Simplifying TMJ

Transcript performed by A.I. Please excuse the typos.
00:00
And she called me the next day and she said, Oh my gosh, Dr. Brian, my headaches have gone for the first time in four years. If you’ve had chronic pain for over six months and nobody can help you, that can drive you crazy. TMJ or TMD is often something that dentists will set aside, maybe not deal with, find out how to eliminate from their care. And then there’s those that are very passionate about it and want to do more of it.

00:28
This is Dental All-Stars, where we bring you the best in dentistry on marketing, management and training.

00:37
Welcome to Dental All-Stars. I’m Eric Vickery, president of coaching at All-Star Dental Academy, and I’m super excited today to interview our guest, Dr. Kerry Bryant. He is our All-Star TMJ clinical coach. He is on our team as a clinical coach working with doctors who want to improve and simplify TMJ in their practice. Dr. Bryant is a nationally recognized leader in TMJ and oral facial pain treatment, bringing over four decades of clinical experience and advanced training to the dental profession.

01:07
He’s a graduate of the University of Connecticut School of Dental Medicine, and he’s earned his fellowship in the Academy of General Dentistry. What truly sets Dr. Brian apart is his deep expertise in TMJ disorders. He is one of the few dentists in the country to complete the full Piper TMD continuum, one of the most rigorous training programs in the world for TMJ-focused dentistry. His work blends clinical excellence with mentorship, helping dentists build confidence and skill in diagnosing

01:36
and treating complex TMJ and oral facial pain cases. So whether you’re looking to grow your understanding of joint-based dentistry or want to provide transformative care for your patients with chronic facial pain, just know that the conversation we’re about to have today is for you and we’re excited that you had a chance to learn from Dr. Bryant. So welcome Dr. Bryant. Thank you. Good to be here.

02:03
excited to have you finally on the podcast, finally on the podcast. you know, we don’t often talk clinical, but we have a lot of clients who know they have to have to deal with this sort of world in their practice. It’s almost like a practice within a practice often in dentistry. TMJ or TMD is often something that dentists will set aside, maybe not deal with, find out how to eliminate from their care. And then there’s those that are very passionate about it and want to do more of it. And so

02:31
From a, from a, just a lead in perspective here, how did you decide that TMJ was going to be a passion for you and your practice? Well, it was interesting. I, I went to dental school between the years of 1974 and 78. And it was during those years, I had a lot of wear on my teeth and I couldn’t really understand why I had the wear. So I went to one of my professors and I said, yeah, I have a lot of wear on my teeth. What can we do about that?

03:01
And the professor who was an orthodontist looked at me and said, it looks like you, uh, grind your teeth a lot. And I said, yeah, apparently I do. And he looked at me and he said, yeah, don’t do that. And I, yeah, I thought, okay, well, I guess treating TMD is pretty simple. The only problem was I was apparently doing most of that while I was sleeping.

03:29
And when you’re sleeping, it’s difficult to control whether you grind your teeth or not. Yeah. that got me started at first, but then there are some other things that, that happened along the way that got me very interested in it. Yeah. Yeah. think, I think a lot of people can relate to everything you just said, because I know I’m sitting here thinking, yeah, I’m glad I’m in a orthodontic retainer to, cause I know at night I wake up and I feel something or I, you know, popping or clicking.

03:58
It’s always a part of this and I’m sure patients don’t even know that they do that. But yet there are signs or symptoms that point and direct that. And is the clinician prepared to treat that and handle it? So did you find that taking on this passion was beneficial for your patients and your practice? Did it stress you out? Did you, I mean, we’re talking about simplifying TMJ. So was it worth it to you to get into this world and open this can, I guess?

04:24
Yeah, it’s been very rewarding. fact, in the early years, I should say in the early years, it wasn’t rewarding. had a patient that came in one time and she had had a headache almost every morning for four years. So I had heard that these guards sometimes help. So I made her a guard and she called me the next day and she said, Oh my gosh, Dr. Brian, my headaches have gone for the first time in four years. And I said, great. I’m happy to hear that.

