Ray Becker, D.D.S., F.A.G.D., a dentist at Howard County Smiles in Ellicott City, Maryland, talks about a cutting-edge diagnostic tool that can determine whether your jaw joint is damaged.
Interview conducted by Ivanhoe Broadcast News in February 2017.
What are the concerns of doctors who are not using this procedure and why aren’t they?
Dr. Becker: I think it’s an awareness concern. Doctors aren’t aware that there are different technologies that are available to help give them objective information to help create a diagnosis.
Why is the approach the one size fits all. Because let’s just start with sixty five percent of the people have problems with TMJ, you go to the dentist immediately they say—
Dr. Becker: Here’s what you do. The problem is that unfortunately there is no specialty in dentistry for TMJ. Patients go to their dentist trying to find resolution for these issues and the doctor really doesn’t have a basis to understand what to do. He usually treats the patient in terms of what his exposure is, which is generally give the patient a generic night guard, or to advice or recommend to get a night guard which may or may not be the best solution for that patient. It’s not really based on a diagnosis it’s just based on a knee jerk reaction to try to address the problem.
Sometimes if you get a night guard and many times the dentist will say, well you know, just run up to the drug store and get one that’s not even fitted to your teeth. What’s the problem with the ‘one size fits all’ night guard versus a tailor made night guard?
Dr. Becker: That’s a great question because everything that you do to the human body creates a change. If you have an ill-fitting night guard that the patient hopefully makes somewhat correct that’s generically sized, it’s probably not going to be very comfortable at best. The patient’s compliance with that is going to be probably very low. A step above that would be to get a full arch generic appliance from the dentist which would cost more but fit better. But it may or may not be the best solution for that patient again because it’s not based on the diagnosis of what that particular individual’s needs are but more or less that generic approach the dentist, that particular dentist, applies for his one stop this is how I fix this problem.
How does a person, going in as the average patient, know what to ask of the dentist? If they’ve got the TMJ and they immediately are told you need a night guard what kind of questions should you be asking?
Dr. Becker: One of the first things would be to try to assess the level of competency or the level of training and knowledge that the individual dentist has. Or hopefully the dentist would be comfortable enough to say, this is just beyond my realm, this is not something that I know a lot about besides just go get a generic night guard. One of the things would be to see if he has some of the equipment and technology available to be able to get an accurate diagnosis. Instead of just putting his fingers in your ears to see if you have a problem with the clicking or popping. There have been a lot of studies done to show us how inaccurate that is. There’s only a fourteen percent consistency amongst diagnosis with people using a stethoscope. That only goes up to forty eight percent for a very advanced stethoscope called a Doppler. But the JVA which is a technology that’s available we can actually get a ninety eight percent sensitivity and specificity to determine if there’s a problem with the joint.
Is there a problem, also just going back from the patient’s point of view that a lot of people have a dental phobia, they’re afraid to go to the dentist to begin with. When they have this issue they might think, well this is going to hurt. Generally you think pain. Tell us about the actual diagnosis using that equipment, is it correct the patient feels nothing.
Dr. Becker: Right. Part of our diagnostic process is set up to make it as benign as possible and to make it scalable. The patient can come in and they can actually have the JVA test quick test done which is very, very simple. It’s just two simple sensors that look like headphones that go on to the ears. There is zero discomfort, there is zero pain and within a minute we can tell exactly what’s going on with that patient’s joint. Seeing if this joint itself is part of this patient’s problem. With TMD there are over thirty one different diagnoses and etiologies that are associated with what can comprise this patient’s individual problem. It’s not as simple as just coming in and putting in a night guard and hoping it works. It’s a better approach to have a method and methodology to be objective about your diagnosis, your evaluation and your treatment of that patient. The JVA quick is the cornerstone in my practice for that because it allows us to eliminate so many of those different diagnoses or possible etiologies to get a better feel for what this patient’s problem is. Therefore, we can become far more directed in terms of how we approach this individual patient’s need. It’s very easy, it’s very benign there’s no pain, there’s no discomfort it’s a very quick easy test.
You said that patients sixty five percent have TMJ so I think you mentioned that sometimes when a physician sees so many patients with the same kind of disorder going on that it’s almost like they don’t see it anymore because so many people pop their jaws.
Dr. Becker: Sixty five percent of the human population has a joint that makes some form of noise. NIH did a study where they found that between four and fifteen percent of the population of patients have pain, discomfort or dysfunction that would benefit from treatment. That amounts to hundreds of patients within an individual dental practice for every practice in the country. Instead of just saying, well ninety five percent of my patients are okay there’s actually five percent or ten or fifteen percent of my patients that I might be able to help. That’s where this kind of technology is invaluable for giving people guidance in terms of how to appropriately address and treat these patients.
