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1360 Advances in Digital Occlusion with Dr. Robert B. Kerstein : Dentistry Uncensored with Howard Farran

1360 Advances in Digital Occlusion with Dr. Robert B. Kerstein : Dentistry Uncensored with Howard Farran

2/21/2020 3:00:00 AM   |   Comments: 2   |   Views: 218
Dr. Robert B. Kerstein received his D.M.D. degree in 1983, and his Prosthodontic certificate in 1985, both from Tufts University School of Dental Medicine.  From 1985 - 1998, he maintained an active appointment at Tufts as a clinical professor teaching fixed and removable Prosthodontics in the department of Restorative Dentistry.  In 1984, Dr. Kerstein began studying the original T Scan I technology, and has since that time, also studied the T-Scan II, the T-Scan III, T-Scan 8, T-Scan 9, and now the T-Scan 10 technology. For many years now, Dr. Kerstein has lectured both nationally and internationally, about Prosthodontics, Implant Prosthodontics, Digital Occlusal Analysis, and treating muscular Temporomandibular Dysfunction with Disclusion Time Reduction Therapy.

VIDEO - DUwHF #1360 - Robert Kerstein

AUDIO - DUwHF #1360 - Robert Kerstein

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Howard: it's just a huge honor for me today to be podcast interviewing Dr. Robert Kerstein who received his DMD degree in 1983 and his prosthodontics degree in 85 both from Tufts University School of Dental Medicine from 85 to 98 he maintained an active appointment at Tufts as a clinical professor teaching fixed and removable Prostidontics and the Department of restorative dentistry and 84 he began the original T scan eye technology he began studying the original T scan eye technology and has since that time also studied the T scan - T scan 3t scan 8 t scan 9 and now the T scan 10 technology dr. Gerstein has conducted original research regarding the role that occlusion and lengthy discussion time plays in the etiology of chronic myofascial pain dysfunction scent syndrome he is now 35 years of research with all versions of the T scan digital occlusal analysis system has led to him becoming a leading author and researcher in the field of computerized occlusal analysis dr. Christine has been published in the Journal of prosthetic dentistry the Journal of cranial mandibular and sleep practice quintessence international practical periodontics and aesthetic dentistry the Journal of computerized dentistry the compendium of continuing education the Journal of implant advanced clinical dentistry and cosmetic dentistry the Journal of oral and maxillofacial implants and advanced dental technologies and techniques additionally Dr. Gerstein has published five volumes of research specifically about the T scan computerized occlusal analysis technology for many years now he has lectured both nationally and internationally about prosthodontics implant process digital occlusal analysis and treating muscular two temporal mandibular dysfunction and disc exclusion time reduction therapy his book is a hit on dental town in fact this is what's really amazing if you go to dental town and you just type in his name you pull up 24 different threads talking about him and are quoting him and these are not amateur league quote these are the most amazing minds on dental town I mean dentistry you know it's a it's a caries pareo and occlusal and I assure you young kids out there today that you are listening to the heavyweight champion of the world in this occlusion and now which is going to computerize a close analysis I was very excited to get you on the phone because all the rumors coming out of align technology which owns Invisalign and the eye tarot scan it turns out that the I Tarot all these scans their algorithms are starting to understand occlusion so you know you can take an x-ray and say oh here's some cavities for Peri oh you can say here's some bone lines bone loss and now we're seeing AI is going to start diagnosing and treatment planning and given us measurements for occlusion and does that sound cool to you or does that sound like a scary movie

Dr. Robert Kerstein:  well first I need to say that any of the opinions that express their mine and not necessarily that of text can so this is like HBO you can say whatever you want well it's important that you know as I am a consultant for the company but I do not receive any compensation for sales well that's a good thing I guess yeah to your question it's a great thing that dentistry is moving towards digital occlusion but it's important that the listeners understand that scanning technology actually is only really using geometric approximation of contact size and it helps design occlusal contacts in restorations but it actually has no actionable force or timing data in it and so it's still doesn't preclude the need for computerized occlusal analysis of the restorations after they are installed so there's a kind of a miss representation in the scanning world that there's actually forces in there and there's no forces in there it's all the geometric approximation of spatial orientation

Howard:  so you're not a big fan of it then of the early stuff you doing about the early stuff the AI stuff coming out of these internal scanners into computers that it's all 

Dr. Robert Kerstein: I'm a fan of it because it means that there's digital occlusion being fostered and adopted but it's important that people understand that it's not real forces it's not measured taken from the patient as you would be with a t scan sensor which is designed to measure forces and timing and and give my actionable data to a clinician to be able to use and so the scanning company is it's great that they're going digital and trying to represent occlusion but it's not the same as what the T scan does okay well 

Howard: we'll explain the difference between those two things between the t scan and what you're saying that these ntral scan data's are showing 

Dr. Robert Kerstein: well the t scan the patient occludes into a sensor which is designed to measure relative force and time sequences and give out pressure mapping and actual relative force information to the clinician and so it Maps the pressure of the arch as the patient occludes or disc ludes every tooth in the order and sequence of teeth hit and it provides you with data that can be used to make targeted occlusal adjustments make a complete occlusal analysis in a way that no other technology is capable of doing that and it's because the data is taken directly from the patient's teeth as they interface as they mill against each other as they strike each other and that the difference is that scanning is pictures of the occlusal surfaces that are then put together and approximated kind of like hand articulating stone models there's no force in there that can be taken from pictures it's just surface anatomy and then they're fitted together which is very nice and it's very positive in that it allows people to digitally articulate and digitally move casts around but there isn't there isn't force information inside there even though it's created geometrically it's not real forces 

Howard: I want to so you and I were old and when people send an e-mail Howard at dental town comm a quarter and we're still in dental school and the rest are all under 30 and so we're probably the two oldest guys are gonna listen to this show today let's go all the way back to dental care dentals kindergarten school we they they're gonna learn dentistry caries pareo occlusion starting with occlusion these kids about a quarter of them have a family member that's still a dentist they're their mom their dad their uncle what what do you think we've been practicing 30-plus years what do you think their dad's letter grade in for the average dentist in America what would you give them for a letter grade for treating caries versus pareo versus occlusion at current 20/20 standing

Dr. Robert Kerstein:  well certainly the education that our generation thought about clusion I mean about of caries and periodontal disease was the center of our education and occlusion really I didn't learn occlusion in dental school other than basic you know to try to make it fit in and not cause too many you know I'm untoward reactions I only really began to understand inclusion and postgraduate so people in our generation would have left school then gone on and taken Continuum's to learn occlusion and unfortunately most of those Continuum's didn't teach digital occlusion so our generation practitioners are a little bit behind in that digital occlusion is a major advance for the patients as well as for their practice and it's so helpful to many aspects of dental care that are trouble in the typical dental practice and so you know the basic occlusal concepts are there from what we learned you know about time and distribution of force be balanced in time everything should hit at the same time but those things are concepts that can only be actually achieved when you measure the teeth so the younger generation if they're exposed to Digital Inclusion will have a leg up on our on our peers 

Howard: so what letter grade would you give the average American so there's two hundred eleven thousand Americans who are living with an active license to practice dentistry there's two million around the world keeping it just in the United States a better sample size for our personal framework what letter grade would you give those two hundred eleven thousand dentists as we know dentistry today in 2024 caries pareo versus occlusion 

Dr. Robert Kerstein: well caries I'd have to give an A and periodontal disease I'd have to give an A and occlusion I'd have to give like a B or B - and the reason I say that as many dentists do try to learn occlusion from the Continuum's it's they make a serious effort to go away for a week and learn you know from the experts and you know that's a real statement that they're really trying but the concepts of occlusion are not advanced to where this to where we are in digital occlusion so no matter what studied it's generally somewhat behind what we know from actually measuring the occlusion which only really began in the 1980s with the t scanner 

Howard: okay so the only it's kind of I don't want to start telling this young kid in dental school how to drive from Phoenix to LA and how to get on i-10 all that without first trying to explain to him why he should want to go to LA so what do you know if you get A and caries and a B and a in Perry oh but let's just say you get a C in occlusion or a D how why why does he want why does that kid wanna learn occlusion what why does he want to go to LA why does he want to learn this

Dr. Robert Kerstein:  if he doesn't learn occlusion what's gonna bite him almost every procedure that he does occlusion is the most difficult aspect of dental care to manage it's why there are so many complications for example the most common thing that I came across as as someone who sought out patients who sought me out for help with their occlusions was the the most common story was I had three fillings changed and my bite changed and that was four years ago and now I have TMJ and no one's been able to help me or I had three crowns put in or I had a tooth extracted and my bite changed and I got pain and people started adjusting my bite and now my bite doesn't fit and so occlusion is the success or failure of most of the things that we do and of course you can have esthetic failures and you can have you can have restorative failure but restore the failure that isn't decay related that's fractured breakage dislodgement implants unscrewing pots unscrewing that's all occlusion and so the most central thing to long-term success is for dentists to learn you know high quality principles of occlusion and the advantage of the T scan is that it measures the occlusion and no other technology can do that there's no there's no articulating paper doesn't measure anything it just marks teeth and that's a big problem that dentistry doesn't really grasp it's necessary for marking teeth but it doesn't show you force or time or quality of the occlusion or balance or distribution and so these are things that a young dentist would really benefit from because they'd be starting out using measurement and learning occlusion will help them only help them to succeed better in practice

