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Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
How to perform dentistry faster, easier, higher in quality and lower in cost. Subscribe to the podcast: https://podcasts.apple.com/us/podcast/dentistry-uncensored-with-howard-farran/id916907356
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1313 Dr. Silvana Beraj on Approaches to TMD and Occlusion : Dentistry Uncensored with Howard Farran

1313 Dr. Silvana Beraj on Approaches to TMD and Occlusion : Dentistry Uncensored with Howard Farran

12/16/2019 6:00:00 AM   |   Comments: 0   |   Views: 348
Dr. Silvana Beraj graduated in 2004 from Tirana University, Albania for Dentistry. In 2006, she graduated with a master's degree in Fixed Prosthodontics, Dental Occlusion, Tirana Albania. In 2013 she got a PHD degree in Fixed Prosthodontics, Dental Occlusion, in Tirana, Albania. She started teaching in the subject of Fixed Prosthodontics in Krystal University at 2006. In 2008, she was the Dean of Faculty of Dentistry in Vitrina University, Albania. In 2014, she lectured in the subject of Fixed Prosthodontics, Dental Occlusion, in Sinai University, Egypt. From 2015-2018 she lectured at the Faculty of Technical Medical Science of Albania. She has been a speaker and keynote speaker at different international Dental conferences in Albania, Macedonia, Greece, Italy, Egypt, India, Dubai, Sultanate of Oman, Brazil, Mexico, and Great New York Dental Meeting 2018. In April 2020 from the 23-26, she will lecture at the University of Corboda, Argentina. She is the author of 66 publications and presentations. She speaks Albanian, English, Italian, and Spanish.
VIDEO - DUwHF #1313 - Silvana Beraj
AUDIO - DUwHF #1313 - Silvana Beraj

It is just a huge honor to bring back to the show and podcast for a second time Dr. Sylvana Buray, DDS, MSC, PhD, graduated in 2004 from Tirana University, Albania; she graduated with a master's degree in fixed prosthodontics, dental occlusion in Tirana, Albania. In 2013, she obtained a PhD in fixed prosthodontics, dental occlusion. She started teaching fixed prosthodontics in Crystal University in 2006. She was the dean of faculty of dentistry in Vitryana University. She lectures in fixed prosthodontics, dental occlusion in Sinai University. Her resume literally goes on for 40 days and 40 nights, so basically she lectures and teaches all over Albania, Macedonia, Greece, Italy, Egypt, India, Dubai, Sultan of Oman, Brazil, Mexico, Greater New York meeting. When I had the honor of lecturing in Albania, I got to meet her and listen to her lecture.

How are you doing today? Good, dear. I'm trying to get involved in dentistry in America. I'm here for a year. Since one year. And believe me, it's a challenge. Coming here in my age and starting over from the scratch is a big challenge, but it's worth it. I'm glad to be here and to start again from national board exams. You know how hectic are those days of national boards. That sounds great to me because it's just giving me a refresh, a new starting of everything in dentistry. Well, you know. So many people are going to relate to this podcast because at least 1% of all earthlings live in a country that they weren't born in. There's seven and a half billion people and a lot of people are changing countries.

So I want to really hear about that story because a lot of people that are born in the same country, you know, if you're born in Canada and practice your life in Canada, you wouldn't know what it's like to come from Europe and start over. So, first of all, why would you, I lectured in Albania, why did you want to leave such a beautiful country of Albania? What made you want to leave there and come here? Was it love? I see. There are two main reasons that I moved from Albania. Two main reasons, love and something else. My passion to work in a research, big research center. I don't have possibility, we don't have big centers of studies in Albania. So I want to get involved. And make a huge study in temporomandibular disorders.

I wasn't able to do it in Albania. So I was planning to come and get involved in these programs in America, but my husband came into my clinic. He was trying to get to fix his teeth fixed. So we fell in love. So we decided to get married and to leave my beautiful country, because my husband is Albanian too, in origin. So we decided to change our country and come and live in America. So your husband's from Albania too? Yes, he's Albanian too. He's Albanian-American actually. Yeah, and so you've been over here one year. So what's it like, foreign-trained dentist? I remember when I got out of school in 87, I came to Phoenix, Arizona. Yeah. And I needed a job for four months while they were building my dental office.

And they said one of the places I was hired, there was this like 85-year-old lady. And so I went and met with her and she had left Germany because of the war and she got to America. And here she's from Germany and America wouldn't accept her dental license. She's like, come on, we make Mercedes-Benz, you make Chrysler, you know, she knew so much more than any American counterpart. I mean, the Germans, even their lab technicians probably know more than many of our dentists. And she just thought it was horrible, but it was the, it was, she said it was the best thing that happened to her because since they took away her hands, she was forced to just own a dental office and hire dentists.

