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Howard:
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It is a huge, huge honor for me today to be podcast interviewing the man himself, Ben Sutter. Dr. Sutter received a BA in psychology, as well as a BS in biology from the University of Nevada at Las Vegas. He then earned his DMD from the University of Medicine and Dentistry in New Jersey, now known as Rutgers School of Dental Medicine, where he was the recipient of numerous academic awards. While in New Jersey, he completed a 1-year hospital based residency at Overlook Hospital in Summit.
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Dr. Sutter is also the author of articles and abstracts of his vast clinical research and teaching experience. He has been studying and treating TMJ dysfunction since going into private practice in 2008. In that time, Dr. Sutter has sought advanced education and training in treating neuromuscular issues. His studies have taken him to the Las Vegas Institute and the Piper Education & Research Center. He has attended equilibration seminars, as well as aesthetic masters. Dr. Sutter is also a certified Perfect Bite doctor, which was the precursor to the True Dentist system of diagnosis and therapy methodologies.
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When you see Dr. Sutter for treatment of TMD, you can expect thorough care that targets your specific needs. Hey, Ben, I called you for this. You did not call me, and I wanted the opportunity to talk to you because this is Dentistry Uncensored, and you have to admit, of everything we do in dentistry, TMD, TMJ, is the most controversial ... I'm just following the message boards on Dentaltown. It's hard to get 2 dentists to agree that today is Friday. Can you get any of them to agree on occlusion? How did you get into this, and do you personally find it academically controversial amongst your 2 million dentists around the world?
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Ben:
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Wow, okay, a lot of questions there. I agree with you that it's hard to get 2 dentists to agree on what day of the week it is. When we were in dental school and we were learning to read radiographs, our dentist would say, our mentors would say, "If you show your x-rays to 10 different dentists, you're going to get 10 different treatment plans." We laugh and chuckle about that, but in the world of occlusion and TMD, it's really, unfortunately it's the truth. The profession has no sense of self where occlusion is concerned.
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If there was one truth, there would be only one answer, and so I think the reality is when you learn some of these different systems, as far as LVI or [Chorus 00:02:56] or Sphere, or TruDenta, whatever, all of these work some of the time. None of them work all of the time, and if you spend time on any message board, whether it's Facebook, Dentaltown or whatever, you get a sense of that. But yeah, I don't really know what the answer is as far as us as a profession, and 2 million dentists coming to an agreement.
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I think for me, being able to measure something and getting a repeatable response from patients, and being able to quantitate that and put numbers to it, which is the reason why I've incorporated some technology into my office like EMGs, joint vibration analysis, computerized jaw tracking, T-Scan [inaudible 00:03:54] with EMGs, so you're able to see what's going on with the musculature in the face in real time with what's going on with the bite. I think a lot of us don't incorporate that because some very important people in our world, in our profession, have said, "Ah, these are really just gadgets." I don't find that, personally.
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Howard:
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Well, I want to ... You're 45, I'm 53, most of our listeners are under 30. Every time I get an email, they're usually been out of school, 2, 3, 4 years. I just want to remind them that when these kids were probably in the 1st grade, you remember, there was a Reader's Digest article where Reader's Digest was on every house, front room, when I was growing up as a child, all my grandmas, aunts, and uncles.
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This, I think his name was Eckberg, took a full set of x-rays and study models, and he literally went to 30 different dentists, and got 30 different treatment plans from do nothing all the way to 30,000, and it was just a perfect line in between. When we say that we're not saying it tongue in cheek, we're not saying that it's funny, but the bottom line is dentistry is an art and a science, and I'm sure a thousand years from now, this might be black and white. But we're going to live and practice in our whole lifetime and not know the answers to a lot of these problems our patients have. Correct?
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Ben:
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I would agree with that. I would agree with that with the caveat that when you measure your repeatability and your success rates go up, and you mentioned TMD, so if you're going to treat TMD, and you're looking at, "Hey, I'm going to send my bite registration and my models off to the lab, and I'm going to have a splint made, and I'm going to start to adjust the bite on this thing and try to get my patient feeling better," you have to understand that we are limited in the ability just to mount models, and what I mean by that is there was a study. A guy was doing his, I think it was a Masters or a PhD, graduate level, and he was a dentist, used T-Scan to measure his own mouth on multiple articulators.
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Just measuring the bite on these articulators, he used the same weight and the same calibrated articulator, and his air, his incidence of air was between 1% and 13%. Now, if you're building a bite and your first step is to build the model, and you introduce 1 to 13%, as a dentist you're doing this, if that's the first step, that air is going to be magnified going forward. What's unique about DTR and what I'm doing is it's all measured in the mouth, so there's no air from transferring from models to the patient. It's all measured into the patient and it's repeatable.
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Howard:
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Okay, well let's start at the beginning. Why did you get interested in TMD?
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Ben:
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Well ...
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Howard:
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What went wrong in your life where you decided you wanted to focus in TMD? Was it early childhood trauma, or what happened to you? You got lost?
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Ben:
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Yeah. I think I was dropped on my head as an infant, but you know, it seemed like I was seeing a lot of these patients had headaches and jaw pain, and sensitive teeth, and I started just reading some literature, and the literature was anywhere from 35 to 20% of the population is untreated TMD.