Howard:  so um so then let's go to the birth a year I don't know how many children you have but I think the first one was the the t scan one did you have any children before 1984 with the T scan no my son was born in 1989 so was he was he born so you had a T scan before he had a child that's that's pretty you get that's pretty rockin hot cool to say I had a t scan before I had a child but so that was in 1984 you're talking to a bunch of people who weren't even born in 1984 god it's 2020 they probably weren't even born in 94 if you were Warren anyway but so go back to 1984 tell these kids what it was like and what was this new T scan one technology and why did it interest you

Dr. Robert Kerstein:  well it was the first version of system that actually took forces from the patient that was what interested me it you  know you were taught we were taught I'm sure you were taught the same thing that you could see force in articulating paper you wanted all the forces to be equal you wanted distribution of forces but you couldn't you couldn't detect that in any real quantifiable way and the T scan one was the first attempt by anybody to actually measure occlusal forces in a distribution of the arch there were attempts to measure absolute forces on single teeth there are a number of strain gage studies done and  things like that but they weren't applicable clinically the T scan was the first dental technology actually it was built right around the time that Sarah Kwan was built and those two of the earliest technologies and they actually incorporated computer assessments so the T scan one sensor was the first device that actually drew forces out of the patient and that's what interested me that I could actually determine where the teeth really balanced where the force is distributed correctly were they time simultaneous did someone discrete immediately as the concept presented to us and  interestingly enough none of that was really true people's teeth didn't hit at the same time and people's teeth didn't disclose instantaneously and there wasn't even distribution of force when you had lots of paper marks on all the teeth so there was a lot of information there that was brand-new and eye-opening and that's why it interested me

Howard:  and you are in Boston Massachusetts I want to fill in this story so the REE it's no small surprise that he that a guy in Boston would pick up on it first is because this was started off with MIT first and it was in 1981 they  discovered a new tactile sensor and that was that was a component that had to be invented before he even considered started at X can right

Dr. Robert Kerstein:  yes Tex Can the company was formed originally what with a number of prosthodontist from tops who were my teachers and MIT engineers and they created this time and force measurement system with this tactile sensor that you just referred to Howard and  they made 16 prototypes that were distributed to I think only prosthetic programs the most prominent prosthodontics programs in the United States and I was in one I was at Tufts where these my faculty were part of the development team so I had access to it pretty much from the time I entered postgraduate and no one understood it no one knew what it really meant no one understood how to make take the data and turn it into a better denture or to assess you know quality of the occlusion and that's what I began to study with it and and and over the years we really began to understand what you could do with this digital data that measured force and time and pressure and

Howard: who was the original founder of the texanne company 

Dr. Robert Kerstein: was prosthodontist named dr. William manis and an engineer from Tubbs sorry from MIT Rob Podolak and a couple of his associates the founder was who was the first said dr. William manis and a number of other dentists who is MA an ESS yes so William manis was the founder yes along with a number of other faculty personnel at us who invested with him and he they were combined with engineers from MIT

Howard:  and how far is uh MIT from Boston I mean Tufts yeah 

Dr. Robert Kerstein: you could walk there in 20 minutes I'll take a taxi in five and and

Howard:  and so we're so that journeys been on a long way I mean you know I say we went east can two three eight nine I'm kind of confused about these numbers because it goes one two three now there's no four five six then we go to eight nine and ten is this like a Star Wars thing where you launch movies four five six and then later you'll launch one two and three

Dr. Robert Kerstein:  so it's a series of changes to hardware and software configurations and as Windows developed there was changes to the T scan one the T scan one was a standalone entity like an oscilloscope and it had a recording handle that plugged in and it had this original sensor that you alluded to and it measured three seconds of ACLU's will contact timing and forced out and played a movie of the bite so it was very dynamic look at the bite which was fascinating actually as a young person and we didn't really have computers back then we didn't have laptops and tough stuffs at the time didn't have computerized records they weren't computerized x-rays as I said the T scan one and the CEREC one was built around the same time and through the years as Windows technology and chip technology evolved the T scanty bald and the company Tex can also applied the sensor in many different ways you know you can walk on the sensor you can drive on the sense you can sit on the sensor you can bite on the sensor you can put it on the outside of airplanes and measure wind shear you can put it on baseball bats if you want golf clubs horseshoes and ism millions of applications engine gasket seals and so they he began to develop a corporation that expanded the use of the sensor and what they learned in these industrial applications they put back into the different versions of the t scan and T scan 2 was a windows-based platform and T scan 3 was that our hardware and better windows had evolved from Windows 95 to Windows Professional and I mean it all evolved together t scan 10 is the you know the current day version which has capitalized on all those iterations and has a really amazing new handle the novus handle and the know of a sensor incredibly economic and the handle does all kinds of things that can play the data for you it records the data for you it controls the amount of pressure not the pressure but it controls the amount of load the electricity in the sensor so you can customize that to theta patients bite strength is there's all kinds of improvements but the essence of the different versions is they evolve along with computer technology and also to match doctor desires various software features were put into the different versions that that people were requesting and things like in the current version t scan 10 there's implant warnings if an implant is overloaded you get a warning tells you automatically there's too much force on that implant you know and so these are the kinds of things that have been added as time has gone on 

Howard: and so how much is it and how do they you trained on it 

Dr. Robert Kerstein: well the system cost about $10,000 u.s. and training is provided by tech scan they've constantly evolved the software to simplify the training process and shorten the learning curve but any any technology that you implement in your practice requires time and practice to learn and in the t scan the most crucial thing to learn is how to record digital data from the patient and fortunately the company has excellent trainers that teach doctors who get involved how to record and understand the data and usually they can get started pretty much from the company training and then there were many online resources and people who really want excuse me people who really want sophisticated training can can actually bring me to their office and I can measure them chair side with patients and teach them how to use it one on one Howard: so how much does that cost

Dr. Robert Kerstein:  it depends on the date the number of patients they want to see but generally for that personalized training between four and five thousand dollars per visit I mean I wish you would do a a C course on dental town well we can certainly talk about that I'm happy to do that I 

Howard: I would um I I would love that you you have some huge fan again go to dental town and just put in just your last name Kirsten and my god it flies over to your biggest fans are mark Piper and Nicky [Music] giannios Nick giannios Yanni us is that Greek or Greek he's Greek it's great okay I was I was wondering that um so um so these are buddies already know them well or 

Dr. Robert Kerstein: yes well I know I've known them for a long time mark Piper is very world renowned oral surgeon who treats a lot of temporal mandibular disorder patients and has in his own way evolved he and I have kind of had parallel careers his in imaging CT and MRI which he's evolved for dentistry which he began also in the eighties when those technologies were first introduced and has he's really changed how people analyze internal joint arrangements and skull based problems and condylar deformation and diseases of the joints and at the same time I was evolving the T scan technology and so we both started around the 80s dr. Janos is a very prolific computerized based dentist who practices with CEREC and chairside restorative work he's been a leader in in that area of dentistry and he's participated in my in both of my research handbooks about the T scan and we've done studies together he actually he actually discovered that the T scan using the T scan can greatly improve cold sensitivity and teeth without changing fillings without using MIDI commands and desensitizes that it's really a bite related problem from poeple hyperemia that comes from excessive bite pressure and too much lateral stress and so he's been a prolific advocate of measuring the occlusion and measuring the joints and he's sort of helped both dr. Piper and myself educate dentists throughout the world and

Howard:  what about William manis

Dr. Robert Kerstein:  well dr. Manus was my teacher in prosthodontics and he it's interesting he he tried to interest dentistry in the T scan one and at the time in the mid 80s he lectured all over the country about the benefits of measuring the occlusion but the T scan was a little early for computerization in that dentist smart really acclimated to computers as I said we didn't have laptops or desktops or computers II the school Tufts had no computerized records everything was still on paper and so it kind of preceded the computer era and although I wrote a lot of articles about it and began to study it by the time he decided to retire from practicing prosthodontics the T scan was still in its infancy  

Dr. Robert Kerstein: um so how was uh how was text and doing today 

Dr. Robert Kerstein: well it's a worldwide company that has many engineering applications as I said the same sensor can be shaped in many different ways so there's podiatric applications as industrial applications there's the biggest area that I'm aware of is the automobile industry engine seals and gaskets windshield wipers how they sit on a windshield chair automobile economics how you sit in your chair when it speeds up your car seat you know how it's designed they also have wheelchair applications they have sports applications it's a it's a ever-expanding number of applications because it's one of the few sensors the T scan sensor and it's and its siblings all measure time and force and so you have dynamic information so an example would be if you wanted to measure the gate on a racehorse you put these sensors on the horseshoes and the horse runs around the track and you get gait analysis and timing analysis and you know I'm not a horse person but I mean that's just one application the same applies to people posture there's posture programs there's balance programs is podiatric programs where you can where you can measure a human gait human analysis and how much pressure is on a foot you've actually seen Howard I believe if you've ever seen a commercial for the dr. Scholl's kiosk where they show you someone standing in front of this machine and above their head is a sort of a red orange blue green foot that is is yeah that's a t skin color map shaped in a foot and when you step on the kiosk it tells you what orthotic fits your pressure map so those are just you know the many applications the company has been able to use the sensor for but the original sensor as you pointed out was the t scan one sensor and that goes back a long way and 

