Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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1464 Radiologist Dania Tamimi, BDS, DMSc, on the Rise of Teleradiology : Dentistry Uncensored with Howard Farran

1464 Radiologist Dania Tamimi, BDS, DMSc, on the Rise of Teleradiology : Dentistry Uncensored with Howard Farran

9/21/2020 3:00:00 AM   |   Comments: 0   |   Views: 121
Dr. Dania Tamimi graduated with a dental degree from King Saud University, Riyadh, Saudi Arabia. She trained at Harvard School of Dental Medicine and earned a doctorate of medical science (DMSc) and certificate of fellowship in Oral and Maxillofacial Radiology in 2005. She is board certified by the American Board of Oral and Maxillofacial Radiology (ABOMR). She is the lead author on two textbooks: “Specialty Imaging: Dental Implants” and “Specialty Imaging: Temporomandibular Joint” and a co-lead author on “Diagnostic Imaging, Oral and Maxillofacial”. She lectures nationally and internationally.She currently runs her home-based oral and maxillofacial radiology private practice in Orlando, Florida and is the mother of three children.


VIDEO - DUwHF #1464 - Dania Tamimi


AUDIO - DUwHF #1464 - Dania Tamimi


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It is just a huge honor for me today to be podcast interviewing Dr Dania Tamimi DDS DMSC graduated with a dental degree from Kingston University in Riyadh Saudi Arabia she trained at Harvard school of dental medicine and earned a doctor of medical science dmsc and certified a fellowship in oral and maxillofacial radiology in 2005. she is board certified by the American board of oral and maxillofacial radiology she is a reviewer and editorial board member for oral surgery oral path oral medicine oral radiology or just go 400 as well as a reviewer for dmfr oral radiology head and neck angle orthodontist ago do she's the lead author of two textbooks specialty imaging dental implants which has been translated to Portuguese in Russian and specialty imaging temporomandibular joined translated to Spanish and a co-lead author on diagnostic imaging oral maxillofacial translated to Spanish she lectures nationally and internationally she currently runs her home-based oral maxillofacial radiology private practice in Orlando Florida and is the mother of three children which is amazing basically three books and three children I bet it took longer to uh um write those uh books than it was to uh have a baby but uh oh my gosh I am so excited to have you on here I was I can't I’ll never forget when a um upgraded my pano to a 3d um CBCT and we took our first image and there were three of us dentists looking at it and we'd all practice for 20 years and we were looking at that it looked like some picture from the Hubble space telescope and uh we didn't know what we were looking at I mean I couldn't believe three old doctors were looking at these spots and I mean we weren't even close uh I just want to thank you so much for coming on the show today how are you doing I’m very good thank you so much for inviting me it's an honor and a pleasure well was I right it takes nine months to make a child uh did it take longer than nine months to write a book a little bit longer than that one of them took about 18 months actually two of them took about 18 months and one took about 10 months wow so yeah and it is very similar to gestation by the way the whole like book rioting thing you know you have this the beginning and this thing that grows and grows and grows and grows you know and that it there's the final like relief at the end when you deliver the thing and uh yeah and then when you hold the baby in your arms for the first time it's great same thing with the book you know when you see it in print on your doorstep it's just an incredible feeling now I read on the internet that you were one of the first oral and maxillofacial radiologists to practice teleradiology um what is teleradiology well basically what that means is that I live here in Orlando and you are in Arizona and you acquire your combined cts and you would send them to me via the internet for me to interpret I’d write my report and I’d send it back to you um yeah so basically that's what it means it's bringing me to you or bringing you to me I’d rather be brought to you so I can go on vacation but uh but that's basically how it is it helps you connect with a radiologist even if there isn't a radiologist close by you know before this is dentistry uncensored so I want to talk about everything that no one else wants to talk about but so let's start with um because these kids are in school they have to know the opposite view of this um some oral radiologists are um telling saying that we dentists are taking too many of these so before we get into what it is and how to read them and what to look for and all that stuff I want to start with the kids um when should you actually take a CBCT and I mean should every molar endo require a CBCT three-dimensional should every um parent who says hey when my little Billy grows up will he need braces does that automatically mean get a CBCT because I had an oral radiologist on this show and she was um she said she was equally pleased by the advancement of the technology but equally displeased at too much radiation on too many people um I’m sure you've heard that before what are your thoughts on what so when do you take a CBCT well you have to proceed any kind of radiographic examination with a clinical exam you know you have you can't just scan or image of every patient that comes through the door you have to examine them clinically you got to see what's going on and depending on what they need um you may choose to acquire a co-vmct or not it's certainly not one size fits all some people don't need a cone beam CT but probably need a periapical or a bite wing or a pano uh some people might need a smaller field of view some people might need a larger field of view it depends on the clinical indication why they walked into your clinic and what are they exhibiting in terms of their phenotype and their symptoms so um yes a lot of dentists are scanning patients sometimes as money making you know as a money making gimmick so basically they're trying to sell treatment plans with Colombian CT and that's not right but uh what they should be doing is examining the patient first seeing if they need that uh kind of imaging or not so do they have anything that's perfect for an endodontist small field of view and an orthodontist two and one oh well two and one I don't know about two and one okay well I mean something that would please an endodontist for the small field just a molar and it please and orthodontist for the large well one single machine that's going to do both please both and be ideal for both no okay because there are some there's some physics that goes into it that um and I don't want to go into physics because I don't want to bore your audience you know oh I love physics it's uh I don't know it is my favorite subject I mean so when people say math is their favorite language I’m like okay math is a language like we're talking English math is a language but the first language to talk about in with math is physics but anyway but they're but still at 2020 there's not a perfect solution from endo to work oh I mean you'd have to know what your treatment basically what is your what is the population that's walking through your door if you're an endodontist and all your patients are endodontic patients then obviously you're going to have to acquire the type of imaging that is required to uh to diagnose these patients you know properly so you would need a smaller field of view a higher resolution um smaller field of view meaning that you don't need to see everything else in the mouth if you're just doing a root canal for tooth number three for example all right um but if you're doing um orthodontics if you're uh treating the tmj if you're treating the airway um any of that stuff that encompasses or more of the craniofacial structures that requires a more comprehensive evaluation of the craniofacial structures and that's when you would get a you know you would choose to acquire purchase a larger machine you know so people send you their x-ray so someone's already thinking uh how would they send uh dania to mimi um a CBCT um do you have a website or what what's the website you go to yeah I mean most of us who are engaged in um in in teleradiology have either a company that they work with or they have their own little business going on because I’m really busy with my kids I haven't set up my own business so I work with beam readers I don't know if you're familiar with them or not absolutely so yeah and they have I think about 30 40 radiologists now and um all over the us and some internationally and um we you know they distribute the load according to you know the licensure issues and you know who has a license in what state and whether the state allows like open um commerce interstate commerce let's put it that way um yeah and so you would go to um and this is not a commercial nobody's paid me any money but if you want to um send me a bottle of Jameson i won't return it in the mail um so beam readers um is just beam readers dot com like cone beam convenient beam from Columbia and so I would um so what do you make an account uh so you go to beam readers and make an account and then you upload that over your internet right so basically I mean and I want to make it clear I work with them I don't work for them so I’m an independent contractor off of this either is that a pretty big file I mean is that like downloading a movie uh sending a CBCT what kind of uh what kind of time does it take to upload and download a CBCT I mean you require it requires a good bandwidth you know good internet speed hi but when you go to read it yourself in Orlando when you download the CBCT how long does it take you to download it not very long we've got a really good connection here both my husband and I are radiologists this is where he usually works right there your husband's a radiologist too yeah now is he uh dental or what no well he's medical he's medical huh interesting and you're um you're very medical I mean you don't sound like a dentist at all I mean everything in your books everything about you is that you firmly believe it's one body all completely related and uh um I still don't even like the DDS DMD thing let alone the DDS to md I like the Russian system better where you start off everybody start does the same undergrad they do the first two years but when you go to declare a specialty you could go into dermatology you could go into ob gyn or you can go into stomatology and what I like about that is the flexibility that if a Russian dentist um can't use his hands and do surgery anymore well he just folds back into the medical system and you find him two years later and he's you know family practice medicine or something um do you do you and then for the consumer in America so many people keep asking uh I mean I’ve heard it for 33 years well what's the difference between a DDS and a DMD and I’m a DDS so I just tell them a DDS is a real doctor and a DMD is just some fake wannabe probably got his license on eBay or something like that and