I am going to say something controversial, but we kind of all know it’s true:

The management of Temporomandibular disorders is like the Wild West.

There are either no rules, or the rules are based on poor quality data.

https://youtu.be/mvWdkd74Khg Watch PDP172 on Youtube

In this episode, we’re joined by Dr. Patrick Grossmann, a retired orthodontist with 30 years of experience in TMD treatment using an orthopaedic approach. Together, we’ll unravel the complexities of TMD, discussing different viewpoints in TMD management.

Whilst Dr Grossmann and I do not fully agree on everything (typical Dentists!) it is helpful to understand the ‘working out’ and philosophy of a treatment modality.

Protrusive Dental Pearl: TMD History Form – which I send to all my patients before they come to see me for a TMD consultation. Premium members scroll down on the App to download (or check the Protrusive Vault). Otherwise download from https://www.protrusive.co.uk/tmd-history

Need to Read it? Check out the Full Episode Transcript below!

Check out Dr Grossmann’s course on February 17th in London: https://www.cephtactics-dental.com/short-courses/p/tmd-splint-day-course

A message from Dr Grossmann: “As of September 1st, I shall for the first time be offering a one-on- one (in person) 2 day intensive course in London. The course will cover ALL important aspects of TMD for the general practitioner as well as a half day ‘hands on’ session with the participant’s own splint. This will include using the splint for myofascial pain dysfunction syndrome as well as internal derangements-clicking/ locking. Moreover the importance of a night time appliance (Garcia) will be addressed and evidence for its efficacy.

For details on this course please email: patrick@patrickgrossmann.co.uk

If you liked this episode, you will also like Functionally Generated Path Technique – Conforming to Funky Occlusions – PDP168

Did you know? You can get CPD from the Web App or Phone App and watch premium clinical videos, for less than a tax deductible Nando’s per month?

Click below for full episode transcript: Jaz's Introduction: In this episode I'm joined by Dr. Patrick Grossmann. He's now retired but he treated TMD for 30 years. He was an orthodontist and the way he treated it was an orthopedic approach. Now I've learned from Patrick but I've also learned from lots of other great clinicians and some of the things that were said on the podcast by Patrick I disagreed with.

Jaz’s Introduction:
So you’ll see me interjecting now and again, but I disagree with respect because I feel as though TMD, especially with the lack of clear guidelines and evidence available. I mean, long term high quality data. I mean, if you look at all the systematic reviews, they all say we need. better quality data. I think there’s totally a place for all the things that Patrick says in the episode and his treatment philosophy, it’s nice to understand it, but I also offer some alternative opinions.

So it’s up to you as a clinician to make up your mind in terms of which Camp you want to follow and what aligns best with your values, your patient’s values, and your clinical experience.

Hello, Protruserati. I’m Jaz Gulati, and if you’re watching this episode, that means that Patrick Grossmann kindly approved it for publish. I felt like I had to interject at certain points to give my viewpoint. And whilst I hope that served the listener, I do understand that this was a very heavy TMD topic. It can get very confusing. I definitely wouldn’t have understood this episode very well as a young dentist, but to get the exposure is really good to this kind of stuff.

And the more seasoned clinicians who are into TMD, I think this one, you’re going to be really, really finding this one very stimulating in terms of the different facets the conversation goes in and both the beauty and the frustration of having so many different treatment philosophies.

Protrusive Dental Pearl
The Protrusive Dental Pearl I have for this episode is my history form. You can totally just download my full history form that I send to all my patients before they come to see me for a TMD consultation. You’ll appreciate how much detail I like to have even before the patient sits in the chair. If you’re a premium subscriber, you can just scroll below and you’ll see the PDF there.

But if you’re not a premium subscriber yet, I found you a way to access it. You can go to protrusive.co.uk/tmd-history. That’s tmd-history that will take you to my history form for patients. And of course I’ll put the link in the show notes for YouTube and Spotify.

Before we dive into the main episodes, I wanted to thank Patrick Grossmann for inviting me into his home to record this. I’ve been on some training with him and I appreciated what he was saying was very different to what I’ve been hearing or reading in the textbooks and some other great people that I follow. And so I like the fact that I’ve got so much exposure from various different clinicians and various different camps.

And it’s all really forming part of my journey in trying to do the really best I can in TMD for my patients. And it’s with great pleasure that I’m able to pass on to you guys with this very insightful conversation, which has a few twists and turns along the way. This one might need a couple of commutes to actually finish, but I’ll catch you in the outro.

Main Episode:
Dr. Patrick Grossmann, it is my great pleasure to welcome you on to the Protrusive Dental Podcast. A rare face to face one. How are you?

[Patrick]
Thank you very much I’m very well and a happy new year to you.

[Jaz]
Thank you so much. Happy new year everyone This is going to be quite an important episode now. You have been someone I’ve looked up to as the, You’re not going to like I’m going to change my term.

I’ve been very careful the terms I use but someone who’s got a lot of experience in treating lots of types of conditions, you’re an orthodontist by training, right?

[Patrick]
Yes, correct.

[Jaz]
And then you took a liking because I was at your live lecture that you did and you talked about your journey about what inspired you to go into realms of Temporomandibular Disorder. So for those listening, just give us, I’ve given a little bit of an introduction already in my intro, but just tell us about what got you into this field.

[Patrick]
Well, it’s fascinating, really. I qualified back in the mid-seventies and studied. and got my diploma of orthodontics here in London. Then I went to Germany where they were doing a lot of work on dentofacial orthopedics.

And I spent time there. When I came back, I dedicated myself to orthodontics and went to every course that I could find. And I went one Saturday to a Functional Orthopedic Seminar at the Thistle Hotel down at the Tower of London. It was a Saturday, only functional appliances and everybody was anybody was there at the time.

John Mew and David Tobias and Hans Irene, lots of other people and came five o’clock and I was really getting tired and I thought I’d really like to get out and go and have a drink. And on the stage comes this huge guy. American guy, and he puts up a slide of a patient who could barely open their mouth, clutching their face.

And he said, this is a patient in pain who needs orthodontics. How are you going to treat them? And everybody said, oh, no idea. Send it to the oral surgeon or whatever. And then he said something really interesting. He said, “How about if you could treat this patient for their limited opening and their pain and then do the orthodontics.”