Howard: who in their company who had T scans in charge of just dental and not Auto and all the other places that division is 

Dr. Robert Kerstein: headed up well the medical and dental division is headed up by a man named Dave Nelson and the product manager the product manager is Alissa Rubino so is is auto since automobiles is so much bigger than dentistry

Howard:  do you think tech scan will be moving the dentistry will become smaller and smaller or smaller part of it 

Dr. Robert Kerstein: well I think the dental and medical division is stands on its own meaning that it's it's it's a say it's not that it's not separate from the company but there's applications in medicine and dentistry that are important to the company to develop and evolve and Texian has put a tremendous amount of innovation and hard work into making the T scan a very valuable product with you know for the for the dental practitioner and for the patients who are receiving the care it's a real game-changer so I don't see them minimizing the medical and dental division but I'm not privy to that information I mean I couldn't really answer that question for you but in my experience I can tell you that the T scan has been evolved to meet the needs of the dental practitioner many many times 

Howard: so when you and I got out of school occlusion was bite bite tap tap tap tap tap and the big occlusal questions were can I just do this with a metal quadrant tray or do I have to take up full arch and mounted on an articulator and now it's digital occlusion and so what now I'm a big fan of you and you have a big book on Amazon with all five star ratings you don't even have a single four star rating a Hamburg of research on computerized occlusal analysis technology applications in dental medicine two volumes tell us about that book and I have always said writing books like you having a child it takes more than nine months to make how how tell us about tell my homies what they would learn if they got that book and is it a book they could do on audible because you know Millennials like to read books in their earphones while they're in yoga class or I assume eating kale or something like that or is this a book where you need to buy the book to see the pictures in the diagrams

Dr. Robert Kerstein:  yes you need to be able to see the diagrams and the images to be able to understand the context of what's being described but there so there are two versions of the handbook the two-volume handbook came out in 2015 and that we recently updated to a three-volume handbook in 2019 and that's the latest version and the handbook contains every known application of the t-- scan T scan and orthodontics TCN and prosthodontics T scan and implant dentistry T scan and periodontal disease T scan and patient education T scan and occlusal diagnosis T scan and t md so T scanning cold sensitive teeth you know it's a it's a vast T scanning digital workflow it's a vast resource for anyone who wants to learn how to use computerized analysis in any discipline of dental medicine and it's all backed by research it's really we've been studying these things for a long time this is 300 T scan research papers in the literature at least I can't tell you the exact number and numerous clinical reports and detailed explanations of how to use the T scan now one of the most interesting chapters is T scan and posture and T scan and balance and so the handbooks are really a complete treatise on how to use the T scan in the variety of disciplines that we all face on a daily basis 

Howard: we're starting to go into digital dentures do you see digital occlusion and digital dentures merging 

Dr. Robert Kerstein: of course because there's no dentures again I like scanning you know there you get pictures of your denture you make it you know in a milling machine or you make it in a an injection molding machine it still has to be adjusted occlusal II nothing about the scanning and milling process negates the delivery of the occlusion at the time of insertion and although the scanning companies may want people to believe that they have forces in there they can use that are actionable that's not the case at all you cannot make forces out of pictures you need to draw that information out of the patient and that's where the T scan technology is unique it's the only available technology that allows you to actively measure internal pressure interface forces of the teeth-gnashing against each other milling against each other banging into each other and so a digital denture would be made digitally processed however it is come out to go into the patient's mouth and then at the insertion stage you would use a t scan to control the forces on the delivery and 

Howard; my god it's come so far I mean I remember when I was in school from 83 to 87 the big new thing in TMJ was condyle ectomy and replacing with artificial condyles and then remember when the boys at LSU had a special coating on that and then then that broke down and fell apart do you remember that one yes and in fact Mark Piper used to be St. Pete's maxillofacial surgeon and Tampa so in your journey I don't know if there's a history of TMJ surgery but how does how does Mark Piper be an MD DDS oral surgeon used to be Pete's TMJ surgeon how does the surgery component look today are you seeing less surgery or is the surgical component of TMJ going up is it flat or is it contracting

Dr. Robert Kerstein:  well to be honest with you I couldn't answer that because I'm not a surgeon and the applications of the T scan fall into treating the excuse me the applications in TMD fall into treating the occlusion where the joints are stable and intact and mildly let's say a disc is mildly to place to partially displaced but once you get into the surgery you're dealing with you know major structural skull based problems or major condylar problems dis completely displaced so I think there's still a fair prevalence of that and there's still a fair prevalence of a closely caused TMD but percentage-wise it's pretty well known that most patients who have TMD symptoms are really about 80% of them are mostly my Oh Janice must problems that's where the occlusion is and the T scan really helps with that that's a one of the greatest advances in use of the T scan is that it greatly cuts down on the number of splints it spins we have many studies and show how the copy use of the t s-- can lessen symptoms cuts down on clenching and grinding reduces headaches reduces facial pain improves chewing these are all things that we've been researching whereas the skull base breakdown and condylar breakdown you would you would determine that in advance and if that's the case that would supersede any accusal treatment to deal with those disease states and then ultimately when whatever that led you to if that meant opening the bite and creating space for the condyle to regrow and then later putting the teeth back together again that's where the T scan would come into it wherever the teeth are part of the treatment that's where the T scan would come in but as I said I can't honestly tell you whether surgery's gone up or gone down and wouldn't you need a surgeon to tell you that well I mean but 

Howard: we both know I mean we both we hear less and less of our colleagues talking about it I mean it's you don't I remember in 87 I was routine when the pano came out of the pan oh the condyle looked funny you'd send it to oral surgeon and look at the condyle and and sometimes they'd recommend that it be chopped off and I mean I heard of that in two decades 

Dr. Robert Kerstein: well maybe Conda left me maybe on a downswing but arthrocentesis and you know open joint surgery may be equally as prevalent firing conductivity but again I wouldn't be able to answer that Imaging has really improved our understanding of how to determine that and so although a panoramic x-ray can show you some things in MRI far more descriptive of the true structural breakdown of the joint space and CB CT also far more instructive of those things because you can manipulate the views and you can turn the anatomy around you can look at the condyle for 360 degrees you can you can cut the patient's head in half and slice right through the different parts of their joint and see the structures and so it's possible that because of imaging there may be less of a need for surgery because more can be known diagnostically but again I'm not one who can tell you definitively so we're 

Howard; so do you think a t scan is standard technology for your basic family and restorative general dentist who does fillings and crowns

Dr. Robert Kerstein:  it should become that and it should be on that because the nature of articulating paper is so nondescript and dentistry has relied on principles of how it's used that are not scientifically valid and I think that's a huge problem for the patients and the patient's have suffered complications related to dentists using articulating paper in a very unsupported scientific way whereas the T scan completely or nearly completely eliminates that subjectivity that articulating paper offers the clinicians so yes I I would say that run the the family dentist would benefit from the T skin just the way you know high-level implantology would benefit from the t scan because the occlusion of a single crown or 28 crowns is still potentially a problem as I said you know many of my patients who sought me out came in where they only had one two three fillings done and they lost control of their bite and they had been developed TMJ symptoms that no one was able to resolve for many years so a simple dental procedure which doesn't seem like it would you know throw off someone's occlusion certainly can do that and at the core of that is that choosing marks subjectively based on looking at ink spots it's not very scientific and research is very clear on the ineffectiveness of that methodology 

Howard:  so is the so you think you're hoping that we start moving occlusion from analog to digital you think tech scan would be a much better thing for that do you think the CB CT is as mandatory as a tech scan to understand this occlusion 

Dr. Robert Kerstein: well I think the CBC tea is mandatory to look at the joint anatomy and skull structures and and and and anatomy but not the micro occlusion a CT can't help you with the micro occlusion and MRI can't help you with the micro occlusion it can only show you the orientation of structures and their level of damage you know all you know calcium changes abrasion where structural breakdown but not treatment  of the occlusion is really at the tooth level and the interface of the teeth meeting and mating and milling and gnashing against each other that's what the dentist on a day to day basis has to manage and so yes the t scan is at the core of managing all of those things but a CT is really a diagnostic tool a great diagnostic tool and very helpful as is MRI but not in terms of actually treating the occlusion 

Howard: so certain it off with a force sensor from MIT then it went to a matrix pressure sensor now it's a pressure sensitive film position sensors it seems like this the MIT technology this is kind of in a Cambrian explosion it seems like it's really coming out with a lot of iterations going in a lot of different directions from dentistry to cars does this seem like what that way to you 