uh they uh but um so but you you're very holistic aren't you yeah um well I am a dentist so my background is uh dentistry I my degree is a bds which is a bachelor dental surgery which in places other than the us and Canada you know we go into dental school medical school straight out of high school okay so the first university degree that you um acquire is a uh a dental degree and but you're still called a doctor even though you have a bachelor degree which is great and um but I went a step further and acquired a doctorate of medical science um while I was doing my radiology residency at Harvard medical school or Harvard dental school sorry Harvard school of dental medicine that's what they called themselves that was congratulations on getting in I applied to Harvard dental school and they filed a restraining order on me uh so to actually get in that I mean that's an amazing feat how many people applied for how many seats did you ever get the low down on that oh must have no not for that that residency radiology isn't as desirable as surgery for example or orthodontics because we don't really um you know as a radiologist one does not really make that much money and when it compare when compared to orthodontics and surgery in the other uh fields but the quality of life is fantastic um but you said it doesn't make much money but you I mean but let's be frank you made a fantastic decision you married a radiologist too that's so I mean but I always I mean let's be frank I always see that with women doctors women doctors always marry male doctors bankers lawyers successful people and so many of the male doctors always marry the waitress from the waffle house um I just think you I seriously think females marry far more intelligently than their male counterparts in school well he's a good guy he's a very good guy yeah that's great a successful independent highly educated person and when you say successful highly educated independent person those first three adjectives just erased uh half the wives that all the men dentists married uh on planet earth uh so um so let's just start with the uh the deal what motivated you to write two books I mean where does that come from did your mom dad and grandma and grandpa have you come from a long line of book writers or well there is my grandfather was a writer but I don't think that has anything to do with this so I do like to write in general I’m I’ve always loved you know editing newsletters and school newspapers and things like that when I was in school in dental school and um I enjoy reviewing as you might have noticed in my bio you know I have a lot of journals that I review for the thing about uh the books that I read uh when I first entered the field of oral radiology and actually it started when I met my husband so he uh we met in my second year of my residency and he is a uh like I said a medical radiologist and I you know when we met he asked me what I did and I told him um well I’m studying to be an oral and exile facial radiologist and he's like what's that so the fact that a medical radiologist had no idea what an oral maxillofacial radiologist um you know was that set off some light bulbs in my head I mean that this is a an area I mean these we basically treat the same people you know we're dealing with the same people we're diagnosing the same scans it's just you know we don't cross talk and we don't understand what we what each of us do you know so I started going to a um a conference with him um called the radiologic society of north America which is a huge radiology conference in Chicago every year of course with kabuto there isn't going to be one this year but um it's fantastic and that brought me together with a lot of uh not only general radiologists of all walks of life but also had a necrodiologist so thinking that the head and neck radiologists would know a little bit more about the dentition and the jaws and that kind of thing in the tmjs you know I attended some lectures and this is what I heard one of the presenters there say you know he was talking about the teeth because like you know they look at teeth too when they're reviewing oral cavity um on the uh on this on their scans and they have to of course name the teeth or number them or whatever and here's how he named them you know the medial incisor the lateral incisor so he even the nomenclature was incorrect you know um so I started to slowly uh infiltrate into their uh society the American society of head neck radiology not infiltrate like a bad thing I I would attend the lectures you know I attend their meetings um I started giving meetings giving lectures at their meetings I actually give lectures every year now to the medical uh head and neck radiologists and to teach them basically how a dentist looks at things and what a dentist needs from them if they ever need to evaluate a tmj skin or an implant scan or anything like that you know what is it that they need to be thinking of because they're not taught to think like us you know uh the directions around the teeth I mean that's like Greek to them you know the mesial distal you know that kind of thing you know to describe things in relation to teeth is just completely foreign um because they're working with the anatomic you know medial and lateral and anterior posterior cranial cuddle or superior inferior so describing things in relation to teeth uh is something that they have to be trained to uh to do well I’m curious um if you were sent 100 CBCT’s to read for dentists like what would they be I mean you go to McDonald’s as a hamburger frying a coat what is the hamburger Frankie you keep saying tmj is tmj the biggest most weighted uh percentage of CBCT’s you get or are they endodontist or you know no for me it is for me because remember I mean my the population that asks me to read their scans are mostly orthodontists tmj specialists and airway people are doing airway stuff like who are treating or dealing with sleep disorder breathing um there are many uh other radiologists in our group who do a lot more endo who don't do a lot more implants so I mean I would say like currently if I were to look at my iq and tell you how much I have from each specialty I’d say a good 70 percent are people who are asking me to evaluate tmj airway orthodontics and I actually have a chiropractor that sends me scans as well as his cervical spine okay and um but that's my practice uh like I said many other dentists many other radiologists have uh pathology I do get pathology as well but certainly not as much as the uh tmj stuff and you know here's a little like uh thing about evaluating the teams evaluating any of these three things or four things that I just mentioned it's all the same reporting it's all the same evaluation because it's all connected you know your teeth don't live in silo you know don't live in space they're actually connected to jaws that are connected to the skull base that are connected to the tmj that house the soft tissues that may spill into the oropharynx in a sleep apnea episode uh the maxilla is you know the roof of the maxilla the pallet the roof of the oral cavity is the floor of the nasal cavity so anything in terms of the changes of the shape of the maxilla inside the maxwell can affect the dimensions of the nasal cavity all right um and you just you just really I mean the quality of what you do is directly proportional to how well you know anatomy of course anatomy is king I think anatomy is king in anything in dentistry or medicine if you don't know anatomy then if you don't respect anatomy then you're going to get in trouble okay um but particularly in my job anatomy is the is the thing uh the center knowledge the central knowledge in a radiologist's training is to know what is normal to know you know um also the variations of normal so that if you see something that is abnormal you can pick it up right away and talk about it you know and tell the referring clinician about it so absolutely you know anatomy is king and I did a lot of dissections a ton of dissections in in my early years um I used to do one every year and now I’m doing one every other year unfortunately this year I won't be able to do it because of covid but um you know do you always find uh studying the trigeminal nerve to be nerve-racking not radiographically it's actually quite simple radiograph quickly but um yes that you know the whole the nervous system and you know the vessels and all that of course and on soft tissue imaging like if you were dealing with an mri of the head and neck which is what most uh head and neck radiologists will I will do will look at well I wanted I really wanted to get you on um so these kids I hope it makes a lot of them um get your textbooks and read them because in oral radiology I imagine it's far less controversial and everything's far more known in molorendo and probably ortho than the three areas you went into tmj sleep airways I mean that's all pioneering stuff I mean tmj I mean you couldn't get two dentists to agree on tmj uh if they were drinking I mean it's just uh that that's uh my gosh so in fact when I got out of school in 1987 sleep the word sleep was never even mentioned I mean it was never brought up all the way through graduation and tmj surgeries I remember there was a big feud at our school because um the oral surgeons were surgically treating tmj with surgery and a few of the lectures in the class would openly call them butchers and I mean that's not very respectful when you're calling your colleague a butcher but it's been controversial my whole life uh tmj is it getting less controversial is it getting more to be an exact science as opposed to a lot of theories well I think that there's certainly a lot more respect for the tmj and how the tmj affects the occlusion affects your bite um which is basically how your teeth come together you know and uh affects the growth and development of your mandible and your face in general so are you going to be are you going to have like a straight profile are you going to have a convex um facial profile you know is that is there going to be unfavorable growth of the mandible because of the degeneration of the tmjs are there going to be an asymmetry because of the degeneration of the tmj or other pathology you know and if that mandible does grow backwards because of you know the growth sites here that drive the growth of the mandible if they're defunct because they're broken down and the mandible goes backwards then the tongue that's attached to the mandible is also going to go backwards you know it's just it's it and yes I mean unfortunately in dental schools we're not really taught these relationships we're not taught to respect the complex you know we just do our class ones class twos class threes you know um our crown and bridge you know preps and all that you know but you know and I went to a really good school but unfortunately you know the tmj was really given the weight that it should have been and it's hard it's not easy I mean it's hard for anyone because you're dealing not with just one joint you're dealing with two joints that work together that articulate with the skull base that change the way you function the way you do anything with your mandible I mean anytime you open