1458 Dr. Alain Aubé on TMJ Growth & Development and Pathology : Dentistry Uncensored with Howard Farran
Dr. Aubé Graduated from University of Montreal in '84, and then went to McGill for a residency program with emphasis in full mouth rehab and orthognathic surgery. In 1995 he went through the full Dawson and Pipier curriculum. Then in '98 he was invited by The Montreal Migraine Clinic to study the effect of occlusal equilibration on tension type headaches. He presented the results at the prestigious American Academy of Resorative Dentistry in Feb 2000 in Chicago. Dr Aubé maintains a full time referral practice limited to diagnosing and treating TMJ pathologies and their consequences, and the consequences of severe parafunction. He is also a husband, a father of 4, and has one grandson and another grandchild on the way.
VIDEO - DUwHF #1458 - Alain Aube
AUDIO - DUwHF #1458 - Alain Aube
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It is just a huge honor for me today to be podcast interviewing Dr Alain Aube’ who graduated from university of Montreal in 84 and then went to McGill for a residency program with emphasis in full mouth rehab and orthognathic surgery in 95 he went through the full Dawson and piper curriculum then in 98 he was invited by the Montreal migraine clinic to study the effect of occlusal equilibration on tension type headaches he presented the results at the prestigious American academy of restorative dentistry in 2000 in Chicago in 2007 he published an article that led to multiple lecture requests in 2008 he founded the Canadian occlusion institute because of his knowledge in the field of joint pathology and its relationship to malocclusion he was invited in 2013 to present to the Quebec orthodontist association uh to the international association of French speaking orthodontists in Belgium and then to northwestern component of the Edward Engels society of orthodontist Edward Engels the founder of orthodontics out of st louis he was also invited by university every vol in France to teach in a post-grad program he more recently created a video for the university of Louisville dental school on mri imaging and dentistry this past December he published an article on condylar surface reformation following osteoarthritic damage in the journal of contemporary dental practice Dr obey maintains a full-time referral practice limited to diagnosing and treating tmj pathologies and their consequences and the consequences of severe parafunction he is also a husband a father of four and one grandson and another grandchild on the way well um my gosh we both had four kids so are we both equally insane what would you tell some uh young kids in dental school right now are thinking I think I’m going to grow up and have four kids just like Alain and Howie what would you tell them be prepared and my four boys I’ve turned into six grandchildren I just got my um this month of august um was born on the 28th and I turned uh 58 the next day so now every year on my Christmas that I mean my birthday the day before my birthday will be Alain so I already told everybody just change my birthday to uh I mean it's only going to be Alain but hey I wouldn't I’m so honored to get you on the uh the show I mean my god Peter Dawson wrote the forward in your book uh I mean if I mean that that I mean that just speaks volumes of everything but um what I would ask you is um when I got out of school in 87 there were just nine specialties and now there's 12. I mean they've been growing rapidly they've added um I mean you know the basics are oral surgery endo perio pediatric ortho pros dental anesthesia but they've been adding oral facial pain oral medicine oral path oral radiology um where would you say um you what you do fits in would you consider it a specialty I mean that that's a tough one because listen I can consider it may deserve to be a specialty it hasn't been considered yet because tmj pathology relates to mild occlusion relates to pain relates to growth and development it relates to a lot of things so it's actually sort of a common denominator for a lot of different problems um on Saturday uh October 17th I’m having uh Drew McDonald an orthodontist present on the consequences of tmj pathology on growth and development and malocclusion and how the orthodontist would treat that and that's a whole point of view in itself in tmj pathology you've got three types of patients basically see a lot of people think tmd is pain or tmd is just about pain uh drew's the current president of the uh New Mexico association of orthodontists a lot of people still think that tmd is just a question of pain uh you know ninety percent of tnd problems do not lead to pain uh they start so there's three different categories of patience for tmd problems and the first and most important category are children growing children have a lot of tmj pathology that most people are not aware of I don't know if you're familiar with David hatcher the radiologist from California that wrote the big book on t j pathology actually 40 university professors American university professors wrote the book and the book came out in 2016 in specialty imaging the temporomandibular joint by David hatcher and Tanya and Dania Tamimi that book shed tons of light on what's going on in the joint in young children we weren't aware that where there were so many problems and a lot of the growth and development issues in the joint actually translate to malocclusion and other problems so drew's going to be speaking a lot about that so that's category number one and they're usually are typically not in pain they'll be in pain after the ortho use around 16 17 or 18 years that's when some of the kids get do get some pain second category of patient is the grown-up that just has an asymmetry or has a retrognathic jaw and doesn't have any pain but is wearing down their teeth because the bite's off and to just to be clear I’m not necessarily just so excited associating the fact that the bites off and para functions a lot more subtle than that maybe we can get into that later the third category of patients are the patients that do have pain and but they're actually about only 10 of the amount of patients that have tmj growth and development issues or degradation issues so they're really only a subset and most of the attention has been giving to them because they complain a pain so when you start looking at this and I’ve been doing tmj pathology for 25 years and when you really start looking into this you start understanding that when the pain gets to the patient you're way far down the line you're not at the beginning of things you're at the wrong end it's just the same with decay if you wait till the tooth hurts you need an endo you need an exo an extraction an implant when the tmj starts hurting typically you're far down the line in the problem okay just summarize that again real quick that they're tm tmj or tmd pathologies what are you calling I know what a lot of a lot of people tmd is typically defined as a pain pattern problem tmj pathology which is tmj growth and development issues or degenerative issues relates to everything that can go wrong with a temporomandibular joint now you do not have tmd without preceding tnj pathology that's in the literature that's been known for years but how does a growth and development issue or pathology lead to pain well that's been a great a great source of debate because some people develop pain and some people don't that's when you get the stress issues and the hormonal issues and a lot of different other issues um I remember and I know there's a lot of controversy on the psychology like if you know if you're stressed out it's part of the problem when a person comes in with tnd or anywhere any type of myofascial pain or teen or temporomandibular joint pain you have to consider both the diagnostics and the pathology and the psychological level of the patient uh or whenever they are because most a lot of those patients that are in pain are stressed out a lot of them are on meds a lot of them have emotional issues but not necessarily all of them so there are different factors to these patients there's different facets to the problem um I still want to stay back with that especially because I always am telling dentists that they're too dentist focused they're not consumer focused and um if you were a patient if you were a consumer and you were on the internet in Montreal Toronto or phoenix and you're looking at these specialties oral surgery endo perio pediatric orthodontics prosthetics dental anesthesia oral facial pain oral medicine oral path oral radiology dental public health do you think they would navigate to oral pathology or orthodontics or do you think or do you think this really needs to be if you were king tut would you make this a specialty or would it be covered under oral facial pain no not under our facial pain technically we should be under orthodontics okay well that that's a whole can of soup right there that's a whole show right there uh why would it not be