Januari 02, 2017
ok we have expert number two. he is a private practice, board certified in sleep medicine and pain management. you all know dr. mickiewicz and dr. mickiewicz, take it away. thank you so much. when lou approach me a week ago or so it was specifically on internal derangements. so i'm gonna take a little different tack dr. malick gave us really nice presentation of
like the overview of like how you take the patient from point a to point b and i want to get down a little more nitty-gritty with you guys and my practice it is unique in a lot of ways because it is all i do. i stopped doing restorative dentistry, you know, for a multitude of reasons. i'm incredibly busy with what i do with the orofacial pain
practices that i have. sutter, mercy, uc davis those are my biggest referers for probably a 200-mile radius. so i get people from everywhere with and i might the the person of last resort i am the neurological dumping ground from all the local neurologists the physical medicine specialist, a lot of the dentists or oral surgeons i mean whoever
and the dentists of course. so and i'm there and fairly available email or whatever. my website, i left some referral stuff and my website back there is drmickdds.com and there's a ton of information on there, links to you know all sorts of organizations pretty much all the information that i can share here and what's a little bit different about my approach, i mean it's
pretty much part and parcel of what they teach at ucla, you know in terms of how we get from point a to point b. you know i'm a uop boy so you know we have a little different bent on things, but it was a similar background you know i started this 25-30 years ago with dr. chase down at uop and they had a pain clinic and we had all the specialties represented and
it was pretty cool but we didn't have the cool technology we didn't have people like dr. rathi have at our fingertips and dr. hatcher who are incredible assets to our community. so we have these incredibly complex patients and we we look at them you know i dr. malick discussed, you know not just from the facial standpoint but we've got like
the skeleton, the airway space, look at the brain, look at their sinuses. we look at the cervical spine and then we start peeling them part we could layer by layer by layer the teeth obviously important the bones important. to have someone do this, i can't do this. i mean the thanks to craig for this video of some time ago with craig dial over at ddi,
shameless plug for them, i have no financial interest in them by the way. but this you know looking at the airway spaces is probably one of my fascinations i got into sleep medicine you know way before it was cool and pioneered some of the techniques and beta test a lot of the appliances it that you people use on a daily basis so
my world you know like what why do i do what i do you know, because it's frankly it's a much more profitable do regular dentistry oh i mean infinitely more profitable and it's getting harder and harder and harder everything i do is build through medical insurance and for all the docs out there
who want to get into this business awesome if anybody wants to be a partner with me awesome i have no problem sharing information people hanging around my office all the time i train the residents from uc davis and sleep medicine it's mandatory that all the sea fellow spend 10 hours with me to learn
about oral medicine and and what we do and how we handle assy patients from a devil perspective what i think is pretty cool for gcd to be that progressive but it's it's not for the faint of heart you know i have to have a full-time medical bill around staff and if you're not prepared to do that you know maybe doing this full time is not for you or
maybe working a part-time is for you i have you know very highly trained assistants and then i've taken it to another level because as she will attest to a monstrous proportion of my practice is the general joint disease and to the point where it's almost epidemic in my practice i find that fascinating from many
perspectives very female-driven probably 98 maybe getting closer down to ninety-five percent maybe down in ninety-three percent right now i'm actually doing a study right now we just did pull 200 charts random and we're going to start looking at things i'm gonna show you a guy who's got some incredible djd later so i look at these
cases a little bit differently than most people because i get the worst of the worst i don't get the the my job pops and clicks you know i don't get that i get a maybe six months later or a year later when they're locked out and in there in tremendous pain and so my my world is a little bit different so i i titled this thing you know because its
internal arrangement that's we're talking about today that's was my topic was you know because it's halloween is things that go bump and crunch and great pop and lock and grind and all that stuff all these incredible sounds of these patients come up with and their descriptions that they have and they're all really important at a neat one of
them means something to me you guys right of steps copic examination i don't use a stethoscope anymore i've joined vibration analysis i don't use that very often less it's a medical legal case i do a fair amount of medical legal work also but you know it just becomes a point after forty thousand patients not making the number up and it'sit's feel