Let me bring this in to it because I mentioned this earlier, I broke a tooth from grinding. Can you let people know if they don’t address this problem it’s not just an annoyance, it can lead to other things.
Dr. Becker: Absolutely and that’s the reason again that we use the JVA Quick routinely on all of our patients all the time. Because there is no specialty in dentistry for TMJ, it really behooves the individual practice to have protocols, treatments and methods to access their patients. Every one of our patients that come to see us routinely, just like you get x-rays from your hygienist, well they routinely get the JVA Quick from us. We can actually get a baseline. Getting that baseline is critical so that if we see a change the patient a lot of times can have an understanding that, well my situation is getting a little worse. Or what is that all about, I’ve never really been given any information on that and understanding that. We found it opens up a whole floodgate of ability for patients to understand and explore these things instead of just ignoring them and putting them aside.
What are those, some of the actual physical problems that can happen if the TMJ is not addressed?
Dr. Becker: It can be quite debilitating. There was a study done just recently that showed that out of every one hundred million Americans that are out there there’s seventeen point five million work days lost every year due to specifically TMD. It’s a pretty significant issue. It’s not something that is unfortunately addressed as often as it should be, but it’s a significant issue obviously from even the workforce standpoint.
Has this been around a long time, is it technology that people are more nervous and stressed and trying to do too much, what’s your take on it?
Dr. Becker: Ironically the JVA quick has been on the market since nineteen ninety.
I mean the actual TMJ.
Dr. Becker: It’s been around since as long as we’ve had human beings. There’s an interaction, actually it’s not just TMJ the better term for it is TMD, which is temporomandibular dysfunction which includes issues with the joint itself. Again there’s over thirty one different etiologies that come in to play with TMD. Dysfunction in the actual joint itself being one of those, that’s been around forever. The stomatognathic system which is a fancy way of saying the teeth, the muscles, and the joint all combine to create whatever that human being has as their way of functioning. A disruption in any one of those systems creates an imbalance that obviously can become systematic for them. That’s where the six to fifteen percent of the population falls in to is an imbalance that’s no longer something that they can tolerate that creates a dysfunction that actually affects their lifestyle, and we see a lot of that. I think that’s something we shouldn’t be overlooking and ignoring trying to console ourselves that well ninety percent of my patient population of patients is okay, so I’m not going to address this other ten percent. And that ten percent is a large number of people in the United States and in the world.
Should patients be questioning if they just immediately get a diagnosis or let’s get you a guard to put on. You’re going through a series of steps to determine how to address that problem. Why do you suppose it is that more physicians don’t utilize that?
Dr. Becker: Well I think it’s a lack of understanding of the diagnostic process. What that means is that most patients go to a doctor assuming they’re going to get a diagnosis. Just give me a diagnosis, give me medication or whatever it may be and off I go. That’s not how the process works, and with something as complex and TMD where you have over thirty one different etiologies it really mandates that you’re able to have the training, the equipment, the knowledge to be able to understand which of those thirty one is this actual patient’s problem. The diagnostic process truly is where you come to the doctor with your symptoms and he goes through a series of tests, one being the JVA. Getting an understanding then of, well how does this part play in to it. By getting all of the information you create a differential diagnosis which means that this patient comes to me with this problem and it could be this, this, this or this. All of the data steers more towards the likelihood that it’s this one problem so I’m going to use that as my working diagnosis which is the one I’m going to work off of to see if in fact this is this patient’s problem. From that you actually treat the patient on that working diagnosis. It’s only after you successfully treat the patient you can actually say, that’s the definitive diagnosis, so most doctors that I run in to don’t even have that basic understanding of the diagnostic process. I think that it’s imperative if you’re going to be approaching TMD issues that you absolutely have that incorporated in to your practice.
What causes a patient to grind their teeth or clench their jaw?