Dr. Robert Kerstein: well that's what happened and the center was evolved as things about it required improvement so the current a sensor is not the same sensor as the t scan one sensor obviously and it's has a very long shelf life t scan one sensors didn't have a long sense self-life they're epoxy matrixes these are new senses of nylon mate mylar matrix with conductive ink and and a lot of sophistication and tech scan researches and analyzes their sensors and on a regular basis for accuracy repeatability durability and so the applications and other industries have stemmed out of the the original t scan one sensor but the sensors in all the fields have evolved in order to meet today's needs and a term that I get a lot of questions on is metric you say treating occlusal problems with the biometric method using T scan and electromyography

Howard:  go slow with that because I'm the the ones in dental school have not heard of probably electromyography and biometric seems to throw them off too so will you explain that fundamentally 

Dr. Robert Kerstein: sure biometrics is simply a term that connotes using measurement and bio means measuring biology so we can measure not only with the T scan we can measure the occlusal forces and timing but there are some amazing biometric technologies that measure muscle physiology that measure chewing function that measure jaw motion and joint damage if there is joint damage and so combining them all can greatly aid in the diagnosis of a patient's occlusal status their muscle physiology you know if they're a chronic pain patient do they have dysfunctional muscle physiology that they have normal muscle physiology if they have joint problems are they displaced disks are they born to go and contact them they affect their chewing motion do they affect their chewing strength there are all kinds of things that have been studied using these biometric technologies that pair with the T scan so you can work with three technologies on one patient for example all paired together to get a full profile of their true function with measured data and for example chewing can be measured the speed of chewing the art of chewing the dysfunction of chewing the teeth can be measured for how much pressure there is on some of the teeth how much it's too much in some area and not enough in other areas the muscle physiology can be measured as to whether there's you know extreme contraction strength whether this weak muscle strength whether there's hyperactivity present at rest and so there are so many things we can measure that we have the capability of truly diagnosing a myriad of occlusal related issues and so using these biometric technologies in tandem is really the secret to that

Howard:  and the difficulties dentists face and practice using subjective occlusal indicators like articulating paper which studies show dennis struggle to interpret properly and leads to many occlusal complications I mean the way I see this is I mean there seems to be a lot of Voodoo and occlusion like like Dennis will always say leave the temporary high and when used to meet the crown take it out of occlusion I'm yeah there's just all kinds of weird stuff like that um what would um so I want to ask you and I know this I asked you to you know you don't want to make it too simple but let's go through I'm trying to think like it was when we got out of school in the eighties right so their first question is okay if I'm just doing a one tooth ground this is how they think and and and the reason we leave anonymous on dental town and the reason it's been growing a thousand member it was a month since we've launched it and is because you can be anonymous and we know who you are so you have to register we have to know who you are but if you want to go out there and tell them that your doctor biometric you know knock yourself out cuz relic Christensen Gordon's wife was the one who convinced me when I was dealing with transparency she said Howard there has to be a place to ask a stupid question she goes every time you lecture you say okay is there any questions no okay well let's all take a 15-minute break and where does everybody do run up to you and ask you that little personal question because theirs is unique and it's as unique as everybody in the room and what I usually do is just write a bad answer when that when they come back so so this is what they think and that well if I'm just doing one crown I don't need to know all that occlusion stuff I can just do a quadrant tray now if I'm gonna do a bridge well then I should do a full arch but then how we win when should it be mounted on an articulator so that's how they think so address that so let's go 2-1 to Tennessee and and you watch their career they start off with one two tennis tree and it takes four or five years before start doing quadrant dentistry and I don't see really anybody doing full mouth dentistry inside of their first decade unless maybe their dad was a dentist or they're you know or they could were really motivated but so just start with that do I have to know occlusion for one tooth dentistry 

Dr. Robert Kerstein:  absolutely as I said many of my patients had one or two or three teeth worked on and they went south and it happens very frequently any patient that's been treated with a single crown who comes back five times complaining about their bite has had an occlusal change so yes a single tooth and whenever by problem 

Howard: I know what my homies all do they just come back have you bite down wherever hit say they take it out that's so what do you think of that methodology oh if that's so Hertz will just keep taking it out of occlusion until you just coming back normative treatment 

Dr. Robert Kerstein: I think it's what happens but it isn't in the best interest of the patient okay but explain to them why because when the tooth is taken out of occlusion if that's the ultimate endpoint other teeth strike worse or let's say neurologically less well tolerated see the occlusion is is like a piano a subtle change in one key and you have can affect many other places in the arch that you can't predict and so a single tooth can start a cascade of many downturns which again I've seen many times and other times a single tooth has no bearing it doesn't take it out of occlusion that doesn't change the patient's comfort zone but it's the difficulty is you don't know who that is you don't know who that is and so when a tooth is taken out of occlusion it can start a cascade of many things and I've seen it for years and years and years so single tooth dentistry doesn't preclude someone from needing to understand occlusion and multiple tooth dentistry doesn't doesn't mandate that they you know are able to do it if they don't understand occlusion but you know it's not it's not well defined by our profession but I would caution people to think that even a single tooth has to be handled well inclusively or you can have neurologic changes that are untoward and this is why patients come back for many visits sometimes after having something done that changes their bite and the beauty of the T scan in those situations it really shines in those situations because it shows you if you took a record beforehand and then let's say you had made a single crown and the patient had trouble adapting he'd be able to compare when they were stable to what you provided to them and make targeted Corrections to get them back to where they were but that's not the case with non-digital goozle indicators like wax and articulating paper and stone models you can't can't see what's really going on pressure wise force wise time wise and yeah so single tooth dentistry warrants a lot of knowledge about occlusion just like any other dental procedure and 

Howard: are you familiar with been sutler been Sutter yeah been Sutter

Dr. Robert Kerstein:  yes he's someone who I personally trained in his office on how to use the t skin and treat TMG TMJ patients with the t scan he's become a very prolific author and lecturer he wrote one of the chapters in the new handbook 

Howard: because I just have the biggest fans on dental scan like when Ben makes a post on TMJ okay like here's a post did he post our references our current scene 2 3 4 5 6 he puts 8 different publications that you he quotes you eight different times and eight different periodicals the effects of reduced exclusion time the treatment of my own facial pain Journal kind of anyway he's like hey it's like talking to a minister quoting the Bible I mean you are just all my friends that are over the top and occlusion do they always quote you have you ever thought of starting a church 

Dr. Robert Kerstein: well we sort of have digital occlusal and following that is you know people who want to advocate for the needs of the page said it's researched well researched treatments that they're rendering and the the benefits of the patient is is dramatic and so Ben has become very sought-after because he's been using these principles and and he's found them to be very helpful so I'm sure that's why he's citing them

Howard:  so for the for the kids again knowledge has no value if it's not transferable so to the kids I'm where do you think they're gonna get in trouble first for the clusion is it going to be one to dentistry is it gonna be their first three in a bridge or is it gonna be III I know a friend that posted this case on dental town his first crash in the wall was when he did a smile makeover the front 10 teeth with veneers and I mean he even says on the deals I mean the veneers are on the outside the buckle side he didn't even he didn't even see this occlusal nightmare coming but after he did ten units of veneers on someone that was when he first crash where do you think they're gonna get into trouble first

Dr. Robert Kerstein:  I think the what's said to anyone up for trouble is relying on the subjectivity of the non-digital occlusal indicators so any any case could be a patient could start a patient downtown it doesn't necessarily have to be a big case it could be a single unit it could be three fillings in a quadrant it could be you know a set of veneers I would imagine in that 10 veneer case he might have come over the buckle on some of the premolars and that would be a change in the occlusion in that area and that's again very it's if there was a ten veneer case and he came over the buccal cusp of four of those premolars that's a four unit case that just changed the occlusion for that person so it's really the subjectivity that predisposes dentistry to these kinds of problems not not the procedure itself it's it's the lack of measurement and choosing paper marks by how they look using principles that have no scientific foundation and unfortunately they're still being perpetuated those principles are a big mark is forceful a little mark is light force and and contacts that have holes in the middle of the ink are forceful none of that is true scientifically it's actually been shown that a big mark is only forceful 14% of the time so that means if you go by that method you would choose incorrectly 86% of the time and just by choosing the wrong mark you can start an occlusal cascade and this is what I saw for years in my patients coming to seek me out in my practice 

Howard: ok so again I'm always I always try to be the champion for the our replacements right that the kids in dental in school so they're succinct question is when can I go with a quadrant tray when do I have to go full arch and if I had to go for arch how would I take a CR record 

Dr. Robert Kerstein: well interesting those are all very good questions there isn't a right or wrong answer you know you can make a single unit in a quadrant impression and succeed very well with the patients who's not so occlusive affected you know and I don't mean they start out with TMJ I mean you just don't know who it is that a quadrant impression might be adequate for you know and then you could argue well if I did a full arch impression did it change I still had the patient come back five times for cool adjustments so it really isn't the protocol of the making of the teeth because you know we can make nice teeth with digital methods we can make nice teeth with a beautiful technician can make gorgeous teeth it's the protocol the insertion that's where the trouble comes and so I don't I can't tell you there's a better answer that full-arch impression is guaranteed to minimize single-unit crown problems over a quadrant impression it's not true any restoration could be greatly accepted by the patient or greatly unaccepted by the patient depending on the occlusion that's given to them and if it's ground out of occlusion possibly because other teeth are now striking poorly that were not anticipated so without a full arch view of the occlusal pressures and it's very difficult to know whether a good result has been installed or not and so again that's one of the beauties of the T scan it gives you a full arch impression not an impression as in stone model or digital impression but a force impression timing impression of the full arch every tooth and what it's doing the pressure wise 