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Howard:
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What percent?
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Ben:
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Anywhere from 20 to 35, 33%.
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Howard:
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Have TMD?
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Ben:
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Have untreated TMD. Now, they may have signs, like occlusal facets, chipping, and not really all of the symptoms: headache, ringing in the ear, sore neck, sore back of the head, sensitive hair, facial tension, facial pain. But, I started reading and decided, you know what? If there's 35% of my practice, you don't even have to advertise. Just start looking a little bit more closely, build up some diagnostic skills, ask the right questions, and all of a sudden you start hearing a pattern over and over and over, and these patients that are complaining of these symptoms or have these [inaudible 00:09:14] facets. At the end of the day, it's the patient's option whether they want to do anything about it or not, but a very wise man once told me, "The more I know, the less normal my patients look." Nowhere is that really relevant more than the TMD world.
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Howard:
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Well, I find it interesting, Ben, that you're undergraduate degree was, you had a degree in psychology along with biology. How much of this TMD is mental stress?
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Ben:
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You know, two parts to that question, or two parts to the answer. One would be, I think stress absolutely exacerbates TMD symptomology, and there was an article that was published in JADA Magazine. It was probably about 3 or 4 years ago, but I think it was the cover article, and it was an interesting study, and they had done brain scans on people who had chronic pain of TMD. They wanted to compare it and see, "Okay, now let's look at people who are asymptomatic," in other words, they don't have chronic pain, "and compare these brain scans." Now what they found was, the brain scans were the most similar to people with Post-Traumatic Stress Disorder." I think people that are in chronic pain definitely have an underlying stress or mental ... There's brain chemistry that has actually changed, so you can see that in the images.
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When you get out of pain, brain chemistry is restored, and some of these depression and anxiety improves. Now, I'm an astute, very conscientious TMD doc and functional doc, but my results aren't 100%. I wouldn't say that the patients that do feel better would come back to me and say, "Wow. You know what? I have a stress-free life now. The dog's not barking all night long. My husband doesn't nag," or "My wife doesn't tell me to take out the trash," or "My boss doesn't ... On my backside chewing me out about this or that." I don't change any of those things. What we're really looking at is a physiologic change in how the stomatognathic system works. When you relieve the pain, some of these things that I think have been coupled with TMD tend to improve.
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Howard:
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Okay, Ben, it's my job to guesstimate the questions ... These thousands of dentists listening to this are all by themselves, they're commuting to work. What is DTR? They know TMD, Temporomandibular Disorder, but you say occlusion, TMD and DTR. What is DTR?
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Ben:
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DTR stands for Disclusion Time Reduction. Disclusion is how the teeth come apart, measured in time. Reduction is we want to measure the time that takes place. In other words, the more tooth on tooth friction you have when you go into right or left lateral excursive movements, the more time that takes, the more muscles have to work to avoid working and not working interferences. By reducing that time and making the bite more efficient, you're changing clenchability of the teeth. You're changing how muscles work, and I'm probably one of the few guys who, on a consistent basis, I have a protocol where I measure before and after that therapy.
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Specifically, we look at the muscles. We look at clenchability. Are you able to recruit more muscle? Are you able to open wider? I find that the first round of DTR, patients open wider. There you go. You don't even need it. But, in essence, DTR is an occlusal therapy, so all the doctors that are listening to this that believe that it's solely a joint position, or it is, "Hey, I've just got to separate the teeth with a splint and symptoms will go down," and that is true. That will happen, but I have many patients that come to me with handfuls of splints. It's interesting with T-Scan, which is an occlusal digital analyzer, I just start popping these in to patients and say, "Okay, bite on the sensor and let's see where your bite is."
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These bites are all over the place, so you might come in, and a patient who is 60% on the left and 40% on the right, you don't have to be a dentist to understand that that's not good. If you dumb it down even further, and I say, "Get 2 scales that you would measure your weight loss on." I say, "Okay, now divide your weight by 60/40 and put 60% of your weight on the right leg, and 40% of your weight on the left, how long could you stand there before your knees, your lower back, parts of your body would start to ache and hurt? These patients that have this bite distribution going on, they never get a break. The teeth are the hardest substance in the body, and that's what's really the dominant force in this. The joints and the muscles try to accommodate, but that's where your pain is coming from.
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Howard:
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How would you describe how ... Let's just focus on just America. How do you feel the average 150,000 dentists treat TMD versus how do you treat TMD? What do you think ... What kind of grade would you give the 150,000 average dentists, how do they treat TMD and how do you do it differently?
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Ben:
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Well, let's back up and not even make it about other dentists, because I can't speak intelligently on what other dentists do in their office. But let's go back to dental school. Is anybody listening to this, thinking that, "Man, I really got a good education in oral facial pain and occlusion?" The reality is no, none of us do. I hear it when I lecture, and just going to lunch with the specialists around my town. No, we didn't learn. Occlusion is freshman year, right next to dental anatomy. Okay, well maybe that's Occlusion 1, but in senior year, before you go out and start treating patients, I think what dental schools do a poor job of is how do you teach somebody not to be a single tooth dentist?