Anyway, the rest of the lecture, I was spellbound. It was one hour. And it was at that time, it’s one incident like that, that made me realize all the years of orthodontics are great, but orthodontics is only a means to the end, it’s not the end. And in a way, once you see the truth about something, if you’re honest with yourself, there’s no going back.

And so now I realize I’m going to have to change everything I learn. And that also included the idea about early treatment as opposed to waiting till all permanent teeth have erupted. So that was another huge step. So the practice became one which was dedicated to early treatment.

[Jaz]
Now we will be talking about that. So we’re kind of splitting into two. In this segment, we’ll talk about TMD, the management, etiology, what perhaps out there which you feel is against your philosophy. And then I want to share your philosophy with the world, but then another part two, we’ll talk about interceptive because I did do one recently with an American dentist and she was brilliant, but a lot of the UK dentists like, okay, that’s great, but what do we do here in the UK where a lot of our specialists are not taught to really get involved at interceptive and the NHS is not really well funded and all these problems and whatnot.

So we’ll definitely talk about that. Now, you mentioned about having diverse training early on, even within orthodontics before you were enlightened by that lecture and that inspired you.

[Patrick]
Yes.

[Jaz]
In the years of training in orthodontics, how much emphasis was put on actual, the joint diagnosis and, and TMJ health?

[Patrick]
Virtually nothing at all. My eyes were only opened to this from this lecture by Dr. Brendan Stack back in the late 80s, early 90s. And since then, I just had to really spend a lot of time in the States on a yearly basis with him and with others really studying how to treat the TM joint.

As well as the orthodontics that goes with it, because there are different techniques that are needed once you’ve corrected the internal derangements. So, very little was taught here. There was a little bit done here, but not in a way that made any intellectual sense to me. So, really, until I studied with Brendan, none of the philosophies really made sense to me.

As to how to treat and, he came up with this orthopedic approach to treating TMD. He founded the American Academy of Craniofacial Pain back in 1984, 85. And so he was right there at the inception. Also, of course, in the mid 80s, MRI scanning came in for the TM joint. Although it was developed earlier, but only for TMD was it available in the mid 80s. So this is the way that we moved the subject forward from an orthopedic point of view.

[Jaz] Now you mentioned Patrick that in your orthodontic training there wasn’t much available. In my restorative training, there was, but it was basic, but I think it’s important for anyone who’s doing tooth wear cases or changing the vertical dimension to have a really good understanding or at least know the red flags know that, okay, I should not proceed.

And the way I see orthodontics is full mouth rehab in enamel. Right, that’s orthodontics. And therefore, what got me into the management of TMDs is learning to assess the health and get a joint diagnosis, whether it’s safe for me as a restorative dentist to continue and to do my orthodontics, because I do orthodontics as well, not to the level that you ever did, but the GDP orthodontics and before I could continue, I needed to know what the joints were like, and that spiralled into me actually helping patients with their TMDs.

But the problem that we have in all countries, I guess, but let’s just talk about the UK, is the hospitals that I worked at. And what exposure I got in terms of the way that we’re managing temporomandibular joint disorders in hospital is very much the following.

You take history, you take an OPG for whatever reason, because everyone just gets an OPG, which even we know that that has a limited value. It’s not that it has no value, but limited value. MRIs are definitely a distant thing in the pecking order. And then usually, no matter what the diagnosis is, well, firstly, the diagnosis is usually TMD.

There’s no subset. Is it myogenic? Is it enzykapsia? Which we’ll talk about here, because they’re managed differently. And because there’s no accurate diagnosis, Everyone just gets a bite raising appliance. That’s like the first tick box, a soft bite guard. And then some of those will get better. And then those remaining ones, oh, let’s go for Botox.

Let’s go for this. If you accidentally or happen to fall in the hands of someone who actually is confident, we know what they’re doing. And then the problem we have is that there’s so many different philosophies and then patients get confused.

[Patrick]
No, I totally understand that. I think it’s a really hit and miss approach, this way that patients are treated in the hospital system. But there are difficulties in the hospital system and within the NHS. So I understand their limitations. I think that what you said just earlier really puts the case in perspective. And that is. the diagnosis. How can we treat unless we have a diagnosis? I mean, if somebody comes in with caries, you don’t give them paracetamol, you try and find out what the cause is.

And with any aspect of dentistry, you’re really trying to delve in to find out where does this come from or what’s the cause and then we can treat it. So the idea of trying this and it doesn’t work and then trying that, that I think has got the treatment of TMD a really bad reputation, not just here, but also in other parts of the world. So, from my point of view, I totally agree that you need to take a history. I don’t agree about taking an OPG as a routine.

[Jaz]
Let’s just talk about that a second, because some dentists are trained that, okay, most dentists that I know, they get a little bit panicky when they see an emergency TMD and they don’t know what to do, they default to TMD and OPG because they, okay, I can see the condyle and they usually don’t really notice anything. So why should we stop taking routine OPGs?

[Patrick]
I think everybody who treats a lot of patients with TMD and has experience in it, will tell you that the OPG just tells you that there are teeth there, there’s bones there, and there are condyles there. But it actually only tells you about the hard tissue.

And the whole problem with musculoskeletal disorders, of which TMD is one, is that we need to image the soft tissues. Now, if you go to any orthopedic physician or surgeon, the first thing they do with a bad shoulder, neck, or an ankle, or back, or whatever it is. They don’t take x rays. They take an MRI scan because the modern MRI scan not only shows the soft tissue, but by taking different images, you can also get a very good idea of the bone and in the patients that we treated over the last 30 years, we rarely had to take an x ray. To substantiate our diagnosis after the MRI has been taken. So, that’s-

[Jaz]
It’s an access issue, isn’t it, Patrick? That’s why maybe they’re taking the OPG, but it doesn’t really add much to your diagnosis.

[Patrick]
But it doesn’t add anything. And also, what you do with information that you’ve got that the patient’s got two condyles, how does that help you treat the patient?