Howard: my favorite thread on dental clinton is what are the zombie ideas in dentistry that have been thoroughly refuted by a mountain of empirical evidence but nonetheless refuses to die being continually reanimated by our deeply held beliefs what are the zombie ideas of occlusion that we know went out with the Flintstones but there's a bunch of people that are old and by old I mean anybody who's an hour older than me still hangs on to and believes 

Dr. Robert Kerstein: well there are many inclusions they've actually been proven scientifically invalid probably the most important one for the young dentist is that the the the principles of paper mock so that I just told you that big marks are not forceful very often and small marks are often very forceful because they're like stiletto heels you know if a woman steps on your foot when you're dancing with her with a four-inch stiletto heel it's gonna kill your foot but if she stepped on you with a sandal flat shoe it's not gonna hurt so much well that principle applies in dentistry and we don't we don't teach that we teach it actually completely incorrect that the paper marks illustrate force by their size and by their color depth it's actually been shown in research that the bigger marks and the darker marks have less force on them because the ink survives on the tooth surface because the pressure gradients are very low so in other words when you have a lot of ink you have very low forces and when you don't have a lot of ink it's because the ink gets squeezed out by the pressure the ink is a physical entity it's not it's not a mark or a force it's just a physical entity and when there's too much pressure it gets squeezed out into little bits and the carbon paper gets destroyed into little bits so we're teaching this in your word you know outdated dinosaur you know belief zombie belief that really gets dentists in trouble and it's it's all been proven incorrect and another one that's really is you got to make that one under ten words the principles of occlusion that bite paper marks matter would you say that articulating paper marks measure force and show force by size and color depth is completely unfounded in research and what's worse than that is that when dentists are tested for their ability to choose forceful contacts by looking at paper marks they perform very poorly okay saying yeah I have the principles of occlusion the zombie ideas of occlusion that articulating white paper marks are based on force that articulating paper marks show for us by their size and color depth so force based on their size size yes size and their what their color deborah color depth

Howard:  okay so and so okay so the zombie ideas of occlusion that articulating bite paper marks show force based on their size and their color depth yes is that right yes and then you would say which is totally false or what would you totally unfit small ready didn't been disproved in studies there are studies that have been done since 2007 what's another what's another zombie idea of a collision

Dr. Robert Kerstein:  that TMD is not an occlusal problem tmd the number one cause of tmd is occlusion and we've also proved that for many many years with t scan studies but the the literature is whenever they do one of these meta analyses that said that start again that TMJ what that tmd does not is not caused by a collision 

Howard: so you're saying the zombie ideas of occlusion that TMD is not caused by occlusion

Dr. Robert Kerstein: right is and that's totally incorrect so you're saying it is caused by occlusion absolutely occlusion is the number one perpetuator of TMD problems and what would you say to the guy who says well as a psychosomatic I mean this girl's graining her teeth but she just lost her job and going through divorce yes stress is additive but it's not causative stress yeah it's additive not causative so her bite is causing high muscle firing which is why she's grinding her teeth and her job gets lost and she grinds worse but we actually have studies that show we can stop the grinding in the clenching and the emotional aspects we did a very interesting study in 2018 we took a II patients who had TMJ problems who were emotionally depressed so they filled out a depression index a known depression study something like the MMPI it's called the Beck Depression Inventory and when we we did that beforehand of all 80 patients then that classified them into mild moderate severe depression borderline depression there are about five or six categories that come from that effect Depression Inventory the vast majority of the eighty were moderate to severe depression and the reason for that is they're living in chronic pain with facial pain and headaches that they can't control and weak jaws and difficulty chewing and pain facial pain and then we treated their TMJ with this process known as disclosing time reduction which is what you read from dr. Sutter's post on dental town the scooching time reduction is a specific application of the T scan that that treats the time of excursive contacts down to fractions of seconds and when you treat the dispersion time you turn off muscle hyperactivity it's a direct effect that's been shown through EMG studies and you can actually go back my paper on the solution time was 1991 so we treated these 80 patients with discussion time reduction and then within a few weeks they filled out a new back Depression Inventory so they were treated and at three weeks they filled out a new Beck Depression Inventory from the 80 that were clinically depressed after three weeks about 17 were borderline depressed the rest were no longer depressed because their chronic pain had left them at three months only two of the eighty were borderline depressed 78 were not depressed and again they filled out a Beck Depression Inventory at three months and so the nature of TMD being emotional is really not true the truth is that the emotions come out of living in crying pain and having dysfunction and not being able to chew and being you know having headaches that interfere with their daily life and when you treat that the chronic depression goes away and so we have again shown in research that this concept that TMD is an emotional problem is not true at all but it gets perpetuated because people want to keep these beliefs of the past going just what you said about these zombie beliefs they keep them going 

Howard: okay I'm sorry to just go into a totally different direction but I'm now there's a lot of TMD theories being added and combined with sleep apnea and and that's thrown a lot of things there's been guys that come on this show that said if you make a night guard for somebody and you don't screen them for sleep apnea it's malpractice so how does the TMB occlusion play into sleep apnea snoring an appliance therapy

Dr. Robert Kerstein:  well it's fascinating actually where again the discussion time and the seclusion time reduction has been shown in clinical reports to open the airway without having to use an appliance because it relaxes all the muscles that are involved with swallowing and breathing that the teeth hyper function so the teeth played a huge role in constricting the airway and making an appliance does two things it keeps their teeth apart from constricting their airway to some degree but only when they wear it when they chew eat and swallow without it in then the muscles get constricted again and the forward appliances the sleep of clients is that you know move your mandible forward and keep the airway open they mechanically open the airway but again when you take it out the teeth come back together and constrict the muscles so there's huge implications for the teeth and sleep bruxism and in airway and yet the sleep community has consistently discounted the role that teeth play in sleep they everyone seems to continually advocate that the teeth are you know like a like like not a component of sleep bruxism that it's a central nervous system problem and that's psychological and it's not true we have studies since the 1990s which show clenching and grinding and nighttime bruxism goes down in patients and people don't wake up feeling facial pain when they have this discussion time changed so there's a very serious direct effect to sleep it's now being understood we've been seeing in in airway CTS after the discouraging time is reduced the Airways widen and this is because the throat muscles among the teeth have a direct effect on the muscles of swallowing and the unique neuroanatomy of the teeth posterior teeth not to get too technical but in simple terms they talk directly to the muscles that control swallowing and your brain controls swallowing because it's a survival skill so the teeth I think you'll find this interesting Howard peripheral nerves do not synapse inside the central nervous system they all synapse outside the central nervous system they stop outside the spine spinal column and enter ganglia and then they travel from the ganglia into the spinal column only the proprioceptive from the molar and premolar PD LS and the molar and premolar pulps go directly into the brain and there is no synapse outside the brain they're the only peripheral nervous structure that does that and Tia in the entire human body and then when they synapse this is with the muscles that control swallowing and so what happens is every time you rub your teeth together you can tract a lot of muscles and so as people use their teeth to chew eat swallow that they clench and grind they contract all these muscles automatically that can't be controlled by the human it goes on automatically and so over time this use of the teeth constrict the throat constrict the muscles of mastication tighten up the head and you get symptoms of you know muscle fatigue in patients that are susceptible so the airway and the swallow mechanism are directly tied together and so we're seeing now with airway CTS as I said you can see a widening of the airway after decision time reduction when the muscles of the swallowing mechanism all relaxed which is why the symptoms go away and it's why the depression goes away so there's huge implications for treating the teeth involving sleep 

Howard: now I'm gonna get you in big trouble okay how's that sound now I'm gonna well hopefully I will because here's what's gonna happen she's listening to all of everything you're saying now and then she graduates and she's gonna go back to small-town Texas with momma who's a dentist and momma only texts with articulating paper if someone's grinding their teeth or as TMJ or whatever she's just gonna have the assistant come in take out for another alginates and make a make an occlusal tray right a bite splint and she'll check that a couple times and that's the extent of TMJ and small town mid-america so how do you and then she starts hearing things like deprogramming and then when she talks to her mom about that here's what her mom's gonna say and ask me how I know cuz I was sitting in a bar in Beeville Texas listening to a girl talk about her mom they were both dentist said her mom was there and basically the bottom line is her mom said I don't you know what do they know about occlusion I mean first it was the joints were up and back and then it was down and forward and now it's out to the left on the ride they don't know where the hell it is this works fine so how does a little 25 year old girl I mean it's her mom her mom's 30 years old how do how does how was she supposed to go back to work with her mom and start a different TMD protocol 