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When we're baby dentists, that's what we do. "Okay, does this tooth have perio disease? Does it have cracks in it where it needs a crown? Does it have decay? Does it have an abscess?" No. Okay, check, go to the next tooth. That's traditionally how we're taught. But the reality is, you've got 28 teeth in most cases, you got 2 joints, nerves, muscles. You can bend your right elbow and keep your left elbow straight. Well, you can't open the right side of your mouth and keep the left side shut. All of this has to open and close, and function in synergy, and I think as dentists, we're not taught that. Now, go out, you buy a practice, whatever you learned in dental school, if you're not spending 10,000 or 50,000 or whatever it is a year to keep the education going with continuing ed, you are a 5th year dental student, and you're moving through as best you can.
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I think we can all cut crowns good, and we can all extract a tooth. There's some basic, remedial type stuff that we all are learning, and we're proficient at when we come out of dental school, but the reality is, dental schools are teaching to what the board exams are. For Christ's sake, you got people that are learning how to do gold foil still and polishing amalgams and that's not really relevant to practicing today, and so if you really want to bring dentistry up a notch, teach it. Make it a requirement that you have to know occlusion, and you have to know how to treat these patients. The dental schools won't do that until all of a sudden ADA credentialing says, "Hey, we're not going to credential your school until ..."
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If 30% of the American population, at some point in their life, is going to have really bad TMD, we should be able to treat it, and there should be some sort of consensus. Now, this was done ... I think it was last year or a couple of years ago, Charles Greene wrote a paper, and it was a firestorm. What he did was he said, "Okay, so what we should do is we should have a guideline for how we treat, and everybody should agree to it." Well, half the docs that are listening to this, if they read that paper, wouldn't agree with what he said. Where do you start? It's not about jumping into somebody else's dental office and say, "Hey, I treat it better because I measure," or "You're not up to par. Let's bring you up to par, and you just need to take these courses." We would love it if it was that simple, but I think it really is more basic than that.
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Howard:
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Let's talk about your practice. What percent of your practice is TMD?
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Ben:
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Oh, let's see. Well, I'd probably say about 75% of my practice is bread and butter dentistry, and there's probably 5% is cosmetic, and about 15% is active TMD, and some of those are neuromuscular cases, because they're not candidates for DTR. I'd say the overwhelming majority are candidates. I'd rather do a limited coronaplasty, but if a patient comes in with blown out, flat teeth, and there's nothing to really build interior guidance with, maybe we need to do some reconstructive work, so as a percentage, let's see. I did 53 DTR cases last year, and I did 3 full mouths.
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Howard:
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Walk us through a DTR case. Now, is it going to be what we hear that 90% of TMD patients are women? Do you find that in your practice, or not so much?
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Ben:
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I think it's kind of the 80/20 rule. About 80% of the patients are female and about 20% are male. Men tend to blow out their teeth. You look at men and women ... Certainly there are some exceptions to the rule, but generally as a rule, women get symptoms and men just destroy teeth, so is there a hormonal balance? Yeah, I think that there's something there that we don't have an answer to, but certainly men get migraines, get headaches, have neck pain. [crosstalk 00:21:25]
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Howard:
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You think estrogen hormone could play a factor in this?
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Ben:
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Oh, absolutely.
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Howard:
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Some people also say ... You're a psychology major. Some people say that women are just more likely to seek help and go to a doctor than a man. I mean, kind of like, think of your dad never asking for directions while your mom's over there having [crosstalk 00:21:45]
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Ben:
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Absolutely. I would agree that that's probably a big factor in it.
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Howard:
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Yeah. I mean, my dad used to drive my mom insane because he wouldn't stop at a gas station and ask for help. My dad just thought that was so beneath him to ask another human where Disneyland is. These patients walk in, describe the mean average, median patient, and what you go through. You've mentioned technology. You said T-Scans. Can you walk us through a patient?
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Ben:
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Sure. Well, what is a typical patient that comes in? God, I've had everybody from a 15-year old young lady, who just got out of ortho and her pain didn't start until the month after ortho came off, all the way to a Microsoft executive who drove down from Seattle because he was having facial tension, facial pain and saw some of the videos online. The spectrum, about the only thing that I could tell you is that 80/20 rule is consistent, but it affects everybody. As far as what is my typical protocol for TMD, the first thing I would do would be a consultation. In that consultation, I use T-Scan and I use EMGs linked to it.
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I want to ascertain is there a bite force discrepancy, and then I also want to look at the bite timing. Now, this is something that's not taught in dental school, the timing of the bite, and that's huge, because disclusion time trumps bite force. You can have somebody who is 60/40 right/left. Let's say if they're missing a lower molar on the right side. Well, there's no way they're going to be 50/50, because they're missing a tooth. There's going to be a bite force discrepancy, but the bite timing and the time that it takes for teeth to come apart and together, you can measure using T-Scan.
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If a patient comes to me and says, "Look, doc, all my pain is on the right side. My shoulder's tense, my neck's tense, my face hurts. My headaches are on the right side," and then I'll check with T-Scan, and if there's a bite force discrepancy that says, "Okay, either they can't bring their teeth together on the right, and they're having to really clench down for that to happen," or maybe they hit first. Now, articulating paper and shimstock won't necessarily tell you anything about bite force. They surely won't tell you anything about timing of the bite, because that has to be measured by a computer. Explain to the patient, [inaudible 00:24:34] scan is a very wonderful technology that's very visual, and patients get it.