Dr. Becker: There are a lot of reasons. It could be something wrong with their actual teeth in terms of how they come together. There could be a psychological component in stress. We know that basically bruxing and grinding is a natural human stress release mechanism that you actually incur when you’re exiting the fourth stage of sleep which is the deepest stage of sleep. You can’t know that you’re doing it and be doing it, so you can’t be in the deepest stage of sleep and know you’re in the deepest stage of sleep. But there’s a period of time for up to fifteen minutes during each sleep cycle that a patient naturally bruxes, especially stressful periods, where what we call sympathetic tone is increased. That’s the amount of adrenalin that you have from being stressed out. Bruxing and grinding is what we call a parasympathetic activity. It’s the body’s attempt to normalize that stressful environment to try to get back to stability which is what the human body tries to do. It’s a known phenomenon that as you exit the fourth stage of sleep which is the deepest stage of sleep that there’s a period of time for up to fifteen minutes during each sleep cycle that you can Brux and grind your teeth which is a parasympathetic activity which is an attempt to get your body back to more stability from the increased sympathetic tone that you have being stressed out. If you multiply that times the six to eight hours that a person would sleep that’s up to two to three hours of bruxing and grinding your teeth every single day. It’s been studied how long human teeth, should and do physically contact. Some studies go as low as fifteen seconds in a twenty four hour period up to fifteen minutes but that’s the maximum amount. Chewing, eating, etc., because teeth never touch, that’s the irony is that teeth never touch. There’s food in between if you’re chewing, they glance in milliseconds. When that’s all added up it comes out to fifteen seconds to fifteen minutes is normal in a twenty four hour period. It’s pretty apparent then if you’re bruxing and grinding for two or three hours that you’re putting the system which may or may not be stable under a lot of strain and that’s how human beings end up with these problems. They put the system that may not be accurate or balanced enough under a lot of duress and therefore it has a tendency to possibly break down, in the teeth, the muscles or the joint.
What are some of the worst cases that you’ve seen that are the results of clenching and grinding?
Dr. Becker: It’s not just clenching and grinding but basically there’s a wide compendium of how people respond to this. There’s a large degree of human beings capacity to accommodate. Your mouth and your teeth are very sensitive in that you can pick up twenty five microns difference in the human tooth structure. You can literally find a discrepancy in twenty five microns in your teeth that the patient can perceive which is one fifth the thickness of a human hair. Imagine when you’re putting a crown in that’s not quite right you’re going to try to find a way to get around that or work around that. We’ve seen a lot of times where if dentistry is one of the issues that can possibly make it where patient’s say it never felt right after I had this crown done. Or they may have never had that right or they have orthodontics done and it didn’t quite feel right. If you’re not looking at the bigger picture, and if you’re not aware of that, and if you’re not trying to pay attention to that then you’re just going to hope that patient can accommodate whatever you have done. I like the approach of trying to understand where they’re going to go and then try and help them get there and understanding these issues so that you can get a better outcome. We’ve seen a wide range of patients, some have had no dentistry done and have significant issues, some have had a lot of dentistry done and have a significant issue. There are a lot of etiologies again that lead in to these problems.
When a patient comes in and then complains about having TMJ problems what are some of the actual results, what else have you seen?
Dr. Becker: We’ve had a lot of different types of etiologies. One very interesting one was a referral from a doctor in London where the patient had visual snow. It’s very interesting. Basically he has an issue where he constantly sees like on the TV screen you see the snow, that’s his environment. There’s a lot of work that some of my colleagues in London have found where there is orthopedic and orthodontic issues that cause pressure on different arteries and veins through the actual neck, through the atlas that actually impinge upon the blood flow in to that region of the brain which can cause these issues. We actually look at not just orthodontics, we look at orthopedics, we look at the structure of a patient, we look at the entire body to see how does the entire system play together and does it play nicely. The most significant part of that though is not just using theory and conjecture but I’m a strong advocate of using data and equipment and technology to get facts so that we can build our responses and our diagnosis and our treatments on that, so visual snow is one of the most unusual ones. We’ve had times where we’ve done a certain approach where we’ve tried even our approach and it didn’t quite give us the results that we initially expected. But again everything is telling you something if you’re aware of what it’s telling you. There is no such thing as a bad result. If you wore a night guard from a drugstore and you put it in your mouth and it actually made your problem worse then that’s telling you something. It’s just a matter of are you aware of what it’s telling you. That’s the biggest key, is you have to have that diagnostic process as your foremost mantra of how you’re going to approach these cases and then you’ll find your success rate goes way up.
From start to finish let’s say I come in as a patient with TMJ and you go through the diagnostic process about how long does it take for the average patient to get to where they experience relief?
Dr. Becker: That’s a great question. Sometimes we get relief as soon as we can start any procedure with them such as the night guards right away. We have a patient that I think you’re going to see today who is a doctor, she’s a chiropractic doctor and she saw immediate relief. We have another patient who tried the same approach and again we call it a diagnostic appliance. If it actually gets rid of your pain then it can become a therapeutic appliance. But everything is steering us towards an outcome, a positive outcome for that individual patient.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Ray Becker, D.D.S., F.A.G.D
410-730-4674
drbecker@howardcountysmiles.com
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