Dr. Robert Kerstein: well that's a very good question I think it comes from within the practitioner they have to want to apply what we know now 30 years later from what all those concepts you're mentioning have been refuted and and it's the modern era of digital dentistry where we know things because of MRI and CT and T scan and imaging and biometrics that are available to any practitioner to learn and it would take her own personal strength to want to learn those things and maybe make a change in her practice as to how she might approach it I I really you know I know it would be hard with a parent saying no you don't need to do that or elder let's say if you're an associate or practice would be difficult to do that but the longer that young person goes without learning really the new understanding the more likely they are going to struggle with occlusion in their practice and create potentially a number of untoward scenarios 

Howard: some questions these are common questions last guns Asha I guess I got the man on what is a deep programmer

Dr. Robert Kerstein:  the programmer is a device that separates the back teeth and allows the muscles to relax because the back teeth no longer touch so it's a can be a made out of acrylic it could be made out of resin it can be made out of it can be possible if we made you know casting gold if you really want to go crazy but it's you know an NT eye is like a deprogrammer it just barriers to the back teeth there's no contact on the back there's only contact in the front and the way the way they work is they disclose the teeth and that's actually the their mechanism of action by disclosing the teeth they cut down on this synapse that I was talking about the back teeth tree contractions of the swallow mechanism muscles and so then the system can calm down sometimes it works and sometimes it doesn't I mean in in there are plenty of people that came into my office who had a bag of deprogrammers who are still having symptoms because when you chew eat and swallow all the muscle activity mechanisms go back into place and so a deprogram I can't stop that

Howard:  so when you said you said nti and that one is actually that is um now an exclusive only at national dentex labs and that's the that's the only publicly traded really dental DSO I mean there there's no there's no dental DSO is publicly traded in the United States there's two in Australia one in Singapore but there we do have dental laboratories are publicly traded through national dentists labs it's mostly all the owners are in China as it's basically an Asian low-cost labor play but uh but  you you're the one that said  is do you have a favorite deprogrammer and you know they do use them very often 

Dr. Robert Kerstein:  I rarely used appliances because of the t scan I was I was able to practice without making night guards deprogrammers multiple years I only used occlusal God's in very isolated situations because the t scan and shortening the discussion time controlled all the muscle physiology problems in many many people and that's what dr. Sardo was talking about when he's posting on your on your forums so i was able to get away from making appliances in the early 90s and continue to do that but i will say that they're very helpful they they can get people out of pain and they they they don't have to be sophisticated they just have to keep the back teeth apart so they work really well to do that and then symptoms tend to wane so

Howard: so you don't use make night guards either 

Dr. Robert Kerstein: very rarely only if someone only if someone who well I have to preface that by saying most of the patients that came to see me already had one or more appliances and they weren't getting resolution and it wasn't because the occlusion wasn't designed well on the appliance it's because the neurology of the pulps and the PDL override the appliances ability to control the symptoms so a typical scenario that illustrates that would be someone would come in they'd say they were 50 years old and I'd ask them their history and they'd tell me when they were 25 their jaw bothered them and they got lots of headaches and they were grinding their teeth and they got a night guard and the night guard worked for a while and helped them but as they got older into their 30s that same night guard stopped working and so they got another one and that new one didn't work like the old one originally worked and the reason for that is the neurology has been amped up for another 5 or 7 years because the appliances can't control the neurology so over time the normal occlusal function and I'm not talking about clenching Ronny I'm talking about chewing eating swallowing overworks the head muscles who in a susceptible patient to where the appliances have no effect anymore so when someone came to see me because they knew I had an alternative approach they weren't coming to seek out an appliance they were coming to get treatment of their occlusion so I got away from making them because most people who came to see me had them and they weren't they weren't effective anymore in a typical practice an appliance can be very helpful to alleviate symptoms and and help people you know get more comfortable and then their occlusion can be addressed and another great application of the t scan is to treat the appliance with t scan data and then you have a much more controllable appliance because the you know an appliance let's say let's say we make one and we just use articulating paper what if the imbalance on the art on the splint was 75 left 25 right that's not gonna help the left condyle that's not gonna help the left joint space it's not gonna help the left musculature but you wouldn't know that with a without a t scan because the t scan shows you what the imbalances are so you can take the t scan and use it on a splint it's one of the great uses of the t scan so but in my own experience I was not called upon to use appliances I was being called upon by the patients to help them directly with their occlusal problems 

Howard: okay so you talk about tech scan and there's another country called Germany and Germany has a company called by dr. Jean Bosh Bosh articulating and she's come up with the what is it the occlusions by Bosh occlusions have you heard of that yes of course and no but I got asked but anyway I'm so what are your thoughts on it

Dr. Robert Kerstein:  well I think it's really great that there's another digital tool entering the marketplace because Digital Inclusion is the forefront of occlusion it's it's the future but it's important that the listeners understand that Digital Inclusion means working with data and you have to ask yourself what does the data tell you well at the present time unlike the T scan because we've been working with it for 30 plus years data is not understood it doesn't it doesn't it's not a t scan so if someone tries to use it they're gonna have to interpret what it's saying in ways that are not known and this is a very important thing to grasp Digital occlusion is using data and metrics and the OCO sense metrics are not understood as of yet and I can speak to that because when T scan one came out in 1984 we didn't understand the metrics then either and through testing and through research and through testing the sensor for accuracy and understanding what the data meant we were then able to apply that data to make a better denture to make a better crown and bridge insertion to treat tmd more effectively than with appliances and so Oakland's data is not understood and  I think this is very important to understand and it's interesting gene Bausch was asked about the t scan about dr. Sutter actually wrote out a paper comparing the two and he found that there were a lot of improvements in the t scan that the Bosch product doesn't have and when gene Bausch was asked that comparison paper in in her words or I'm not sure but to he or she she said well it's really not a tea skin so I think it has a long way to go before it has clinical application it's um it's just not understood and as I said Digital occlusion is using data and until the data is known a clinician is not going to be able to apply it in a clinical sense with any with any knowledge of what to do with that data 

Howard:  knowing everything I just know when I get off with you sir or are we okay to do overtime yes because I know I know each punch I'm going to get in the stomach if I don't ask you and I didn't even I haven't even asked about pharmacology yet there's a you know in the last thirty years a lot of dentists someone starts grinding and they get an episode they would give him a what was what was the most common one it wasn't valium it was ativan wasn't it like technologies valium in generic form so are you is one of the tools in your toolbox pharmacology at Walgreens and CVS

Dr. Robert Kerstein:  for a toothache maybe but not for muscle relaxation again the muscle relaxation can't come externally that's why Botox fails every few months that's why medications have to be continuously taken the only way to relax the system is to treat the occlusion in specific ways which we've been studying for a long time and actually there are a number of studies in the literature that that I published that show we can reduce medication ingestion by treating the decision time again the same entity we've been talking about is has a very far reaches in terms of how it affects the head and so I would use medication sparingly as part of my treatment it would not be a frontline treatment it would usually be after treatment if someone was struggling to get good healing I would I would assist that healing with medication but not as a primary treatment and so it's interesting the Beck Depression Inventory study and another study from the past 1997 study that we did showed clearly that people could reduce their medication ingestion once their disclosure time was treated properly so this is again a huge advantage to the human physiology a great benefit to the patient if they can take less medication

Howard:  now you're in on you're in Boston so if they're Irish you just give him Jameson or is that treat the Irish ah completely different

Dr. Robert Kerstein: I tried to give everyone the same high quality care 

Howard: really even if there that is amazing so pharmacology is not a big deal another one is I'm if I asked any dentist at first ten years out of school what's the scariest monster in occlusion I know what they're gonna say they're gonna say opening the bite and they just all they want to do is never never do that because they know if they do the clouds will open and a tornado will suck them into the universe white why is that that one of the scariest concepts and what what do you think about that 

Dr. Robert Kerstein: well it's interesting Marc Piper has shown that you can open the bite a long way and help patients you know with certain structural problems in their jaw joint so it's scary I think because you have to react lude the teeth at a new place and that means creating a new job position and either orthodontic we bring them together or prosthetic we bringing them together and of course that forces the practitioner to treat one arch and total one way or another some something has to be done to react lude the teeth so it's a big undertaking and yet from the standpoint of succeeding we actually have a fair amount of room to open the vertical within reason so and it's it's something that we do routinely in prosthodontics when people have worn their teeth down you know when they're sanding them in to Denton or if we feel their vertical fascia is is you know too closed so dentures we have a lot of latitude with vertical dimension so it probably shouldn't be as scary as it is but from a young dentists standpoint who hasn't done you know any kind of formal prosthodontics it would be the complication would be now I have to put all the teeth back together at this new vertical how am I going to do that

Howard:  okay now I want to switch gears you probably gonna take your digit or I'm done so the two fastest-growing segments of the global dental economy are obviously implants and clear aligners and so whenever you go to ortho let's start there whenever you go to ortho it seems like the really hardcore occlusion guys they're not impressed with how orthodontists treat occlusion they're like man they blow out the curve of speed I blow with the Wilson they do for bicuspid extraction they don't have a lot of respect for occlusion and then a lot of them sit on the sidelines and say to these young dentists can i school dude if you're gonna go into clear aligners you know like if the patient has a small mandible and anterior deep bite that's just gonna be a TMD case waiting to explode so I know I threw 20 ortho questions at you because they're all so dumb I'm hoping one of them might be good enough for you to bite on did you see any of those questions as bait that you could respond to