your mouth you use them so certainly and there's a lot still a lot of controversy on how to treat a tmd whatever the tmd may be because temperamental disorders can be muscular they can be osseous they can be you know whatever there's so much uh that can that so many diagnoses that that you can have for a temporomandibular disorder and there are different philosophies as well and people who treat the tmd with splints uh some people who treat them with orthodontics you know um specific types of orthodontics not just like whatever um people who look at the tmj and the airway as a continuum and treat one and the other together you know uh and rather than separately so yes there's a lot of infighting between these groups because everybody thinks that they're right but the way that I see it is that this system is so unique it's so important anytime you open in your mouth just like I said to eat to drink to kiss to whatever you know every time you move your mandible you are using your tmj's and I believe in god and I believe god created it with this incredible ability to heal itself so it's a very adaptable joint and in order to maintain life in order to keep these functions that are important for us so do people like do certain philosophies treat tmd partly but I think that the tmd itself is just so the tmj itself is so adaptable that it takes a lot to help to break it down you know and it's just screaming to be helped in my opinion you know so well um yeah you know I always um what I learned is uh you know tmj stands for temporomandibular joint but tmd stands for too much detail I just uh I just uh would send the film to you in fact do you um what is it like on a day do you do you have like a CBCT that someone sent you that you could uh pull it up and show us what a day uh for Danny is like a day for Daniel even after sending the kids off to school well you know the commute from my bedroom to my office is like five steps so maybe 10. if I’m walking baby footsteps so it's great I mean I work from home um I’ve always worked from home and it's just great uh for any woman who has uh children who wants the flexibility to travel and that kind of thing but in the normal you know in my normal life uh first I of course download the scan from the internet and open up a report and I’d use my software to view this and I’m going to share my screen with you right now let's see if this pulls up and uh okay so do you see my screen I do okay perfect so um so I would get the images and hang on one second if you're listening to on iTunes uh switch over to uh YouTube uh just go to youtube.com forward slash dental town magazine uh because she's showing a video uh so but you might want to talk as if they were listening on iTunes too so am I goanna explain this for sound uh explain it to me like I’m Stevie wonder I wouldn't I wouldn't trust Stevie wonder to read a combination okay so um if you have an iPhone it will appear as braille on the screen so I don't know if that works on android or not all right so basically what I’m what I have on my screen right now is my software the software that I use is in vivo in vivo by anatomize and I um I have the combi CT data displayed in three planes okay it's called a multiplanar reformat and I’m pointing to the axial and pointing to the coronal and I’m pointing to the sagittal so these are slices that are along these planes these anatomic planes the axial the coronal and then the sagittal okay so when I look at these scans I make sure to use two parts of my brain okay one of the most common afflictions in dentistry is tunnel vision and as a dentist I am a dentist first so of course I notice people's teeth you know when I meet them and the same thing here on radiographic imaging our eyes tend to go to the things that we like and we look at teeth we look at the area that we're trying to treat we go straight to that area gravitate to it so I try to turn that side of my brain off the dentist's brain okay and I’m going to turn the radiologist part of my brain on okay so radiologist brain is very similar to my head and neck radiology colleagues which is basically look at the anatomy and make sure that there's nothing abnormal on the skin okay so I’m just going to show quickly you know not going to go into much detail what I do all right what I how the methodology of going through a scan okay so I’m goanna start from the top of the skin as such and because there's just so much anatomy here you know I try to simplify it I try to break it down okay so I look at the black things first and the black things are things that filled are filled with air so those would be the sinuses the air passages and whatnot and the trick here is to look at one anatomic structure at a time so you don't want to be your eyes you don't have your eyes flitting to a bazillion places at the same time because then you're going to miss stuff okay so using that that methodology we're going to look at the black stuff let me make this a little bit bigger right here and as I’m scrolling I’m looking at the ethmoid air cells as they are starting to appear okay and the ethmoidal cells are a group of sinuses that we have so these are the sphenoid’s I’m not going to look at those now because I want to look at one anatomic set of structures at a time and scroll all the way to the bottom of that and then go all the way up okay to the top and look at these areas which are the sphenoid sinuses from the top to the bottom okay so I just do that for every single air filled space the maxillary sinuses of the nasal cavity going from the top to the bottom you know I’m sure that my eyes don't go anywhere else you know just keep it here keep it focused on the one anatomical structure that I’m trying to look at you know now I’m going to look at the nasopharynx going from the top all the way down to the bottom and it's contiguous with the oropharynx so I’m going to scroll my way down and notice how small the airway is do you notice see how little this is like a straw a tiny straw okay this oropharynx is traveling all the way down okay to the and that's the epiglottis and that's the bottom of the scan all right so now I’m going to climb my way up and look at the bony things so I look at the air filled things now I’m going to look at the bony things so scrolling up through the uh cervical spine okay I see some degenerative joint disease right here and then scrolling up going all the way up coming into the skull base and this is where it gets really tricky and this is where the anatomy is very important to know okay uh here's the occipital condyles form and magnum um and it's exercising cranial nerves from 12 like 1 to 12 only in reverse so looking at all these foramina I’m not going to name them I’m not going to you know tell you this is this or that I’m just letting you know that I’m looking at every single anatomical structure in this uh in the skull base as well as in the cranium itself making sure that no calcifications in the areas of the carotid arteries or anything like that and that's basically it and I do that in in the three planes so I’m going to I’m not going to repeat it but I’m going to do the same thing here and on the coronal and I’m going to do the same thing on the sagittal okay on the sagittal where I start to look at teeth okay and we start from the right side of course I know which side is the right side right now but I’d like you to look at these teeth and notice the sclerosis in the periodontal bone okay so I noted the airway being tiny I’m looking at this sclerosis let's keep going and I’m noticing that there are these exostoses okay so another finding them so I’m connecting the dots trying to find the clues to what's going on with this patient okay scrolling all the way around checking the teeth from 1 to 16 okay and I do have a little bit of sclerosis here on 14 and also a little bit on 15 right here and then I’m taking it back from the area of 17 18 and the bone looks a little sclerotic here as well okay scrolling and I can still see those exostoses as I grow all the way to the other side okay I don't see any pathology all right so now I’m going to take the radiologist I’m done with the radiologists all right now I’m going to go into dentist so as a dentist our comfort zone is the panel so I created create a panel and I’ll just look at the general appearance of that mandible of general appearance of the anatomy and I noticed something about the position of the condyle in the fossa okay I noticed that it's a little bit entirely positioned that's an interesting finding so I’m going to write that down and then um so let's take a closer look at the tnjs and in these tmj cross sections I do see that the condyle is inferiorly positioned as well here and here as you can see all right so these condyles are not completely seated in the fossa okay it's there it's not in an orthopedically stable position so let's check if it's if the condyle is out of the fossa are the teeth in maximum intercuspation okay let's take a look at the volume rendering so yes it looks like the teeth are in maximum intercustation okay teeth are in maximum intercuspation but the condyles are not seated in the fossa hmm all right so my findings so far are small airway condyle in fairly positioned I see the teeth and maximum intercastation I see the tauri I see sclerosis in the periodontium surrounding the molar teeth um the maxillary curve of speed is relatively flat okay so all this stuff together let's look at the airway and just see how small it is okay just to get a sense of where I am in terms of numbers I know I mean dentists like to measure things I’m a dentist and I understand but really with these airway measurements in uh on cone beam CT they're not very reliable because we have this um sorry this is because we have the airway is a collapsible tube and it's governed by the um position of the heart tissues as well as the position of the soft tissues okay but on the skin I see that the minimum area diameter is less than 50 okay even though the head is forward look at this the head is forward the cervical spine is extended and that's because on cone bct's that they're usually like positioning devices and in this case it's a chin uh stop as you can see right here okay so putting all the stuff together all right so what happens this person even with this head forward has a small airway and if you try this with me Howard if you'd like to uh try this little exercise with me okay if you're just bring yourself into a neutral position like sit up tall okay and take a deep breath in and out through your nose okay and now I’d like you to move your head forward just like move it forward just keep your shoulders where they are and just move your head forward and take a deep breath in and out through your nose and then move your head back like that okay just like true to your head yep and take a deep breath in through your nose so what do you notice about your the ease of breath which one was the easiest to breathe through forward yep because when you move your head forward you open your airway dimensions so one of the things that human beings do in order to protect their airway is to move their heads forward to open up the dimensions of the oropharynx so that's one protective mechanism