The REAL Hidden Cause of Tooth Sensitivity – Sympathetic Dental Hypersensitivity – PDP240

Teaser:
Remember misfolded proteins? If you as a human, which is rare die of prion disease, you are a complete biohazard. They don’t even know what to do with your body. Cremation is not enough, but guess what kills prions? Well, they’re not alive. Guess what destroys prions? Their misfolded proteins. Ozone, trigeminal, cervical,*** and this all ties into sensitive teeth because it’s not just trigeminal. It’s also***-

Jaz’s Introduction:
Most of us have the same protocol for managing sensitive teeth. We check the patient’s oral hygiene, we check for acid erosion, be it intrinsic or extrinsic. We try and take care of the acid basically. Most of us are heavily recommending some sort of desensitizing toothpaste, like a Sensodine or an Oral B sensor version, or a pro relief from Colgate, whichever it may be.

Some of us are scrubbing desensitizing agent into tooth, perhaps even fluoride. And if the sensitivity is coming from like a Class five region, like abrasion a fraction, we might slap a composite in there hoping that the sensitivity will improve. Unfortunately, have those patients who no matter which brand of toothpaste they try, like it all helps, but they forever have sensitive teeth. I already have some patients in my mind that fall into this category. So what’s going on there? Why are these patients’ teeth sensitive?

Well, hello there, Protruserati, I’m Jaz Gulati, and welcome back to your favorite Dental podcast. For those of us dental geeks who like to spend a lot of time on YouTube, you probably already know today’s guest: It’s Dr. Nick Yiannios. I remember seeing his videos like, 10 years ago, 12 years ago. And I was like, what on earth is going on? This guy is using a computer to inform him about the bite, and he had all these like EMG leads on the patient and you are thinking, what on earth is going on? I’ve never seen anything like this before.

And then you hear about all these patients problems like they’ve got like clicking, popping, muscular pain, headaches, sensitive teeth, and by the end of the video it shows on the computer screen what the new bite is showing. But amazingly, the patience and their response was pretty spectacular.

When I look back in my journey into occlusion, and now how I’m diving deeper into digital occlusion, like using the T scan for example, and next month, I myself am getting those EMG leads flying out to America to shadow Dr. Bobby Supple. Who’s a previous guest of this podcast and his podcast was called Occlusion Wars and was just a brilliant summary of the history of occlusion. You have to check it out.

Anyway, Bobby’s the current president for the AES and their conference in February in Chicago is one that me and Mahmoud Ibrahim are speaking at. But we are small fish we are tiny tadpoles in this ocean of giants that they have presenting, including Mark Piper and Dr. Nick Yiannios who we’ll be hearing from today.

So that’s my plug in there you guys have to check out the AES. If you can come to Chicago in 2026, February, I’ll put the details in the show notes. It’ll be great to see you there. Anyway, I’m digressing I’m just sharing my excitement from learning from all these people and what Dr. Nick has to share is pretty mind blowing.

We will answer that question of can a patient’s sensitivity be linked to their occlusion? Is occlusal adjustment indicated for sensitivity? What is the mechanism behind that? And as per the title of this episode, you’ll get to know the real cause of sensitivity. And once you check for caries and exposed dentine and that kind of stuff, that the most common cause of sensitivity, like leakage and stuff like once you’ve accounted for that and you found that, “Hmm, actually this patient has no signs of cracks, there’s not significant amount of wear, there’s not much exposed dentine, why is my patient saying that my teeth are so sensitive?”

Then the diagnosis, my friends, is likely sympathetic denting hypersensitivity. And if you want to know what that’s about, wait all the way to the end of the podcast. Honestly, it’s going to blow your mind. I learned a lot from this podcast. 

Dental Pearl
Now, just before we dive in, it’s a PDP episode, so I’m going to give you a Protrusive Dental Pearl. Today’s Pearl’s inspired by a webinar I gave two days ago on Resin Bonded Bridges. I walk through on our platform Protrusive guidance. I do a monthly live, at least one monthly live. And this one, it was a full walkthrough on a Resin Bonded Bridge. I truly believe that for a single missing lower incisor that a cantilever, resin bonded bridge is the standard of care for replacing that incisor.

I’m very open-minded, I’m happy to learn and change my views, but it’ll take a lot to convince me that an implant for a lower incisor is better than a Resin Bonded Bridge. So anyway, I was fitting this bridge and I’ve got the whole thing videoed and I’m talking through it. And what I notice is that when I’m checking the bridge on the model, I’m noticing a bit of a gap, then I show you how to manage that, but then I transfer it into mouth and I still see a gap. 

So that means it can be an increased cement gap. We don’t want an overly large cement gap, obviously. So one thing you can do if you are unsure about the quality of the fit of your Resin Bonded bridge is you get some light bodied PVS.