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Fifteen minutes with it and they understand what all those colors mean, and the peaks and valleys, and the right and left, and how their bite comes together and they'll say, "Oh my God. Yeah, I told the dentist 15 times that that crown wasn't right." We can see it. It's not right. Not only can we see that there's more force on it, we can tell if it's in the front of the crown, the back of the crown. Whereas if we're just relying on articulating paper, it's just a sea of blue. You can't really assign any bite force. If you're thinking that, "Well, if it's darker than the rest of them, or if it's a lighter surface area, that means that that tooth is hitting hard in that area." It's like, no. The research says that that's not true.
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Howard:
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Okay. Are you talking about the T-Scan made by Tekscan in Boston, Massachusetts?
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Ben:
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Sure. That's exactly what I'm talking about.
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Howard:
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Not to interrupt you, but you've mentioned a lot of things I think a lot of these townies aren't going to understand. You've mentioned EMG, T-Scan. Can you talk about the T-Scan? Like how much does it cost? How do they get one? What does it actually do? Can you go into more detail about that?
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Ben:
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Yeah. T-Scan is a digital occlusal analyzer, and if you can imagine a Mylar strip that we use for class 3 cavities, it being in an arch shape and covered in over 1,000 sensors. That's what they're biting their teeth on, and this technology, this Mylar strip allows flexure, so it'll fit in between the teeth. You have a patient bite into MIP, or CO, and ...
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Howard:
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What's MIP? What's CO?
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Ben:
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Yeah. Centric occlusion or maximum intercuspation, it's the same thing. Different people probably know it by different ...
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Howard:
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Centric occlusion was CO. What was the other one? MI?
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Ben:
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Maximum intercuspation. MIP.
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Howard:
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Okay.
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Ben:
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Okay. Just basically bring your teeth together so that they all touch as evenly as you can. What that'll do is it'll give you a movie that you can watch in real time from first tooth contact all the way through to maximum clench, all the way to when they release. Do they start their bite on the right side? Do they start their bite on number 8, and number 8's all chipped and fractured? Have you done a cervical composite cavity on number 4, and that thing just keeps popping out and you keep redoing it free? What's the patient doing? You've done other fillings on this patient that aren't popping out and failing. Well, it could be that there's more force on that one tooth and the flexure of the tooth is causing that cervical erosion or that composite to pop out.
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Howard:
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How much is that T-Scan and how accurate is it?
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Ben:
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Good question. T-Scan, you'd have to contact the company. I think I paid $10,000 for a T-Scan. The sensors themselves, which you would use for each patient, that would have their own, are 6 bucks.
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Howard:
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Does the information transfer into the computer's, into the patient's chart, or is it a separate storage?
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Ben:
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Yeah. What I was trying to think of ... What was the second question?
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Howard:
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How accurate is it?
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Ben:
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I'm sorry?
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Howard:
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How accurate is it?
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Ben:
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Accuracy. I'll tell you a study that was done on accuracy. Robert Kerstein did a study where he took an arch of a patient. It wasn't really even an arch, it was more like a quadrant. It had occlusal markings on it. He asked over 200 dentists ... I think it was either [inaudible 00:28:48] or 255, to interpret those blue dots. The dentists were from every background of, "I don't do occlusion really," to "I've done a lot of studying in occlusion," and the doctors were right, picking out the most forceful marking 13% of the time, 13. Now, T-Scan is 97% accurate, and it's funny because even the papers that try to disprove its accuracy prove that it is accurate.
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There is an article coming out in CRANIO ... I want to say in January, and they have a machine that records force, and they took a sensor, and they had it go up and down on the sensor. Every time the machine went down, T-Scan registered that the pressure went down. Every time pressure went up, T-Scan said that it went up. There's this perfect correlation of up, down, parallel with the data of the original machine. It works, despite what anybody wants to say about it. It is a good piece of technology. Incidentally, the US government uses that same technology when they're moving nuclear warheads. It's precise, it's reliable, and it's accurate.
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Howard:
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Do you use it on just your TMD patients?
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Ben:
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No. I use it on ... If I'm doing a single unit crown, I'm probably pretty lazy. I'll get my centric stop. I'll have the patient go right and left, get rid of any excursive interferences from my crown, and then I'll seat it. If I'm doing 2 single units or 3 in a bridge, I'm bringing T-Scan out, absolutely. In my office, the ladies just have it sitting out for me, especially if you're doing cosmetics or a long-span bridge, oh my gosh. It's happened so many times, even in my own hands, where I thought I could do it by hand, and all of a sudden on the distal of number 2, distal abutment for a long-span bridge or even a 3 unit bridge, you break off a little piece of the porcelain.
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What do we do? Do we redo it? Do we tell the patient, "Hey, the lab messed up. We got to do this over?" Well, you've been using the lab that you've been using because it's a good lab. Really, what I think is going on is on the ones that break, I didn't check force. I didn't check pressure. The ones that I do check, I don't have a problem with chipping and breaking. All of a sudden you have to weight, $10,000, yeah, that's a lot of money, but your guys who are 30 years old, $10,000 amortized over how many years in their career, not to mention chair time. How much does it cost you to redo a 3 unit bridge? How much does it cost you to replace an arch because the bite's not right? That's a lot of money in itself, and I'll tell you, where it really saves time is in the reconstructive and the cosmetic.