under oral facial pain and of the um ten thou we mail uh every orthodontist ten thousand eight hundred orthodontist ortho town magazine every month um what did what letter grade would you give them on occlusion some people think they do a great job now there's clear aligners um you know so why would it not go under oral facial pain and how would you grade the overall specialty of orthodontist in the united states and Canada you just gave me a noose to hang myself [Music] [Laughter] oh my god it's true right okay so let's try this without getting tomatoes thrown at me on one side I would not put what I do into strictly oral facial pain because most of the tmj pathology problems that lead to consequences are not pain patients necessarily so again the pain patients are only a subset so oral facial pain is one thing but the pathology leading to degradation leading to airway troubles leading to headaches leading to malocclusion leading to a lot of degradation on the teeth and periodontium that's another subset of patients and sometimes patients walk in with everything now so that's a quick answer to that we could talk hours about just about that but if we're going to talk about how orthodontist rate and occlusion well having been around and having seen great orthodontic work some of them are fantastic I I’m in a study club with a guy called bob Casper’s out of Detroit mercy and he's doing research and he's just fantastic at how he controls his occlusion and the tmj pathology drew McDonald I invited he does the same they control things absolutely fantastically because they have a sense that the system is a system starts at the joint and that occlusion depends a lot on what's going on within the joint so that's why I think that you know since the sister Tamimi hatcher book is out tmj pathology is now being taught in a lot of orthodontic faculties so a lot of orthodontic schools are now teaching tnj pathology because it's at the root of a lot of their problems not all their problems but a lot of them sub-growing condyles are a pandemic sorry for the word at this time but they are the what's out of pandemic sub growth of the condyles this a university of Alberta study came out in 2000 in the angle orthodontist uh signed by Brian never Brian and David hatcher were together on this and they demonstrated that in the pre-orthodontic adolescent sample 90 of girls and eighty percent of boys have at least one displaced disc at age 15. we're dealing with populations of displaced disc people and a lot of those displaced discs are related let's not use another word let's just say related with or come at the same time as condylar undergrowth leading to either a symmetry that's on one side or a retrognathic mandible if it's bilateral so having a displaced disc can actually impair condylar growth that's been demonstrated and that's what's coming out now this is a little head ahead of the time for the com or for the conversation maybe but that's what's coming out and that's what's in hatcher's book so take me back along your journey I’m waiting so you come out of school you see all these uh patients I need root canals fillings crowns what motivated you to chase down this specialty to the level that you had I mean um did your mom have this did your wife's uh what motivated you to just chase tmj frustration in dental school I mean what did you learn about occlusion in dental school I mean you and I graduated just a couple years apart what did you learn that was absolutely great in occlusion in dental school I don't know but I don't know about you but we didn't learn that much it was like okay you can do this you can do that and there's not much to learn and you do is flint and what's the efficiency what's the effect of a splint well half of the patients wear them half of the patients don't ends up eighty percent or are in the drawer after a year and it was just frustration that I didn't learn anything that was truly intelligent about occlusion in dental school then in my residency program we were we went a lot further then we went into seeding joints then we went into anterior guidance and nibs was sort of um we did peer prosthesis back then the morton amsterdam theories that from the 1970s so at the jewish general where I did my residency with Miguel uh we were into pure prosthesis we are into full mouth rehab taking care of periodontal problems and getting the occlusion spot on and that would that would help the patients get their get their bones straight and get their periodontists good and get them comfortable and get the joint pains away and the muscle tension away and we did great with patients back then we weren't totally understanding everything we were doing but we were advancing years ahead of what was going on in in the dental faculty at u of m but this was a residency program with high-end professors so down the line so I started into general practice and I was in general practice for a number of years doing splints and doing things and doing a little bit of rehab and still there was something missing and then at one point somebody came up to me said you should go to peter Dawson so I went to Pete and that was just like that was just illumination so I went to Pete in the mid-90s Pete introduced me to mark piper and I did the full curriculum with Pete full curriculum with mark piper and that really kicked it off that I started understanding how occlusion works started understanding how the joint works how they relate the pathology in the joint how that creates occlusal problems and that's how things got started then I started having answers for my patients then things started going well then I could do something that was intelligent and relevant for the patient then I went elsewhere then I went to almost everything I could find I spent a lot of time with jeff locus in Kentucky and I spent time with the American association of cranial mandibular pain and I went to a lot of different places and it's just in the end once you've been around the pathology the joint pathology is the source of most of the troubles so you have to concentrate on that first once you got that down and then you understand the occlusion how those two relate then you can get to the pain patients then you can include the stress levels and then you include all the rest but you know so that's sort of how all of that happened but it was frustration that of not being taught something I could really use so I really use and being face to face with my patients and being in trouble or in facing problems I did not know how to solve so Pete um Dawson uh 1930 to 2019 we lost him last year a great legend um what did Pete um what did peter Dawson mean to you he was my dental dad can I say that yeah he was my dental dad after dental school and after um I do suppose you've met Pete um Pete was a father figure he too was a father of four and he was a true father figure and he's the one that had me presented he was president of the American academy of story in the dentistry that you represented he was the one that invited me to present so he was a father figure to a lot of people he was a father figure to me I mean and I don't want to insult his kids by that but he was a father figure to all of us and he meant the world because of his passion the way he did things I mean he was right about a lot of things I mean there are details science is advanced and you know there are things that have changed and we understand and that's okay and of his own words he said you know I’m saying what I think is true today but in 10 years what I’m saying today might be all wrong and I want you guys to know that and to change if it does happen so we're evolving do you think oral radiology um has been a big change I mean I’ve seen some crazy stuff where you would have never ever assumed anything and then you see uh cbct and there's like some little ball crystal right there in her joint in your and you I mean so has it made a big impact on you and the profession it has made the impact because doing I do a little bit of cbct but I mostly mri the joints so you know where the disc is you know if the if the marrow of the canal is inflamed you know if it's perforated you know if there's inflammation in the pterygoid muscle or in the around the joint or around the condyle superior space inferior space you know what's happening in the joint with an mri a lot more than with the cdct but they're complementary they complement each other okay so when you say uh you prefer an mri instead of a cbct are you sending them out for mris definitely not all my patients but about 10 15 of my patients I will send for an mri and um explain to uh explain to the kids why um well why do you do that and what's the difference between um an mri and a cbct and why do you uh why do you prefer the mri well for me for my practice the mri gives me a lot more information the cbct will give you the bone the bone quality and it'll tell you if it's osteoarthritic or not it will give you the position of the joint those things are good but it's not the complete