And because of that, she now had four locations and she had this big limousine and this driver would drive her to her four offices. Every day. And she says, Howard, I'm 85, I wouldn't have been able to do dentistry at this age anyway, but since they took it away from me as a youth, it forced me to make lemons out of lemonade. So I was wondering, did you, with all the DSOs, did you think of, ah, forget the boards and forget hands-on, I'm just going to start my own DSO. I'm just going to start a dental clinic and where are you at right now? Philadelphia? Yeah. Philadelphia. Can you see the Liberty Bell from your, from your window? No, no. I am in our fifth Philadelphia.

I'm not able to see that, but, uh, I cannot live without my patient, Howard. I need to work with my hands. So I have to pass boards. I cannot just manage dental offices. It sounds great economically at least, but for me, no, I want to work. I want to feel this. I want to smell. I want to smell dentistry and I don't smell just managing or just lecturing. I love lecturing. It's my house part, but in the same time, I want to smell dentistry. I want to smell saliva and blood. Sorry. I would want you to be my doctor that that's a, that that's a passion. So when, when you come to America, you have to, what do you have to do? You start with national board.

Well, first of all, is how hard is it to come? Even to America? I know it was that a hard process. How long did it take you before deciding you want to move here? And what would you do? You go, go online, fill out a form. What, how was that? Basically for me wasn't difficult because I was, uh, I was applying for participating in an international conference for me, it was easy. I don't know for others. I can share my personal experience. It was easy as I, you can get it. And after that. Making the marriage and everything go into the process. The hard part is to know the fact that I have to start and study all materials from the first year of education in dental schools.

So, uh, starting again, uh, anatomy, physiology, biochemistry, believe me, I, I had forgot all those reactions, chemical reactions in our body. But it happened. It helped me a lot. It helped me a lot to understand more the path of physiology of the, uh, of the mastoid artery system. So it is, uh, the best thing to happen to me because I'm feeling much more stronger. My knowledge are refreshed and I'm feeling that, uh, my subject, I am much more competent in my subjects right now. Next time. That is great, man. And you've studied and taught in so many areas, prosthodontics, occlusion. What is your main love? Is it prosthodontics? Is it occlusion? Dental occlusion inside the field of fixed prosthodontics. So rehabilitation of dental occlusion with fixed prosthodontics. This is my subject of my PhD.

And what I always wondered is when you look at the 10 specialties, I mean, there's orthodontics, there's endodontics, there's pediatric dentistry. Most of the specialties don't have many arguments or disagreement. In pediatric dentistry, there's a lot of disagreement about silver diamine fluoride. In orthodontics, there's really not that many. But occlusion and TMJ, that seems to have more. I almost think it's like. There's more world religions in TMJ. You have your Buddhists and your Hindus, and you have a whole spectrum. Why do you think dental occlusion has so many different camps? There are a lot of reasons for that, Howard. First of all is the fact that TMJ problems or diseases or pathology is just an umbrella term. It encompasses a lot of pathology. Pathologies, including temporomandibular joint, masticatory muscles, teeth, and all associated structure.

The second is the fact that in dentistry, we are perceived, we are taught to perceive only dimensionally. What I want to meet with this. For example, if a dentist in any country of the world diagnosed a caries disease, a DECAE, the treatment protocol is the same. It would be exactly the same, with a difference just using composite or amalgam as filling materials. All the other steps, it will be exactly the same. But if a dentist is treating TMJ problem, let's say he's numb in front of this problem, because we are not trained to think multidimensionally. So we are fallen in the void. We are in a vicious cycle of treating what we see and see what you treat. For example, if a dentist GP is seeing as a cause of the TMJ disorder, muscles, what he does?

He treats using occlusal splint or occlusal deprogrammer. If a dentist is seeing as the cause of the TMJ dysfunction, the teeth, he's treating using occlusal deprogrammer. So he has an occlusal equilibration. And if the dentist is a surgeon, he's willing to treat this TMJ with joint surgery. So we don't have a single or unique approach. Another reason is the fact that we are taught to see the masticatory system as an isolated entity without the body. So we are dentists and we are focused on treating only teeth. Teeth as the teeth was outside of the body, and we don't want to hear that this dental occlusion is connected with our postural behavior and with the way how we speak and how we walk.

And the most important in medicine not only in dentistry but in medicine, we are taught to treat the diseases but not to treat the patients. We want to have a clear schema, this is diagnosis treatment methodology. If we have puzzling problems, puzzling pathology like temporomandibular dysfunction, we are totally numb and we are working blindly, and guess. Working another problem is the fact that we have a big problem, is the fact that we have a big problem, is the fact that we have a big issue in the terminology of dental occlusion, and on my opinion this is the main cause. Of the problems, different definitions of CR or centric relation from 1987, something like that, the check they totally change the definition of centric relation from most most posterior to most anterior superior position of TMJ in the glenoid system.