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I did an arch about a month ago, and I called T-Scan. I was so excited. I'm like, "Wow. I just put in an arch, made myself use T-Scan through the whole thing, and I had that for the first round of occlusal adjustments, 20 minutes." That's not very long. Well, actually when I went back and looked at them, because all the scans are time-stamped, it was 16 minutes. How much money do you put on that value? If you're doing large restorative cases that are complex, it behooves you, I would think, to measure. Now, and I'll say this, I'm not a spokesperson for any technology, firm, or company. I'm not involved with any secondary education for any dentist or dental company, or materials company. What I say is free and clear from any financial incentives.
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Howard:
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I just want to add that I actually am a spokesman for Calvin Klein and one of their models.
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Ben:
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Models?
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Howard:
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Yeah. This jacket I'm wearing was given to me free to build their brand. You also threw out the term EMG. What is EMG?
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Ben:
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Sure. Eletromyography. Much like a cardiologist will put leads on your chest to monitor electrical activity in cardiac muscle, I measure, and guys who use EMGs, measure electrical output in muscles of mastication, temporalis, masseter, SCM, trapezius, anterior belly of the digastrics. If you can record a higher level of electrical output, that muscle's doing more work by definition. If you're monitoring cardiac measurements and there's a lot of electrical activity, you're going to have a higher heart rate. That muscle is doing more work, and the skeletal muscle in the face is no different. It is a gauge by which we use to help us diagnose myofascial pain and TMD before we pull the trigger, so to speak.
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Howard:
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I want to go after a very, very common question that I see on Dentaltown all the time, and I get emails for this. They're young, they're coming out of school, and they sit there and they say, "If I were to learn occlusion ..." You've been doing occlusion for decades. They want to learn occlusion and they say, "Well, I'm confused. I hear Dawson has his own type of occlusion in school, and does Pankey have the same occlusion as Dawson? I've heard LVI is neuromuscular."
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I was wondering if you could do 2 things for me. If some 30 year old kid's listening in, and says, "I want to learn occlusion," can you explain the different camps of occlusion and where you would go to learn which camp, and what camp would you recommend starting at? Because you said in the beginning that not every camp solves every problem, and that nobody's 100%, but can you explain the different occlusion camps, and where this 30 year old podcast listener driving to work right now could extend their study on occlusion?
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Ben:
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Sure.
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Howard:
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Don't you like the way I throw out like 38 questions for every question?
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Ben:
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Pankey, Dawson, Kois, Spear, LVI, they all have their own paradigm, if you will.
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Howard:
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Would you go ... Just stop, sorry to interrupt. Would that be about the 5 camps, Pankey, Dawson, Kois, Spear, LVI? Is that pretty much all the occlusion training camps in the United States?
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Ben:
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I wouldn't say it was all of them, but I'd say you're hitting probably the big 5 there.
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Howard:
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That'd be the big 5?
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Ben:
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Yeah.
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Howard:
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Would that be the 80/20 rule? Would those guys cover 80% of the occlusion camp training?
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Ben:
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Yeah. I'd throw another one in there, TruDenta. TruDenta, while it's not really an occlusal camp, per se, they are measuring in between the teeth, and so I would give them a lot of credit, in my opinion, for doing that.
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Howard:
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Where are they at, and who heads that up?
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Ben:
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Oh, God. I'm not sure who heads that up. They're in Florida. Just Google TruDenta.
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Howard:
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That is amazing. Pankey's in Florida, Dawson's in Florida, TruDenta's in Florida. What is it? Those old people down there? What are all those old people ... [crosstalk 00:37:32]
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Ben:
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They're eating crab shells, and they're not taking the meat out of the crab before they eat it. I don't know what's going on down there, but I think a lot of that is marketing and where's a fun, nice place to go when you're doing your CE. But, wow. It's tough to say, looking back retrospectively on my career and my CE, what I've done. Maybe a better response to the answer is here's what I did, and your guys can take it for what it's worth. I got into ... When I started getting into TMD, somebody said, "Oh, whatever you do, don't go to LVI. Don't drink the Kool-Aid," whatever. That instantly peaked my curiosity. I went there and these guys were measuring muscle, they were taking scans. They had digital equipment that was helping them treat complex restorative cases in pain patients, and so wow. I'd never heard this was even remotely possible. I went through that camp, but when I went through there and ...
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Howard:
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Now, LVI camp, that's neuromuscular?
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Ben:
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That's neuromuscular. LVI, yeah.
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Howard:
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Taught by Bill Dickerson?
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Ben:
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Yeah. I had really, really good results. They teach a coronaplasty course there, as all of them do, but no one's measuring in between the teeth. A buddy of mine, Mark Montgomery, who's taught at PAC Live and he's at TruDenta now as their main dental guy. He said, "Well, you got to check out this technology and start measuring in between the teeth." I took that course, and he's right. There's a lot that can be learned by measuring in between the teeth, that a K7 or bioresearch type of modules will not give you. Then I kind of thought, "Well, wouldn't it be neat to put the EMGs on and be able to see what's going on with the bite in T-Scan in real time?"