another one is to move the mandible forward okay so when you move the mandible forward you're moving the soft tissues that are attached to it forward as well the floor the mouth and the tongue all right and that kind of opens up the airway as well so let's try to put this whole picture together so I’m going to bring it back to this 3d and if you look at this patient again and put all the story the pieces of the puzzle together to make the story what I suspect has happened with this individual is that he has a compromised airway one of the protective mechanisms like I said is to move the mandible forward okay when you come into protrusive or a little bit interior of your um of your maximum intercostation what happens is the condyle will drop out of the fossa okay and over time you can have a super eruption that occurs to the teeth so a dual bite is formed so this guy has two bites he has a bite that is you know where the condyles are seated in the fossa which is not what we have here and he has the bite where the teeth are in maximum intercuspation the condyle is not seated in the fossa now what may happen in you know with time is that these condyles are going to sink back into the fossa they're going to creep back into the fossa and when they do that the mandible is going to rotate and there's going to be an anterior open bite and there is evidence on the scan of a traumatic occlusion one of them is the exostoses that we saw and the other is the sclerosis around the area of the molars okay so when I write my report I talk about all these things of course if there are dental findings in terms of peripheral disease carries what not periodontal disease I’ll talk about that but I try to put the whole picture together so that the clinician sees what I see and then they can go back to their patient and they can evaluate them for these findings and of course the clinical evaluation is more you know you have to use the clinical evaluation to verify these radiographic findings because in the end what I’m doing is I’m looking at a static image uh at one time point but hopefully that there are some clues that can help the clinician when diagnosing and treating their patients so it's a diagnosis of the entire system rather than one tooth or a few teeth you know so that's my spiel that is just amazing I mean that is uh now you have three children right yeah so do you um if you practice um proper um parental supervision uh you should teach them radiology then they can um actually uh have super vision 3d vision 3d there you go you'll go from supervision of your children to 3d vision or x-ray vision so um so basically you're getting mostly tmd so what are you um what are you mostly seeing in tmd I mean I i've I I’m a believer simply because one time uh this patient you know she was young she was fine she was healthy but she kept complaining and I just bought my new CBCT from Carestream and I thought um well let's go take a peek and sure enough she had like this little granular ball you know um in her uh but anyway so luckily and I’m in a big city so I could refer out but um what are you what are you looking at where you say no she doesn't have this or yes she definitely has this I mean what is it what does a typical case look like to you I mean thankfully most of them are relatively normal um a lot of people do have this displacements so I don't see the disc displacements on column beam CT but I can tell that the soft tissue isn't where it needs to be because the condyle isn't in the fossa where it isn't seated in the fossa the condyle would be either superiorly positioned posteriorly positioned the space that soft tissue the soft tissue of the disc would inhabit between the condyle and the fossa is diminished so that tells me that there is a displacement and I see a lot of that in our in the human populations that I see that I see in other populations but I also see many patients who have narrow noses and narrow transverse dimension of their maxilla and it kind of makes me think what's happening uh that this is now rampant you see a lot of people with narrower faces and narrower noses not like big sternal nose but the actual um nasal cavity the bone that encases the lumen of the nasal cavity uh the transverse dimension there would be would be narrow and maybe it's our diet maybe it's uh you know because there's a big generation of children that were not breastfed maybe that changed you know the development of our faces the development of our maxilla you know like I said the maxilla and the nose they basically share that wall so um in terms like I said that's the most that's the most these are the most common findings that I’ll see okay once in a while I’ll get some pathology um I’ll see you know tumors or uh there's a lot of dental stuff as well you know like I said peripheral periodontal um but most of the patients that I receive don't have that issue they're orthodontic patients or um you know their teeth they're uh or their the dental condition is isn't that bad um yeah I mean what else can I tell you well I want to um well first of all um make me think of so many things um I’m convinced um I’m not an anthropologist but I pretend to be one sometimes um I love anthropology and I um you know in business um you read when I was in MBA school they talk about all the time about the reason it's so important for all the departments to be transparent is because everybody within the department gets tunnel vision and drinks a Kool-Aid and it's usually someone from another department that says I don't understand what they're doing next door it seems like it doesn't make sense because of blah blah and then everybody looks like holy moly you're right and no dentist ever brought this to my attention but the anthropologists were publishing stuff saying why don't we see all these um malocclusions just dropping back to a 200 year old human let Luna 5 000 10 000 million year old and and it looks like it a lot of it correlates with um going to a diet of mush I mean and we're not chewing on the leg of a stegosaurus we're uh you know we're not taking down a woolly mammoth um we're actually just eating mush and then the bottle too I read a study on this where um the amount of force it takes to nurse I mean it you know the amount of effort versus these bottles where you know it just comes guzzling out and so um you know um been there done that so when you look at just I mean hell let's just go back to 500 years when you go back 500 years all the way back and you don't see any of this stuff and then today you see it everywhere well obviously something's changed and it's changed during the growth and development so yeah I think baby bottles pacifiers and feeding kids mush um out of a jar is a big part of it but I want to go to your book let's go to the first one um you're talking this one was uh um specially imaging temporomandibular joint um by dania tamimi um on amazon I posted this on dentaltown under tmj and um you go through the you know extensive uh normal versus abnormal temporomandibular joints and how those um look on radiographic imaging but I want you to go into the hot topics of uh understanding the temporomandibular joint through biomechanical engineering structure function of the tmj joint in normal and pathological joints and clinical radiological correlation of temporomandibular joint findings because I have as you as I own a media company I you know I own a magazine since 1994 and my gosh um very rarely do I publish an article on endo and get a big backlash and that was only one time that was scott Perkins who wrote an article called the 15-minute root canal and I literally thought both of us were goanna get killed um but um my gosh when we uh they submit an article on tmj we send it to your reviewers they're never goanna you you're they're never goanna agree to publish it I mean it's always a war and then internally we're just like a screw it and publish something else on another topic so let's go to the hot topics why is what so go into the hot topics I mean um where is the um the um you know the disagreements between our colleagues and and how are you helping them on these hot topics especially with your textbook well I’m Switzerland you see in between all the dental specialties and all the different philosophies I really have no preference to one philosophy or the other and I’m not going to tout one method of treating tmd or the other I speak at many different like many different conferences many different uh you know philosophy conferences and I I listen objectively you know I listen uh and I I don't um [Music] I don't threaten I’m not threatening to I think my my dental colleagues because in the end I mean I’m not treating patients I’m not telling them that they're wrong and I’m right and um I I try to show you know and help them further understand the tmj um as this central structure you know for like I said the growth and development of the face and for function and uh interestingly enough you know just like to go back to your breastfeeding versus bottle feeding um just understanding that the you know the condyle and the eminence but the condyle have this very thin layer of cells called the fibrocartilage and that fibrocartilage is what's responsible for the differentiation of the cells in the in subsequent deposition of bone that will create the condyle okay and it's through the growth of the conduct the growth of the rest of the mandible will occur you know and if I take us back to our breastfeeding versus bottle feeding in order for that growth to occur optimally the condyle needs to sustain mechanical force okay an optimal mechanical force so let's pretend that these are the gum pads my fingers right here are the gum pads okay of an infant and in order for for an infant to extrude milk from a nipple from the mother's breast they need to go like this if you've ever watched a child do and there's a lot of action going on with the tongue as well and when they're doing that with their gum pets they're actually doing it with a mandible so they're activating the fibrocartilaginous cells to divide they're stimulating them okay whereas when we have a child who is bottle-fed they just like feebly go up and down up and down up and down and sometimes not even because you know the milk is just going to come pouring out of the hole in the teat so um understanding well first of all understanding the role of the tmj the role of the position of the disk in the correct place in the relationship of the disk with the osseous components and then the relationship of all that with the teeth and the muscles and the neck I mean that's common that's a common language you know it's like love it's not um it's like a smile it's not it's not that like I’m gonna speak English because it's great and someone else is gonna speak French because it's superior and someone else is gonna speak Spanish because that's you know whatever you know everybody here is talking about their philosophies in their own tongue and not listening to other people probably not even trying to understand them or learning their language but they understand the anatomy and they understand the function of that anatomy because that's a common language right so like I said I mean I through