04:53
The only problem is I didn’t really know why it helped her. And then a few days after that, I get a call from her neurologist who had been trying to treat her with headaches. And the neurologist said, Dr. Brian, I have a lot of headache patients here. I wonder if I could send them to you. And my short answer was no. And I was honest with her. said, well, I don’t know why it helped. Yeah.

05:20
To make things worse, I went to a course down in Massachusetts. My practice is in Maine, but I went to Massachusetts and I took an all-day course there on TMD and the gentleman who gave that course said that if you’re going to treat TMD patients, you need to work with a psychologist because these patients are crazy. You need to work with a physical therapist. You need to work.

05:49
with a pharmacist and you need to work with a lawyer because a lot of them are probably going to sue you. So I drove home from that course and I was thinking, yeah, I’m never going to treat TMJ patients. Yeah. And then you got suckered in somehow. So what changed your mind? How did you end up shifting out? Cause I know you care around that big book with the jaw skull, skull, circle, triangle thing on it with you everywhere you go. So what, how did you

06:18
What made you make the shift? There was one person that changed my whole life in dentistry. And I’m sure that most people know the name. His name is Pete Dawson. Pete Dawson. Yeah. He wrote the book that was read by, I believe more dentists than any other book that was written. And ironically, about three months after I went to that course in Massachusetts, I got a flyer from Pete Dawson.

06:46
And it said the 10 must know factors about occlusion. And I was still hungry for an answer. thought this has got to be simpler than this. Yeah. I went to the course. was a three day course and it totally changed my life. That one person, those three days. And, uh, I haven’t looked back. Yeah. We love the Dawson Dillon Academy. They’re, huge. Uh, we’re, mutually huge fans of each other all star. And, and it is such a powerful.

07:16
skillset to learn. And when they can tap into that, we see from a coach’s standpoint, offices that are thriving because their patients are thriving. So immediately you saw a difference in your practice. took a while. It’s a lifelong journey. What would you, what would you say? It’s a lifelong journey. Uh, Pete Dawson had a, uh, an amazing philosophy on life itself. So when you went to his courses, you’d spend the day.

07:44
talking about dentistry. And if you wanted to, he would meet with a dentist at nighttime to talk to them about life in general. It was a philosophy also based on the Panky philosophy and the fantastic life philosophy. The four, the four crosses or whatever that is, I think that’s what the, they based that on at Panky, but I don’t want to pretend to know that. So, uh, I love that it created a fire in you. So.

08:13
Now you’ve got someone listening to this, maybe in their car or on the treadmill, hopefully on a treadmill, and they’re a dentist or they work in a practice and they’re thinking, how do I get comfortable like you did in treating and stepping into the TMJ world? Let’s start with this. What do you think keeps them from stepping into the TMJ world? Is it just they don’t know, they’re afraid that the whole lawyer thing?

08:40
I think in the beginning, there’s just a lot of mystique. I think there are three schools of thought that I, that I dealt with in the beginning. One was psychosocial, which basically says that TMJ patients are pretty much crazy and you want to be really careful. Um, you need to work with a psychologist if you’re gonna, if you’re going to deal with those patients. The other one, uh, the other group I’d say is the oral facial pain people.

09:08
In their philosophy, I, I’m sure it’s probably improved since 40 years ago, but it used to be, uh, if it ain’t broke, don’t fix it. In other words, doesn’t matter what their mouth looks like. If they’re not having pain, just their way out. Yeah. And then I think the most accurate, um, I would say the way I practice TMJ, uh, dentistry is the orthopedic approach. The problem is.

09:38
They don’t teach orthopedics in dental school and the orthopedic guys don’t really deal with the TMJ. So that makes it difficult. So unless you’re a nerd like myself, you’re probably not going to, we’re probably not going to learn very much unless you stay with it. The other thing I would just say about that is, you you go to a lot of courses and the sales pitch is come to this course and.