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That's when I met Robert Kerstein and started reading some of his work, and started going down the DTR path, because what was happening for me is I was seeing Nick Yiannios and Kerstein, they were doing the same thing that I could do, but they were doing it a lot faster. They were getting results in 45 minutes to an hour. Well, I wasn't even through taking my impression, and I had 2 weeks to wait before the lab would bring me back an orthotic. They're patients are already starting to see results, so I'm missing something. You start linking the EMGs to the bite, and you start seeing more stuff, but I think for me, the CR based occlusal paradigms, when you start manipulating the job in a superior ... Part of the dentists say it's posterior, part of the dentists say it's anterior, superior ...
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Howard:
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Well, it moves every 10 years.
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Ben:
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Well, yeah. There's like 7 definitions in The Glossary of Prosthodontic Terms. Pick one. I think now the flavor of the decade is it's superior/anterior position, but 99% of the work done in the country is done at MIP. That's where DTR is. The neuromuscular guys, LVI and the bioresearch guys will say, "Well, when I move the jaw down and forward, I see EMGs go down." That's true. That happens. You can measure that. When we do DTR, the jaw comes down and forward all by itself, so I have a problem with biolateral manipulation and bringing the jaw back, whether it's back superior, superior forward.
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Starting to do occlusal adjustments in a position that may be diagnostic, but it's not physiologic, at least with the stuff that I measure with, so I try to do the DTR at MIP, and let the jaw just kind of go wherever it wants to go as part of the natural healing process. It's conservative. Some guys, I know are listening to this and saying, "But you're adjusting enamel." Yes, I do adjust enamel. I'm adjusting the enamel that every book on occlusion says is wrong. It's interferences. I'm not touching centric stops. We're not closing people down. We're removing the stuff that Dawson and Jankelson, and Ashe and Daniels, and these guys who wrote these books say is problematic. But equilibration is different than DTR, and DTR, to do it you have to be able to measure disclusion time, and you have to have technology to do that.
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You cannot just rely on, "Let me move the jaw around and I'm going to put some bite paper in here, and we're going to start adjusting these slides." I can't tell you, I've got ... Well, I'm getting off a tangent. Let me get back to your original question. What I would do is I would find ... Get a Tekscan demo in your office. What I would do is I would do a lunch and learn, which is what I did. Have some doctors over. I had a prosthodontist come, I had an orthodontist come, I had a pedodontist come, and we just looked at doctors' bites. We didn't even adjust them, and you could see the gears turning in these doctors' head while Tekscan was doing their demo.
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You'll find, Howard, that when you measure objective- ... Because I don't belong to any camp. Now, yeah, I've got a couple of accolades, and I've done a couple of courses and this one and that one, but I measure every single time. What you're going to find when you do that is some tenets and pillars of occlusal therapy, that the profession has held onto, they don't have any weight. Like for example, I'll give you one. Non-working interferences are part of the problem, or a major component as far as TMD is concerned. It's not. It's working interferences. It's 180 degrees from what was first published.
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Some of us are still holding onto, "Well, it's in a book, and this is what I'm holding onto." When you can actually measure it on every single patient, and you see a right lateral excursive movement, they're in group function and not in anterior guidance where those posterior teeth come apart, they're going to ... Not everybody's not ever going to have pain, but the patients that are symptomatic, usually have that one thing in common - muscle hyperactivity due to working side group function. Some of the old books still say, "We really want to have anterior guided, immediate posterior disclusion, but working side group function's okay." Man, it is not okay.
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Howard:
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Okay, but, Ben, what in your opinion are the 10,600 orthodontists in America doing to all these kids? We run all of our kids through an orthodontic tooth mill. What are they doing? What is your thoughts of a before and after occlusion after they all go through the 10,000 orthodontists?
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Ben:
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Well, you know, let's speak frankly here. An ortho consult, they take a pano. They may take a 3D [inaudible 00:46:16]. They're taking a [inaudible 00:46:17]. They are measuring skeletally ... They're not measuring occlusion. "Wait, wait, wait, wait. We do measure occlusion." Yeah, okay, angles class 1, angles class 2, angles class 3. How many orthodontists are measuring bite force and disclusion time? Bite timing? Very few. When I talk to ... And I'm not going to beat up on orthodontists too much here, because my daughter's in interceptive ortho now. We need ortho. We do.
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But I have a, I guess a philosophical problem with specialists moving teeth around somebody's skull and then say, "Well, we really don't do too much occlusal adjustment.We let the general dentists do that." Really? The guys with the bite paper? If you are taking on moving teeth around in someone's skull, it's your responsibility. Can you imagine a prosthodontist saying, "I'm going to do full mouth rehab on this patient. I'm going to put all the porcelain in, and I'm going to send the patient back to the general dentist, and he's going to get the bite right?" No. No one would ever send any referrals to that prosthodontist. But somehow it's okay in ortho. Incidentally, I will say that my go-to guy in my area says 90% of adults would benefit from some sort of coronaplasty. I think that's a fair statement. Now, not everybody needs it. Not everybody's symptomatic.
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Howard:
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But what are the orthodontists doing before and after to the [inaudible 00:48:10] and in particular, canine guidance that you're talking about? When kids go into their orthodontist with crooked teeth and canine guidance, do they come out with straight teeth and canine guidance?