you know and it is listening and that's probably the the the biggest skill that that we lack is listening and asking the question why you know why that tooth break why is there you know a craft and that to why is there pain why is there a headache and we start to dig into the whys of things that makes you a better dentist and makes you a better doctor
makes a better assistant makes you better hygienist so and a better front desk person if they got answer the phone answer those questions and triage patients who have a half-hour story because we give an hour and they wanted they want to tell their story you know they go to the position they get seven minutes if you're lucky
so what do they get prescription so that's where a little bit different so my world is more about things like creeping creeping has to do with how discs move in space and and what happens to the hydrodynamic activity of that little piece of cartilage were so fascinated with measuring and where it's going to be no indeed
eccentric relation and how we're going to manipulate the jaws that by manual is that this isn't that so we were about that it's a hydrodynamic force and we're trying to measure this statically and we're obsessed with it as dennis we love the measure stuff i'm not a measure guy i'm a touchy-feely guy so we talk about creeping weeping things weep the the
fluid weeps out of these these little hydrodynamic things like sponges and depends upon the force you put on it and it's different forces there's torsional forces you gotta worry about and probably most you know and compressive forces of course there's a traumatic injury of some sort whether it be a car accident a blow to the face being
cranked open because no offense the dentist's out there but i i will throw people under the bus the the trend towards cranking person open with a rubber dam i and o post build up the crown preparation for hours one visit numbed up i think is a disaster i think is wrong i know it's efficient i think is wrong because i
think that that you're asking that patient and if you're not looking at those joints yes it's very efficient yes you can make some money but what you're asking for trouble from that patient and so it's one of those things where i never got into that world because it was all about comfort and you know it's split therapy
first before i did that crown prep identify that problem for thrust you pull out full mouth impressions you know to make sure i've got everything mount things up facebones i mean that was for simple crowds so it's it's not like sure you can do is no such thing to me is a simple crown and there's nothing as a
simple patient and so everything i see is is i feel extremely complicated i treated as such even though they come in with like the slightest little poppy clicky that thing and they finally get to me after five months of navigating the medical system there in my chair and it starts out but when you get the story it's it's like it goes on and on and on
and on on and the whole thing about that you know this organization disorders and and crypto trauma i you know where people but suppressed sexual abuse and physical abuse and there's so many fascinating things that will come out these patients and that's what i that's my juice
you know i've been doing this 30 some-odd years so it's a world that i've chosen for a reason and so if you want to get into this world were you worried about tumor necrosis factor-alpha you worry about interleukins and cytokines and when it comes down to it everything that we deal with i don't care of his heart disease cancer
tmj problems cavity everything we deal with an inflammatory process and that's where we're moving towards so their tests now that are available rizal publishes the last last year you can do a urine test and with a 98-percent specificity i find out what not they have sleep apnea offer 24-hour urine test
that's where it's going so all this stuff of bringing home sleep study test and the officers spent 5 grand one just last week but you know bringing all this stuff into the office for me it makes sense because i do you all see 527 new tmj patients every day and maybe 325 sleep patients every day new plus all my ortho patients present with an attic
patients so i'm you know also 30 40 50 patients a day not not uncommon working on 23 operatories some a busy guy and so you know you've got to be on top of this stuff if you want to enter this world so i'm gonna let you enter into my world and basically because of the nature of the beast the disc once it's destroyed it's
destroyed and you'll see some examples of that and in great detail on there there's two really famous movies out there was called the joint you know which is these incredibly boring swedish guys and i have it on my other computer back there if you just youtube the joint video its it'll put you to sleep is a really great great sleep aid but i'm
just listen to their voices but the the diagnostic work they did which was fresh cadaver dissection is pretty cool the one i'm gonna show is done by dr. tonight cut down on scripts and it's for the old but it's much more detailed similar thing and i'm just going to run and so this is this is your this is the tanaka
video this is your normal joint so orientation real quick there's the head of the condyle there's the temporal fossa annoyed fossa post your attachment apparatus back in here there's the disk by concave shape that's well-described boom fat skinny avascular zone right here in the middle very very thick fibrotic tissue back in here look
at all this soft mushy stuff i meanwhat go ahead and listening doesn't show your you know okay thank you ah right it's so much better ok so i believe we move on to dinner of disc so looking at the difference with this little perforation right here and you can see the you know this is the