my book I’m trying to help people understand the tmj whether it is a dentist that's reading the book or even a medical radiologist and by understanding not only the function uh the anatomy and the function in the biomechanics but also what is it that is that is the sequence of events that leads to the dysfunction and I’m going to talk very briefly right now skimming the internal derangements you know the displacements the you know I’m going to say something for the dental students in the in the audience right now okay so and when I was in dental school I did not understand what reduction meant like how what the hell is this reduction thing you know this displacement with reduction this displacement without reduction and it wasn't until I replaced the word reduction okay with recapture that I understood okay so it's just take the word reduction out I mean you have to use it because it's correct terminology but put the word recapture in your head basically that's what it means okay so when the disc moves forward if the disc is displaced when the condyle moves forward it recaptures the disc and then moves back into the fossa and then the disc slips back again that's with recapture with reduction displacement with reduction and then if the disc is forward and the condyle is moving forward and it's never recapturing then it's this displacement without recapture or reduction okay so understanding that and understanding the sequence of events that leads to eventual breakdown of the tmjs the osseous components of the tmj is creating the appearances that we see on chrome beam CT or even like plane films or even mri the degenerative joint disease the osteoarthritis um that's all mechanics okay so your bones you know a normal tmj a normal condyle and fossa the surfaces are rounded and it's like how can these surfaces be rounded against each other like that you know it's because there's a bi-concave disc that sits perfectly filling the gap you know in between the stereo thin part of the disc is here and then we have the posterior band and we have the anterior bend okay so if that disc comes out that there's a problem because the disc is supposed to be like a cushion for these bones it's a shock absorber as the disc comes out then we have a situation where now the bones with the movement with the function are rubbing against each other and they become flattened okay so we start with functional remodeling where the bones are trying to increase their surface area and they're trying to you know dissipate that increased loading over the largest surface possible either by you know flattening or by thickening the bone sclerosing underneath the in the cortex okay chondrosclerosis uh and then when the bone can't take it anymore it breaks down so then you get the osteoarthritic osteoarthritis changes so I mean I just wanted to describe this because unfortunately when we learn the tmj when in dental school or even in our programs in our specialty programs we are taught to just identify what they look like but we don't look at them as a sequence of events you know if I see it at the time point five okay or d or whatever what I should know that it went through all these other things all these other morphologies and all these other dysfunctions before it got to this end-stage degenerative joint disease with the with the osteophyte and with the subchondral bone cysts and the sclerosis and all that so to me the to me the uh condyle always looked like a loaf of french bread but then again I’m always hungry um what would be the next closest joint that it reminds you of I mean some people say that it's the only joint that can go forward backward left right up and down that it's completely unique um is it completely unique in moving three directions is there any what would be the next closest joint you know they're all different and this is the only diarthroidal joint in the uh in the body [Music] so basically because you only have you don't just have one tmj working by itself you have two tmj's and they're connected with a mandible okay whereas all other joints work independently or semi-independently nice uh the tmj um is the only you're going to spell that for me the only dye arthrodial joining the human body um you say you're Switzerland so um you know as I get older you know I’m 58 a lot of my friends are getting arthritis um rheumatism things like that do you is this a big factor can you see this on x-ray that this person's suffering from arthritis and their that's what's causing all their issues I mean you can certainly see the osseous changes um to see the soft tissue changes you need an mri okay soft tissue um and then um another um thing that confuses kids especially in school is maybe um she went to dental school because her mom's a dentist and her mom's really big into this um but her mom as most of her patients are coming there because of a migraine stress things like that is there any CBCT component to um looking at tmj CBCT’s that are coming in for migraines and stress and are hoping to get relief from their attention headaches or are you just verifying that what are your thoughts on your on Columbian CT you're just verifying that the osteostructures of the tmj and you know any other structures in the craniofacial complex are okay you know um so you can't really see actually you cannot characterize any of the soft tissues the intracranial structures or anything like that so I guess for that kind of thing you'd send them to head and ex sorry a headache a pain specialist not so do you ever get mris do you read mris I do I read tanja mris and do you think um someone's gonna make an mri small enough for a dental office or is that still I mean I know a brand new mri is 5 million bucks from general electric um do you see someday an mri getting down to under 200 grand to uh go into the dental office well you never know really but the problem with that is that with because the technology of mri is basically a very powerful magnet it's not about the machine itself it's about the suite that you have to create so you have to you know in a hospital the mri has a sweets and the magnet is always turned on so basically when you walk into that suite you have to make sure that you're not carrying anything that's fair or magnetic or else it's going to go projectile missile straight into the bore of the mri you know forceps or whatever it is anything that's um you know even oxygen tanks or stainless steel arch wire is ferromagnetic I think that's why so many dentists are attracted uh to an mri uh it's the magnet so let's talk about your other book um diagnostic imaging oral and maxillofacial um another uh amazing um book I mean that's just uh congratulations on all that um so how if um how is that different than the first book so my homies are thinking about should I get um special specialty imaging temporomandibular joint or should I get diagnostic imaging or a maxillofacial well it depends on what your scope of practice is you know if you are an orthodontist a tnj specialist or a you know a sleep medicine specialist then you definitely want to go with the tmj book there's a lot of material that is similar in in both books like the in anatomy for example um the oral and maxillofacial book this was a joint effort with Dr Lisa Koenig and others and it's more of a pathology book so there is the anatomy section but a big portion of it is any kind of oral and maxillofacial pathology that you might encounter so maybe if you're a surgeon a pathologist a radiologist um or just interested in this kind of stuff you know that's the kind of thing that you would uh that's that you would be interested in you want to you want to get a book that has a lot of images of the different types of pathology so you're doing an oral and maxillofacial radiology um review of the findings do you ever suggest treatments or um treatment planning or uh appliance or ortho no that's not my call that's not my call I’m not the referring clinician I’m not the treating physician or clinician okay um and like I said there are so many different ways to skin this particular tmj cat and I can't tell the dentist what to do because everybody has their own specialty everybody has their own way of doing things if something needs a biopsy I’m certainly going to say biopsy you know if something needs a follow-up I’m going to say follow-up um but I’m never going to tell them okay so you need to do this type of ortho or this type of tmj treatment or any of that because you know that's just not it's not right because I’m stepping over their toes you know and when I put this in writing in my report I’m kind of like tying their hands so I try to keep it as broad as possible in terms of you know I tell them what I see I tell them what might occur and then they have to use their clinical judgment and what they want to do for the patients um you were talking about you know your husband's radiologist and you've been going to these um radiology conventions that cover radiologists from every part of the human body um do you notice um who else do you notice is taking the lead in sleep or tmj or pain or things like that what other type of specialties are you seeing that are treating these where's the overlap between the dentist doing tmj sleep um versus the rest of the radiologists for the rest of the body um all right so basically for the tmj it's mostly dentists that are working on it there are some cranial facial pain people um some head and neck pain individuals ents that are dealing with the tmj with the sinuses some of them are doing some of the surgeries that are necessary for uh sleep disorder breathing um I mean I think that there are more um in terms of the tmj there are so many people looking at it but only the dentist is really treating it effectively you know and focusing on it as a part of the functioning structures because like in head like I said the medical radiologists of the medical doctors they don't have an understanding of how our teeth work you know they don't have an understanding of how you know the function of our musculatory system so um a head neck radiologist general radiologist will diagnose a tmj but I think that the treatment of the tmj is mostly a uh a dental one when it comes to sleep of course there we have sleep medicine clinics all over um the country and all over the world you know but it's only the dentist that can fabricate the oral appliance um and uh do the maxillary expansion that's necessary if it is necessary um or mandibular advancement you know for the kids and again I that that's my uh major focus I mean I you know i've already raised my four boys they've turned into six grandchildren in fact shout out today little jasper just turned two years old today and uh I can't um uh yeah I can't wait to go see how it was uh first um what 730 days went um but um just uh but these kids are learning in school and it's kind of um it's kind of tmj i think is confusing because you know with other dental conditions such as a you know a toothache or a sinus problem um it seems more black and white to diagnose and treat a tooth or something like that um this is a very complex issue where do you think they should begin I think we both agree um that they should first learn the fundamentals