We don't have a clear terminology and this terminology is not based on clear fact but is most empirical, unfortunately this is the main problem in dental occlusion, on my point of view. So why, what, what makes you attracted to it then? How come they didn't make you go into restorative dentistry or endodontics? Why were you attracted to this, what is obviously the more challenging I mean we treat karyo perio and occlusion. Why did you pick the hard one? Because it's like a puzzle to me and makes me love dentistry more. I mean it's not easy to understand what the problem in a particular in a special patient or what was the source of TMJ in a particular patient.

It's challenging you have to think, you have to understand how the patient is living his life, how the patient is treating his old body, not only masticatory system. This is a challenge, and I like it. So your last post on Dentaltown was on the thread 'Pete Dawson no more.' You said RIP to the most amazing and most influential guru in dentistry. What would it Pete Dawson mean to you, and what do you think? Pete Dawson will be some of his first concepts that will withstand the test of time, and what concepts do you think will not stand the test of time? First of all, I'm so sorry that I didn't have a chance in my life to meet physically Peter Dawson even though Peter Dawson is living with me every day of my life since I was student in master's degree in Albania.

Peter Dawson, and particularly his book from TMJ to small design, is my bible in dental occlusion. It makes me understand occlusion thanks to Patrick Dawson; I understand and I fell in love with occlusion. Otherwise, believe me, horror with all studies that I made in my country in my university I wasn't able to understand occlusion because you know, unfortunately, in our dental school, not only in Albania but worldwide, we are focused on just explaining to the students what is the occlusal interferences, what is the intercostal position, how it's working in lateral, in tuterative, and so on. But we are not trying to help students to understand how can we use this information in a real patient? How can I use this information to understand me? What is going wrong in the occlusion of this patient?

Okay, I noticed some occlusal interferences, so what? What this occlusal interferences is creating in my occlusion is... (pause) Believe me, 90% of dentists doesn't know this. So they are trying to do occlusal equilibration blindly without understanding the principle of dental occlusion. So Petter Dalszín to me is the father of dental occlusion. He's the creator of my words in TMJ. What a nice tribute. In America, you know, the United States is, I mean, it's a huge country. There's 211,000 dentists. And most of the dentists, the whole of the United States is... (pause) The whole concept of TMJ comes down to, we'll say the 80-20 rule. For 80% of the people, if you say, well, I grind my teeth, I have TMJ issues, they're going to take an alginate, they're going to make an upper splint, you're going to come back a week later, they deliver a splint, they check the bite, you're done.

That is four out of five treatments for all TMJ in the United States of America. What would you tell somebody who's listening right now, if that's really their whole TMJ protocol, what would you say to those people? I'm so sorry to say to those people that this is totally wrong. I mean, you cannot help a patient just taking an alginate impression and building a deprogrammer. Deprogramming is just helping you to diagnose. And to diagnose, you have to deal with the temporomandibular dysfunction. I'm helping you, just helping the dentist to deprogram muscles and to hide that muscular engram that is trying to fool us, the dentist. So, with deprogrammer, we just or with occlusal splint, we can help the muscles to get relaxed. And after the muscles are relaxed, we can record the central correlation.

Without recording the central correlation, we cannot record the central relationship; we cannot help the patient to solve the grinding and clenching problem. Just making an orthotic with the alginate impression is totally wrong. We're just making a camouflage of all situations, and the patient is coming back and back and back because we are not treating the etiology, we are treating just the symptom. We're not helping the patient, we're damaging more than more. Nice, nice, nice. So a lot of kids when they come out of school they say you know they have a lot of student loan debt but they're glad to be out of school but you know they've been in school eight years they average $285,000 student loans and they say I didn't get to do a case of clear aligners like Invisalign.

I didn't get a plan. I didn't place an implant, and they don't feel like they learned enough occlusion. What would you say to somebody who's 25 that just walked out of school and she says 'I want to learn more occlusion'? What path would you put her on? What would you tell her to do? I'm gonna tell them to do exactly what I did on my path because believe me, in my country, in my time, we didn't have even books. We are trying to write what the professor wants. The professor was saying in the lecture, 'to be able to prepare for the exam.' We didn't have a book in my times. So writing oh I was the master of writing in speech; you know just to catch what the professor was explaining.