anterior portion we're coming out here that supposed to your portion of the of the joint and as the disc pops back and forth you can start to see right in here that a vascular zone right in there so when you start to load this joint and you start to worry about you know what what you can do about doing a crown a simple crown on someone like that and
how this changes so much because the weeping the creeping happens back in here as that tissue box back and forth and this is these are fairly fresh fresh cadaver dissections i mean tanaka has a pretty cool setup or he did at least you know it's like people die they've gone into the body to science you get some first and he goes and he grabbed her
head chopped off spices him up and he does this and and he's is an amazing guy who never heard speak he's really a gym but looking at this this a vascular zone and we get so fascinated about i'm going to dubai manual manipulation of a jaw and i'm going to find this perfect centric relation position well what the hell eccentric relation on
this person look with this tissue going to the inside what what is that look this you know his policies kind of bending the head of the condyle out this is the most common thing this is your popper clicker take you just talk click right there right there is the head of the condo pasa muscles superior fibers of the lateral pterygoid their
attachment apparatus back here and you can see is that little pop and click right in there but look how it just all jams up in here so what's happening to this soft tissue you know how is this changing the shape and its getting fat here again where it should be a vascular was a vascular before that's the the seeping in the
creeping them and the the viscosity of that fluid that's inside of that joint changes depending upon the force we put on it and so again we get so fascinated i'm going to recapture that disk how many times have you heard that one you know and everyone's got this fascination with recapturing the disc and you'll see in a minute why you
cannot you cannot recapture a disc there are situations where you can duplication saw a young lady right before i came earlier today this will watch this when you stop after this one for a sec so this is plus your attachment apparatus post your part of the disk you guys we really gonna do this in no time head of the condyle probably some
arthritis circles really flattened off pasa muscles out here now said watch what happens this disk where the words ago thank disappears or to go it's behind the screen somewhere magic and it's going to pop right back out again so when a distance places when it pops and clicks almost invariably is going to go
auntie rio immediately because of the pull the fibers has no other choice so when you're when you think that you can recapture that by taking your auntie repositioning splint and moving that jaw forward and put it right there and you've captured it and and you open and close and you have something pops and clicks and you say put your teeth edge
open and close ok to the top and click no i don't hear any sounds okay perfect i've cured you but now your teacher edge to edge maybe that's where you need to be maybe maybe not so that's why we do splits that's why we put them in you know diagnostically so this displacement you know to try and recapture that you
really can't try to force this back into place because of the the dynamic of that soft tissue but we think we can do it how many how many times have you seen it and so how many lectures have you heard and how many articles have you read where you think you can do and and you know gurus are out there who will tell you that this could be a new they are
not going to name them you watch what that thing does and when it goes medially and all the sounds disappear you think you're a hero because all the sounds went away well guess what happened the disc is permanently displaced the medial family displaced to the end to the interior and
your function on some sort of scar tissue and that's fine that's perfectly fine as long as you recognize this what you're on so limited opening so the disc is stuck right there and he can't go any further because again the hydrodynamics of it imagine this is a feather pillow okay and you're looking at this this is some
of the feathers and this is some of the feathers back here and this is the middle and you got your hand the middle you put a great for the middle of it it's like this three-dimensional figure 8 and it's draped over the top of that you hit the feathers on one side they're all gonna go to the other side that's what's happening here in those feathers
are smashed into the back but periodically because of the hydrodynamics again and because of the thickness of the tissue that's in there and because of the forces put on it all that tissues gonna get stuck up in front here and it won't translate any further or if because the first part of opening is a rotational movement right 10 to 20
millimeters and the second part of movements translation going down the the faucet here this is you know one of our nice perforated patients this is like my bread-and-butter right here where there is no disc their bone on bone so post your attachment apparatus disc tissue all bunched up here fairly decent range of mountains and of course