of just all the anatomy I mean they just can't learn enough anatomy is there any um any anatomy resources um online where you think they uh teach great anatomy i've seen some uh high tech out of the san fran that's uh well you said you use animoj I mean they have a really nice table I mean I don't i've never you know i've seen it but I haven't gotten a chance to actually do like the virtual dissections and all that uh it's pricey though how much is it oh I can't remember but it's certainly out of my league yeah i'll never forget I was lucky in um in uh bishop carroll high school in biology our teacher dr bush hager actually drove all the way up to ku got a cadaver and drove back down and we were dissecting in high school and um so you know we started early on this but um do you still are you an old-fashioned girl where you still think head and neck on a cadaver is the best way to learn it or do you think animage is the way to go and these dental schools should just bite the bullet and invest in it I like the smell of formal and no just kidding oh my gosh and dr bush shaker even told us like when she was my teacher her and bernard uh butterworth they were they were they were you know probably pushing retirement and she actually said that she'd been around from allied so much um she thought that's why she was seeing uh colors and strange colors in her eyes and she'd looked into it and it was from uh formaldehyde poisoning so oh my gosh but she told everybody that she absolutely had formaldehyde poisoning but then back then in dental school we were before we would cast them we'd line it with that white uh insulation paper yeah that's pure asbestos and then we would heat it up till it was glowing red then quench it always nice to know that you were quenching red hot asbestos uh in the dental school but um so how would you um what advice would you give them um while they're in school or um or even out of school want to learn more about tmj um would you would I mean um I’d say anatomy and I would say your book a good section like about 50 pages about understanding the tmj so the first 50 pages are all about understanding the growth and development of the tmj and how it develops and how it affects the development of the airway how it develops the um the occlusion how it changes the occlusion you know how facial growth will change as well according to how this tmj grows uh talks about embryology talks about biomechanics so that's the first 50 pages of the book but I’m going to give you guys some advice and let me see if I can find my book here uh oh here it is so this is what I carried around for the first few years after I finished my radiology residency and it's netter's head neck anatomy for dentistry if you don't have this please go buy it it's a paperback it's easy to carry you know I took it with me everywhere I went and you know it's well marked yeah so I recognize whenever I marked the books like that it was always because of a debate um you know like I was going to be debating uh anti-fluoridationist on tv or something like that why was yours marked is it because when you're lecturing if someone asks a question you know which page to open up to first well some of it is more like the more complex stuff like I have here the nerf supply of the oral cavity so you know the nice thing about nutter is it's all in like tables so they've got the nerves and the innervation and what it does and all that so when it's something that I came back to over and over again like for example if I had a case where you know the history said something about I don't know whatever it is burning mouth you know whatever it is um or not feeling sensation in a certain area you know I would go back to this and look at all right so for this particular area what are the nerves that supply it you know um yeah and this is how you learn you can't it's there's no way you can just like read this like you know front to back you know you have to apply it every single day in your practice I feel sorry for your children because uh you're so intense I bet you can see right through them oh I wish so um how would you um one of the hardest things for these kids to learn and it and it predicts their success rate the most is who can just talk to people in fact i've told so many dentists over the last 30 years you know dude you know what you need to do you need to go get a job as a bartender on friday and saturday night because everyone's sitting at the bar is drunk and you can't talk I mean when consultants go into a dental office they write scripts for them of how to answer I mean when you have to teach your people how to talk to another human you're usually in dentistry or accounting but what do you have any models where you could pick up some models and uh and show how you would explain this to a normal human who didn't get a's in calculus physics geometry and uh knows all the uh not that that when people say the three laws of thermodynamics you say no there's actually four now but um how would you explain this to uh normal humans and you're in orlando there's a lot of normal humans flying in there from all over the world there's a lot of strange people here all right well basically remember I’m a radiologist so by definition I’m like sequestered in my little cave okay are you cloistered you're a cloistered radiologist but I mean I’m a people person if you haven't already you know figured that out I like talking to people and I like dumbing things down you know not that I see that it needs to be dumbed down but I feel like speaking in a very clear terms uh even when you're teaching medical professionals you know when you speak in simple terms the idea sticks and by not complicating things like when you give a lecture you're not having too many points find one central point and then just like elaborate on it you know so that they so that that central idea sticks and they explain it to me like I’m five is perfect because if we were plumbers it wouldn't make sense to an electrician or a roofer or a let alone a dentist or you know something like that so um nobody knows what you're talking about if they haven't spent 10 000 hours in your field of dentistry I mean even my plumber uh won't do any electrical and my electrician and I’m like well you know how to fix that he goes no no I’m not gonna do that you need a plumber so I think x you should always talk about dentistry to every patient as if they were five and it's not dumbing it down it's just realizing that they didn't put 10 000 hours into this and absolutely explain it so explain it to do you got any models i've got my skull oh my god oh and he looks just like me I love the hair nice beautiful bold skull explain it explain that blue skull to me like I’m five all right so let me just like tell you what this skull is about this is my favorite new toy all right so this is a magnetic skull technically are you a nerd or a geek I mean oh I think a combination of books okay dania nerd geek yeah daniel nerd geek if that's your favorite toy my gosh the world needs more of you well let me show you why I think it's really cool because it's a magnetic skull basically each one of these bones is a separate structure so meaning that I can like take it apart this all everybody knows you can take the mandible apart so much you know but when you start to be able to take away the zygomas you know and you start to take the maxilla and see its articulation with the stuff inside you know look at it from the back and maybe even like if you have some time you can take the two maxilla apart you know and actually appreciate that you have to maxilla not just like one okay and all the structures that are inside all these little bones that live inside the nasal cavity that make up the inside of your nose okay so let me okay so I’m going to speak stupid about nasal resistance how about that okay all right so what this is your upper jaw okay as you can see the upper jaw here you've got your teeth you've got the bones that support the teeth are called alveolar processes okay and if I were to flip this uh jaw this way you'll notice that there are actually two bones that are connected in the center okay so um when we look at this okay we can notice that this upper jaw isn't just the place where the teeth live but there's also the nose that lifts here as well okay so anything that happens at the level of the teeth can also affect the dimensions of the nose okay because if I were to take this apart and we look at it the bottom of the uh the nasal cavity the bottom of the nose is actually the top of the mouth okay so if you are um if you are narrow in your maxilla this way horizontally there's a very high chance that you're also going to be narrow in your nose [Music] and of course the term is really transversely but you know okay um so when you're when your upper jaw develops and if it develops subnormally if it develops small then your nasal cavity your nose is also going to be small okay so that's going to make it hard for you to breathe out through your nose why let's pretend that we have a set of straws here you have a smoothie straw you have a regular straw and you have a coffee stirrer okay try to breathe in and out through each of these straws and which one would be the easiest one you tell me howard a bong a what a smoothie which one would be the easiest straw to breathe through the smoothie straw the regular straw or the coffee stir or straw the biggest roundest straw right well not the biggest one like if you were to take a pvc pipe you wouldn't be able to breathe through it because you know but certainly the smoothie straw would be easier so if your upper jaw doesn't develop properly and your nose doesn't develop properly and it's small then sucking air through your nose through a very small straw is going to be so difficult just as it would be sucking through air through a um a coffee stirrer straw okay you know this coffee stirrers that actually hold yeah okay absolutely all right so yeah I mean that's how I would explain that portion of it I have a question where you're out there um some orthodontists say that you can only expand the jaw with a rapid palatal expander you know at a young age six or seven but some people are claiming they can do that on adults um do you see um how do you how does your anatomy can you expand the upper palate and the nose volume as an adult without surgery or it would have to be surgically assisted it would have to be surgically yeah there are some appliances out there that claim to stimulate the production of undifferentiated mesenchymal cells they call them stem cells I’m not sure really I haven't seen studies that show long-term uh changes with those but um in the end I mean I don't I can't really recommend treatment and I really can't tell people what to do but if that rocks their boat and they're trained to do that and they see results then you know all the power to them well they're they the camp that says it can't be done after the um uh suture is um formed is uh they're saying they're just tilting the teeth they're not really expanding uh the mandible and you have to do a surgery can I ask the most bizarre question selfishly just for me I know no one cares about this but I can't find the answer