It doesn’t, because it doesn’t tell you anything about the muscles. It doesn’t tell you anything about what’s going inside within the joint capsule. So, I think it’s a very limited value. And that’s really been shown now in many papers that taking an OPG is really, really virtually a waste of time for this particular problem.

[Jaz]
So my first interjection here to add a little bit more context whereby I’m really annoyed that sometimes when I have to refer to the hospital service for the management of temporomandibular disorders, either because the patient can’t afford my fees, or I really need a bit more of a multidisciplinary, I need an OMFS input here, that they want, it’s a prerequisite to have an OPG.

I think that’s a real shame actually, because if someone’s got just clicking, popping, the occasional locking, then, just like we’ve discussed here, very rarely will you find the clues or the answers from an OPG. I think for the vast majority, it’s irradiating these patients for no reason, and only in a few patients will you find an actual pathology.

That truly is part of the problem, so it’s quite rare. I experienced this when I was in hospital doing a training post, and a patient came in with a deranged mandible. I really freaked out. I was like, why is this patient’s mandible all the way up to one side? And so I took an OPG because I was told to do as a trainee and my consultant who’s quite hot on TMD, he said, “Jaz, why’d you take an OPG?”

I was like, “Well, I thought it’d be good to see the condyles and the TMJ anatomy and make sure it’s okay.” And he explained to me that actually this was a myospasm of the lateral pterygoid, which is why the jaw was off to one side. And just as he suspected, the OPG didn’t really tell us anything, didn’t really add any value because you can’t see soft tissues, you can’t see muscles, you can’t see the disc.

Now I’ve also seen it in my practice where patients come for a second opinion. I’ve seen some previous plans that have been given and some of these comment on the appearance of the condyles on the OPG radiograph. The fact that they are slightly different in size and this may be potentially part of the problem and part of the reason why this patient’s having headaches and clicking.

Well, have we considered that actually it might be a positional error? Like if you’re an OPG machine and you turn your head a little bit more to one side, the condyles will look asymmetric. It’s the same if you bring your head too far forward or if you tilt it, the condyles will not look the same. So we have to be very careful in our interpretation and actually drawing conclusions from an OPG.

It’s not to say that they don’t have a place in TMD diagnosis at all like they sometimes do when you’re looking for that kind of bony pathology, if that’s part of your differential diagnosis, but it’s not something that we should be taking as a routine. Now, recently I emailed Mr. Andrew Sidebottom. You may remember him from PDP 118, when we talked about what happens when your splints fail, what happens when conservative care fails, and the surgeons have to come in.

Now, he said that he sometimes uses OPGs as a screening tool to exclude a dental cause, i. e. he’s not really looking at the condyles per se, he’s looking, is there potentially a wisdom tooth that could be causing an issue? Sometimes you have a differential diagnosis. Is it TMD? Is it a wisdom tooth issue?

And in that same audit, they only found TMJ changes in 1 percent of the cases. So really, if you’re taking routine OPGs, we’re looking for that 1%. This is not worth radiation in my opinion. Now, as you listen on throughout this episode, we will touch on MRIs and why I think they are good, but they have a lot of flaws and issues, which I will elaborate on later on this episode.

Yes. Yeah. Agreed. And let’s just talk about the different diagnoses that we can make as a general dentist. It’s no longer TMD, shouldn’t be TMD, it’s an umbrella term. So what are the main, obviously we can’t go through exhaustive the diagnostic criteria, but are the main categories of diagnosis we can make?

And then my next question will be after that is, what do you think in your years of seeing patients? Because etiology is that, thrown out as genetic and this and that. What have you noticed in patterns? But before that, just diagnoses, please.

[Patrick]
I think that the way that I studied with Brendan Stack, and I need to go back to talking about him because very, very few people have had the, really the privilege that I did with some other of my colleagues from Ireland to go to Brendan’s practice in Vienna, Virginia, just outside Georgetown, Washington, and spend up to a week, a year with him in his surgery where he had five chairs.

And was treating from eight o’clock in the morning to five o’clock at night. The beauty of that was that every year we went back, we kept seeing the same patients. So we were following his patients and we will be going back there for 20 years. So we have seen a lot of patients and most of the patients that are on his website, although sadly he died a couple of years ago, he still has a website with videos.

We’ve seen those patients. So what he used to say, and it’s absolutely true really, is that muscle problems within the TMD muscle spasm is secondary to disc displacement. So Annika Isberg, a wonderful researcher from Umeå University in Sweden, she did a PhD back in the mid 1980s when she was told by her professor that clicking joints is a variation of normal.

Well, we can talk about that. That just is not the case. I mean, something’s either pathological or it isn’t. You’re either pregnant or you’re not. You can’t have it always. So she did an EMG study to show that every time the intraarticular disc was displaced, the muscles in and around the joint, temporalis, lateral teragonic mass, and all those muscles that she measured went into spasm.

Every time the disc was back in its correct position, the muscles were relaxed. Now you’ll begin to see how I’m thinking about treating patients. I’m not treating muscles because I know muscles are responding to some other problems. So all joints are straddled by skeletal muscles. So if, for example, I dislocate my shoulder, the reason I got pain is the body tries to put the articulating surfaces back into intimate contact so that they can function again. That’s why the muscles go into spasm, get tight and painful.

[Jaz]
Would you agree that if you aim to treat the muscles in someone who has a combined intracapsular and muscular element that really what you’re doing is you’re almost putting a plaster on the situation, the muscles might feel better.

[Patrick]
Sure.

[Jaz]
But the internal derangement still persists. But because it’s now got to a level where it’s no longer symptomatic, but it could be again in the future. Whereas what you’re saying is that perhaps if we treat the internal derangement at the same time, then that could be more stable?

[Patrick]
It will definitely be more stable because actually what you’re doing is putting back the bits. In their correct anatomical position, which is what we try to do. That’s what we do in dentistry. We try and recreate the tooth contour or whatever, whether we’re doing a crown bridge or whatever. So the same applies to the joint and it’s an orthopedic principle that you don’t just manage the symptoms.

And yes, of course we use physiotherapy. It’s an adjunctive treatment and we use laser and soft laser and all other aspects as well if we need it, but the main thing is to get the structure and the anatomy right, because if we know what is the correct anatomy of the joint, we need to get that back to where it should be, the way God intended it to be, and that’s the best we can do.