picture your picture of the joint is not complete without an mri if you look at radiology articles you'll see that when medicine radiology articles mri is the gold standard and there was an article out about I think was 2014 about with uh done with ten different medical radiologists who concluded that mri was the gold standard even for the temporomandibular joint uh the article was in the world journal of radiology a simkay bag signed that one bag so if you want to look that up that was a great article because it summed up all the pathology within the temperament all the pathologies within the temporomandibular joint and this was done by medical radiologists so they're they agree on what we know in what we're doing and know in joint pathology so why mri just because we get a lot more information from it see cbct will give you the present status of the joint will not help you with prognosis mri can tell you more about the past and more about the future let me put it that way well did you um like how much are what how much are these mri machines that you're setting out for I mean the machine or the cost of the mri no the cost of the machine well machines in Canada for a 1.5 tesla regular machines about 1.5 million for the mri yes um yeah so I mean it's just out of reach for that but um did you also did you also buy a cbct for in your office or do you refer those out too there's a I have a great oral maxillofacial radiologist just across the street so I send them out yeah and you know what um it really is strange to me um you know they always complain about their four hundred thousand dollars in student loans but they buy a hundred thousand dollars cbct and that they don't need if every doctor I go to sends me somewhere else for an image you know they don't have the machines in-house furthermore look at your phone how what's the longest you've kept uh your smartphone before you upgraded it was it two or three years maybe I know so I mean every two or three years you're like um you know you upgrade your and now they bought this 140 000 cbct and they want to get the most money out of it so they want to own it for 30 years because it's paid for and it'd be like 30 years now be like a nokia flip phone made for motorola um but so do you um so are you exclusively tmg tmj tmd yes uh and what do you go I know if you say tmj dennis get mad you know whatever but I just want to tell the dennis straight up one thing um dentistry doesn't exist until a human gives a dentist a dollar and says will you help me and it started off in france um who was the uh oh my gosh I can't believe I uh forgot this that guy's name but the uh who's the uh who's the guy who started it in france um yeah I got the dinosaur yes no not pure for shard the century before him that they really got it I’m going um before him um let me uh then you lost oh let me find it because uh but anyway um you know oh there it is it was at ambrose pear 1510 to 1590 was a french barber surgeon his philosophy was um meaning uh um the physician cares why nature heals or whatever but he's the guy who started the track this was different and then pierre fuschard picked up donna and took it to another level then gv black or whatever but dentistry doesn't begin until a patient walks up to you and says well you help me and gives you a coin and you take the t so um when endodontists try to change a root canal therapy to endodontic therapy that that's insane if all the patients call tmj it's tmj I don't care what the doctors with eight years of college want to call it because they'll call it something latin greek whatever I mean it's all about the consumer the patient um and that's what they're there for and um and by the way when I went when I lectured in france the uh pierre fischer museum was closed to be remodeled I’m like what is the chance of that I go to france i take three of my four boys with me and the damn only thing I wanted to say I had to go see the mona lisa uh because uh this was uh closed but um but you think imaging has been a game changer absolutely it's helped us to understand what's going on why don't you just send it to an oral radiologist so that you don't have to buy a six-figure machine um that I mean I don't know would you would you recommend do you do you recommend that would you say that just send them all out well I can see that a person using the machine every day doing implants or doing orthodontics would want to have one in-house I can under I think I can understand that desire uh I’m not sending them all out and I don't need them for every patient so I’m I can just use my radiologist across the street and it's good for me so I’m not putting in implants and I’m not doing orthodontics so I don't need them for every single patient if I was an orthodontist though i'd probably want one in my office and if I was doing implants all day I probably would want it with me close by to take new images whenever I needed them but from for what I need to do with it the radiologist is across the street and she's absolutely fantastic and her machine's great and she gives me fantastic reports so who who's calling you up and coming to you um I mean the jokes about tmj is it's always the crazy stressed out lady you know what I mean and you would never want to be a pediatric dentist because just a bunch of screaming kids and you never want to go to tmj because all going to be a bunch of crazy ladies with crazy eyes um where does that stereotype come from I mean it came from somewhere well it comes from the fact that people that complain are usually so far down the line they're in pain they're depressed the pain patients again the pain patients often have anxiety issues and the ones that complain the most are those that are either depressive or have anxiety issues so these patients are the worst nightmares for the dentist because one typically they're not made for us because we're not psychologists or psychiatrists they're not for us but we have to treat them because they have the pain within our sphere of knowledge so with those patients you have to work with psychologists you have to work with their physicians you have to work with meds that are out of our hands the origin is this of this is because the first patients that used to complain of tmj problems were on the crazier side that was true but again when things start when things start off you get the worst patients like 10 years ago when I limited my practice to tmj problems I got all the crazies and that was true it was a tough time but what I’m getting now because I’m educating the dentist around me I’m getting preventive cases I’m getting children that are sent to me to assess the tmj level problem is the disk reducible is it not is it going to grow can I use it I gotta I gotta stop because I uh I’m well aware a quarter of my listeners are still in dental school so when you use terms I’m um reducible that whip slow down spanky and explain what you just said no problem all right thanks for slowing me down in the joint we all have a disc we should all know at least that much the disc in a bunch of kids and adults of course because it doesn't go back into place is displaced that's what we thought that's we used to think was not true we used to think that most people had their this their joint dis in place that is not true I have 2400 joints in my database 2 of them have a disc in place 98 have displaced discs okay I have a special clientele but if you do it at large like nebby and hatcher did you will find at least 80 to 85 percent of the population does have a displaced disk now this displays a little bit medium a lot or a ton basically but a little bit you don't hear a click a little bit more you can hear a click what does that mean it means that when you open your mouth the disc that's a little bit ahead of the condyle well when you open your mouth the conduct slips underneath the disc and that makes the clicking center so that's the click you're actually recapturing your disk and we call that reduction so that is a anterior disc displacement with reduction if your disc is set further forward if the retrodiscal tissues have stretched more or that thinned out your disc is further out and at one point the condyle when you open your mouth just pushes the disc even further so you stop hearing a click so your classic patient that says oh yeah doc I clicked for years and just stopped clicking two weeks ago and I’m fine well that patient isn't better that patient is worse because now they're only functioning on the retro distal tissues and that's that may thin down and you can eventually have osteoarthritic damage because you have a perforation there so a reducing this is when the clicks and a non-reducing disc is one that the carnal just pushes more forward and they get thinning of their retrodiscal tissues and they're at risk of having perforation and bone to bone contact but there's ton of those out there the youngest patient I have on mri of having a non-reducing disc so a fully displaced disc is seven years old and they have perforated