So usual runny light body stuff, you put it on the intaglio of the bridge, so basically the wing, and then you place it on, you let it set, and then you take the bridge off. And as you peel away the PVS, now you get to see how thick your cement layer or your resin layer is going to be ideally you want cement thin layer everywhere.

Now in my case, it confirmed that the wing on the incisal region had a bigger cement gap, but everywhere else it was going to be okay. So I went ahead to use my PANAVIA™ V5 and bond it, and the whole video is there. It’s on the RBB Masterclass, it’s also on the webinar replay section of Protrusive Guidance. 

So if you’re not a member already, check it out www.protrusive.app if you love our video walkthroughs. And without further ado, let’s check out this episode. What is this sympathetic dentine hypersensitivity all about? 

Main Episode:
Dr. Nick Yiannios, welcome to the Protrusive Dental Podcast. Honestly, as I was saying in the preamble earlier, I’ve been a long-term admirer of your work and it’s an absolute honor and privilege to have you in front of me.

I’ve got a gazillion questions, but because of time we have to hone on in, on something. And the topic of sensitive teeth, I’m so excited to hear your take on it. But for those few people that haven’t heard about you, like people need to go on YouTube and see your videos over the years are just. Incredible how you’ve served patients with their pain. So please give us a flavor of who you are, where you are from, and how did you get into this strange world that you practiced in.

[Nick]
You want me to tell you a story then? Okay. I’ll give you a story. So I’m almost six years old, so I’ve been in this a long time. I graduated in ’93, practiced in Dallas for a couple years. I’m in the US. I decided to move, married a girl, moved up to Missouri, which is about, I don’t know, 10 hours north. Practiced in a small town, got divorced, tried to build my practice, tried to get my life back in gear. I’m in the woods, basically, and this is not a wealthy community.

Bass fishing is the big thing around there, things like that. Anyhow, long story short, about 2007, I’m probably your age, and I decided, back then Sarah could just become to where you could get things done in a day, like a crown in a day. My most frustrating part of practice was having to deal with crowns that didn’t fit contacts that were off, things like that. Margins weren’t right. 

Once it got to the point with Cerec that I realized I could do this in a day, I thought to myself, I’m going to take this on. So I’m pretty obsessive, very kind of a type, A kind of guy. I pulled in Cerec, got really good at it. I saw training by a guy named Rich Masek.

Dr. Masek was in San Diego. He was probably the best in the world at the time with Cerec technology. This is like mid two thousand. Got good at that. He pulled me on his board of advisors. He had a teaching center called the Academy of Cadcam Dentistry. I met a guy named Robert Kerstein in one of our meetings. 

And Kerstein was the T- scan guy. So digital occlusal analysis, if those aren’t aware of what that is, basically, instead of using articulating paper ribbon, shim stock, things like that, you’re using a Mylar Sensor. USB controlled little handle and you stick in these disposable sensors. They’re about a hundred microns thick and there’s inks and circuits in there and they pick up four screens at a time.

So in other words, what hits when is documented and you have a record in a Windows computer. Okay, so basically when I met Kerstein at that meeting, I looked at him in the lecture, shook his hand, got his number, bought a T scan, went home, started applying that with the Cerec technology. Started applying his DTR principles, exclusion, time reduction.

[Jaz Interjection]
Hello, Protruserati. Let’s start with the first interjection. As you know, some episodes ago, I started these interjections because I feel sometimes you can get so deep in the episode and for our younger colleagues or those who are unfamiliar with some of the terms that we use, it’s really important to make things tangible. That’s always been our mission since 2018.

So let’s start with what is the T-Scan and what is DTR? So very simply, let’s start with something that we all know, right? Articulating paper, whether you use something like an inked silk ribbon kind of thing, or some type of paper, red, blue of certain microns. I like to use Parkell. It’s like a 25 micron paper, the red one, it just marks so well. I also like troll foil, which is a 12 one, but I’m digressing. 

Okay, so articulating paper, you put it between the teeth and it inks up, right? So you might see lots of ink marks on the teeth, right?So what’s that telling you? It’s telling you where the teeth are hitting or potentially hitting. Because sometimes it marks up, but that’s not really hitting. It’s like a near miss like it’s almost hit there, but it’s still inked, but it’s not a true contact. But anyway, it tells you where the contact is. 

Now, the T-Scan is basically a sensor. It’s a sensor that you put in. And what this sensor does is when you bite it, when you get the patient to bite on it, it tells you not only where the contacts are happening on the sensor, but more importantly it gives you so much more information that ink doesn’t. So what the T-Scan does, it tells you about how hard the force is.

So when you see two different ink marks, it’s difficult to know which is the heavier one. Okay? You only right 14% of the time based on studies. So when you see you use the T-Scan, they’ll tell you that, oh, actually the upper right first molar is taking 35% of the entire bite force and the upper right lateral is taking 10% of the entire bite force, and the rest are not doing much work, right?