That said, the success rate, if you do it like that, it’s very high. It’s not 100 percent nothing is, but that’s the only way that treating a patient with TMD made sense to me, and that’s why I’m studying with Brendan for over 25 years and saw it and then doing it myself. I realized this is the only way that makes sense to me and it makes sense to the patient.

The moment you show them how the joint works and what you’re trying to do, they go, aha, why didn’t the other person tell me? Why did he say I should try this or try that? So I said, look, I don’t know, but this is the way we do it. And it’s the way it makes sense. And it’s very important for the patient to be seduced is the wrong word. They need to be-

[Jaz]
Lead, lead. Lead. Lead some leadership.

[Patrick]
Absolutely. At the first consultation, you only get one chance. You only get one chance at a first impression. And that first consultation is absolutely paramount. If that goes well, the chances are the rest of treatment will. If it doesn’t go well, it’s really, really difficult.

[Jaz]
Okay. Well, what I’ve experienced in my practice so far of a decade and much less than that, actually just focus more on TMD. So this is why I seek to you, I come to you for guidance and mentorship is the general patients. I have my own patients. On whom I make a diagnosis of myogenic tmd. Yeah, and their intracapsular component is very minimal. And when I help them with an occlusal appliance therapy occlusal adjustment, whatever and that’s it. They’re in a good place now, but the patients I get on referral who seek me out they are much more, in the intracapsular they’re much more complex, and that’s where I do believe everything you’re saying in terms of, okay, let’s treat the joint and get that in the right position.

But to be, to play devil’s advocate with you, perhaps what other people have said to you in the past is, well, if you go around taking MRIs in everyone, we know that a lot of people will have disc displacement with or even sometimes without reduction with no issues at all, which then takes a very nicely to that.

What do you then believe causes someone to become symptomatic causes someone to seek care. What is the etiology of the TMD that you find in front of you?

[Patrick]
Well, a lot of studies have been done and You’re absolutely right. There are some asymptomatic volunteers who have displacement and they’re asymptomatic. The problem is how long these patients will be followed up. And there’s research to show that, if you have in a cohort of, let’s say, 100 patients and 30 have asymptomatic TMD with displacement and no symptoms within 10 years, they probably will go on to develop symptoms. Now, the symptoms they develop may not be TMD.

They may not be pain in around the joint or limited opening. It could be headaches. It could be ear related things. So, of course, they’re going into different practitioners. They’re going to ENT people or to chiropractors, people like that. So, I’m not sure about that.

[Jaz]
Okay, guys, I’m interjecting again, and this is a tough one. This one took me a long time to be able to break down and make some notes in terms of how I can make this friendly for a podcast or a video, however you’re choosing to tune into this episode. This is the part where the episode kind of takes a twist, like I respect Dr. Patrick Grossmann, but there are some different viewpoints that we have, which sometimes I look at myself and I think, do I have the right in front of someone so experienced like Patrick to have a different viewpoint to him.

But actually, when you look at the literature and people’s experiences, especially with TMD being this wild west. There’s so many different approaches that I’ve seen that I’ve learned from and there are definitely people who will be backing up Dr. Grossmann saying, yes, this is absolutely true. And there are some people who say, actually, no there is an alternative mechanism in terms of what’s happening here. So let me just explain this in just a couple of minutes. Wish me luck.

Now let’s start with Dr. Grossmann saying that all muscular issues are secondary to a disc displacement. Now, if some of our younger colleagues are watching this, what is a disc displacement? It is basically when there is like a click, right?

A click is an example of a disc displacement. The disc starts usually, for example, and very often in a forward position to the condyle. Now it can be forward and off to one side, but for simplicity sake, let’s say the disc is no longer on the condyle and as the condyle rotates and translates, so the mouth opening happens, you hear a click and that click is the disc coming back on to the condyle.

So that is like a disc displacement. That particular example I gave you is a disc displacement with reduction, i. e. the disc reduces back on to the condyle. It doesn’t reduce doesn’t mean it becomes less. It’s like when you reduce a fracture, you join it together, right? So that’s a disc displacement. And according to what Patrick believes, because we know we’re buds on WhatsApp and we discuss cases.

He is a strong believer that actually it’s everything to do with the disc and the muscles follow the disc. Now, I have to say in my experience that this is true for some patients. I have found this to be the case for some patients. But I would say that most patients that actually, once you get the muscles calm, The disk issue still continues.

Like there might still be clicking, but they’re clicking painlessly. Have you ever seen a patient that’s got a painless click? I’m sure you have. It’s actually very, very common, right? Where I work in Reading, my general patients, I treat a patient base that is more elderly. So I see and feel and hear all sorts of preppitus, those crunchy sounds and clickings and pops and take their history of, oh yeah, I used to have clicking, popping and that kind of stuff.

So the general patient that I have definitely display clicking, but thankfully, they are asymptomatic. Now, because I see lots of TMD patients on referral and self referral, I see the symptomatic end of it as well. So it can’t be as straightforward as disc displacement, muscle issues, or that disc displacement is a pathology.

Like it is a pathology and I agree to that, that it is in an ideal world. We want the disc on the condyle, but I would suggest that there is a degree of biologic variability. And this is also what Professor Daniele Manfredini in Italy would agree with, and also Dr. Jeffrey Okeson from the USA. In fact, here’s a snippet from PDP 080 where I had Dr. Jim McKee, and we discussed about the Piper classification.

Here what he had to say about a Piper 3A, which basically means the disc is slightly forward and to the side. But part of the disc is still covering the condyle, so it is a disc displacement. There will still be a click. But this may not be progressive.

Dr. Jim McKee: The classification system is misunderstood as a progressive disorder. But if I have someone who’s a 3A and stable, most of the time if they don’t have another joint injury they’ll stay that way their whole life usually.

[Jaz]
Now the other thing to consider to sort of counteract or play devil’s advocate in terms of making a balanced argument in this episode is that I have seen, because I’ve sent these patients for MRIs, when they have pure muscular TMD and for one reason or another we end up having an MRI of the TMJs, it showed perfectly healthy beautiful joints on the MRI, yet quite severe muscular temporomandibular disorder.