tissues that kid has perforated tissues and is having a totally arrested growth condyle so one condyle has the disc and is growing and the other one has stopped growing because the disc is totally out of place and that kid is starting to have osteoarthritic damage and she is seven years old and where do you think the chin is if one candle is growing and not the other one she's way up to here so we used to think that was okay that's asymmetry but where does that asymmetry come from and can that be can or can an orthodontist use a violator or something else to stimulate growth when the disc is still a little bit in place you can get some growth but if it's not in place you're just going to harm the child even more with your with your appliance and that's been tried and tried again so these are things that people have been sending me to assess the state of the joint I mean I have I get referrals from general practitioners but I get referrals from prosthodontists from orthodontists from a lot of surgeons because they want to assess what the status of the joint is before they do some sort of major intervention so um one of the things that scares a lot of the people listening to you right now um is that um you know should they um change the bite um like when they're doing like a denture you know there are a big case they're frightened that they might change the bite and if they change the bite that will cause all the tmj and tmd what would you say to that well if you're if you're changing someone's bite and they have if they have both discs in place and tmj's are fine you're not going to be causing a problem because the t and j's that person's tmj's are resistant they're just in place things are good you're not going to have a knee problem if your meniscus is in place and you go walk a mile or two that's not going to happen so changing a bite with healthy joints is not going to be a problem but a person with healthy joints is a rare occasion so yes changing a bite to another bite that you're not sure the pin the patient's going to tolerate well that can be a risk factor but you have to know what you're doing so that's when knowing what type of occlusion see there's a consensus now of what type of occlusion creates the least amount of effort from the muscles and from the joint and I have to underline what I said because that's what I said and that's all it meant if you have what Pete always taught him what panky teaches and what the prosthodontists teach you seat the joint you seat the teeth canine guidance anterior incisal guidance going forward that is the occlusion that will generate the least amount of stress on the muscles and the joints now will that cure every one of everything no is that tolerated by most people yes so if you if you want to change into conclusion you should go to what the prosthodontist almost all do now seat the joint make sure the tmj isn't inflamed make sure it's stable seat the joint seat the teeth canine guidance incisal guidance and you're good that's what jeff wilkerson teaches that what Dawson teaches uh panky teaches that's what most people teach now because it we know that this is what you know that's what generates the least effort from the muscles and from the joint doesn't mean it heals everything but it's the best situation for long-term use and for calm in the system now there are other occlusions that can be tolerated by this patient or that patient but if you're doing guesswork you're doing guesswork so you got to know what you're doing you got to understand your joint if you're going to change your bite you got to understand the status of the joint if it's healthy stable at least or if or if it's pathologic and if it is pathologic you have to know what to do to stabilize it before you do any prostate on the patient okay so how many uh you have four children how old's the oldest children child uh she's 29 she's been 30 and uh so uh my god my oldest 32. so here's the exact problem she graduated from dental school and she's uh 25 uh to 30 and she only became a dentist because of her mom or dad and she's in there and her parents practice and any time anybody has a tmj anything her dad just calls the assistant to run over there take some algebra send it to the lab make an upper splint and then it'll come back in a week and then the assistant tries it on and then comes the doctors that I need to check and he goes in there and bites down twice and that's tmj I’m telling you that's how over half that's how over half of all tmj is treated in america and then a follow-up question that some of them will throw in pharmacology and write him a prescription for um you know that value or something so I guarantee you that's how half of america works um I don't know about Montreal if that's the same but what would you but she's trying to you know it's her mom it's her dad she's you know and um what would you how would how would she uh talk about this with her mom and dad how would you try to get what does the millennial do when that's what mom and dad do and have always done and you know well that young well if you agree do you agree with that absolutely howard this is you just named you just named the game this is that was that is the issue you I mean of course your experience in dentistry you know this but this is absolutely the issue um listen the reason the Canadian institute was founded inclusion institute was founded is exactly what you said what is being done is not up to par with today's knowledge people try things because that's what they learned in dental school but it is very basic knowledge yes sometimes it does help but a lot of times it doesn't and a lot of times it does make the case worse so what that young dentist should do is get knowledge I mean if they want to come to the Canadian inclusion institute they're welcome I mean I’m founding I’m doing something now I’m preparing something for the states um it's going to be called starting with the basics and that's not out yet but sometime it will come out uh okay so that so that site's not lot not live yet but you said the other one was um uh center um center denter it's in french sorry my french is uh just do Canadian inclusion institute you'll find it or our ico uh our uh oh it'll go it'll um you got a website in uh english too the Canadian yeah both my clinic and my school website have both versions french and english okay so you the same one and they're linked you go to one site okay the sites are linked okay so tell them what that is um and um okay so if you go to the website is ico hyphen institute I-n-s-c-I-t-t dot c-a for Canada um so that's the website that you're talking about right that's my main website for the school and tell them about your school and how they would learn more well where when they come to us they get the basic um I teach now in the province of Quebec with Pete Dawson’s blessings and mark piper's blessings um they both of them gave me permission to use their material and to teach the dentist in Quebec in french about everything that they what I had learned from them about occlusion and the reason I did that is that a lot of people from Quebec were not going to piper and Dawson and that this was a number of years ago of course it was about 15 years ago and now things have evolved a lot and a dentist that would come to our courses will get the basics on how to do a proper splint a split see the article I published in descent last December about counter reformation I was able to do that using a splint that reduces the level of pressure within the joint and you just have to understand how that works you have to then understand what the problem is so I’ll take I’ll tell you about that I’ll tell you how to understand how the occlusion works and how to make a splint that's going to be relaxing for the muscles and it's going to take a little bit of pressure off that joint so the joint can adapt and maybe heal a little bit and then we're going to talk about occlusal principles which is basically the same as Dawson and bank you're teaching and then we'll go into tmj pathology and I’m going through the basics of what mark piper teaches about the pathology of the joint and basically how to treat minor beginning problems so if you come to the first three courses you're going to learn a lot about how the system functions and you're going to be able to adjust your bites a lot better doing anything doing implantology doing regular crown and bridge doing just a filming you're going to I gotta back up a little bit because I know where they're at on that journey and the first fork in the road they're going to come to is um they're going to and I saw this live when buying a car this person was my sister was totally going to buy the car and she loved it and then the guy said to her said uh she goes I just love the sunroof and he goes well actually that's a moon roof and then my sister's all confused and she's paralyzed because then she was so that she didn't buy she had to go back and talk she had to go back and talk to your other friend