And believe me, I wasn’t able to understand nothing of occlusion. What helped me a lot is studying on my own in my home with books of the experts. Peter Dawson, starting from zero to endless because, you know, studying never ends. I'm not saying from A to Z because Z is the point of ending the knowledge. In biology, in physiology, we don't have an end, Howard. So I'm still studying and I am studying until the last day of my life. We can’t stop in studying. Just start, be focused, and believe me, the best approach in studying and understanding occlusion is Manuel's writing from Peter Dawson. It's the concept that he, all the concepts that he was writing in his books is just recording and copying the nature.

And if you are copying and recording the nature, you will never work in blindly. You are trying, we are trying to help our patient based on the fact that trying to give them the most harmonious relationship between functional and aesthetic. How can we do this? We can do this just respecting physiology of our body. And we cannot, we are not able to understand the physiology if we don't study. We are not able to hear the physiology of each individual patient. So, if a student, of just graduated student, want to learn about occlusion has to be focus on Dawson's theories. I'm sorry, I'm sounding with a broken record, but is the best for me. Um, a lot of people, um, they start really thinking about TMD a lot when they're working with their patients.

Treating someone with extreme wear, extreme erosion. I mean what goes through your amazing mind when a patient walks in and they've literally ground their teeth down to nubs? And you know usually they show up in the dental office and they don't like their smile; they severe worn dentition, and it's usually a 50-60 year old man. What do you think when you see a case like that? Unfortunately, among us, among dentists, the concept of abrading the teeth is normal of age. In fact, according to Dawson, abrasion of teeth is not normal of age; if a masticator system is working harmoniously, it's perfect occlusion, and the teeth never will be worn down. So, if the patient - my patient has worn teeth, that means that something is wrong, something is going wrong in his masticatory system, and I have to find out.

But on my point of view, we haven't just to focus on the masticatory system; we have to see how the patient is living, how the patient is using his body not only the masticatory system. The masticatory system is not only the masticatory system; it's the masticatory system, the masticatory system, and the masticatory system. Is our main topic I totally agree, but is mostly of time, it's the expression of our let's say limbic system, so our masticatory system is managed not only by no central nervous system, but it's managed by limbic system. Why if you are nervous Howard what you are doing in normal day, you are clenching your teeth, doing nothing, you are doing nothing, reading or working in your patient, your mind is stressed out and we're changing your tip, your muscles are working hardly.

This is because of limbic system, because you know the masticatory system is just an orchestra of most of muscles working all together, there are 138 muscles in masticatory. System neck and head working in harmony to give us even small smile to be able to smile, have to work 136 muscles all together to clench, to close the mouth, to swallow, to masticate. All these muscles have to work in harmony with each other, but not only with each other, but with all muscular orchestra of our body. So if I see the patient with worn out teeth, I have to start from the scratch. I have to examine every detail of the puzzle called health. Unfortunately we are trained to see that we have this symptom is related with this etiology and is treated in this protocol.

The health is not like, it's not such easy. We have to have mind, we have to think out of the box. We have to be more vital and we have to integrate all parts of mechanical and emotional behavior to be able to understand what is going on not only in the masticatory system of our patient but in the whole body. Very nice. Are you familiar with Jim Boyd? Yeah, I heard of him. Yeah, Jim Boyd; he's on Dentaltown a lot and he's a one of the people who associate a lot of migraines with TMJ, TMD. Do you associate that way? Migraines, TMD, TMJ - is that associated with you? I am. Me, I personally, I am fact of this association. Because I was suffering a lot from migraines, taking at least three or four Oki's per day.

Oki is acetaminophen, used in Albania, too much. And I started to use Oki to help me to get rid of that heavy migraine that I had when I was working. What I started to do? What I started to do? Howard. I started to reorganize my masticatory system according to Delson principles. I started to be more aware where my tongue was located. And changing, just changing the position of the tongue. I was convinced that my tongue was in rest position. And what is rest position? Just as a definition: We have problems even in rest position. Rest position of tongue, if you're going to Google on this topic, you're going to see a lot of differences. Rest position is the moment when we have minimum expenditure of energy to keep the tongue or any organ in the position.

Right? But in accordance with tongue, this is not right. Because we want the tongue to be positioned on the top, behind. Behind of the frontal teeth. On the top of the insides of papilla. And to be able to keep the tongue in that position, believe me, it's not rest position. Muscles, intrinsic and extrinsic muscles of tongue have to be contracted to hold the tongue in that position. It is the most physiological position of the tongue. Keeping the tongue in that position helps me to deal with my migraine. Believe it or not, it's true. Just taking care about what I was doing. Because you know, Howard, we are trained, we are used to understand the para-functional of the masticatory system, like bruxing and clenching. This is para-functional function. Right?