Dr. Robert Kerstein:  well I can tell you from doing from either being a co-author or from editing orthodontic papers that involve the T scan buts there are many actually clearly the orthodontic treatment tooth movement isn't precise even though it might line the teeth up nicely it doesn't provide for high quality occlusal endpoints and but they're not gross endpoints like the curve of speed isn't good or the you know this this inclination of this tooth isn't good there's that in there as well but I'm speaking about the micro occlusion how the tooth how the teeth relate to each other and what that means in terms of the head neck neurology both it on a treatment tends to hyper occlude the posterior teeth and either non occlude or very lightly occluded the anterior teeth and that creates very difficult scenarios to people it sets them up for excessive muscle activity being made by their head so that's a very significant concern in terms of how orthodontic treatment and results are but another one of the great Apple the T scan is that you can case finish the orthodontic patient to very high tolerances and stop them from having future occlusal problems if you finish their braces or their aligners using the T scan and since it's a it's a great way to optimize the end results

Howard:  so are you familiar Donald Warren 

Dr. Robert Kerstein: no 

Howard: okay don't worry that was another I'm trying to think I just want to make sure I'm not missing anything that um one of my homies gonna get me for gosh I think we've done so much well in okay so now I want to leave the country I've jumped all around now let's go leave the country when I go to major what like Poland I mean Poland what what a huge country Cairo Donticts takes is taken off and and they took off with a lot of the occlusal people I mean that the TMD people and and now when you go to a major dental meeting and I probably lecture in Warsaw every five years there's actually Cairo Don --tx Marcin de lucky do you know Marcin de lucky bro probably the most famous Cairo dentists in dentistry but it started with in dentistry and then as he's getting older you know went from single to two quadrant to forge and third it uh learning into TMG and TMJ and then that followed the whole body posture and the whole the whole thing but so have you heard of Cairo tonics and what are you thinking  

Dr. Robert Kerstein: oh of course I think it's a great combination of you know assistive therapy and you know the gentle components that certainly people can benefit from having the therapy applied but again that alludes to the idea that the occlusion is not at the core of what's really going on and this is what's being lost on many dentists throughout the world is the neurology is not being considered and then the neurology of the teeth overpowers all of these therapies so a person who gets assistive chiropractic care can't get better until their occlusion is no longer throwing off high muscle activity in tensing up their whole head and so there's repeated therapy it's like Botox you just keep having to go back whereas when we treat the occlusion with the t scan definitively we don't need Botox very often so there's a lot of there's a lot of things that have not made it through to the mainstream and some of that has to do with the you know that the measured occlusion studies haven't haven't necessarily made it through to the mainstream but I think highroad onyx is an interesting field and it has applications but it won't be a curative field without occlusion being a component of that

Howard:  interesting interesting and by the way you keep talking about Botox and all that stuff and I just want to say for the record if you're watching on YouTube this is all natural everyone accuses me of having a lot of work done I'm not wearing a wig I'm gonna throw another a wild crazy thing at ya fino paletine ganglion blocks and neuromodulation for managing TMD you know or a facial pain a big fan of that or not really

Dr. Robert Kerstein:  I'm sure it has applications but as a front line therapy no I wouldn't call it a primary approach again all of these approaches are trying to neurologically manage the patient or physically manage the patient but the occlusion hasn't been neurologically managed so if you give someone a ganglion block it'll help them I imagine for sure for some period of time until the anesthetic wears off and then their occlusal neurology will overpower that and so it's just the nature of the problem the occlusion is at the core of all of these things and so external approaches even one that's internal like us like a paletine sphenopalatine block is still an external approach it's outside of the occlusion and its impact will only last as long as the the anesthetic lasts it won't it won't last forever and when you treat the occlusion definitively it really does last for a very very long time unless the patient has because we have Studies on this unless the patient has dentistry done they have the new set of crowns made to change their bike or they have a filling change that throws their buy it off or they lose a tooth which changes their occlusion symptoms can research but if the patient's teeth stay pretty stable once they're treated definitively with the T scan in this specific way that dr. Soto is referring to the decision time reduction lasts very long time and again we have Studies on these things so this just the information is not necessarily reaching the mainstream which is why it's so great that you're talking to me that because you have such reach it's a it's really impressive that you have so many followers 

Howard: well I mean I'm selling something for free and and it's only guy he's getting like you on so you know if I was charging $1 for the show I would be impressed but it's free and so I'm telling my listeners you you get what you pay for right but I want to ask another I'm just trying to always try to listen to the kids and what they fear and what they're afraid of another one is they're always afraid that one day they're gonna tell the place to open real wide and their jaws gonna walk open and they they just they just they don't want that to ever happen they don't ever want to see a face and with their jaw locked oh so first of all is what is a jaw locked open have you ever seen one what do you think causes it 

Dr. Robert Kerstein:  I've seen it a few times it's where the disc is now positioned enough that the condyle can't get past it back into the socket so it's it's it's hard to say exactly what that means but it's where the disc is out of place enough that the condyle can't move in and out of the socket correctly so now it's it's basically in front of the disc instead of the disc being in front of the condyle or over the condyle now when that happens there's no real treatment for it except to manually put it back kind of like you've seen in the movies where someone's dislocated shoulder gets shoved back into this Hockett and how do you put it back how would you describe them to manually put it back mm well I tell them to call a surgeon rather than to try if they haven't done it because many oral surgeons have done it but it's emits a downward pressure to try to get the condyle below the blockage of the disc and get up on the other side of it you know sort of pull it down and it'll spring load back up into place because of the musculature and the ligaments and all the things that have the elasticity but it's a mechanical process you know it's a manual okay 

Howard: so so so hold that thought that this here's my bait and switch for 30 years a lot of worth it honest if you send someone for a TMD consult to an orthodontist a look that this is what they say they say look Howard if I straighten out my arm it's my hands determined by my elbow if I straighten out my leg my foots gonna be in a place determined by my knee and this is the only joint where the joint where the teeth are gonna determine when I join us so what I like to do for my TMD patients is I like to put the joint back put them in full ortho and arrange the T so their joint can be fully seated with ortho on so when I'm doing a TMD I like to do the ortho first to line up the the joints to the teeth and then we'll take it from there now that's a sales pitch I have heard orthodontists and general dentists say for three decades what do you think of that sales pitch 

Dr. Robert Kerstein: well on some level it makes sense that you should align all these things together so that they function together but the condylar position the condylar position in the in the joint space is best served by being under the disc so that would be the ideal place not necessarily up and back or posterior rise the too far anteriorly way down the eminence whether we're normally actually mark piper showed that when you have a slightly torn disc the best place to make the teeth the best place to put the condyle is in MIP where the teeth support the disc when it's slightly out of place so what it might be is they're young and my people all the teeth meet you know they fit together yes all right and when the disc is torn slightly dislocated the condyle sits under the middle of the disc more often in MIP than in any other job position so striving to have that position be where the teeth meet is ideal and I think that's what the orthodontic sales pitches you're talking about is trying to do so that may sense but if it comes out that way can only be determined by imaging the joint and seeing where the disc is I mean it's just not it's words it's kind of like Howard people have been saying for years and years and years and you've heard this and all dentists heard this all the teachers meet at the same time it's words all right when you put the T scan in there you find out that that's not the case one side hits too early three teeth hit too early one side of the arts doesn't come in till very late in the game because of the way the teeth line up you know so words don't translate into true anatomical reality so the orthodontist saying we want to line up the discs the joints of the teeth and then make that all work is obviously that's the theory does the treatment do that is really the true test of that theory 

Howard: you know there's clustering now there's autoimmune clusters one autoimmune cluster I mean you know these people had celiac sprue that Emma said arthritis at hypothyroid now they realizing with DNA testing and 23andme that these are all in family trees that if you're if your family if you have a family reunion and someone's got hypothyroid and takes thyroid medication someone else got rheumatism someone else has celiac sprue someone in that tree is gonna get MS do you think that's a component to tmd a lot of people are asking is rheumatism linked to tmd do you think some of this is an autoimmune disorder

Dr. Robert Kerstein:  interesting question well I can't speak to those specific conditions being related I think that's possible because those conditions would predispose a person to be susceptible to their own human functionality TMJ as we understand it now through biometric assessments and treatment over the years and during studies many many studies is a lack of resistance to the overworking of the swallow mechanism caused by the teeth and so yes the person is susceptible to their own body so in theory it could be autumn in principle in other words you might have an occlusion that has all the elements that are poor in it and yet you don't get symptoms and someone else has the same elements in their occlusion and they get symptoms and we don't know why that is we don't know what is the the reason that symptoms appear in one person they don't appear in another so an autoimmune component could very well be at the core of it but not necessarily one of those disease states I think a lack of resistance to the muscle activity that is made in the swallow mechanism is is a lack of tolerance that should say aye let me rephrase that a lack of tolerance to the muscle activity that's made in the swallow mechanism is why TMJ shows up but what it is that results in a lack of tolerance is not understood at all and and yet it's it's very prevalent because only certain demographics really suffer with TMJ problems you know Asian women are very susceptible Caucasian women are very susceptible Caucasian men are eight times less likely to suffer and women in general my favorite disease 