which one was better and I said and I thought to myself from a sales point of view what the hell would you do that for why would you confuse the person uh but anyway the first thing is going to confuse them is whenever they hear a collusion they hear there's um this um neuromuscular or the other kind so yeah so she's at a fork in a row what would you call your kind verse if neuromuscular is neuromuscular what is your kind called uh I don't know if it has a name um pinkie Dawson yes you could call it Dawson yes would you call it traditional or whatever um well that's right is now what most prosthodontists are doing in teaching and that is what panky and Dawson the both the institutes are teaching now and that is what is most popular now uh okay we'll explain to her why she should learn pinky Dawson occlusion um versus neuromuscular what's the difference and that's the first I learned both I went I went to both I went to both sides of the story because I was going to teach I need to I need to learn and understand both sides of the story back when I went which is 2006 seven and eight what I saw on one side to me was making more sense than what was on the other side and was definitely more complete now I could not speak about what's doing what's being said or done today but back then definitely what was going on in the dossier corner Dawson panky corner was definitely much more complete especially that I had all the joint issues and when I went to the other side I was actually asked as a student there to teach them about the joint because they were not knowledgeable about the joint pathology so actually I was a student there and there were questions from students that only I in the room could answer so that sort of confirmed to me that my education was more complete so when I might go to your website www.ico um and that is um institute dental ins well what is that in french it's the french ico institute Canadian the occlusion is that how you say it institute I do remember I only learned this is all the french i know from one date she taught me uh that's perfect yeah what does that mean I love my wife yes yeah and uh so that's the only french i know I’m sorry I’m uh um so the website stands for um ico institute Canadian um is it d occlusion yeah I mean it's oh but there's a d in front of it how does that sound d with that little apostrophe is that how you say it in english yeah occlusion okay so that's ico um institute and you go there and you're going to see that the um the courses um so you have the basic level one intermediate level two masters level three so base level um course one is effective bite splints and course two and three are effective occlusal adjustments and then the intermediate level is course four determining the stability of the tmj for everyday practice course five is imaging and then the master's level is advanced seclusion and advanced tmj and then he runs um a parallel um curriculum for staff for basic intermediate masters and then um and then they have other courses uh for everyone so the logistics so um you have uh one two three four five six courses do they um should you take them in order yes definitely yes absolutely yes if someone wants to come to Canada to do the courses yes definitely they should take them in order do they need to be there physically or can they also do it online well that's what we're starting to do now since colbit we've been doing a lot of zoom presentations and as you can see they work absolutely great they're fantastic so we are now preparing all the courses to be done online so we're actually doing that now and that's where the other thing starting with the basics is going to be because I’m going to be doing both in french and in english for the Canadian and American market and when do you think that will be done hopefully we're aiming for january it's the film people have told me it's going to take two to three months to film and edit so that's I think um I think the best marketing um pinkie and suit did this and Dawson did this where um you know they have a one week course and it's a it's a big um disconnect to go from I read an article to a week-long course so what they did is they um they put a one-hour uh dental town has 400 one-hour courses they've been viewed a million times you should make a one hour course um of your you your philosophy all that kind of stuff and then that is the intermediate between you know that'll be they can meet you they can like you they can all that stuff and then that will um lead them on I mean my job is to try to motivate them down the road and I think if you if you're going to make all that material you got to put the first hour on dental town please do so of course um another question I have is um you know some people say dentistry is three things um carries perio and occlusion and um a lot of people wonder that why do the dental schools why do they teach caries and perio so much better but not really occlusion why is that still I mean it doesn't seem like it's changed since I got out in 1987 it still seems to be the weaker of the three kids in the family coming out of school do you agree with that absolutely and again that's what that's why that's why I founded the institute to complete with the knowledge that is not learned in dental school you see kids come out of dental school with very little knowledge about occlusion and they need the knowledge because what does a dentist do in life we work on the occlusion every single day I mean you're not you're involved in occlusion every day when you work in dentistry unless you're doing class five buckles on upper sevens only I mean whatever you do is going to be oppositely related remove a tooth fill a tooth do a crown do anything it's supposedly related so you need to understand the problem I think our the problem is that the misunderstood part up to now was the joint because the joint does influence the occlusion and in my one hour presentation that I did drink covet that I could probably put on your site I explain and show a lot of cases how the variation in the joint actually generated the bite shift that was creating the problems for the patient and I got a tons of cases to illustrate so what is misunderstood that is that occlusion is not a static thing joints are not static I mean at our ages we know that our knees and hips have changed the temporomandibular joint also changes with time so does or bite teeth don't just shift for nothing the maxilla's move if you've seen a couple of years ago at a convention I saw a guy give this presentation on an implant that was put in on an upper central and how the whole pre-maxilla in the next 25 years came down but that implant stayed up our bones change with time and so deserve light so you have to when you're when you're involved in occlusion you have to understand where those changes come from and the joint is one of those origins of change so you got to understand the joint to understand what's going on now you got to understand the joint to understand what's coming in the future and how you have to treat the joint the inclusion for now and for later I know this may sound complicated but you know basically the whole system as a system was not understood as a system we think of the joint and the bite as being separated they're not I want to um I want to ask the question that's probably going to derail the whole train but uh um when you start talking about like orthodontics and stuff um there's a lot of people not in dentistry that are in anthropology saying man when we look at um homo neanderthal and hablas and I mean there's a lot of people coming out and saying we don't see any of this as little as like 500 years ago and they're going back not far but just a million years and there's so there's a lot of people saying that something's really happened to humans uh do you see that great article in scientific American came out just a few months ago exactly on that subject uh an anthropologist wrote a fantastic article I don't remember exactly which I think was November the scientific American of last November great article on that subject um don't remember the guy's name I wrote him and he answered he was just too fantastic it was just a fantastic article it started 250 to 300 years ago the thinning of the palette the shortening of the lower jaw uh the displacement well actually they don't have skulls with this so they don't know what to displace this but that's one of the things we suspect changed uh yes that our jaws are becoming smaller and we're having airway issues and occlusal issues and joint issues all because of something that happened and there's something that's changed older skulls have great bites they have big jaws they have wide airways full face I mean how many people do you know grew up fully full-faced class one I mean they're almost non-existent today they're a rare occasion most people are either a little bit class three or slightly class two um so do you think that's because the softer diet eating mush baby food or do you or what do you