So we’re thinking lots of masseter of pain, lots of temporalis pain. referred pain to the teeth and beyond. And this is also echoed by TMJ physiotherapist, my colleague Krina, for example, in her experience of treating lots of TMD patients, she’s found that disc displacement and muscular pain can coincide, but it’s not always that the muscular pain is secondary to a disc displacement.

However, once again, I do and I have, and I will see some patients whereby I strongly agree with Patrick Grossmann here that in that cohort of patients this is part of the issue because they keep locking and popping that elongation and the reflex of the muscle and the spasm it can go into. That can be part of an issue.

And once you stabilize the disc displacement, it helps the muscles to stabilize. So I don’t think there’s a black and white here. I think there’s a gray area. But I definitely wouldn’t go say that all muscle issues are secondary to a disc displacement which some colleagues like Patrick believe, and that’s totally fine.

And this is what we’re here to discuss. Now, I looked at this iceberg study that Patrick quoted. It was with 15 patients. So the issue that we have with the evidence base in TMD is there’s lots of case reports and 30 patients, 20 patients, that kind of stuff. But we don’t have the big numbers and we don’t have follow-ups.

And there’s a lot of differences in the populations, big age ranges. So it’s difficult to get good data. All the bigger studies, the systematic reviews and meta analyses, they all say that we need more studies. Now, back to the iceberg study, 15 patients who had signs and symptoms. Now, this EMG spike that Patrick described, this was observed in 9 of the 15 patients.

So not all these patients with this disc displacement exhibited this EMG spike. And what’s interesting is 10 months later, when 11 of these 15 patients were reviewed again, and whilst all 10 of these still had signs and symptoms, now this one didn’t state in the paper whether painless clicking would count.

And I believe that in some patients it was a matter of just painless clicking. Anyway, at review, only two of these patients actually showed this EMG spike. So still had disc displacement, still had signs and symptoms, but this time when the study was repeated at 10 months, there was only two patients who exhibited this EMG spike.

So I think there’s a lot to say about biological variability and how EMG data may not correlate with signs and symptoms. Like I’m someone who does quite a few anterior midpoint stop appliances and I would love for the data to show that what I’m trying to do here is reduce the muscle contractions of the anterior temporalis and the masseter and the EMG studies show that yes we can reduce the contraction of the temporalis and masseter muscles but the studies again with the low end numbers show that this did not improve the patients in my own population of patients where I carefully select them.

I’ve seen answers very successful. In fact, on the splint course, loads of delegates email me all the time saying how answers have changed their practice and how they’ve been able to help their patients with headaches and jaw issues that had for lingered for many, many years, thanks to using B splints appropriately and safely.

But the evidence base would not agree with this at this moment in time. And so unfortunately everything we have to take with a pinch of salt. Even though my clinical experiences have said that AMSAs are very, very helpful to my patients with myogenic pain, the studies say otherwise. Which is why I also think Patrick Grossmann’s values are very important, his experiences are important, because one third of evidence-based dentistry is the clinician’s experience. So we can’t take this lightly. Now, this concept of variability and adaptability is something that Patrick himself just mentions in the next bit.

[Patrick]
What I do know is that everybody has a sort of limit to what the body can cope with till the straw breaks the camel’s back.

[Jaz]
Adaptive capacity.

[Patrick]
Adaptive capacity, and that’s impossible to measure. It seems to be that men, very rarely in my years of practice, complained of pain coming from the TM joint. They would have other issues like bruxism and reduced opening and so on, but pain wasn’t one. Pain to me is also not a very good indicator of pathology. You can have a lump in the breast, it doesn’t hurt.

You can have a brain tumor; you don’t have any pain till the rest. You can have carcinoma of the tongue that doesn’t have any pain till later on. So pain is not a great indicator. What we’re interested in is pathology. What I do know is that the patients who have this disc displacement with pain and other problems, benefit very well.

The question about what you do, if you’re going to undertake, let’s say, 20, 30, 000 pound work of dentistry on patients who have internal derangement and are asymptomatic, you just have to tell them, if you develop symptoms, I may have to redo the whole thing. And I’ve seen that in staxpractors.

People would have a full mouth rehab done and they start breaking all the crowns and He takes an MRI and says you’re off the disc and things aren’t okay And you’re going to have it all done again. The woman said I just spent eighty ninety thousand pounds. He said well, I’m sorry There’s nothing I can do which brings me on to one really important Intellectual point that nobody really talks about we know that there is a disc in that joint and we know where the disc ought to be from autopsy from thousands of years of anatomy and so on.

The question now is that every dentist has to ask himself, not just an orthodontist is does it matter where the disc is when you treat a patient? In other words, are you treating your patient on or off the disc? That’s the question. Now, if you’re an orthodontist and you’re moving 24, 28 teeth around simultaneously, And it’s your child.

Would you prefer to do that on healthy joints where you know everything’s in the right place or it doesn’t matter?

[Jaz]
That’s something we need to decide as a profession don’t we?

[Patrick]
That’s absolutely right. It doesn’t make sense to me to treat off the disc. It doesn’t make sense. It’s not biologically correct. Whether you get away with it, it’s another thing. It’s up to every individual to decide. What you’re going to do, if it’s just a class one amalgam, does it matter? But if you’re in a full mouth rehab where you’re doing implants and orthodontics. Now that brings me on to something really, really interesting.

And that is the case back in the mid 1980s of Brim versus Malloy in Ann Arbor, Michigan, where a teenager girl went in for orthodontic treatment, had premotors extracted, had headgear, and after the appliances were removed. Complained of intractable headaches and TMJ pain, and then had some wisdom teeth out as well, and everything got worse.

And the case was brought against the orthodontist, and the plaintiff won, about a million dollars. And that threw the entire orthodontic profession into complete turmoil because the argument by Witzig, who was the plaintiff’s expert witness was, you don’t expect to go in for orthodontic treatment and come out with straight teeth, but feeling really bad with lots of symptoms.