this tissue all washed up here so basically you know it really decent range and i'll come down to you know what what we need to try to accomplish and what we need to focus on as dentists and is practitioners in this area surgeons uh you know if you're doing arthrocentesis for instance you know and much this working from dr. hatcher way
back when and dr galon think you're in that office way back when back on folsom boulevard and dr. hatcher go in and use the radiologist and and they used to our programs on joints and and whenever there was something they look for perforation and all the things we just saw and he was masterful at it you know and since we put the needle narration to
die and superior departments and if your compartment frasca p and then you take pictures of it and then oftentimes if you put to sleep it's not very comfortable to have died shot in your joints and you can see preparations and leakages and he could read these things with amazing this is great free cone beam ct what they're finding
was that just that activity just flushing that joint you know flopping back and forth the patient's felt better when they're done they can open fully is an artisan tsys you know by proxy and it worked and as dr. gallagher was probably done more ja surgeries i would think that anybody in northern california least not
california you know open joint close joint i was last time even did an open procedure yeah so not very often arthroscopy he's you know probably not as often arthrocentesis bread-and-butter the works and we have tremendous result with that and this is the crux of it right here is you know understanding this
displacement and this hydrodynamic activity of this little piece of tissue right here and you're going to tell me that you can find that when you tens a patient and you're gonna pull some pulsing pulsing pulsing pulsing and then you're gonna take a bite record and you're going to tell me that that's where the disc is
supposed to be so you tell i'm not a big muscular guy so that's my world and what i'll get into what i do about it as we go on here so we worry about this viscoelasticity of the joint and there's different kinds of forces that can go on to this joint that can create problems compression force take a big blow car accident sports is probably the
biggest one we see young female volleyball player soccer player basketball player can't count how many girls have my practice and great athletes low body weight estrogen levels plummeted and you see how much arthritic changes are happening there this whole concept of going from progressive carlo resort option seen
prepubertal arthritis saw the nine-year-old today female asian girl who hi super-high strong athlete volleyball player soccer player everything you know superachiever plays the violin a weird angle you know and cute great kid and you're open bite big red red flag for me when i seen and ear open bite that usually means
arthritis arthritis in the joint because you get on a rotation as the muscles start to pull down the front teeth start to come apart is why i'm i'm a huge cum being fan right i think i think it should be the standard of care doctor hatcher's much for polite about it he thinks it should be the standard of excellence and he has a vested interest
i don't have a kobe machine in my office i send out five the ten a day maybe about so i could certainly justify the expense i don't have the capability to do with that cool little video that craig whipped up for me several years ago actually and it's even better now what they can do from an orthodontic standpoint i'm
sure you can attest to you know look at impaction and a custom passion and pulling on stuff out and get you become beam in your office we got no we might use them fairly regularly good great so i do a fair amount of ortho myself and so i i do it on everything i do it on invisalign cases i you know there's to me there's
no such thing as simple ortho as you know you'll testify everyone they always a simple class one case right no such thing and when you start getting into these kind of situations and i've built a lot of orthodontists and i'm glad to do it because what what they fail to recognize is they don't look here or i've build-out many an implant
surgeon periodontists and oral surgeons who are getting what i call the cheater comb beams that just do the trough that comes across here because i want to see what the implants go they go in and they do their implants to do a beautiful job the implants were lined up nicely they do everything by the book and they go to do the restoration and also the bites
open the bites open anterior-posterior something's going on with a look at the joints and my thing about cone beam and i'll get off of that after this is it i'm not qualified to read those i'm good i'm not as good as her and not not even close and so i can look at them and i can do a pretty decent job and i come up with
some really crazy stuff and once in awhile collar on something are dr. hatcher or we'll work on something together we see some very very unusual things the amount of calcified arteries the amount of weird pathologies as salivary stones masses in the brain av malformations i mean it'sit's crazy the pathology comes with maybe just my
practice maybe just me maybe i'm lucky the amount of arthritis you know yes numbers you know are three of these verses my origins pain probably my practice you know maybe sixty seventy percent arthritis that's huge that's a huge number and if you have a machine in your office awesome but
pay the 70 bucks and ever read you know have a professional look at it because for a couple reasons number one she knows more than you do number two cya because we missed something you're responsible get that machine you miss it you're responsible if they have a vascular lesion you're responsible they have something in their brain and