what do you think it is well whatever I think it is won't change what the truth is but definitely that's a factor now are there hormonal issues with hormones in our food uh are there other issues of other or a pollution is that an issue uh is it just a diet and a couple of articles that come out that changing diet in animals will produce malocclusion so uh that's been studied so to what extent is that fully true I don't know but definitely that seems to be there seems to be an agreement that that may be an important factor okay um another controversy um ab fractions um she again she graduated from school and every time someone has had fractions her mom fills them all in with composite you know blah blah and um there's controversy on what even causes the ab fraction um if it even needs treated some people that never treat him say well I’ve never treated him and nothing happened so rant on ab fractions are they connected to tmj tmd wakazum should you treat him what happens if you don't see what I do is I’m such a bad interviewer I throw like 10 questions out there hoping that one question is good enough for you to bite on okay well that's another news for me to hang myself with so um ab fractions my feeling on it and I don't have the total science I don't have total knowledge but my feeling on ab fractions is that well I got them when I started having them on the you what are those numbers I think two and three in the states number one two one is uh but two and three uh I had I had fractions on those that appeared within a six month period in my life about 30 years ago when I was hyper stressed about something that was happening around me and that I was grinding like crazy and that's when they happened so I got I got like two millimeters of gum recession on those two teeth and I got a fractions within a six month period of being stressed out and I know those teeth were interfering back then because I hadn't been equilibrated yet um it hasn't progressed since my equilibration 25 years ago so my personal experience my anecdote of one makes me think that there's a definite possibility that occlusion is a problem is what is part of the problem is it the only problem maybe so maybe not I think there's a lot more research needs to be done on that typically I do fill them because I’ve seen patients come in with ab fractions and a virgin tooth and need root canal because the ab fraction was deep into the nerves so deep it wasn't was to the nerve patient needed root canal because of a nap fracture all right could I have prevented it before I have no idea but I know I tend to fill them because I hope it's going to help was that enough you know the mind um you can't teach a mind till it's ready to learn and I have to tell young kids that I’ve been blown away so many times like um I when I got into school no one ever told me sleep wasn't even an issue I never and never even it never even came up one time and then when I started learning about it a decade ago then I started noticing every time I go to someone's house and I have kids you'll see like a six-year-old sleeping on the couch just grinding away and can't breathe and so then the question is again the same question is sleep related to tmj tmd um are they separate or they're the same that's been proven that's a given a retrognathic jaw is a problem for sleep that is that is a given not all of them but you have a higher risk of having obstructive sleep apnea if you have a retrognathic mandible that is clear and you it's an extreme exception to have a retrognathic mandible without having the joint issue being there and you know we're starting to relate the fact that the tmj dis displacement is at the origin of the short ramus that is causing the retrognathic mandible um you know you're um you're so fluent jumping back I think is it because you are live in a country that at mandates french and english that you go from jaw to mandible jaw to mandible I mean so many dentists that they talk to a patient that pays to know one thing because it'd be mandible endodontic therapy but you just fly it back over to jaw root canal I wonder if that's a bilingual it's what because that's the words the patients use so no I know I think one of the neatest things you can do is when you're over there waiting for your buddy to get off or whatever's in there talking to a patient just turn your phone recorder on and then just go lay it on the table there and let and then send it to your um your notes person and that transcribes it and then take a big black magic marker and wipe out every mandible where you didn't say jaw and you know and you come back and just like this is why the patients don't know what you're saying I mean you they teach you latin and greek and that's okay if you're talking to you but not the patient um so um so then are you when they have a retrognathic jaw is your first thought to have orthognathic surgery oh uh that depends how old they are if they're 72 definitely not if they're 12 uh we're going to try to do something before they need the surgery and if we can get the jaw to grow before the surgery will great but it definitely is going to be a discussion with the kid and the parents that it might be an issue when they get to 17 18 19 or 20. definitely uh if you're 35 uh we're going to have a discussion about it I mean I never my role in life is to sit with a patient and talk patient as a language and to help the patient understand what's going on and what are the possibilities for them the patient I’m not the type of person that will tell a patient what to do I will I will give them their options I will sit there with them discuss with I spend an hour with every patient every new patient gets at least an hour with me so we spend an hour talking we look at the panoramics we'll look at the bite effects we'll look at different things and we'll definitely chat things out and look at all the possibilities now sometimes a 30 year old just has two young kids it's not the right time in their life to have orthognathic surgery sometimes it is time for them sometimes they don't really need it sometimes they do every case has to be assessed individually but it definitely it's an option and we'll talk sleep as you said 10 years ago we started hearing about sleep a lot more so everybody in my consult everybody has their I don't do a full sleep test I don't do that we're not allowed to do that here but I will definitely discuss are you sleeping well and is there an obstructive sleep apnea possible problem then I’ll send them out to their physician to get that checked out so we do we'll check for the sleep we'll check with the quality of the sleep we'll check the stress levels and then we'll check the diagnostics on this system and then yeah so what percent of the people in uh north america today that are on a cpap machine do you think have been thoroughly evaluated dentally probably not that many pro let's put it this way not enough and how many of them do you think are connected to them yeah now a ton remember the average I’ve done the math on that that's only about 12 people um you know tons only two thousand pounds these americans are getting heavier and heavier and heavier uh but um but yeah um there seems to be so much overlap and like I’m telling the young people I mean I never saw I never thought of the sleep apnea never thought of that issue when I got out of school in 87 so it's a very fast moving game that goes faster and faster but I want to I want to hold your feet to the fire on one question if you saw a hundred patients do any of them get pharmacology does anybody get a prescription oh yes they do because a lot of them walk in with severe pain and they need they need help with the pain while whatever else we're doing to try to control the source of the pain so medications we I use medications I don't use a lot of them I don't use medications very often but there is a subset of patients that what patients that walks in and definitely needs medication and some of the medication I won't even prescribe myself I’ll send them to the physician because often these people are on other meds and I don't want to be interfering with what's going on with the physician so I’ll write a note to the physician and say I would need this and can this be prescribed to the patient and would this fit within their context so I do some of the prescriptions myself I use the physician for other things uh but i'd say that probably less than 10 of my patients get prescriptions less than 10 and what would those prescriptions be that the ones that you write or are those 10 percent that need prescriptions all going to their family physicians or are you writing anything I’ll prescribe I will prescribe muscle relaxants whatever the brand name b uh so we'll do we'll use an amitriptyline so elevil whatever it's called in the states uh which is which will help with pain will help with clenching will help with uh a little bit will help with sleep with sleep um we'll use other things to help a little bit with the quality of sleep uh but