And that’s where it all started. And that’s when the orthodontic community got together and started to find ways of publishing, which they’ve done very successfully. Lots of papers show that orthodontics has nothing to do with TMD. Well, if you look at the systematic method system, I mean-

[Jaz]
They say orthodontics has nothing to do, but that’s like saying, the position of the teeth, the way the teeth meet together has nothing to do, it’s the same, it’s saying that, right?

[Patrick]
It’s nothing to do with the static occlusion, it’s to do with what happens functionally, and whether the mandible-

[Jaz]
How it reaches the static.

[Patrick]
Exactly, it’s not whether it’s class 1, class 2, class 3, none of that. It’s how the mandible gets to its final position of intercuspation of the final position of the mandible and the shift of the mandible will be dictated to by the arrangement of the upper and lower teeth.

[Jaz]
Which obviously has a huge bearing on the two joints.

[Patrick]
Well that’s why I tried to put forward the go back, to first principles where we talk about the stomatognathic system and people say, well, what’s that? Well, it’s basically three elements that have to work beautifully together as a system.

And those three elements are the two TM joints, the muscles and the teeth. And then I have been thinking recently about, well, what is the most important part of the stomatognathic system? Well, babies don’t have teeth and a lot of dentists people don’t have teeth. So, but if your muscles and your joints don’t work, like if you’re born with some of these craniofacial deformities, you really can’t function.

So, yes, of course, the teeth are important once they’re there. But the foundations for me are the muscles and the joints. And now we’ve got to get the teeth to be in harmony with those two other parts of the stomatognathic system.

[Jaz]
Well said and I think it raises a really good question that I have now is whether we’re treating on the disc or off the disc because one question that we get in the restorative circles is can you treat a patient with a clicky joint?

Can you safely raise their vertical dimension and do a full mouth rehab and you kind of touched on it? Well, what if they have problems later on when you wouldn’t have been better if they were on the disc and you treat them. But my only then there’s a gray area. And if we look at the Piper classification, which to me as a restorative background, I favour the Piper compared to the Wilkes, is if the medial pole is in the right position, and it’s the lateral pole that’s out, because it’s not brace, it’s not supported, and you can get a repeatable position, repeatable bite, and every time you do a centric relation record, it’s fine, do you feel as though it’s a sin for a restorative dentist to accept an asymptomatic click that’s been there for many, many years, and then proceed to treatment? Or do you feel as though that patient should have that click fully eliminated and the lateral pole in the right position before commencing major work?

[Patrick]
Well, luckily, I’ve never had to make that decision because I’ve never done full mouth rehabs. The thing is-

[Jaz]
I mean you have though, you’ve done orthodontics.

[Patrick]
Well, yes I have. But we haven’t followed those patients through long enough. I think that’s the answer. I mean I don’t know. One would have to really decide and tell the patient what’s what and then see what happens years down the road. Would I do it? I prefer not to because if I know that everything’s in the right position, then I know medico legally also I’ve done the very best I can.

Whether you get away with it asymptomatically, I don’t know. It’s very similar to a lot of people who say, oh, well, you can do a pull forward splint, to recapture the disc. And then what you do is you walk them back. And then what you do is you take it out and you just use it now and then.

So all you’ve done is you’ve taken them from a symptomatic position to an asymptomatic position, you are now putting them back to where the pathological position was and people say, oh yes, but in the meantime, they formed a pseudo disc and the retrodiscal tissue and the bilaminal zone is all stiffened up and so on, but that’s still to me a bit of a cop out.

[Jaz]
So what you’re suggesting is if you do phase one and then wean off the phase one and don’t proceed to the phase two and actually bring in the teeth to the new position where the disc likes to be.

So guys, let’s just reflect here on something very important Patrick said, which is a symptomatic patient.

Okay. When you do a pull forward splint, which is type of like an anterior repositioning splint, bringing the mandible forward. So it’s kind of like getting the condyles on the discs again, right? And then let’s say the patient’s pain goes away. Now sometimes I’d argue and some of my mentors would argue that perhaps it wasn’t the fact that the condyles on the disc that resulted in the pain go away.

Sometimes there’s other mechanisms at play. But let’s assume that’s what’s happened. Now, what Patrick said is that when you actually take the splint away and then you walk the condyles back, so the condyles go back to their normal position, then you’re putting them back in that sort of symptomatic position again.

Now, this may be true for some patients, right? But the key word here is symptomatic patient because if we do go down the phase two approach, basically, phase one is when you bring the jaw forward, you’re trying to capture the disc, okay? And then if you stay at phase one, that means you’re just holding on that splint which holds the jaw forward, or you take out the splint and you go back to normal.

Phase two would be that when your jaw is now forward and your discs are now captured, you are now doing something to the teeth, like orthodontics, for example, or restorative, to hold that position. Now that the condyles are, quote unquote, in the right position, what can we now do to the teeth to keep them in the right position?

Now, Patrick being a very skilled orthodontist, the way he would do it is he would actually do ortho, extrude the molars, and get everything to meet together with the condyles in this forward position with the discs recaptured. Now, after having been on Patrick’s course, which I would recommend because it’s really great to get a different perspective and to learn from someone with so much experience, and what he showed was cases whereby things can take a lot of time.

To achieve those orthodontic movements, to get the posterior teeth to meet together, can take a long time. Now, if you throw surgery into the mix, i. e. someone’s got a disc displacement, without reduction. And now you are doing disc plication, which is like suturing or stapling for when, for want of a better word the disc back onto the condyle, right?

And then you’re doing this therapy whereby you’re bringing the condyle to the right position, and then you’re doing the orthodontics or the prosthodontics. It can cost a lot of money and take a lot of time. Now we’re talking years here. So I think the juice must be worth the squeeze. So if someone is asymptomatic, surely we shouldn’t be doing something so drastic just in order to get the disc in the right position if your patient is asymptomatic to begin with.

The other thing to consider is, are there ways that this patient could be treated a bit more conservatively? Like, I do think there is totally a place for this kind of treatment, which Patrick is very skilled at doing, but I think there’s also a place for what I do, which is basically following a pyramid.

Do the most conservative things first and escalate upwards. This may be a classical stabilization splint, for example, and relying on this pseudo disc formation, which I know that Patrick isn’t the biggest fan of, but there are lots of camps that would say that actually this is a suitable way to go. So which way you treat it, I feel like we need some clearer guidelines, some good research, because like I said before, the bigger papers all say that we need more studies, we need more trials, we need some data over long periods of time to see how our patients do.