10:07
Uh, we can get you using this stuff on Monday when you go back to your office. Well, I don’t think that’s the case with TMJ. think you have to have a basic level of knowledge in the early stages. You know, it’s basically a tooth, mostly a tooth issues, the joints, the joints are pretty healthy. Um, but so it’s, uh, I call it dentistry, but it’s a joints aren’t healthy. If there’s something going on in those.

10:36
joint, some kind of breakdown, then it becomes more orthopedic medicine. So my philosophy is basically to try to prove to myself that the joints are healthy. If I can do that, then I move on to looking at, dental issues. Yeah. The teeth part of it. Okay. So, so what are they, so how do they flip the page then? What?

11:01
I don’t want to step into it, but now if I understand this, this, and this, I’m stepping in. So, ruling out problems with the joint, joint’s healthy. Now it’s a teeth issue, but what if the joint isn’t healthy? Then you’re referring them out or you’re treating the joint because you’re doing something there. Yeah. I treat the joint. If I can prove to myself that the joint is healthy, which I would do by clinical exam and imaging, then I would just.

11:32
relax and look more at the teeth. One of the best things that Mark Piper taught me was, uh, well, let me put it this way. In dental school, I was taught when you see a bad bite, the first question you ask is how do I correct that bite? Well, what I learned from Mark Piper is that’s really not the best question to be asking yourself. The best question to ask yourself is how did that bite get that way? Why is it that way already? Yeah.

12:01
And lots of times it’s because of trauma, about 80 % of the time people do have a history of some kind and 20 % of the time they might not. So that is one of the mysteries still that still happens in industry. the fact if they have a, if they have damage in the joint, there’s a term that Mark Piper coin called joint based occlusion, which means the bite is determined mostly by the joint.

12:31
Not by the teeth and you have to solve that problem first. All right. That sounds scary. Yeah, it can be complicated at first, but it can also be very rewarding. I have a number of patients that, uh, you know, they’re just, uh, very, uh, thankful. One, one lady that was in her sixties and she had TMJ issues since she was 27.

13:00
and nobody was able to help her for 40 years. She’s And she’s very happy now. looking back, it seems like they’re fairly simple way, but we got to diagnosis just like you would with an orthopedic. It’s examine, diagnose, and then treat. And pain, just like about 600 other diseases like

13:30
high blood pressure, diabetes, gum disease, tooth decay, cancer. Usually, that isn’t a good way to judge. Where were TMJ issues? Yeah. So what did you do for her? I’m curious. We made a guard and we kept, I saw her, well, what I recommended was a year of bite therapy.

13:58
What I used to do was just hand people a, a guard and say, you go. And then what I do is I, uh, sign them up for up to a year of bite therapy. And I keep checking that guard periodically over a period of weeks or even months. You see, uh, how things are going and what can happen is as the joints getting better or worse or what have you.

14:27
That splint will change that guard will change. And if, if there’s an issue in the joint, there’s a 100 % chance that the bite’s going to change because the mandible is connected where the condyle, which fits up into the glenoid fossa. And if you don’t stay on top of that, then you’re going to possibly have a beautiful bite today, but

14:56
two or three or four weeks from now that might will change because the joint is changing. Sure. Something’s got to win. Something’s got to lose, right? Yeah. Some of you got to stay right on it. And that’s what a lot of, that’s what I used to miss. And that’s what a lot of dentists miss. And then they, you know, they feel like, well, I only charge $50 for that dud. So I don’t want to spend a lot of time with this patient.

15:23
Well, there’s no profit in it. don’t, cause I literally, as you’re saying that a year and I’m charging $800 for a splint, there’s no way for me to do this and keep my doors open if I have this. So, so you’ve been able to make it profitable then by, still see this patient for what? Once a month, twice a month for a year? Well, it depends. I usually like to see them. I usually spend an hour when I’m inserting the splint. I usually do a lower, a lower splint. There’s reasons for that, which I can explain.