basically anti-inflammatories and muscle relaxants those are my go-to things uh the elevil will happen a little bit less often but I do go to it sometimes uh I won't go to lyrica or rotten or things like that that'll definitely let the physician prescribe uh how would you answer this question that is very common on dental town remember going back to that young girl the age of my oldest eric is 30 and yours is the same they say well what lab do you use for tmj meaning that someone has cmj they're taking impressions send them to a lab so that's why I want to get really good in tmj so I need a really good lab what lab do you recommend for tmj how would you answer that dan do you use a lot of labs do you only use one lab if you saw 100 patients how many would need something from a lab uh well not that many now because we've been printing our own splints uh we scan the mouse we scan the mouse and we have a piece of software and we have a printer and so we print out our own splints now actually I have um there's a lab that came to a lot of my course there's at least three or four labs that came to a lot of my courses and I now are making splints in a fashion matter that um we've sort of done in Quebec we're a small group like 5 000 dennis and we're pretty tightly knit and we have our facebook group and we're like close together so the word has been out really went out really fast that when you make a splint in a proper way it does get the patient's muscles to relax and gets their headaches down and things like that so we have a splint that's a little bit more effective than others that's the way I teach when I teach about effective splits it has a measured efficiency of over 90 at reducing pain um so what so you take a cbct and connect it to your uh printer oh no we scan with a with a normal interval scanner okay so intro scanner what scanner are you using trios the uh from uh three shape okay so use a trio scanner from uh Copenhagen Denmark and then what is the printer the printer is the form lab oh okay the form lab oh my god you should do an online course on that well oh my god that's in the discussion that's coming yes yeah so they're going to want to know why did you go with trio scanner and um and set a true def well first of all true def is gone now 3m got rid of it and we told them why before they bought it had you had to spray a um a powder got rid of it and here's the deal I had so many people calling me to quit saying that about it on this show whatever and the bottom line is um if that's what the market is saying you don't um it's kind of like there's no raisins in raisin brand so every commercial is a there's two scoops of raisins in every box hey why don't you drop the commercials and just put some damn raisins in the box wouldn't that be a lot easier and instead of trying to tell everybody why the powder is no big deal why don't you just remove the powder but um so it looks like three shape is walking away with the oral scanner for uh implants all kinds of things like that um and but if you're going to do clear aligners it seems like they're going with itero because the line technology that invisalign owns itero um do you do um clear aligners do you do ortho I do no ortho at all none at all I don't have the time I get over I get over a thousand referrals a year just in my field and I do not have the time for ortho so I work with orthodontists or gps that do great ortho and do you know the name of your foreign lab printer which model or anything like that or not really what I have is formlab too it's the formlab tube yes uh and uh what about your trios it is the move it's the trio scanner the move yes move it's memove yeah and this is another request i'd like to tell companies especially a shout out to gc uh who I’ve been to your headquarters right there by mount fuji um and um but you can't call a product different in every country it just doesn't work with the internet pre-internet you could do that but you can't have because the dentist in Australia versus Belgium you know when they're all confused and I’m sitting there like I’m reading this like they're all talking about the exact same thing but the world is gone digital um I want to um some people say um you know back in the day uh you know in the 70s and 80s you were a rock star if you had your own business card and you know and now a lot of people are saying the new business card is to have a book and you have a book um becoming your patient's hero nine secrets for creating exceptional trust and new income for your dental practice um by um yours truly and um and my gosh um it's uh by Donald reed ford by uh peter Dawson founder of the Dawson county what do you think of that book and what do you think of books like that well those little books are great I mean I mean I wasn't the initiator of the book I participated in the book but uh those little books are great because there's a lot of people that will read them and it's a short read it's a simple read it's quick but you can get a lot out of it because you're talking about you have a lot of people with a lot of experience in different areas saying things that can help out a lot of people so those little books are great and yes that is that is the main thing right now that that that is a fad a lot of people are coming out with books now that's true and uh I need you to comment what do you think of bite um bite fx well what do you what do you think of bite fx and the reason I’m asking um because um I know he always talks about you a lot um but what do you think about bite fx I love it because well listen I use it every day with every single patient it's a great piece of software to get you started in occlusion and joint pathology if you need if you see when I use I did with you a few minutes ago explaining reducing non-reducing what do I do I use my hands no you don't do that with a patient anymore right I have the software it's up there it's on the screen you got the images of the joint the disc and everything it's moving the patient's say elaine thank you at least at last I understand because the previous guy was doing this with his hands so yeah you need the software you need the images and they working there they are working extremely hard to get everything right so they've got the whole story but they've got I don't know 75 or 80 different uh sequences out there animations and they're just fantastic people well you know the one image I’ll never forget is if you look at a um uh sharks um they had a shark next to a human and the um anyway the humans eyes part of the brain looked like two tennis balls associated with the eyes and then like two little cherries associated with the ears and then there's other animals for that's reversed but sapien along with primates especially our two first cousins uh chimpanzees and bonabos we're a totally visual animal and if they don't if they don't see it they're not going to understand it and even when they're listening to radio they need a sports caster that can say in such a way they can see it but um do you think I think visualization to a patient if they if they don't know what you're talking about I doubt they're going to part with a dollar no definitely absolutely you got to see it the patients want to see it they love to see it and often with the clicking joint when they see the clicking joint on the screen where they point to whoever's in the room say that's that that's what I’m feeling and they relate to so that sells the case right away that that's just so now I want you to risk losing all your friends and family I mean every everyone um when you're looking at these tmj tmd patient problems how much of that problems do you think are iatrogenic from the dental profession versus how much is because they're a long lineage of primates and this is all natural how much did we do and how much was it's just life it is what it is um oh my god uh okay um I’ve thought of that I’ve tried to answer that I don't think it's a question that for now it's actually possible to answer if you're going to if you want to quantify that that would i'd have a hard time quantifying it um i'd say it another way i'd say how many patients are not being helped by what could have been done there's a ton of the okay there's more than a time there's a lot of those so there's a very high percentage of patients that should be getting help through what our hands can do that are not getting it I started teaching because of one of those patients who had been to two specialists actually she had she had the orthognathic surgery in the orthodontics and was in worse pain after than before I mean she spent two years with the orthodontist and the surgeon trying to find ways to get rid of her pain took me a week with my splint I mean what were these guys not understanding I just made back then it was just a basic Dawson splint she was out of her pain in a week so what did I understand that these guys were not understanding and why did it take a gp like me to get her out of her pain instead of the specialist so see it's