when you see this in younger people. So if you have a sixteen year old, eighteen year old, twenty year old young female coming in. Their susceptibility to developing progressive jaw joint problems is greater than a forty-five year old man, who says ‘yes I have that on the left side and it clicks like that, doesn't bother me at all. It's been doing that since college and I played sports, and probably hurt it back in highschool when I played football’, or something like that.
So that man who is forty-five with an intersect click that's been there for a long time, probably isn't going anywhere, it's probably not going to turn into anything. But when I see a young female come in and she's got clicking or, as you said, locking which means maybe the disc now is stuck in front and they're not able to negotiate getting back under it, and they actually have a mechanical blockage to opening which would be probably the most common reason for that locking. Then you're thinking about something that actually could be progressive and get worse and worse, and you really want to study that and understand it and look very closely at it.
If someone comes in with a click and especially a painful click, or as you were saying a lock, where they're getting stuck. Then the bottom line is the first step is diagnosis. So a diagnosis of a joint problem like that that seems to be significant would involve getting some imaging, and so the the gold standard for imaging temporomandibular joint that is painful, or that has soft tissue issues like clicking and locking would be an MRI. An MRI can be done today whereby you can actually see the disk, you can see obviously the hard tissue of the bone, you can look at the disk, and its position all the way from the inside corner to the outside corner in slices, and you can precisely see what's going on.
You also can see if there is fluid in the joint, which there may be oedema or fluid in the joint and that can be a source of pain. That fluid in the joint can be back in that retrodiscal tissue where it's innervated and vascular and that'll swell when there's problems inside. So to answer your question, the first step in a joint problem that is symptomatic or maybe progressive, would be to get a good diagnosis and that is to go inside the joint look at it. It's no different, Howard, than if you came in with a clicking knee and you may have a tear in your ACL, or you may have a meniscus tear and some tethering there. You're getting swelling in that joint it and problems like that, some discomfort. It’s very similar to that and what would the orthopedist do in that case? They would get an image of the joint and take a look inside and see what's going on. So they can get a clear diagnosis that can be the basis of what their options might be for treatment.
Howard: When someone comes in with temporomandibular disorders and they're in pain do you ever utilize pharmacology?
DeWitt: Oh sure. Of course anytime there is significant pain you're going to use pharmacology. So if someone came in and they were holding the side of their jaw in the area of their joint and they said ‘it’s just killing me’. The first thing we’d probably do is give them medrol dose pack and say ‘well let's hit it real hard for the next five or six days with a good steroid, and see if we can reduce the inflammation and oedema that may be in that joint and see if that gives you some relief’. So that would be a first step.
If someone has severe muscle issues going on and they're just really in knots as a result of a jaw joint or temporomandibular problem, then we wouldn't hesitate to give them a muscle relaxer. One of my favorites is diazepam which is valium in very small doses like two milligrams, that doesn't affect the way you feel, you don't feel groggy, you don't feel sleepy, you don't feel compromised. Yet the muscle discomfort will often subside quite quickly. So we might take someone who comes in with an acute problem and put them on a medrol dose pack, and give them a prescription a two milligrams of diazepam to take three times a day and soft diet, non-chew diet and give it four, five days and see what happens especially an acute problem like a injury or something like that.
Howard: I know you're a busy man and I was so grateful to get an hour with you. Do you have any more time? Or tell me when I need to let you go.
DeWitt: Oh sure, I've got another five or six minutes, Howard.
Howard: Okay. I want to ask you, this is dentistry uncensored, I don't like to talk about anything anyone agrees on. Let me ask you a big controversy.
Howard: Anyway you said earlier that TMD, TMJ you said is an inverted tripod. You've got two joints and then you get the teeth touching, some dentists and orthodontist when they see a patient with TMD they say ‘I want to unravel your teeth with braces, I want to let your joints be seated and bring your teeth together, I'm going to use orthodontic treatment as a major component of treating your TMD. Other people say that's just crazy. How do you weigh in on that?
DeWitt: Well I think it depends on the diagnosis. So if you have somebody that is like one that we just spoke about, they have a internal derangement, they’re off the disk. Then the first thing we want to treat definitively is the joint problem, and so whether it's working with trying to stabilize it with an occlusal splint that would even the bite out, and reduce some of those stresses in the joint of closing and biting together, if they're clenching we can use anti-inflammatories and etcetera. We may, in some cases, reposition the mandible just slightly for a period of time to try to decompress slightly the joint.
But the bottom line is we're not going to do anything irreversible with the bite until we've got the joints stable, and I said earlier that a rule of thumb is if the joints are unstable the bite will be unstable. So that would imply that we're not going to go in there and just perfect the bite, and expect that to heal a damaged joint. Any different than putting a knee brace on your knee is going to solve your meniscus anterior cruciate ligament tear or something like that. So if there's damage in the joint we need to get that stable to an acceptable level, even if it included surgical intervention in some cases which is not that many. But there is an appropriate time for surgery in the jaw joint. We want the joint stable.