Howard: Caucasian men are eight times less likely to have this disease yes oh my god that's the next one better than male pattern baldness then so is it well so so um and then here's a big can of worms for you when you see these extreme where in erosion cases I mean they they just like I mean like like a text scan I mean how would you even measure that bite I mean you've seen them they wear them all down to Nub's and then you look at these cases and you say my god I'd have to crown 14 upper teeth 14 lower teeth at have to open your bite what do you think of when you know is the dog wagging the tail is the dentist to tailor the dog what does she do when she's 30 she's 25 years old she just got out of school here comes Frankie's I got a promotion and he wants to look better his teeth are all worn down you've seen the severely worn down deal he has no pain no TMJ just wants a moviestar smile and at first she's thinking I got $400,000 student loans I'd like to prep 14 upper teeth for a thousand each seat them then prep 14 lower teeth what would you tell her about that case 

Dr. Robert Kerstein: I would tell her to refer to a prosthetic it sees the young if she's a young practitioner or take a course in full mouth rehabilitation where she might even be able to bring that patient with her and and do it under guidance there's some very nice you know hands-on Continuum's that actually have you bring patients and treat them and then you learn well aesthetic professionals in California is really run by Bruce Crispin and his daughter Christy Crispin they eat a variety of on patient courses that teach people how to rebuild mouths and deal with aesthetic reconstruction but it's all you know with the patient and yeah and of course LBI is also hands-on with the patient continuum you know and they often do full mouth rehabilitation so you know she has places she can go to learn but the the be in the simple early evolution of a dentist it would be best if she made an appliance and referred that person to someone who can address a full mouth case like that and and then learn how to handle those things I mean it's yes you it looks appetite wedding when you see 28 unions to be made but as a prosthodontist I can tell you it's a big undertaking and you know there might be many endows that might be gum surgery involved there might be minor ortho depending on the positions of the teeth those treatments they can take up to two years so no it's not like doing 28 single units where they're over in two visits or three visits it's a very very different process and I I think I would caution the young dentist to jump into that because they  see the you know they might be exciting or they would really want to help the person but their best strategy would be to make an appliance that would curb some of the damage and refer them to someone who knows how to manage it that was 

Howard: that was a really good answer and crispin is a he really is an amazing guy at me he was on the show he was number 12:45 and the reason he was on first over the news because I asked you in the first ten ii-i've been asking you for four years so I'm still just excited that I got you on the show I'm so wrong so I want to say one thing to the kids though is that I'm the fastest you know Five Fingers what's what's faster what's easier what's higher quality what's lower cost what's smaller and you don't want to hear the answer that the answer is a book like like and I have no connection Robert in his books but I mean he's got the handbook of research on clinical applications of computerized occlusal analysis and dental medicine it's two volumes and my gosh I'm you know when I want to update I'm already the new pathways to the pulp well pathways to the pulp by Stephen Cohen and all those chapters I mean oh my god that that's got to be equivalent to taking 21 day lectures and I remember when I went to the mission state I'd just was blown away it's like people would be asking questions like do they he answer that in chapter one I mean it was like it was like seven three-day weekends and on the seventh three-day weekends people were still asking questions that were covered in the first three chapters of his book and I'm telling you kids that um you could get this guy's book and I mean you might have to read it three times but I know it sounds fun to go get an airplane and fly to Phoenix or Seattle or LA or something sexy because you live in you know Toledo Ohio and it's snowing outside but damn just just go to resort there with your family and read the book you know have to go to that resort and then leave your your kids and your spouse in the hotel room because you're sitting in a lecture I mean Abraham Lincoln was probably one of the greatest lawyers in America and everyone went to law school he went in sat in the library for six months and passed the bar exam which you can still do today in several states you don't need to go to law schools in the Constitution that I mean it's different so I would rather you go to resort with your wife and kids and and just read I how long do you think it would take if he just sat down and start reading your two-volume book how long do you think it would take to read it one setting if you just read it like you would a sci-fi 

Dr. Robert Kerstein: well first is the new one is three volumes so it would take a little longer than the two volume interesting question because understanding the t scan it requires certainly study but it requires also hand on hands-on exposure it's not I don't know if you this relates if you can relate to this but I remember being a dental student and you know we were sent to gross anatomy to you know cut up the bodies learn you know learn the head neck and the night before I would read the section so if it was the ear or the mouth or the whatever we were cutting up I would read it and there were all these words and all these structures and all these nerves that traveled through all these holes and and it was pictures right it was it was looking at the pictures even the really great where there was one atlas I forget the name that was actually dissected pictures and it was amazing to look at but it didn't stay with me I didn't go there the next day and say I know that's the foramen ovale or I know that's the dis or I know that's the that because I didn't have that frame of reference all I had was what I read in words and a picture of it it wasn't until I actually did the dissection and I peeled back the fashion and I saw where the muscle attached to the bone and I saw where the nerve came out of this part of the skull and went to this structure did it stay with me well the T scan is like that you can read a lot about it but you need to have a hands-on reference for it you need to understand what the data means in somebody's mouth even if it's just cursorily recording on patients and learning how to record not doing any treatment just to get a feel for what the data is showing you and then have explanations of what the data is showing you so I would say if person had training on the T scan at least initial training they would have a much more success reading through the book without that it's just a lot of scientific occlusal information that although very valuable and very valid and certainly scientifically tested is not yet understood by the average person without a hands-on frame of reference so they have to do both hands together read and have hands-on training

Howard:  now you know this Dentistry uncensored so I'm gonna have to level with you and be honest of the final thing I have to say to you you do know that as a DMD you're not a real doctor I'm a DDS I'm a real doctor you or not does your DMD and if no no I'm not even kidding because if you go to Outlook and you put Robert Kirsten DD DMD it populates your name as your last name DMD it only recognizes the DDS degree which was the first degree University of Baltimore in 1850 and that's what Amazon did to you when you go to Amazon and you search your name you have to put in the your last name as DMD because it has you as DMD Robert B Kersting and it's just gonna kill your SEO on that site so you need to go to Amazon and fix that DMD and I do wish and I'm being serious it's not fair for the patients there's 325 million Americans they see MDS and dio's they see DD s's and DMD s and in Phoenix Arizona where it's all a transient society and nobody's really born here or unless you're a millennial or younger we always get questions what's a DDS or DMD and what the American Dental Association needs to do is just make it one I don't care what it is I just need the only way you could have one guy be a DMD and one guy be a DDS is if there was a difference in training and you could measure you're talking about biometrics measuring something in biology well where's the dental education metrics that separated BDS from a DMD and here we aren't on Microsoft and Amazon doesn't even recognize a DMD and I'm telling kids go find your book on Amazon and if they go search your name well they don't think your last name is DMD so uh please fix that on Amazon and I'll give you a marketing deal it would be so unbelievable if you did a one Millennials like online scene and they like it in short units an hour if you did an hour online see course on dental town that just summarized your three books if they fell in love with you and they and you got an interested in it and in that one hour you piqued your curiosity and that's what a leader has to do you'll lead them to go read all three of those books and I bet to read those three books and be a summer don't you think I'd take a summer take a while oh I mean what do you think it'd take a 25 year-old to read that paying attention not on their Facebook put their snapchat away and just read it and learn it how long do you think that would take them to read it if they're working full time

Dr. Robert Kerstein:  easily a number of months yeah so

Howard:  so that's my advice you got you got to change you got to change your Amazon account DMD is not your last name it's your degree and and then I hope you I'm Howard at dental town calm the other Howard is Howe go Howard gold Saint thérèse Hou yo he lives in Bethlehem Pennsylvania I wish you do to our course of summarize these three books and because I'm like say you said at the beginning we started to show that you they're well trained on cavities and gum disease yes but occlusion is the weakest of the three right now that's work right right now and it's all gonna change rapidly because I like say with a digital digital everything I mean I lived through when I got out of school in 80s it was the materials revolution we were going from full gold crowns and P FM's and amalgam to these composites and all this stuff you know so the first decade my life was this huge dental materials revolution and then that was as soon as that started to get stabilized where you kind of figured out which bonnie agent yeah I mean you know are you on third generation fifth generation I think I'm on PI generation bonding agent then the the digital revolution came out and you know it's 2020 and I think the Invisalign hell they're on squawk box talking about how all these scans are gonna start getting some measurements on on TMJ but anyways it's gonna be a fun exciting thing to watch it was an honor and a privilege for you to come on the show and talk to all the talk shows today again I think you're the most quoted TMJ guy on dental town thank you for that and thank you for all that you've done for dentistry and continue to do so

Dr. Robert Kerstein:  well I'm honored to be here and thank you for asking me to participate with you I hope was helpful to your listeners and my only question is is 

Howard: my goal was to try to make this podcast I know you're from Boston I was trying to make it longer than the Irishman but I realized I'd have to go 3 hours and 30 minutes so I apologized all the Irish and in Boston that of this podcast was not as long as the movie but alright have a rockin hot day thanks for coming on the show yes my pleasure.

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