um my um boys were you know we're third generation wrestlers my grandpa we just love it and then um so that leads to like boxing I grew up on muhammad ali and now it's uh ufc and all these great boxers what I don't understand as a dentist is that you can punch a person in the nose all day long but this but everyone knows if you catch him right at the end of that mandible from the side not straight on but if you clip the side of that mandible it slides out so something electrically is happening and the other place you see is in the temple and I don't want to go to the temple because you know um a lot of people think that if um but anyway what do you think electrically is going on where because you just took off that mandible like no problem why do you think if it gets torqued to the side really fast and hard and in fact a lot of times you get knocked out just like a short little punch but they if you land it just perfectly you know you don't have to reach back and swing your whole body but if they hit it just perfectly it slides out do you think that's an electrical issue I you know I’m not 100 sure about that have you ever thought about this I’m thinking I’m thinking as you're talking and I’m thinking it has more to do with the actual position of the mandible it may have something to do with the position of the neck you know and the sudden movement you know we've got a lot of stuff going on in this real estate right here you've got your carotid arteries you've got the spinal cord you've got nerves cranial nerves coming in and out you know the skull base so it may be I’m not I’m not 100 sure um it may be something to do with that now with that said you know in martial arts there are certain points that you if you were to touch them or to you know deliver a punch or like a quick whatever let's just look at the movies I’m sure i've seen you know where they do I don't know something with two fingers and the person's like out um in in ayurveda is a form of uh therapy uh coming from the yoga traditions and all that um there are points called marma points okay and these marmot points are known to be connected to different parts of the body so for example you know if you have issues with your heart with emotions whatever you know you'd stimulate the marma point which is right about here you know so I’m thinking that there must be some kind of a you know if you're going to think holistically there must be some kind of an energetic field that has to do with that you know that kind of impact you know I really can't explain it to you anatomically right now you would have I mean a medicine person yeah I mean obviously like you know a rear naked shake should um choke hold obviously you know the carotid arteries their throat they can't breathe or get blood flow but it just seems to me that that is it just looks like an electrical issue it looks like someone just turned off the lights and I want to ask you another thing um you know there's eight billion humans they're all the same I mean it's only one species our species has less diversity than about any other species so a big red flag I always pick up on is when they are thinking different thoughts all around the world and you've lectured around the world you were um you even went to school um in saudi arabia um Harvard their classes oh it's always international I mean I bet what percentage but anyway harvard's it's all international they come from everywhere where do you see the diversity of tmj thought around the world as you move from the americas to africa to europe to asia um antarctica I know most of their work is done on penguins and uh doesn't apply but do you see did they have tmj's [Laughter] do you see any variants um or big variances or are uh different schools of thought let's talk about that because someone's yeah because that's got to be the most interesting um and I’m just going to say that say it like it is and I don't mean to offend anybody but it seems that in the u.s and other places that follow the us's teachings there's a lot more rigidity and a lot more um this is the way it is and this is how you do it you know whereas if you go to south america or to other places in europe you'll see that the clinicians are more willing to incorporate some of the more adjunct therapies so things like osteopathy chiropractics or my functional therapy um without feeling threatened that their turf is being you know stepped upon um and that's how I see it you know I’m physical therapy for example um you know it just seems that um many people here in the us are very you know one track-minded in terms of this is the way it is and that's all there is you know and I’m not in Oregon in Arkansas they tried they took a license away from an orthodontist because he brought in a hygienist he didn't want his patients have to go to the dentist have the hygienist take him off come in first check then go back so we just brought the hygienist and said well we'll just take them off clean your teeth and do your check and then like you can't do a cleaning at an orthodontic office I mean it was like I mean it just yeah I agree I agree they're very rigid so what advice would you give Americans how do you get an American to loosen up besides alcohol yeah i've always thought that um every lecture I went to getting my FAGD magls stuff like that um the one or two hours in the bar at 10 I learned more from the guy that during his all-day lecture and I would just sit there and say well why didn't you say that at the lecture and we uh he's got his three-piece suit on it his powerpoint yeah um yeah just lighten up Dennis just lighten up that's good advice for anyone I mean if I say this I mean and this is meant for all human beings not just Americans you know any human being you know um let go of your ego you know tame your ego and and just don't let it get the best of you because like the ego makes us emotional and makes us angry and defensive but if you listen objectively and you just step back and try to walk a mile in the other person's shoes you'll be surprised what you learn well um you um you were talking earlier about yoga I mean you got a huge um fitness background and certified in Pilates yoga and spinning um do you think um I always thought bikram yoga and it was I was so upset when he got into trouble and had to flee the country or whatever because I’m I just love bikram yoga I don't like the other yogas because with bikram yoga you knew it was going to be 26 poses twice and you were going in there and it was just so easy to follow and you could just get in the zone but then now I have to go to other yoga classes like trying to follow some cheetah around the jungle and she's jumping around and going this I just find it it's just too exhausting it's not even funny more but did you find uh did you ever do bikram versus uh it's too late in Florida for me to go into a big room you know I can just like step outside and do whatever yoga class there you know with the humidity and the so I see how that would be fun you know if you live somewhere like Boston but do you think yoga is um a good um for the mind too when you said you know relax and you know let go of your ego do you think yoga is a big mental um probably even maybe even more mental than physical as opposed to other sports like say playing racquetball or something well it's really okay so let me take a step back and say it's not a sport it's not like a gym class it's really a way of life so if you um if you really will go into the yoga philosophy and you'll go into um the teachings of yoga and I’m not even talking about like you know a religion or anything like because it's not a religion but it's basically there's a code of conduct how you treat yourself how you treat others you know and part of it is not harming okay and non-harming is not only not harming other people but not harming yourself with negative thoughts with internal chatter that is unnecessary you know that brings you down and I think that that is a common affliction in many of us where we ruminate and we go back to past experiences or maybe things that we did that we regret and um and we keep bringing that up in our heads internally and you know just regurgitating it and going back and forth on these thoughts and that keeps us from living in the moment rather than you know um you know if you're always there always in those thoughts then you're living in the past and if you're worried about the future who knows you know if it's going to come or not but so yoga helps you be in the present be in the moment okay um not stealing so it's not just stealing somebody's possessions but not stealing these moments from yourself like if you were to uh once again just sit and worry about this or that or think I wish I didn't do that you know you're stealing this time from yourself so it's a lot of things and the practice itself the actual movements the what they what we call asanas or poses those help tame those traits you know um within us so that we find a bliss inside of us and um I mean I did um let's see when I was going through my residency I did about 200 my 200 hour certification my oral radiology residency that is a gazillion years ago and recently because of covet I was able to complete my 500 hour certification because everything came online and then also I’m completing my yoga therapy course work as well so yoga therapy is about it's basically life coach coaching with a twist quite literally you know so you're trying to help people figure out what how to get rid of the past if they have past issues post post traumatic stress disorders you know we have a lot of issues now with cobit and others a lot of trauma in the world a lot of suffering so if we you know through yoga therapy you know and through helping people liberate themselves from these negative thoughts that just keep on coming also chronic disease you know yoga therapy helps people who have cancer who have diabetes and the central idea is that these negative thoughts and attitudes is what causes the harm to our bodies you know by storing these negative thoughts inside of us we are creating a fertile ground for the development of these chronic diseases so um yeah I don't know if I digressed from your original question though when I when I podcasted the uh the president of the American dental association just about a month ago chad um I was saying well what's the biggest thing on you on your radar now and he says it's actually not even coveted it's the sudden spike of suicide among dentists and on dental town the longest threat going right now since covet is actually suicide and I cannot believe some of the people that have checked out I mean it just looked like the all-american you know mom with kids husband everything's just perfect in the middle of the pandemic she just you know she checks out and uh several and so yeah mental health I mean who cares about oral health if you don't have mental health right exactly and it's harder to get rid of mental health issues you know the physical issues the physical elements you know the acute physical elements we get over but then we get to a point where you know if we keep these negative thoughts inside of us they never go away and you know what they don't just stay with us they