not so much what we're doing that creates the problems even though we are doing things that that are creating some problems those do exist but I don't want to accuse anyone but what i'd like people to do is get the knowledge to understand what they can do that can be beneficial to the patients that's where the name of the game is get all these people okay forget about what we're doing that's wrong so because we've been doing it and let's not feel guilty about it because we weren't educated about it but we what we can be responsible about is what we're going to learn and what we're going to do next to help these patients when mouths are breaking down see howard a lot of premature wear on teeth comes because the people are lopsided because the joints are lopsided there's more pressure on one side so they're breaking down one side more than the other not necessarily because of para function but because that's where the bite shifted to because the joint's bad on that side and how can we help those patients because most status will just see the broken down tooth and just make a crown and then that tooth will hurt so they'll do a root canal and then that tooth will break between the roots and then they'll do implants then the implants go bad and what's the problem when you took when you take an mri you see that the joint is really small and all the pressures on that side it was just not assessed it wasn't seen so did that dentist hurt the patient no that dentist tried to fix the patient but that dentist didn't do anything to help the patient that's where I think we need to go from now because a lot of that is happening and a lot of wear and tear on the mouth comes from ill bites and again not from para function but from the bite being off in a manner where there's more pressure on one side than the other or more smoke more posterior more anterior and that's the part that's breaking down the most so once we start understanding the relationship between what's going on back here and what's going on out there well then you start understanding what you can do to help the patient to stop the destruction of the mouth and the premature wear and the headaches and everything that can happen from that I’m sorry we've gone over an hour but can I ask a couple overtime questions I am there for you and this when you know it's done okay um arthritis um it just seems I don't know if it's because I’m older I’m seeing a lot more of it but how much does um just regular flavor arthritis um play into all this I don't see many arthritis patients with joint issues so I’ve seen a couple but uh arthritis is not a temporary mandibular joint typical problem osteo osteoarthritis where you have degradation of the joint and wearing down of the joint you have a lot of those there's other conditions like us you can dread as disaccounts or it's some form of a vascular neurosis that goes on uh so you do have bone issues within the joint but arthritis per se it's a systemic problem and I don't see much of that so then what's the difference between arthritis and osteoarthritis okay osteoarthritis is a localized problem it happens when two bones rub together and you lose the cartilage surface over the bone and then you have dimples within the bone itself that's osteoarthritic damage that typically happens when the disc is off the condyle it happens sometimes with the disc is on and but partially off and creating a pressure point but that typically is a pressure point problem it's wear and tear from over wear again my goal is to make you have no friends um what is your comment on the nti that's a big brand name in the states uh very common question um what would you say to someone says um do you recommend treating tmj with an nti uh treating tmj with the nti is no the answer is no treating muscle spasm with the nti the answers can be yes uh there's a there's a there's an enormous difference between the two and uh we will be here until uh next Thursday if we start getting into that but um there's a difference the nti has been demonstrated and demonstrated to reduce muscle spasm yes that's true uh it has downsides uh it has upsize it has downsides personally I typically do not use them long term I will use them short term but it has downsides so it's not as good for the patient as a full coverage splint that's well made now it will be effective at reducing tension and tension type headaches in a lot of patients yes should it be used long-term in a lot of patients my personal opinion is that probably not or if so with a lot of surveillance uh on the patient you want to see that patient regularly make sure things are not happening but you see the picture is larger than that it's not it's typically not just muscles the muscles are not firing because they're just on their own there's a reason and usually there's a structural problem too and the nti does not address that structural problem are you um considered in your community I mean when you're busy you're booked you're successful are you a headache migraine doctor or is this is this why people are talking about you on social media and coming down and they're calling your reception saying does he cure migraines uh I manage migraines I can't say cure them um I did a little pilot study with the Montreal migrant clinic about 20 years ago and the neurologists invited me to do things with them and we did a cruisal collaboration well we presented that in Chicago at the aard um I some people do come to me for that it's not the mainstream patient I have but some people do come to me for that it's a percentage of what I do um so it's a person is but would you say small medium large not the main thing um 10 12 something like that 10 to 15. um oh my gosh I could go on and on but you're three hours ahead of me I really would I um I try to get great information to my homies and uh my gosh I really wish you would uh turn the community on with a an online ce course uh to learn more about this because it's uh it's kind of underweighted in dental schools now all my dental school deans uh that I uh drink with um they say come on Howie we we're taking a kid off the street from scratch and we gotta turn them loose on the you know they just they just say they just can't teach them everything and it goes on so I got my final question this is the dumbest question you've ever got uh but um so I’m our family it's third generation wrestling my grandpa got me into my four boys our garage was just a wrestling mat the whole time and my boys always asked how come in boxing and mma well how come the shot right on the money shot right on the jaw something electrical's happening because they just black out and you could hit them much harder in 10 other places but why is the money spot the end of the jaw I don't know that when I know did I stump did I stump you too but it's uh but every you I I’ve actually gone to many of the fights as a dentist and I asked the guy in the trainer he goes well if you hit him right there it's lights out I know but why well I I’ve met gsp a few times george st pierre oh my fave oh my god what a classic what a monster what was he like in person he's a great guy he's such a fantastic guy oh he's nice like you're like crazy you want to have a drink when you want him to be your buddy uh yeah of course we all want him to be our buddy what a class act legend but this guy this guy has a severely injured jawbone but the only reason I can think is that your temporomandibular joints the condyles are at the base of the skull and right in the middle so if you get that hit you're transferring impulse directly to the skull so that's the only thing you can imagine why your blow to the jaw will actually knock you out uh you just say one other thing about the boxing which I don't wanna say but you know you know in boxing when they're bleeding real bad and they put that stuff on to make it stop bleeding it makes the astringent we use like I’ve often thought about um starting a boxer's astringent uh supply deal but um amazing so do you think um he'll have a lot of um problems and you know as he gets older and older from being in a war zone like that forever well maybe yes maybe no who knows time will tell uh he's at risk but what will happen nobody knows all right well hey man thank you so much for coming on the show um I learned so much this is a weak area uh in dentistry compared to carrio perio and you are a class act uh like george st pierre or how do you say his name in french oh my god my all four of my boys we all love that guy he's just amazing but uh thank you so much for coming on the show and uh next time you see george uh have him punt hit you right on the side of the jaw and maybe you maybe if you experience it a few times you'll figure out what the what's causing it but uh thank you so much for coming on the show thank you for having me thank you very much it was an honor to be here it was a pleasure to be here for you guys oh thanks man and uh we'll talk to you later all right take care
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