15:53
But, um, I usually try to have them back within a week or two to see how they’re doing. Most people are doing better. Some people aren’t doing better. And, uh, unfortunately, some people are continuing to do worse. And sometimes the reason they’re doing worse is, possibly because I didn’t do a great job adjusting the splint. I don’t like to say that, but, you know, I’m not perfect. I, I adjust it the best way I know how, but if.

16:23
If the bite is still off and I don’t catch that, they might come back, uh, you know, five or 10 % of the time. And they’re just not that, uh, not doing that great, but almost. I’m going to say 90 % of the time over the course of a year, maybe 95 % of the time they do continue to get better. In fact, had MRIs of, uh,

16:48
the joint changing, they go from osteoarthritis to a totally corticated condyle, which means it’s totally repaired. disc, may not recapture the disc, which is what we’re looking for, but they’re still more stable and happier. can open wider. Yeah. Although that’s awesome. That is the other thing about it is when you’re talking about an orthopedic approach, there can be many

17:18
Diagnoses. That’s another thing in my early years. thought there was one diagnosis called TMD, Temporal Mandebrile Disorder. Some people call it TMJ, uh, but that’s a body part. So it’d be similar to coming in and say you had a back problem and the doctor came out and said, yeah, you have back. You have a back. and throw and then the retreat back problems. No, you can have.

17:47
disc issues, can have, you know, the back can be at alignment called spondylolisthesis. You can have a lot of different issues. And also another comparison would be cancer. Ask an oncologist, how do you treat cancer? Well, it’s about five or 600 types of cancers plus the same cancer may be more advanced than the other ones. So you might treat that differently. So that’s a good analogy.

18:18
Yeah. What would you say? Let me, let me ask you a question. What would you say? You know, someone’s listening to this and they’re thinking, okay, I know I have patients who are showing up like this and what I want to enter this world of TMJ. What would you recommend to be their first step in understanding this world and taking a step in this direction? Say, I want to treat this. I want to treat it accurately. Yeah. Unfortunately, Dr. Piper has retired. I think going to a basic course.

18:48
Like Panky or I think dr. Spear dr. Coice I Mentioned Dawson earlier Dawson Academy. Yeah, Dawson. Yep. There are a lot of introductory places but there is a lot of mystique to it and You know, one of the things I found interesting is I’ve never seen

19:14
A higher percentage of crazy people in the TMJ world that I don’t see in the regular. The exception is that if you’ve had chronic pain for over six months and nobody can help you, that can drive you crazy. So if people are having psychological issues, say, would say it’s the result of not getting help. It’s no, there’s no, no one providing care for that. Not the problem. Yeah.

19:42
Yeah, I think that’s great. so of course, um, talk, maybe talk to other dentists who are doing this. Like, I think sometimes I, I don’t, I obviously I’m not a dentist. I feel like dentists are just maybe not talking about it because they don’t want to open that can of worms. They don’t want to be embarrassed. They don’t want to handle it or, something like that. I, it, am I making something up here or is there some truth to, Hey, this isn’t something we don’t really talk about dentistry because we don’t want to admit that we don’t know what we’re doing here or, or that we as a whole, but

20:12
that, that individual dentist maybe. Yeah, I, I believe so. And I think some of the advances in dentistry have really helped a lot. One of the biggest ones for me is, uh, imaging and imaging. Well, cat scans, I have a cat scan in my office. I would never have thought of that, you know, 46 years ago. And that’s helped a lot with diagnosis. Um, but basically I think the most important thing to remember is that the

20:42
Temporomandibular joint is a synovial joint, just like the knee or the hip. And a lot of the principles apply. In fact, one of the books that I’ve read partly is the book that orthopedic residents read the first year of their residency. Yeah, that book helped me quite a bit because if you think of the long bones, technical term is diaphysis and epiphysis.