transfer to the next generation through epigenetics so um so certainly I mean there are certainly a lot of uh there's a lot of people suffering I mean in general you know life is full of terrible things I mean here in the us or anywhere in the world we have a high incidence of uh abuse and you know child abuse or marital abuse and um you know these things they harbor these um these feelings these negative destructive feelings of uh lack of self-worth lack of self-confidence um not to mention you know just the fear and the anxiety and the depression well I mean nature is brutal I mean I mean I mean I mean someday the sun's gonna as it slowly burns out will engulf the whole earth even if we survive that the whole milky way is gonna go through a black hole I mean uh all of nature is uh pretty brutal I um I’m always shocked when people are um tell me about all the bad things that uh happened in human history I’m like guy you can just watch an ant hill an ant hill is brutal just get on the ground and watch it have you ever seen uh ants fight uh another ant have you have you ever been sitting there where uh two tribes of ants are going after I mean they line up I mean it's all of nature is just brutal it's very brutal so just relax and enjoy the ride um and I um you said something that I thought was very profound um where you talked about where uh um you know one of the biggest secrets is just be humble and my gosh dentists could learn so much from so many people humility is a big part of um increasing your comprehension isn't it absolutely you know if you the thing is here's the thing I mean if you go to the fountain with a cup that's already full then you're not going to have any place to put more you know if you go in with a perception that you know everything then you know where's that openness where is that vessel that's going to receive more you know you go to the well with an empty cup and uh you know and bow yourself about your head to your students because the students are the best teachers you know um so definitely humility like I said it's taming the ego it's work it's hard work I’m saying this now I mean this is years and years of really hard work uh self-improvement and self-thought and contemplation of well emotions I want you to talk about that because um so many dentists you know they'll start talking and they'll say you know I want to be really successful and I’m like well what does that mean and he'll say well you know someday I want to have 10 offices I’m like well what does 10 offices have to do with being successful and it seems like the common traps um I don't know that'd be my question boy that's what I’m gonna when I get done ranting I’m gonna say uh do you see anything different uh mental issues with dentists versus the rest but they always live be up above their means I mean they're always stressed out but they you know they can't drive a ford you know they can't drive a prius it's got to be a benz or a range rover they can't have a three bedroom two bath so it's they got too much house too much car and their wife if it's a radiologist probably didn't buy a five thousand dollar gucci purse uh she probably bought one from target I mean I don't know maybe you're a purse uh maybe that's your weakness purses but I just think dentists so my question is what do you think makes um would be the definition of a successful dentist and do you think a lot of their stress is brought on because they just financially live so far beyond their means I mean again everything in financial planning they'll never talk about financial planning if you don't get married you won't get divorced then you won't have all the money if you don't have kids are excellent I mean so they go out and they get married they have a whole litter of kids they build a mansion big cars they can't go camping at the lake they have to go to hawaii or take a cruise and then they want to know why they're running 45 hours a week stressed out of their mind and at 50 years old they still have debt and I’m like duder you know so what is a successful dentist in your radiology yoga mind of yours one whose colleagues and patients and family regard him with the utmost respect and pray for him after he's died wow I’m gonna have to get that in writing that was that was awesome now now you'll know how slow a type of him a successful dentist because really what is all this stuff someone who I’m saying a successful dentist is someone who I mean whose colleagues and friends and patients and family regard him with the highest respect and you know when he dies they pray for him and whenever he's mentioned he or she I should say she because I’m she right you know um these individuals you know pray for that for that dentist or pray for that person that is beautiful that's the best i've ever heard um a successful dentist is someone who's colleagues friends and patients hold them would you say them in their highest yeah he or she s slash h-e patients hold them in their highest respect and pray for them after death that that that's beautiful my mother loved that I was but I want to ask you since you since you added um religion to um oral radiology science um i've noticed some um dentists their whole career has always found it bizarre that um actually around here it's a lot they'll say well how can Gordon Christian be the main scientist you know over the years yet he's very religious how do you how do you reconcile a scientific mind that's only based on facts and a religious mind that's only based on faith how do those two things come together well I’m Muslim so my faith basically tells me to look around at nature and constantly god at everything and contemplate all the signs of his existence you know the planets and stars the animals the plants the turning of the earth around its axis you know the sun the moon just looking at everything and seeing him and everything so it's not it's not separate um for me you know to be scientific to see him even in the smallest details of the cell organelles you know uh and his hand and all these things it's not it's certainly not separate you know you know i've podcast interviewed 1500 dentists and uh you're the only one that reminds me the most of my oldest sister mary kay who entered well she entered the nunnery it was she entered the nunnery straight out of high school she's been a nun uh ten years longer than i've been a dentist because she hadn't but anyway um my gosh seriously when you talk it's like I’m talking to my older sister uh mary kay or sister yeah I you know what I love about her you know what I love the most about my older sister is that in her uh in their cloistered convent when they die they bury him in the in the backyard right in the garden they're like on a six acre deal the average life expectancy of everyone buried out there is over 90 because they don't have any stress they just and whenever you go visit her um when they're all together they're always giggling they're always laughing in fact I wanted to write a book um my a non-dental book called the giggle factor because I noticed right out of the gate how come when I lecture in a very poor country everyone's laughing and everyone's giggling and then you go to like japan germany the united states and you know and it's like everybody's just wow they're just wired up tight and it's like holy moly and it does and then it's like I wouldn't trade the giggling in kathmandu and rio de janeiro to live in Seoul Tokyo or berlin I mean I just I mean my gosh I mean how long do they how long is lunch in uh and uh and in your neck of the woods in Miami well while in orlando I mean if you go to a conference lunch isn't that long you know but if you go to a conference for example in uh in Spain or in south america it's about two hours long because it's about not just about let's just get food in us real quick and go back to sit in a dark room you know for a long time the afternoon's more interesting because when you lecture in Spain or brazil and all those places when they go have a two-hour lunch they're always going to have some beer and wine and they talk and they come back and they're even more loose and happy and lucid and talking and I yeah um I feel sorry for people who were born raised and died and never left the united states south Korea japan or germany because they don't even know I don't think most Americans even know how uptight they are until you go see a whole another culture that's like dude you take yourself too serious just relax chill have fun you know but um I really like that and you wonder why so many people have tmd yeah you know just you know you're um I’m you know I probably shouldn't say this but uh oh it's sinister uncensored transit come on you feel around let it out so in yoga basically you know the issues around your mouth are related to issues around your anus so if you are you know are over here basically you also have issues with your digestion and you have with your actual elimination so um in the yoga therapy world at ayurveda um well I mean bringing it back to that subject you know uh one of the things I want to do one day you know probably like when I have time is to write a book about yoga for the tmj yoga for tmt so basically helping put these two worlds together that I have you know the dental world the scientific world and the more holistic world and try to help um my dental colleagues understand that their or a facial pain patient uh their sleep disorder breathing patients you know their tmj patients um they already say tmj their orthodontic patient you know all these people have issues especially if they look at little girls you know these days they've got a ton of issues and they all have issues and these issues affect not just their faces and their necks but the rest of their body as well and part of it part of the I believe the success of one's treatment is to deal with the whole person and not just the physical manifestation of disease what is it that caused that disease what is that deep internal knot inside that person's heart or that person's body that manifested as the cascade of events that led to the tmd you know and why is it always caused from the mom and not the dad that's what I can't figure out what this internal knot of stress and all that yo you always get that from your mom not your dad dads are perfect you know that ask your husband everything that went wrong you always blame it on mom your kids your kids must be uh very young but no I’m just kidding but hey my gosh um I think you're just a wonderful person inside and out um my gosh from radiology to yoga what an amazing mind you have and it was uh your textbooks are amazing and I can't believe that you spent uh my gosh hell we're coming up on two hours thank you so much for coming on my show today and talking to my homies about all things from tmj to the whole mind and body and spirit uh what a wonderful person uh if you ever want to come back on the show I’m inviting you to come back um before this one's even over that's how wonderful you are um thank you so much danny uh to mimi oral a maxillofacial radiologist at beam readers have a rocking hot and wonderful day today thank you so much it was a pleasure you 
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