Now we're going to look at the occlusion. I see patients all the time coming in to see us who are in misery, I would say half of them have braces on their teeth and we do an MRI and they're off the disk, they've got fluid in their joints, they've got oedema, and swelling in the retrodiscal tissues, and they're loading on retrodiscal tissues, and they're in a lot of pain and they've got braces on their teeth. I'll ask ‘well why the braces on your teeth?’ ‘Well I've got braces on my teeth because they said if we straighten my bite out that that would help my jaw joint problem’. You see we're not thinking like orthopedists if we say that, because we're not thinking about damaged joints and what it takes to correct the damaged joint.
It's not by just making them a nice bite in the front and so I have a problem with that. No different than someone who has an internal derangement in the joint, and we say ‘well we're just going to do orthognathic surgery and that's going to heal it. I've seen people that have had orthognathic surgery to correct their bite, and six months later their bite is wide open in the front because they're still breaking down in the back. Yet they’ve gone through major surgery as you know and so we want to be really, really careful about that.
Howard: Last question, we have fifty categories on DentalTown on the message boards and one of them of course, the number fifty, is (inaudible 49:30) TMJ TMD. Earlier when I asked you about pharmacology you said when a patient comes in they're holding their face, they're in pain. She asked ‘how can you tell the difference between an earache and a joint pain?’ When they're holding that area.
Howard: What's going on in your brain to decide is this an ENT problem or a dental problem?
DeWitt: Right. Well of course you have to ask good questions about their history and what they're experiencing right now. So if someone's pointing at their ear and I don't identify anything going on with the jaw joint then I'm going to refer him to an ENT right then. But I see a lot of patients who come in they say ‘I've already been to the ENT and they sent me to you, because they don't think there's anything wrong with my ear, they think it's in my jaw joint’. So the truth is, they can overlap and so if you've got swelling and the oedema we’re talking about in the damaged joint. Then it can cause problems in the ear for sure and vice versa.
So I would say we want to get clear diagnoses and we need to take whatever steps or measures that are necessary to get to the bottom of it. Sometimes that means I need help from my physician colleagues, and other times we may try something for a few days and see if there is a response. So to give someone a medrol dose pack and a muscle relaxer if they're coming and saying I'm having pain on the side of my face, and my muscles are hurting, and I've got a headache, and I can point right to the joint area and that sore. There’d never be a contraindication to doing that over the course of a short period and seeing if there was a response. Whether it was an ear problem or a joint problem, we probably would get improvement in many cases using something like a medrol dose pack.
Howard: So final question, if she's listening to you right now and she says ‘I didn't learn enough of this dental school, I want to learn more’. What textbook or courses are you teaching at the Pankey Institute? Give her your pitch on your best book and best course at Pankey or to see you to learn more about this.
DeWitt: Yeah. Actually, Howard, I taught at the Pankey Institute. But I teach at the Dawson Academy so we have courses throughout the year, and you can go on the Dawson Academy website that will address temporomandibular joint problems, occlusion and diagnoses. Then we have courses on airway problems, and integrative dental medicine, and all of these topics. So those are all addressed through our curriculum, and I’d invite them to go the Dawson Academy web site and take a look at that, because everything we're talking about is right in the center of what we're addressing with now over forty thousand dentists that have been through the academy for training.
Howard: Well a lot of these millennials follow me on Twitter so I just went to Twitter and retweeted the last tweet from @Dawson Academy. I just retweeted a quick tip ‘how to increase your confidence and treatment planning’. The other one a couple of other tweets. But that is amazing. The millennials also love online CE, it would be beyond a huge honor if you would ever create an online CE course. We've put up four hundred and fifty courses on the DentalTown app and they're coming up on one million views. I think it'll be a good hour to go over what they don't know, and I think it be the best marketing for the Dawson Academy or your courses so they can learn more about occlusal disease.
DeWitt: Yeah, we're planning to do that, Howard. We're all set up to do that with you all and we may do two or three things. So I'm looking forward to doing that probably between now and Christmas.
Howard: You are an amazing man. It was such an honor to get someone of your caliber to come on the show today and talk to my homies. Thank you so much for giving everyone a precious hour of your life today.
DeWitt: Well it's my greatest honor and thank you Howard. I appreciate what you're doing to change the world.
Howard: You're too kind, have a great day, Witt.
DeWitt: Thank you. Thank you.
Howard: By the way one last thing. Your dental office, by the way, just go to your website. That is the most gorgeous dental office around, I mean everybody would be so lucky to practice in that office. What a gorgeous office.
DeWitt: You're so kind and if any dentists are listening to this or ever in St. Pete, Florida please have them pop by and say ‘hi’ to us.
Howard: Okay. We will thank you so much.
DeWitt: Right, Howard. Have a great afternoon.