And we are not used to understand para-functional position. Having the tongue, resting down on the floor of the mouth, is a para-functional position. We are not doing any function. It's not para-functional. But it's para-functional position. Because we use a lot of energy to having our tongue, or our structure of our organ, doesn't matter, in a non-physiological position. And we are spending energy on doing that. And think about 24 hours in a day. Because how much? 24 hours in a day. 24 hours in a day. 24 hours in a day. Do we talk? Let's say, two or three hours per day? How much do we eat? 40 minutes per day? And the rest, what we are doing with our tongue? Pretending to put our tongue in a resting position.

But what's our resting position on the tongue? This is the main problem in dental occlusion. Terminology. Dr. Justin Marchegiani So, when you've lectured and talked about, and taught around the world, I mean, when I met you in Albania, you had taught everywhere, I mean, Italy, Greece, Egypt, all around. Do you think the disease of TMJ, TMD, whatever, do you think it's different in different parts of the world? I mean, or do you think it's a homogeneous disease? I mean, would it be the same in Brazil as it is in China? Same as Albania, as Egypt or Italy? You're asking about the prevalence of the disease? Dr. Alina Tvarela Or as the concept among dentists? Dr. Justin Marchegiani Just any variance. Any variance at all. Dr. Alina Tvarela It's prevalence and in the dentist's perception.

As dental perception among dental professionals, let me give you a personal experience. In 2013 or 2014, something like that, I was lecturing in the Lancaster University of the History Skopje, Macedonia, in international dental conferences. Where Mother Teresa is from. Yeah, exactly. She's Albanian, by the way. Yes. And I was lecturing occlusal diseases, how we see in our daily practice. This was the topic of my lecture. And I was explaining the occlusal diseases, the definition, and blah, blah, blah, how we see, how we can help the patient. And the dean of Tirana University, at the time, an amazing lady, and I love her so much, she was so angry with me. Because I was using terminology 'occlusal disease', not 'occlusal pathology'. And she started a war with me in the middle of the conference.

It's not correct. It's not scientifically correct to say occlusal pathology. Okay, you can imagine, she was my professor and the dean, and I was just a child, let's say. I said, 'Professor, it's not my opinion of calling occlusal disease.' I'm just following his legacy. And I believe in his legacy. It's occlusal disease. Why do you have to call occlusal pathology? So, the perception of occlusal problems is vague. It's vague. And it's different from a dentist to a dentist, from a professor to a professor. Unfortunately, this is the main problem in dental occlusion. About the prevalence, I think the more developed are the countries, the more people are concerned with the stress and the pain, orofacial pain. In the poor country, like, unfortunately, Malawi, is the people are most focused on surviving than giving a lot of attention to their health.

And treating orofacial dysfunction, if it's not acute, but if it's chronic, believe me, it's luxury. In poor countries, treating chronic TMD is a luxury. The people are trying to treat only acute symptom pathology. Another controversy or debate in this is some people think that it's very mechanical with forces and teeth and jaws and joints. And some people think it's very psychological. How do you, where do you put TMD from mechanical forces to psychological forces? I mean, when someone's grinding their teeth, maybe they just lost their, they lost their job, they're going through a divorce or dog got ran over by a dump truck. Does any of this stuff weigh into it? Or we have to think outside of the box. If you are train our mind just to see as mechanical, it will be always mechanical to us.

No matter how was the social life or the social problem of our patient. If you are used to seeing as only psychological problem, we will be focused only on the psychological influences. As Vita Lombardi states in his philosophy of football, there will be only two or three players that will determine winning or losing a game. But I'm sorry, I'm not able; I'm not able to say who of them are these determinants are. You have to play all of them. I'm a hundred percent. So even mechanical, even biological, even psychological effects have a huge influence in TMD etiology. I'm sorry. I'm not able to say in your specific case which is the main influence. You have to play all hundred percent. You have to be focused on all details in these puzzles.

It's not just, it's mechanical. In every case is mechanical. It's psychological. Psychological in every case is psychological. We can say we can treat patients in this way. Another huge controversy in dentistry and TMJ is that I'm, you know, we learned about the curve of speed, the curve of Wilson. We learn about all these things, but then we take our important children and we send them to the orthodontist between, you know, 12, 13, 14, and they kind of change the curve of speed, the curve of Wilson. A lot of them take out wisdom teeth. A lot of them change the bite. There's a lot of dentists on tee on a dental town that do not like the way America puts all their youth through the orthodontic factory.