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Ben:
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Some of them do. Some of them don't. Straight teeth does not a good bite make. Who's measuring what? I've got a couple of guys who are very interesting. I did T-Scan on them before ortho. I did a T-Scan on them the day before they were debanded, and when you start talking in terms of bite force and timing, these cases, while the teeth are beautifully straight, they're horrific in terms of occlusion. Not macro-occlusion, but I'm talking micro-occlusion. How the teeth all interdigitate, and when you look from side to side, you can only see things on the cheek side. All right, so how do we view all the lingual cusps? Okay, you can scan it.
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You can take models, but are all orthodontists even doing that before they deband their patients? Then the rebound, it's interesting to watch ... There's some orthodontic settling because of the ligaments that hold the teeth in the bone, and we want the retainers and the wires to be bonded in place, so the sexy social 6 in the front don't start having these rotations and twists and turns. Well, if you're measuring that occlusion, I would submit to you that it's really a bite force imbalance, and these teeth are twisting and rotating a little bit to make room so they interdigitate better on their own.
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Howard:
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Okay, Ben, I want to throw some tough questions at you that I know these kids ask, because I hear them ask them, I see them ask them on Dentaltown. One of the first things that kids say is, "Come on, Ben. When you eat, your teeth don't even touch. You just chew the food. Your teeth aren't touching, so none of this matters." What do you say to that?
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Ben:
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Yeah. I've got some videos I'll post, where I tell my pain patients the exact same thing, where doctors are going to tell you that what I did has absolutely nothing to do with your pain level and your threshold, and you feeling better. This is all pseudoscience. When you take a patient who's been suffering for 40 years, Howard, and all of a sudden you get ... Not the envelope of motion, but the envelope of function, correct, their pain goes away.
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They'll look at you and say, "Whoever is publishing that the way teeth come together is not important to how I feel missed the boat." Yeah, and it's funny. I've got a question for all the people who say, "Look, the teeth don't come together." It's not about teeth coming together. What you're saying by definition is you can put any piece of acrylic in that person's mouth and you never have to do a post-insertion adjustment to that appliance. If it's all about separating the teeth, who cares how the teeth are touching? It's not about the teeth touching.
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Howard:
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Ben, how could we get a ... We put up a ... The continuing education has been migrating from the classroom to online as fast as the University of Phoenix online has been growing. We put up 350 courses on Dentaltown. They've been viewed over half a million times. I would give anything for you to put a course on Dentaltown. Is there any way we could get you to do that?
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Ben:
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Yeah. I would do it. I think a lot of people are going to be shocked, and I think you guys might be getting hate mail that I'm a heretic. But what I do, and what would be really interesting is to film it in my office, and let's go over a couple of cases. Let's not just do one. Let's do like 3 in a day, and let's take the measurements before and after we do one round of DTR, just one round, not even ... I usually do 3, because as the muscles relax, the jaw comes slightly down and forward, and the bite has to be fine-tuned and refined a little bit. But a lot of times you'll see joint vibration analysis where a Piper 3A goes to a Piper 1.
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What does that mean? What did I just say? What are those words? Most of the guys listening to this aren't going to know what that means. Basically, the simple thing is occlusal adjustments of noxious stimulus, meaning working interferences and trying to get that interior guidance going, changed not only physiologic response, but changed the structure of how the disc sits in the joint. That's something that you can measure with join vibration. It's a different world when you start bringing in diagnostic equipment and measuring.
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I'd be happy to do that. I think one of the challenging parts to doing that is having a camera that will sit on the teeth, because unlike showing a perio surgery, or unlike showing a implant surgery, where you're looking at a whole quadrant, I'm looking at a couple of teeth at a time with blue dots on them. Your magnification's going to have to be ... That problem I can't solve, but to really see what I'm doing, you're going to have to be able to show that in addition to how the patient feels and what the results of the diagnostics are.
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Howard:
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I'm going to throw another hard hitting question at you. There's a lot of dentists now saying that all this occlusion stuff is really sleep apnea, and that the reason they're grinding and having TMD and all this stuff like that is because they have sleep apnea. What are your thoughts on that?
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Ben:
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No. I wouldn't say that. I would say that there is a very real component with obstructive sleep apnea in TMD, absolutely, but no. I have sleep apnea. I'm asymptomatic. I don't have any [inaudible 00:54:55], so again, maybe it's the 50/50 rule, the 80/20 rule. I think what they're alluding to is there was some research done where anybody that's had a PSG done, or a polysomnogram, a sleep study, they hook you up with all these wires, and they're monitoring the heart, they're monitoring the brain. They can monitor anything, including facial muscles, and when people stop breathing, they can clench almost 300% more than when they're awake.
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Anybody who treats TMD should be including an Epworth sleep scale along with it, because I've gotten bit before I started to do that as a matter of habit where you're treating TMD and the patient doesn't get better. All of a sudden you turn around and the guy's asleep in your chair and you asked him a question, he's out. Hey, you have daytime sleepiness a lot? We should go and have that checked out with a sleep study. He starts breathing better and then all of a sudden his pain's gone. Anybody who's doing TMD work should include a sleep study, absolutely, but I don't think there's a cause-effect relationship.
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Howard:
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You don't think that sleep apnea causes TMD. You think they are ...
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Ben:
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No. I think it'll exacerbate it if there's a problem there, absolutely.