21:12
Well, the diaphysis is basically the long part of the bone, and the epiphysis is the growth center of that bone. And when you think about the temporomandibular joint, the ramus is equivalent to the diaphysis, and the disc is equivalent to the epiphysis. The growth center of the jaw is the disc. So if you’re five or six years old and you damage that disc, that epiphysis, you’re

21:41
Mandible will stop growing. So one of the things to look for especially in children is an asymmetry so look at the face very closely because kids usually don’t have pain they can have a severe TMJ problem and They don’t have pain lots of times until around there 15 age 15 or 16 so those are things to remember but again imaging has helped me I

22:11
order MRIs of the joint. There’s a saying, nothing can hide from an MRI. And we didn’t have MRIs until around 1983, I believe. And I graduated in 1971. So my treatment used to be exam, treat. Well, that’s really not the best way to do it. Now it’s more like exam, examine, diagnose, and treat.

22:40
And you find there are different ways to treat TMJ issues. Do you, mean, someone listen to this. Do you find that treating TMJ benefited your GP practice? Cause you had this GP practice that was already very successful and then you added this TMJ component to it. was like you had these two practices, a practice and a practice. So someone thinking about this, do you find that it is a, a productive way to run a business?

23:08
Yeah, the way I do it is productive in the early stages. There wasn’t because I didn’t really know what I know now. And I didn’t know, you know, I didn’t want to charge too much, but I didn’t want to charge too little either. Yeah. When charged too little, you tend to want to take shortcuts and you think, well, is this going to work? So, yeah, we started to talk about that, that one year of therapy.

23:36
So you must have built your fee into the hour long appointment and then you had a sequence of appointments for them for adjustments. And so you’ve, I remember we were going through coaching on this. just reversed engineered the length of time it was going to take for you to do this. And then we built the fee into that. that, that still how you recommend to do this? Yes. Uh, what I do is I, I think my basic fee is equivalent to, uh, four, I’m going to say four crowns.

24:05
And I have assistants that do probably 50 % of their work. have assistance that take the, um, the CAT scans. have assistance that do the photography because I want to get a baseline. Uh, I have assistance that do the study models, take the impressions and, I use a face bow. Another funny thing is I couldn’t wait to get out of dental school because I was going to finally get rid of my articulators. I hated.

24:36
I hated it. Moon mountains. And then articulate it. I thought, wow, when I get out of here, I’m never going to use one again. Well, now I use one all the time with a face bow. Yeah. Yep. Yep. Yep. So for those, for those that are listening, Dr. Bryant, uh, the first practice I managed, so I have a lot of insight into this. My, my, one of my first mentors in dentistry, obviously my, my father-in-law. So the names obviously don’t match on purpose because

25:05
You know, I married his daughter. So, um, full disclosure, full transparency. But I remember being your working, you know, running your practice, I guess you’d say is whether I knew what I was doing or not at that point, you know, you taught me so much, but I remember having to explain to patients what that first visit was going to be like with all of these things going on and the cost of all of that and overcoming that. I think we went to the school of hard knocks on it and really learned to figure out on our own.

25:33
I think that’s where we put such an emphasis on the verbal skills that go with it, the case acceptance and all those things. But you know, when you have a patient that’s in pain for, think of it in Adonis, you know, if they’re not in pain, there is asymptomatic. Talking about doing a root canal is pretty tough, but talking to a patient who has a toothache about a root canal, lot easier. And so I think there was a lot of similarity to that in TMJ when they’re already in pain versus you have an existing patient in your practice.

26:00
And you’re seeing all the signs that something is wrong with occlusion and what’s happening and knowing how to verbally get them aware of this and the consequences of doing nothing. And so I think there’s a lot of, uh, there’s a lot more to uncover here. There’s a lot more to discover and help, uh, people out there that want to do this. Cause I don’t think you could just say to a patient, well, you have TMD. I don’t think that’s how it goes. Right. Yeah, that’s, that’s what I used to do. Then, uh, it was.