And, um, and then when they get them back, how do you, so I call it the aesthetic health compromise. Mom just wants her baby to look pretty enough to get married and make her a grandchild someday. She really doesn't care about the curve of speed or the curve Wilson. Um, what letter grade do you give the orthodontist? I mean, do you, do you think they're, um, helping TMJ hurting TMJ? What, what would, what letter grade? I mean, you have a PhD in occlusion. Um, what would you, um, what would you say to the orthodontic industry? Honestly, Howard, I love the orthodontics because they can be tremendous help in treating TMJ, but unfortunately, the majority. It's just doing. The Holocaust in our kids, this organizing everything occlusal curve speaker will some curve and not taking into account how the teeth fit together.

Not only how the teeth fit together, but how this intercostal position is fitting in harmony. All the TMJ occlusion is just creating a disaster in masticatory system of our kids, the orthodontic. Treatment is just focus in a perfect alignment of anterior teeth and what is going on in the back teeth, which has are, which are the most important sensor of our system, which are the most important part of our system. They are not taking into consideration. And the children, how they are using their teeth, how they are using their tongue, how they are using their lips. It's fundamental in how the bones are organizing, how the bones are a position and resorption at the same time to remodeling the form and the shape of the bone and, and the face, you know, um, I had 17 nice nephews in total, but my last niece, she has my heart.

She's seven or eight years old right now. But when she was in kindergarten in Albania, three or four years old, uh, it was cool in her kindergarten to talk with the movie, uh, The Leap on one side. So having a function, uh, had having a habit. I noticed my niece talking to me and her; her lip was moving or shifting on one side. And I was so stressed out with this going on. This. I'm going to lead to an asymmetry of the, of the, of not only all the lip, but also to the, to the job because you know, that symmetry of the lip, I can reorganize with Botox or with filters who cares, but why we have to have this asymmetry on the face.

And I went to her kindergarten and you know, how are from 32 kids in the kindergarten, more than 24 were talking in that way, just to be, to feel cool. Among them. So it's not orthodontic should be focused, should be directed to help our kids to raise all this habit and to raise all these discrepancies to have a perfect occlusion, but not only perfect alignment of our, of the tip, but perfect harmonization between intercuspally, the position of the condylar, glenoid fossa. Are they, are they doing this? I'm sorry. I cannot say. I'm not saying that all orthodontic treatment are working blindly. I can't dare to say that, but the majority, believe me, they are working blindly. If the orthodontist is a really careful about the health of their patient, they have to give much more consideration to the dental occlusion.

Just all I can say. A lot of the kids have a very specific question. They come out of school and they say there's two types of camps. One's more Dawson CR. One's more called neural linguist, neural lingual. TMJ and if they go that route, it's more LVI, but they need to buy equipment there. You know, there's some $10,000 pieces of myofunctional. Equipment they, they need. If some kid came out of school and they had a lot of student loan debt, would you say in learning TMJ that they need equipment? And the same question is CBCT. Some TMJ people say they don't want to treat this with a pano anymore, that they want a 3D CBCT view of each joint. Some people say, well, I want a myotronitor, etc.

So the question is, what equipment do you need to do what you do? You have a PhD in TMJ. Can you do it without expensive equipment? I'll be crazy to say that we don't need CTC or MRI to diagnose how to diagnose our patient. But believe me, Howard, if we want to help our patient, we can start from basic and basic is not CT scan is not NMI. Basic is to understand how the system is working. Believe me, you don't need expensive equipment. They are helpful a lot, but it's not the basic. If you are not, if you are not able to understand the basic, the basic, you can't deal with the expensive equipment. So without understanding the basic, starting from the basic and with a year for sure, you can buy expensive equipment.

Why not? But not from the start. Because going to prevent you from understanding how the physiology is working. Another controversy. Some people think that sleep apnea is all TMD-related. There's some people that think it's malpractice not to treat that if you have any type of bruxing TMJ. Any TMD issues. That you need to be worked up for sleep apnea. Do you think sleep apnea and TMD are related? Are they do they overlap? How would you line those two categories up? Honestly, a sleep apnea and TMJ problem can overlap to each other. It's not that TMJ is causing sleep apnea or sleep apnea is causing TMJ, but they can be. A co-cooperator into each other and it would be helpful to work.

You know, the most important concept is to work with other professionals in medicine and to speak the same language, to speak the same language is the main topic. I mean to be able to help a patient that is suffering from sleep apnea. Maybe this patient is has in the same time a TMJ problem and we have. To work with not a house called Amy in English the otorhinolaryngologist otorhinolaryngologist otorhinolaryngologist the the medic the medical doctor of ears and larynx. I just call me NT. I can't pronounce the word what is it? Odo? Yeah, ENT otolaryngologist here. I'll try to we have to work in Junction. With these doctors to help our patient because maybe this problem are just aggravating each other.