you miss it and they have a stroke you're responsible they have a pituitary gland tumor you're responsible av malformation you're responsible was the one we had something in there cervical spine they had like a baby information in there and c-130 yeah i know i don't know the names of that's what she's for she came over the fancy names you know
so it's like you know we did all this crazy stuff that you can see you're responsible once you put that machine in your office great stuff great technology i think it's everyone it's the future obviously so what am i looking for you know i'm looking for homeostasis i'm looking for you know what if you really
want to get into this you know what what's the alignment of the of the collagen fibers there's there's several kinds of collagen fibers are in that disc and the alignment of those is going to dictate what sort of force they can handle and what sort of stresses they can handle and the the compressional force the blow we started with that you
know the blow is pretty easy to understand and usually self-limiting you know unless it's really significant car accident gunshots i'm have seen all sorts of fun stuff for the the day-to-day stuff is this you have torsional forces you know someone you know stretches too far to one side crank open for an endo for
instance they end up with a closed-off someone who sleeps funny on there john you know their jaws off to one side so they have more of a myofascial kind of activity in there puts a strain on the joint but it's the shearing forces that created the biggest problem so when you have a sheer against that particular disk it doesn't handle that very well so
if that cheering for us could be from a blow basketball elbow to the to the jaw uh it could be from a crown that's not properly placed it could be just a massive clincher grinder who's got all sorts of where four sets and and wear patterns and and dugout teeth and i it just boggles my mind how many patients i see today just today eight new patients
and every single one had massive dental problems i'm diagnosing dentistry right left i'm making guys rich you know like you need you let me get you comfortable and then go back to see your dentist you're gonna get this and this and this and this and this and come up with a plan because and here's why and why did my
dentist tell me all that the question why do my physician tell me that when i start talking about you know calcifications in the carotid arteries why do my physician tell me about that and so these are the kinds of questions if you can get into this world that you've got to have good answers to do i have all the answers no but as einstein
says a good scientist will look things up so what i look up last night i thought this lecture was tomorrow so quick search this was just these are just abstracts i read all these last night just abstracts on articles google like internal arrangements tmj boom tonight focus down the abstracts and lubrication of the temporomandibular
joint this is an old article this old-school tanaka stuff goes way back to 2007 when they first started learning about hydrodynamic forces they never thought about that stuff before they never had the capability of making those measurements this one just came out it's a phd real thesis biomechanical characterization of modeling and
modeling of the human tmj disk and that's you know pretty heady stuff and its that thick so and i i will actually read that whole thing that's that's what i call fun so so if it's you and you did not read if you're not up on this literature you know this is stuff from 2000 this is 2015 2016 iii by narrowed it down and that these artists abstracts
so there's only like you know five lines in each one so there's so much information out there but what i find fascinating is the information excuse me the information is not coming from united states is very little primary research done united states because liability risk reasons i'm
presuming from turkey is from israel is from chile it's from honduras the philippines to you name a country europe but not hear very little so you gotta you gotta dig you know i page 27 google before you get to some some good juicy stuff so moving on a little bit there's other cool things we can do now this is something we don't do much here
they do this a lot of japan because it's they have these machines and they care more is using functional mri and this is a little trickier to read especially the lights up but there's the head of the condyle right there the disc i'm sorry i'm a bad angle here the disc is right there see it a little bowtie right there so there's the bowtie
that little disk and they slow down a little dance here so that's normal in quotes biconcave just like we'd expect so here it is without reduction so the disc you know it's this rotating this translated little bit but the disc is right here it's all balled up right there so it's not popping back over like it's supposed to her gliding over things
glide they don't pop and click we want things to glide we like smooth we like like the the tissue in here when you start reading how thick like even in a degenerative joint there's a layer of these proteoglycans are sitting on top of there that are so thin so here's that reductions the disc is right there there's the head of the