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Howard:
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It'll just make it worse?
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Ben:
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I think it'll make it worse, yeah.
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Howard:
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Okay, and I only got you for 4 more minutes, but I get this question a lot, and sorry to be over-similar, but they keep saying, "What exactly is neuromuscular dentistry?" What is that?
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Ben:
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Well, I think neuromuscular dentistry, you're concerned about ... There's some differentiation between, "Okay, we're concerned about how the nerves, and the muscles, and the teeth all work together." I think that there's a lot of people listening to this that'll say, "Well, hey, I'm a CR doc, and I have all the same equipment as this guy does." That may be true, but I think when the ... Barney Jankelson, when he first started building some of his equipment, and his myomonitor for TENSing, people thought he was crazy, but hell he was measuring things. He had to call it something, and so there's a CR based camp. His was totally different.
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But I think dentistry as a whole, people who do this work, there are neuromuscular components, which I think if you don't know, you're a mouse fighting a gorilla. It's interesting, I went to ... 2010, I got my fellowship in the Academy of General Dentistry, and I had to go to New Orleans to the annual convention. There I heard some CR guys talk and I had heard a lot of neuromuscular guys talk, and what's funny to me is both paradigms cite the same literature saying, "See? We're right. Told you." But they're totally different schools of thought, so I don't have an easy answer there for you either, unfortunately.
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Howard:
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You know, I'll tell you what. I'm a big fan of your YouTube videos. How many YouTube videos do you have?
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Ben:
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Well, I've only got 9 videos out there.
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Howard:
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That's a lot. That's 9 more than 99% of all the dentists in the world.
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Ben:
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Well, yeah, but Nick Yiannios has got like 90 case studies, video ...
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Howard:
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[crosstalk 00:58:48] Nick what?
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Ben:
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Yiannios. Y-I-A-N-N-I-O-S. If you go to my YouTube videos, his are going to be sprinkled in on the right-hand column, because they're all DTR tagged. But, they are pretty amazing and I don't put all of them up, because I'm too busy doing the work, and it's a huge time sink to build those videos, but I have a couple more that I'm going to be putting up in the next couple of months here.
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Howard:
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Are you putting them up for dentists or for patients?
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Ben:
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No, I'm putting them up for patients. My frustration has been that I think medicine and dentistry for quite a long time, has failed a lot of these chronic pain patients. When you see my YouTube videos, you're going to see something on there that says, "Meniere's Disease." Well, what is that? How is Sutter, as a dentist, how is able to make these people feel better? Well, you have to get down to the physio-, you have to measure something, and so a lot of these diagnoses are really done verbally.
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We listen to what patients say. "Hey, these are my chief complaints. Can you help me, doc?" Then we somehow have to build a vocabulary. "Okay, well, is the pain stabbing or lancing or electric?" Based on some of that language, we come up with a diagnosis. Read Weldon Bell's Oral Facial pain. It's ridiculous. My contention is that a lot of this is TMD that's misdiagnosed. Otherwise, there's no reason why a TMD therapy would make these patients feel better.
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Howard:
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You kind of opened up so many questions in your podcast, and we're into over-time. The hour's gone. Can our listeners ... You're talking to several thousand dentists. Do you think someday you could put a course up on Dentaltown?
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Ben:
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Yeah. I would be happy to do that.
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Howard:
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It would be an honor, buddy.
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Ben:
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Yeah, I would absolutely want to do that. You know what? If the guys listening to this would like an article published in Dentaltown on DTR and occlusion, I could do that, too.
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Howard:
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Absolutely. Email it. I'm howard@dentaltown.com. There's 2 Howards. The person in charge of the online CE is Howard Goldstein, so his email is hogo, for Howard Goldstein, H-O-G-O at dentaltown.com. I'm howard@dentaltown.com. By the way, any of our listeners, if you want a special guest, a special topic or whatever, send me an email. [inaudible 01:01:42] but, Ben, seriously, dude. I know you're a busy, busy man. I'm a big fan of you. I've watched all your YouTube videos. You're a big fan of my friends, and the reason I went after you is because I actually think TMJ, TMD, occlusion, Kois, LVI, TruDenta, I think it might be the most controversial part of all of dentistry. I think more people agree on how to do a root canal or a crown prep, than how to treat oral facial pain.
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Ben:
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Yeah. I would agree with that statement.
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Howard:
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Thanks for having the kahunas to state your views in a society, a dental society that likes to argue about this until midnight every night.
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Ben:
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Oh, well, you're welcome. I'm sure my email is going to be busy over the next couple of weeks.
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Howard:
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Do you mind giving them your email? What if a dentist has a question for you?
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Ben:
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Sure. My email is basdmd@gmail.com.
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Howard:
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B-A-S, for Ben A. Sutter, D-M-D at gmail.com. What's the A stand for? Adam?
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Ben:
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Arvy.
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Howard:
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Arvy?
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Ben:
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Yeah. You know, don't even ask man.
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Howard:
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Family name? It beats being named Howard. When I was a kid, who were the Howards? Howard the Coward and Howard Cosell. I probably got teased on the playground as much. But hey, Ben, seriously, dude, thank you so much for an hour of your life. I really appreciate it. I know our listeners do too, and I hope to see you on the message boards, and I hope to see your online CE course someday.
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