But not only even with the opulence the doctor of the eye we have to work because you know, for example tell you hypertellurism or tellurism is just expression of of muscular dysfunction in masticatory system. We have to work with also path with. Doctor of ears and larynx with oculist. To understand what is going on in our patient. There are a lot of studies that said that sleep apnea is more. These are movement disorder. Because during sleep apnea in in also during brachiasm. There are movement of lower extremities. So how can you have this patient? We have to work with neurologist to. Can you treat the brachiasm only with grinding or a night the spleen guard? We are fooling ourselves. And patient to. What about holistic approach holistic view of what is going on in this specific patient?

It can't help him. Do you ever see a need for pharmacology in your patients? Pharmacology is trying to convince you and your patient that you have deal with the disease. I mean pharmacology is trying treating the symptomatology is just making camouflage. It's not treating pharmacology is not treatment at all in T and a on my point. We should erase the concept of treatment pharmacology treatment. Is just helping you to relate to in extreme cases. By the way, you can use corticosteroids only in extreme cases to release muscles, but it's not treating at all. It's not the treatment. You are fooling yourself. If you are thinking that with the painkiller you are cheating TMB. After one week or after finishing the painkiller, the patient will come back to your office like Sylvester. He came back so quickly because the doctor never found out the real etiology.

So it's just like Botox. You know, there are a lot of dentists all over the world. They are treating bruxism or T and A with injection of botulinum in botulinum, but not correct. It is not correct. You are just making your sleep. You are making muscles to sleep for six months after that, after that what everything will come back and maybe worse. Well, a lot of people think that I have had Botox. And cosmetic surgery and I want you to know that I am all natural. Those are all all rumors in my phone. You have Botox in your front. Yeah, for sure. It's aesthetically. It's perfect because you know, I am a person that I speak with all my spirit and when I speak I use all my minutes all my muscles to express what I'm trying to say.

I am a teacher. So I want everyone in my audience understand what I'm trying to share with you. And to do this, I use all my body language is wrong. So I have to control this. We've got oxygen trauma. Let's go from occlusion as a disease to more occlusion and restorative life. Some people like myself. I'm older. I am all my crowns and fillings are all gold because they're they're they're soft some some people. People think that the move that porcelain fuse the metal was more acceptable than this zirconium. Some people think zirconium is so hard that since it will not break that that the force is going to actually fracture more roots and cause more endo down the line. I don't know anything about that.

But when you're looking at occlusion and or you know does gold to porcelain to zirconia to Emax. Do any of those things affect your treatment plan. Honestly, this is connected to it. The correct case selection. I mean, it will be different in a brook sir. It will be different in a brachycephalic patient to be different in a dolicocephalic patient. It will be different in a patient that has a lot of stress to be different in a patient that is like me using all muscles to express. I mean the success, long longevity in if of all treatments depends on the correct case selection. If you select correctly your case for porcelain fused metal will be perfect for your occlusion or is what is wrong.

But if in another case if your patient is the you know is a dolicocephaly, his muscles are not strongly. Clenching is not strongly contracting are not directing a lot of forces along to the teeth. Okay, do zirconia. Well. Or if your patient should have zero negativity in his mouth, zero negative influences in his mouth. Do it gold is a perfect; is the most perfect material that we have had in dentistry. Okay, it's not aesthetic. I totally agree. But this is the main disadvantage of God only. If you are using Emax zirconium porcelain fused metal or gold depends all on comprehensive evaluation of the dental occlusion of the patient. I can say this is good or this is bad depends on the case. You do a lot of talking and writing.

On stable TMJ our stable occlusion. What do you mean by stable TMJ or stable occlusion? The majority of dentists are working based on stable occlusion stable intercostal position. What we are checking in our daily practice. How the patient is making intercostal position lateral movement protrusive. It's according to our rules perfect the patient let him go. I was two months ago here in Pennsylvania. It was a private lecture of one professor from California. I guess I don't know. I don't remember a lot of people new people for me here. So I don't remember all names and he was presenting. He was an implantologist. I guess. Yes. He was presenting a lot of cases. In implants amazing successful cases in implants after 10 or 10 or more years.

But I was so surprised because in whole his work. I never saw a CT scan of TMJ. I never saw resonant magnetic resonance of TMJ. So he was like 90% of dentists working and focused only on intercostal position. If the patient has a stable occlusion, intercostal position, it's perfect. Let's go. But what if if our patient is in burden of TMJ problems? What if our patient has already what Delson called adaptive centric posture? We have deformation, TMJ deformation, condyles. What is the concept? Of deformation? The only point that I disagree with also is exactly this adaptive centric posture. I mean, we cannot accept deformity as normal because as long as we have a structural deformity, we have a functional cause, a functional etiology for causing the deformation. Why?