condo right there so mris you can read backwards black is white and bonus black and soft tissues opposite so the this pretty gleich and it's very thin layer of tissue it we're talking like 125 micrometers thick as nothing but that's that still there even a degenerative disc in a general degenerative joint class one around this is a 3d model
again thanks to craig this with it with our cool 3d printing that we can do now so this is a natural patient this is an actual joint this is the actual head of the condyle okay we got our orientation there on the process okay so when you look at this and all the spitting inside here that's what the joint looks like it's the real deal and this is the fossa
so hopefully you can figure out how to put this together and you look at the lining of the fossa and you can just feel it it's one thing to see it something to feel it touch it understand it and understand that that we want things to flow into glide and to be smooth and just like you want that crown to be have good form good function and
aesthetics and all that comes from angulations and the shear force that you put on that crown and it means it means something not only to you as you know as as restorative dentist and orthodontist and you know getting everything to line up just right and get good force distribution when you have good force distribution is golden this is really a
physics problem this is not a dental problem is the physics and engineering problem and that's what we need to focus on and we're so television know we get out of school and it's like gotta make money you know we've got a big bills to pay and you know i was kind of fortune i was did public health big so i was three years in public health service so i was
down in the desert in san diego and i had no one helping this is like they hated me because i was competition to the they're like one of the dentist in town and is literally one stop sign down the desert and so i you know this is before cell phones and the internet so i'd be on the phone like in looking at you know
books the ic pathology i had no clue i was looking at half the time so but i looked it up and i knew who to call and call the anonymous i call my buddies up at uop and i'd go read about it and i go back and i do the procedure and but you know that's how you learn and it was great because you know that the patients were very very grateful they got great
service i worked ungodly hours but it's ok and end up having like four officers by the time i was done working with the public health in order two minutes mountain place i paid off my bills i didn't have any student loans and has done so that was nice but the average and is coming out now with three thousand dollars in loans it's pretty
tough out there is a tough it's a tough world and dentistry is getting tougher you know for all the way around you know medicines medicines really tough dentistry is getting tougher and meditate because moving in the same direction so not to scare anybody out of his still the most amazing professional the world but focusing on the
engineering and it translates not only to what we do from a tmj standpoint and how you make your splint by the way shameless plug for bont they make all my splits they have for forever and so they have a picture of my perfect splint like what i want and it's nine percent of the time takes me five minutes liver split i don't sit there and grind on it
i don't sit there and have to polish it i don't have any financial interest in provence but respect for kip and then their team out here they understand what i what i need and they understand my standards and they know better if it didn't look right they'll call me and say doctors allows the impressions and i'm gonna i'm gonna
say fine i'll get the patient back in because that's the right thing to do so unusual presentation looks like a really healthy guys 45 years old got a little bit of ortho stuff going on a little bit open bite starting right here maybe but overall you think you know good range of motion you know not too bad lateral motion
pretty good so what's going on he's in pain things i look for and i i had them change my protocol little bit of ddi i looked at net posture is these out here like this side red flag airway red flag referred pain from the traps up into the the masters i look at shoulder posture he sloping down hill to the left here
something's going on something's happened with this guy who looks perfectly healthy and perfectly normal so we start peeling back heel back the layers this is part of that movie like we saw earlier looking at his airway space was always really not too terribly bad you know when we measured out that somebody
came in but i check it anyway i look at it i look at their sinuses i look at the cervical spine i look at the but the steep angle this job orthodontist like yeah i see it ok and then you start to see these little wings coming off here in a mite it'll show probably better on the sf so i get a cell phone everybody why not coming for
orthodontics but i want to know what's happening i look for look at this little a symmetry right here you see this these things don't quite line up on this lateral sef you start to see this little flare in here we can see the cervical spine which isn't too terribly bad pituitary gland issues sinus stuff we're starting to develop angles of the teeth
and tonic issues i mean we're looking at all this stuff is part of our work up here we get a panel here's your really red flags this joint ok so this is this is joining and he's easily asymmetric when you look at his mid lines tough angle here but he's going off to the right here and