And this can be very, very tricky. One mentor I’ve learned with is Dr. Jamison Spencer in America and he says that for a patient to get treatment, especially if it’s more aggressive treatment or irreversible treatment, they must have PDQ. So PDQ stands for Pain, Dysfunction, a Quality of Life Issue. So one of the three or all three, for example, and that should be the basis of treatment.

If they don’t have PDQ, then why are you doing the treatment? And I quite like that philosophy and I like to explain to my patients who are worried about asymptomatic clicks. The other thing to consider about pain is the more I’ve been learning about pain, especially the last four to five years, you really learn that pain is a very complex beast.

And when pain develops this characteristic called chronicity whereby it’s been there for so long and your nerve signals are firing even though perhaps that trauma or the thing that was causing the pain is now gone, but the pain signals still persist and how pain is regulated by so much more than just trauma.

It makes me as a clinician worried about doing irreversible things in the hope of overcoming pain. Because learning how chronic pain works means that even though you can get things anatomically correct, the pain can still continue. So the biggest thing that I advocate nowadays is something called Symptoms Modification.

This means that I will try to do some sort of reversible conservative therapy. This could be an appliance; this could be even an appliance that Patrick would do. I would do something similar to him to first check that we get the patient out of pain. And I know that Patrick does this as well. He gets his patients, he puts them on his pull forward splint, he gets these discs reduced, and once the pain settles, then he considers his phase two, and that’s the way it should be.

But I guess what I’m trying to say is that I might try to do this phase one without having to bring the jaw forward, if it’s possible for that case. And it’s difficult to make sweeping statements when we don’t have a specific case in front of us, because each case brings with it so much variability is what I found.

But if there’s a way that I can use a splint that is perhaps permissive, like a stabilization splint, along with some physio or an AMPSA if it’s appropriate for those kinds of patients. And if you can improve the patient scores and get rid of that P, D, and Q, then perhaps we can avoid that phase two and persist with the regime that has modified the symptoms.

The other thing that I’ve just remembered that Dr. Jamison Spencer taught me is that when you bring someone’s jaw forward and you try to get the condyles back on the disc, the way he famously says it is that it could take a peanut on a salad to undo all this hard work. So, how stable is it long term?

Well, this is why the anterior repositioning splints data is a little bit worrying that actually the stability of that position long term may not be so good. Or what Patrick argues that actually if you do that therapy and then follow it up with the orthodontics to the phase two to try and keep that jaw in the forward position, then that might be the secret source to getting higher success rates and more stability.

But I personally have not seen this long-term successful data whereby phase two has been carried out and we’ve had good stability at five years or ten years. Now when you look in some studies, especially from this textbook, which I’m holding, for those of you watching the video, those of you listening, it’s Jeff Okeson’s Temporomandibular Disorders and Occlusion, Edition 8.

And what it shows, as well as doing some background reading is when they have done phase one and phase two, so they brought the jaw forward, they got rid of the clicks and the pain improved, and then they did the orthodontics or the prosthodontic therapy or the occlusal adjustments to keep it at that new position.

What they found over time. is that at the interval period, so a lot of these studies are three years, four years, six years, they found that they were 80 percent and above successful for pain, which is amazing. So if you’re a patient in pain and you’re going to have this therapy done of bringing the jaw forward and having some orthodontics and 80 percent of the time, then amazing, it’s worked and 20 percent of the time, well, that’s biology.

That’s how it works. Whereas if you actually have a look at the click, so have you successfully eliminated the click long term? The same study found that the click returned in about 50 to 70 percent of cases. So let me repeat that again. Pain, it helped a lot when you follow it up as well, but the click returned.

The pain was still gone, but the click returned. So let’s think about it. The click has returned. The disc displacement is back again, but you don’t have pain anymore. So perhaps could there have been a way that the treatment could have been done without the phase two and to live with the click, for example, but manage the pain, just like what the data showed for the more aggressive therapy.

Now, this is just some wide overarching examples I’m giving. Patrick shows some very nice cases in which he made a huge difference in people’s lives with his treatments. So this is why I encourage learning from everyone. Especially if you’re interested in this field of TMD, which is, I love it, but it is very overwhelming.

I think in terms of the different mentors I’ve had, like, I’ve learned a little bit of ortho here. I’ve learned lots of restorative, which I love, but the differing opinions I’ve had in terms of what’s the best management technique in the realms of TMD is immense in terms of wide variation of the great clinicians that we have out there.

Which is why I personally now default to what is the most conservative of the two or three treatment philosophies that I have available. And I explain this to my patients, I get them on board, or at least I give them the option like, look, I can treat you this way, but here’s my reservations about being more aggressive.

I’d like to treat you in this less aggressive way. And here’s my working out. I’m a big fan of always sharing my working out to the patients in anything I do, restorative treatment, or TMD show you’re working out.

Then you’re perhaps missing the benefit. This is probably the problem within the literature. So the literature that I read about anterior repositioning sits or mandibular advancement is they have good short term data, but poor long term data in the sense that what they found was that it relapses. But I’m not suggesting that that we shouldn’t do it. I mean, I’m really suggesting that perhaps the studies weren’t designed the right way.

They haven’t been carried out correctly. You probably know more about that. What do you think about the studies? Because they are something that we look at for guidance. And a lot of people then get shy away from going into it because they, well, it’s not going to work. It’s not going to be stable in five years time.

[Patrick]
I mean, there may be studies. I’ve got a lot of. Four cabinets here. I’ve got hundreds of articles, some done in the 80’s by Williamson to show long term results of an anterior repositioning are very, very good. What is really important is that once the anterior repositioning plants has done its job and it’s an orthopedic appliance, it’s not moving teeth, then you have to get the occlusion in sync with the new Maxillomandibular relationship because if you are altering the mandible to the maxilla. And there is the problem in the same way. And that’s why the orthopedic approach that Brendan did because Brendan by, was a university-trained orthodontist as well. That is why, in a way, orthodontists are in the ideal position to treat these patients because once you do the splint and then you can fix the teeth, you can do the lot on your own.