Because physiology is organized in that way and it's protecting the structural anatomy, right? I mean, if crying are damaging the structure of the eyes doesn't make sense, right? If saliva or talking is destroying our mouth does not make sense, or if smelling is destroying our nose. This is not correct. So function in physiology is organized to be had to be able to support. The anatomy in the moment that we have deformation, we have a dysfunction and it's come flashed is camouflaged by the muscular engram. So in these cases that is not majority. Let's say is not majority because on my point is majority but let's say it's not majority of people you put implants or you put a restoration or you put bridge. And the patient has unstable TMJ.

But stable occlusion what's going to happen? It will be an acute temporomandibular symptom pathology. We caused it was the pathology was sleeping and we just wake up wake up without not taking into consideration. Not all people have problem in TMJ position. But we cannot guess. That this patient has stable TMJ or this patient has not. We have to check all them both. It's not enough just to organize one's or to offer patients a comfortable functionality of the teeth. We have to help the patient to have the treatment comfort in and out function. If you are not doing this, we are not helping patients. We are just putting them on the edge of expressing dysfunction that probably they already have. So I can't believe we've already gone an hour.

My god, that was a fast hour, but I want to still had a couple of questions. I'm going to ask you some there's a big threat on Dentaltown. That's quite emotional. It's called the end of occlusion and TMD. A major crisis is on the horizon. It's a talk about whether TMD should be a specialty with the ADA. What do you what do you think of the need? Should it be like orthodontics endodontics Pediatric Dentistry? Do you think TMD should be an especially? Absolutely not. I was discussing with Ben Sutter TMJ TMJ specialist in here in New York in America. Pardon. And I remember one sentence from him. He said the only dentist that has no to do with dental occlusion is radiologist.

So dental occlusion should not or TMJ should not be a specialty is GP all dentists have to know dental occlusion. Why let me give you an example. Example of the TEO a TEO the others and 2005 make a very interesting experiment. They put an occlusal interference on one side of the mouth of the rat. And immediately after these occlusal interferences, the spine vertebrae, the column spine of the rat was totally disrupted, was totally disfigured out after one week. A TEO thing to balance the dental interference on the other side of the mouth and immediately after balancing the end of these occlusal interference, the column spine was redirected and in perfect position. What is this showing us that even with a small feeling we can interact and destroy not only the masticatory system but the total skeletal system of the body.

No dentist have to have must to have knowledge good foundation good knowledge in dental occlusion. Otherwise we are just damaging our patient not helping them. And last question because I know it's late there you're two hours ahead of me and Phoenix right now but the mixed dentition is very confusing because you know like Thanksgiving you know I think everybody saw Thanksgiving a five-year-old. You know taking a nap on the couch who's sitting there grinding their teeth and you know, I don't know if I was ever aware of this before I became a dentist but once you're a dentist you know you notice so much teeth but it seems like the older I get the more and more times I'm witnessing five six seven-year-old kids grinding their teeth enormously and they're they're an all baby teeth or they're in mixed dentition.

What how does your PhD in all of this apply to pediatric dentistry and the mixed dentition? Oh let me say that if a baby patient is grinding his teeth until the six years of age is totally normal because all these grinding all these muscular contractions is needed for the central nervous system to be maturated. The problem. Is not till six years of old the problem of grinding and braxing the teeth is after six years of old when the central or the central nervous system is maturated already this it will be a problem to dentistry before six years of old is the normal process of maturation. We need this pattern of movement to create engrams of the movement in our brain. After six years of old it's a big deal.

It's a big problem. It was such an honor to podcast you. I wish we were doing it in person back in Albania. That was so much fun. Have you. Have you seen Krenar Paprenikou? How do you say it? Krenar Paprenikou. How's he doing? Oh he's doing good. He a couple of months ago he sent me an email. He said I need to do this. He was trying to have some votes for K that he was trying to support. He's a very active dentist, and I really respect him. He's doing great; he's actually doing great. And I really respect you. I had so much fun in Albania. I thought the city was amazing. We got to drive all around the countryside. My gosh! It was just fantastic.

And congratulations on your move to America and your marriage. How long have you been married now? One year, and a month. So, you've been in America with a new husband for a year? I don't know how he can handle me studying all the time. Well, that's that is life. Man, what a what a wild time too! I couldn't imagine picking up and going to a new country. Getting married and going to a new country in one year - so, you are a busy woman and probably too busy to come on my show, but thank you so much! It's an honor to have someone who has a DDS, a master's in science, and a PhD in inclusion to come on the show today and talk to my homies. It was an honor to podcast you. Thank you so much for coming on the show. Thank you for everything. Thank you, dear heart.
Category: TMJ and Occlusion
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