obviously you know this is active degenerative joint disease actually in pain you know that's why you came and paid my jaw hurts now he came from his dentist who had a pano who took a panel and that same thing was on that panel that you mention it to him didn't mention it not that they need to treat it but least
retinal disease bone loss between here to tiptoe over adverse forces shearing forces share this that these are shearing forces right here so when you start to see these biomechanical problems developing its it's not just about what's going on here that's not all i'm looking at i'm looking at like what's going what's happening down here
think of the adverse force with that vector coming down here and creating his bone loss so we look at that dig deeper look at these big wings coming off here this is where this little bend in this bone right along here where they attach an apple of the master muscle is is generating this huge
bone density here is generating for 270 pounds per square inch on that little custom so what are the odds that to fracturing pretty darn high so bam root canal crown this is soon- crown then look at the quality of the bone and this is one i called her on like what's going on with this guy does that when i questioned the patient is asked to penis
which is kind of rare for 45 year old black male that's really rare and so i mike kyle i saw this in my car i said you anything else phone was going on yeah they're working across two pina my hips like wow you see an athlete you know is a football player something back in the day so trauma degeneration osteopenia osteogenesis imperfecta which
is not just you know jaws it's it's it's all bones and so that's what we're thinking is going on here but that's a separate mechanism i think from the defender degenerative joint disease a degenerative joint disease is more an inflammatory process it's a load process that cheering process is gone wild and so once that degeneration starts in
that joint is going to keep going and going and going until you stop it somehow it stops itself in females it starts off in progressive common resort shin in jung prepubertal girls or precocious puberty is probably the biggest thing we see now young girls on bcps for a variety of reasons when there 8 9 10 years old which decrease the
restoration levels gunson arnett beautiful work on estrogen if you haven't read it read it is written a journal oral surgery 2010 maybe 12 michael gunson out of santa barbara did a nice study on the estrogen levels and he looked at it in rheumatoid arthritis patients and he had a population of approximately twenty four females
i just had randomly mice one of my staff members pull charts and we had a hundred and fifty charts in about four minutes of young female with arthritis active in four minutes so i got like hundreds of these people these poor girls but we getting better at school then they'll get better that's what's up i think is awesome so
we go deeper look at their sinuses sciences a pretty good and so then we start to section out the jobs this with this point in place so basically what i'm trying to accomplish with this point is pull this job down and forward i mean it's i don't use interior positions plans i don't use ntis i don't use toys deprogrammers i mean i've used
all those things and i might periodically pull that out of my little bag of tricks once in a while there's a great product that they're called sisu sis you it's a if you're gonna do a boil and bite it's a really amazing little product is 20 25 bucks makes a great mouth guard put over braces for sports and put over the bracelet them tmj
problems start popping and clicking and what's cool about it is it doesn't so the ortho down so i get i inherit all these ortho cases or disaster so it's like well let's just say i don't want your braces off and once i don't see that progress down let's treat it to something get the pressure off treatment medications you know trigger points i do
treatment little bit differently will talk about maybe five time but uh but it's really great product sis you and they have a so something like that which is like a mouth guard but what schools you can put it back in hot water and they don't like flattened out again put it back their mouth and then format again so if they screw up and it's not
so thick it's really thin maybe five millimeters assault maybe less so it's really cool material but so this guy with this you know this is a standard you know even contact anterior displacement you know i on the cuspids and custard rise and whatever you want to call it simple simple simple simple didn't have to be fancy and i in my
hands that works i always make maxillary splints really will make many response application begs me to it works in my hands soft splints shouldn't be made unless you're baking for football or if it's like emergent like i need something like today and i'm gonna wear it for two days and i don't want them to go to the storm by dr. bob's famous you know $25
split a boil and bite they do it wrong mike dr. bob's famous supplies taken by over-the-counter so it's a similar thing this is just worried is closed this is without the splint in place so he's not too particularly posterior displaced and this head of the condyles very well centered in the faucet here but you know there's not much fossil left in certain
parts that depends on where you look at it now its destruction is going on here and it's all for the load issues it's all from the shearing forces it's all from the the degradation and the inflammatory process is going on in that joint interleukin tumor necrosis factor-alpha that's what's happening that joint cytokines all these