Now, obviously that’s not possible because most specialist orthodontists in this country are not even interested in the joint. They don’t even know where the joint is.

[Jaz]
And general dentists as well. They don’t want to go far out. They don’t want to see these patients.

[Patrick]
And most orthodontists just want to make the teeth look pretty, move them up and down an archway. That’s why I said for me, when I saw the light, I realized it wasn’t the end, it’s the means to the end. However, it’s a team effort often. And so if you do the splint, you then try and find an orthodontist you can work with who can do stage two. Now you can give a much better overall treatment for your patients.

So that’s why I’m really upset that so few orthodontists or people do orthodontists are not interested in this field. I understand why though, it’s a difficult subject. People don’t like treating pain patients who are in pain for a long time and they come with a lot of social problems as well and psychological problems often.

So, but this is so rewarding when you can do it and if you have a scheme and a system that makes sense and it goes through like a cookbook, then you’ll get really good results.

[Jaz]
Well, I think that brings us really nicely onto the actual etiological factors. Now you mentioned already if there isn’t an optimum position of the disc that is an etiological factor.

Now we know from the opera study about them having an actual biological issue plus extremes, a stress or a crisis in their life, plus genetic elements and there’s a whole loads of factors like Irritable Bowel Syndrome and various others which are correlated and then that makes a perfect storm. What are your reflections of when you look back at your career of all the patients that you’ve had?

What are the common themes because let’s assume that yes, they have something not quite right in their articular system but what actually what are the other biopsychosocial factors?

[Patrick]
They usually go down the list from bio to psycho to social, right? Except for men in my experience who have a social problem. For example, I remember having one patient and his wife said, look, you’ve got to treat my husband. Cause every time he eats, it makes such a loud noise. It’s really distressing at the table. So he came for treatment, not because he had pain or anything else. It was a social problem. Usually though, it starts with some form of pathology.

And then with umpteen treatments by various people, people get depressed if they’re in pain for more than six months, they do become depressed, whatever problems they have.

[Jaz]
And becomes chronic pain, and this is a huge problem.

[Patrick]
Chronic pain, and then of course it becomes a social problem, so all the people around them in the family and their friends, they all know that this person has got terrible pain. They can’t go out and so on and so forth. So it becomes really, really difficult going back to your question, which was?

[Jaz]
What are the different factors that you’ve noticed in all the years, we looked at the opera study, but what are the classic features of the TMD patient that you saw?

[Patrick]
The most common ones are limited mouth opening, painful joints, noise in the joints, headaches, ear related problems, neck related problems. And then of course, knowing the anatomy of the trigeminal nerve, and this is something Brendan did at least 10 years ago with his co worker Sims, is that they worked out the neurology of what happens in the brain stem when the fibers from the trigeminal nerve enter it.

And also what happens there is that they interlace mainly with cranial nerves 7, 9, and 10, and because of that you get other symptoms in some patients, such as involuntary blinking, Tourette type symptoms, and probably because it also affects the vagus nerve, you will get other symptoms related to, so for example, irritable bowel syndrome.

So I think they’re all related to this trigeminal is an extremely complex nerve. And I’m not sure we know everything about it, but a lot of the vessels innovated in the cranium by fibers of the trigeminal. So it is hugely, you drive symptoms hugely.

[Jaz]
But with all the symptoms and the signs that you saw, when we look at why that patient, what happened within that patient that led to them to become symptomatic compared to very many other people who may have the same sort of joints, skeletal factors, occlusal factors, but they didn’t become symptomatic. Stress, was that a common?

[Patrick]
Stress is one, obviously, and parafunction I’m sure plays a huge role and all the patients that we treated, we all not only offered them. We all told them they had to wear a night appliance, but a specific type of night appliance in order to protect the joint. Because once the joint is weakened, it needs to be looked after for life. And you can’t do that with the TM joint other than using an appliance because you don’t know what’s going to happen in sleep, grinding, clenching.

[Jaz]
This isn’t after phase two, after you’ve achieved everything. This is in phase two. Is that what you mean?

[Patrick]
This is in phase one. So they have basically in phase one, they need 24 hour care, which means they have a splint in the daytime, and they have a different splint at night. So 24 hours a day, they’re being treated, not just being treated at night, like some people do.

[Jaz]
And during eating?

[Patrick]
And during, absolutely. Every single second of those 24 hours, they have something there to get the joint into the correct position.

[Jaz]
Which is not a stabilization splint, which is permissive.

[Patrick]
No, no, because the moment you take the splint out, the muscles go back and start moving the mandible back to a different position and you’ve lost it. You have to keep the proprioception the same. And that’s what makes a successful case, in my view, a 24-hour care. And then after stage two, when they’ve had the orthodontics done to get the occlusion in sync with the joints, they get another nighttime appliance for life.

[Jaz]
To protect that weakened joint. Now, what does that nighttime appliance after phase two, the protective one? What does that look like? What can you describe it?

[Patrick]
It’s basically a bimaxillary appliance. So it sort of looks like a bionator, but it isn’t. It was the one I use was developed by a guy called Ralph Garcia down in Florida, whose practice I went to see.

And it’s absolutely magnificent. Basically, what it does is it holds the maxilla and the mandible in such a position that you can’t clench, you can’t grind, you can’t move around. You can only open and close into this thing, right? It doesn’t alter the occlusion in any way. It’s got a labial bow and we’ve made some modifications to it over the years.

And it works really, really well. Studies have shown that when, what Ralph did was very interesting. So he took a patient and put them into a sleep study and monitored all the EMG recordings of the muscles and then put same patient back in with the appliance and lo and behold, there’s virtually no muscle activity.

So we know that once the joints are in the right place and you put this appliance in, there will be no muscle activity. Very, very little. This is why when patients came to me with a box full of appliances, said, well, I’ve got this one I had at night and somebody made me another one. I’ve got a Michigan and this and that.

To me, it doesn’t make any sense because if we look at it logically, a Michigan splint is made with so called perfect idealized occlusion. But if one joint is in and one joint is out, how can that make any sense? What’s the point of having an ideal occlusion on joints that aren