26:30
You know, it was just pretty basic. used to basically, I used to diagnose acrylic insufficiency, which is a sarcastic way of saying that everybody needed a guard. You don’t have enough acrylic in your mouth. Let’s put, let’s put a piece of acrylic in your mouth. Yeah, exactly. Well, what I’m finding is that if you can convince yourself that the joints are healthy, but they still are having issues. There’s no reason why you can’t just go right to the teeth and.

26:59
And this is already treating. The other thing that’s interesting, I was talking about pain. Some of the people that are in the worst pain have very healthy joints and their pain is coming from the buildup of lactic acid because their bite is off, there’s muscle in coordination and those muscles are working overtime to try to stabilize the bite at a different position.

27:26
Uh, the best analogy I can come up with is if you take your arm, uh, you me, right? You hold your arm, just hold it for awhile. Eventually it’s going to hurt because lactic acid builds up. You’ve got muscles that want to hold your arm up and you got muscles that don’t want them to go further. So they bring them down and the rest position is just let your arm drop to your side. Well, the rest position in the joint is a fully seated condylar position.

27:56
In a healthy joint, I call that relation. The other interesting thing about centric relation is, uh, imaging what Mark Piper has done in my opinion is he’s eliminated need for the occlusion wars. remember 20 years ago, people used to get into fist fights over neuromuscular online fist fights. Yeah. They go to courses and you know, have a rowdy.

28:25
You know, you need to have a black belt karate because of, of the dinner muscular versus centric relation. Yeah. I think imaging, imaging has really, uh, eliminated the need for the exclusion ores. In fact, and Liper made the point that when you have a, in fact, Pete Dawson, I’m going to risk being a name dropper, but the highlight of my career.

28:50
was when Pete Dawson actually called my office to talk about some emails that I had been writing on behalf of Centric Relation. Now I now actually disagree with some of my emails people. I think there are cases, neuromuscular position is actually what you end up with and it’s not Centric Relation. But again,

29:19
Mark Piper long and he, he just took Pete Dawson’s education to the next level. Yeah. No, it’s hard for me to describe here in the time we have, but it was just fascinating. I just learned a whole lot from Pete Dawson, but then Mark Piper, uh, like I said, took it to the, to the next level. I love it. I love it. Well, yes.

29:45
Time is important for everyone. We want to respect people’s time here. We like to keep our podcasts to the point and helpful. I will say this. I’ve seen, I’ve probably coached over 300 offices in 24 years now, and I’ve seen both sides of those things. I’ve seen things. We just learned so much in dentistry all the time. And I’m always amazed at the dentist who are handling these tough cases, who are

30:14
helping patients and they’re doing it in all sorts of ways like you’re talking about. like it’s all coming together as one way really. And so I love that you’re on our team and if you’re listening to this and you’re thinking, want to learn more about this, like we’re just scratching the surface, but I wanna learn more about this, I wanna tap into this, let us know, comment, send a message, email, eric at allstardellacannaby.com and just say, hey, we want another podcast on something with TMJ, we’re happy to do that for you or.

30:44
If you want to do a discovery Zoom session with Dr. Bryant and just meet with him, just email Heather at allstardentalacademy.com. And we love to support the dental office every way we can, whether that’s tapping into TMJ or learning how to convert new patients into appointments and all of the above. So everything in between. Well, Dr. Bryant, I want to thank you for your time and joining us and letting us.

31:12
pick your brain a bit on this. Thank you very much. You’re welcome. Thank you. For those that are listening, thank you for giving us some of your time. We appreciate you. Share this with your friends and colleagues, please. We really appreciate that. Until next time, go out there and be an All-Star.

31:35
We hope you enjoyed this episode of Dental All-Stars. Visit us online at AllStarDentalAcademy.com.