inflammatory chemicals that's why our first line of defense is usually a nonsteroidal anti-inflammatory dose of motrin at it through muscle relaxer at it you know you gotta break up the cycle somehow i don't go to the joint very often you know cases like this you know if come back a year from now you'll see this bone will feel back
in we use a protocol internet protocol rnet you will get up google it will arnett is a surgeon down southern california orthognathic guy he's got a huge protocols a treat the word they get the worst of the worst to their cash only and they're in montecito so they can get big charge whatever they want right they got it made
so but the basic protocol that we use in sama website you can look it up but it's a calcium supplementation omega-3 fish oils vitamin d supplementation magnesium that's the basics you get a little fans here on a case like this especially because i can get away with this with his physicians i go back to md to get this approval and plus i'm not a
physician but we will take this and we'll throw simvastatin at the patient in very low dose which is an anti cholesterol drug which doesn't seem to make sense but it works it helps to bind zinc into the area brings more bone into the area and we use doxycycline and a very low dose 50 milligrams twice a day i helps to bind bone in the area for it
gotta be on it for a year so they got to be willing to be on antibiotics for a year and if you're down in montecito their use emeril or yumeiro one of the other the one of those and you can buy drugs i call you know what that's like the last thing they say when they do the ad for phil mickelson mike h and you can die so so it's a but it's a great drug
and use it for a short period of time for six months or so and you'll take this arthritis and you'll make it go backwards they do it on rheumatoid cases all the time we do it on the general vaas two cases i've yet to get it approved up here by any rheumatologist and i have i've got connections with every position probably several
thousands of them every ologist you can imagine in the greater northern california area i can call upon and i've yet to get 12 to do the emperor because they don't piss off way off label use amanha cedo 1,500 bucks and injection whatever you know i they pay their guard and put ok so it's no big deal to them but they do beautiful work down there if
you ever get a chance to read some of their work it's pretty amazing so that's my world this is this is this is what i do this is how i live you know that place to sleep medicine i do a lot of orthodontics i do a lot of orthognathic cases probably have five or six or eight going at a time at any one time which is enough for me so very complicated and
often times i'm you know i had it the my last case i saw today and i wish i had a thing she said you can put my case if you want i didn't have her come beam but an orthodontist refer to me she had broken jaw she's seen by her famous oral surgeon daddy back east who made her auntie repositioning splint early on that she fell broke her jaw our her face
i took a facebook for left and your midline it looked pretty good but also the midline she's off by crime axles off by a whole you know tooth to the left and she's got no joint and she's in some funky split always build up so mike you know so course your thoughts like tim you take you to this or though mike no what you do or want to score so we're
fighting back and forth like glass first time in orthodontics actually begged me to take other cases but uh we'll work on it together so it was very much it's gonna be fun case but you know to see that you want to be treated with invisalign that was another thing you know and i love invisalign is great great product but you know
post your open by bilateral you know moving teeth down with you know buildups on within this line not think so it's not gonna happen so it's like that's when you gotta sometimes you gotta learn to say no you know and that's the hardest thing for us tennis because we we all want to be the hero and we learn to say no once in awhile and on and like
alex you mentioned earlier it's like sometimes you gotta take that crazy person who's really got psychological issues and incentive away i have the luxury of being able to you know sent back to their medical providers and and working into the system is you know a little more delicately than just because they're already parkin all i get back
their pcp make that let that pcp make the referral so it makes it easier for me but i'll be i could be blunt obviously i'd have no problem being blunt so what i want you to think about and what i had worked out with this amazing slide presentation before my staff ruined it that's a blunt i am so i i i had this
great video i had the the joint video and i was going to follow it up with with what do you think about everything old saltwater taffy machine you know how that kind of bends and folds so i had a video you know of that have one these great machine just to play and then there's some german guy in the background i'm so mesmerised so just
because of that because halloween i want you to go home and i want you to chew on this on this saltwater taffy don't pull any crowns out and i want you to enjoy that because the exact consistency when this warms up is going to be the exact same consistency you can trade flavors if you want the exact same consistency of a joint i'll get more
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