So it tells you how much force, but most importantly, it tells you about when it tells you about timing. So for example, when we bite together, did you know that our teeth don’t all meet together at the same time, right? When we bite together, you might find a premolar hits first, then a canine might hit and then a molar might hit and then the next molar might hit, and then so on, so forth until all the teeth are in contact.

So that kind of brings in the element of time. And of course, as we know, teeth don’t hit with the same intensity and power. When a patient bites together, a molar might be taking a lot of the bite force, and when you put your finger in that molar, you might feel a lot of freis that’s like that vibration feeling that you can feel.

So, you know it’s taking a lot of force. What the T-Scan does is basically technology hooked up to the computer to tell you which teeth hit when and with how much force. So it’s like articulating paper on steroids and for occlusion geeks like me, it’s awesome. It’s nice to be able to measure this data because think about it when we do implants or big cases, we want for there to be as much balance and harmony and distribution of force as possible, right? So that’s the T-Scan.

Now we use the T-Scan in a special way to carry out something called DTR. DTR stands for Disclusion Time Reduction. I’m going to explain DTR is, we all kind of know that when we bite together and grind our teeth side to side, in an ideal world, we would get posterior disclusion. I know that occlusion wasn’t taught so well at Dental school, but we all remember something about posterior disclusion, anterior guidance, that kind of stuff. That’s a true philosophy or not, that’s debatable, sometimes group function can work, but some of my colleagues, like the people who teach me DTR, are saying that actually group function can be pathological.

Anyway, I’m digressing. So back teeth should be out of the equation. As quick as possible, we should get disclusion. Usually somewhere along the front teeth like the canines for example, they pick up the force and the back teeth are no longer in the picture anymore. Yiannios use is posterior friction, right? Think of it like speed bumps as posterior friction. 

So you want to get the back teeth out of the way according to this philosophy of DTR. Now because the T-Scan can measure when someone bites together and starts grinding to the right, the T-Scan can measure how soon are the front teeth doing the work and how soon are the back teeth no longer touching. That essentially is DTR is Disclusion Time Reduction.

So the time of them in their normal bite, i.e. their maximum intercuspal position and they grind to the right, how quickly can we get them onto their canines or on their anterior teeth and how quickly can we disclude those posteriors? It takes a couple of seconds to do that, right? You bite together and you grind to the right and it takes a couple of seconds for this patient to eliminate the back teeth rubbing together. 

So this actually means that your muscles are working over time and so what Disclusion Time Reduction does is through some adjustments and maybe some additives, like adding some canine rises, you’re essentially refining the guidance and therefore you are shortening the disclusion time. So the patient goes from MIP, you grind to the right and you quickly get onto your front teeth and you’re no longer rubbing the back teeth together. You’re no longer having that posterior friction and that’s Disclusion Time Reduction therapy.

I have been seeing some of Nick Yiannios videos on YouTube for over years. And I was always wondering what on earth is this guy doing, some sort of wizard. And over the years I understood and I got the T-Scan now I’m actually being DTR trained actually the day this episode’s going live, you are listening to this right now. 

If you’re listening to this day 1, then I’m actually being trained by Robert B. Kerstein right now as we speak on DTR. So now what T-Scan is, and now you know what DTR is. Let’s rejoin the episode.

[Nick]
In other words, he’d been publishing for over 20 years about how when back teeth hit too long in time, this can become problematic, cause headaches, cause problems like that. TMD world. And I wasn’t necessarily interested in the TMD world, but I was sure as heck interested in getting my crowns right? I’m just a GP trying to do good work for my patients in the woods.

So I wind up noticing something that he’d never seen before. I’m starting to adjust bites per his research theory where I’m adjusting discursive movements. In other words, when they bite down and grind off to the right or to the left, on the T-Scan sensor, you’re studying 3000 of a second increments like what hits when. Okay, so it’s almost like if you’re an MIP and you’re chewing your food, grinding around milling and maybe not quite touching, there’s still contact happening. I want you to think of sideways excursive movements like speed bumps. The more speed bumps, the more likely the nervous system doesn’t like all that extra bump, bump, bump, bump.

So you want to kind of smooth out the ride when you’re going left and right. Imagine you’re in a car, you want it to be a little smoother, so fewer bumps is a good thing. So based on timing, and he was talking about lactic acid burns, all these things. But long story short, I’m applying his DTR principles in a private practice real world. 

And I’m starting to notice that as I’m adjusting bites, maybe they came in, they had a problem with a crown that the guy down the road did, or maybe I did the crown last month, right? And I’m using the sensor and I’m applying its principles and I’m starting to notice they start out really cold, sensitive water and air from the handpiece. And then all of a sudden it drops down to almost nothing.

But it doesn’t make sense because some of the time they already had exposed Dentine. And now there was even more exposed dentine. But yet they were less sensitive. So I started handing people ice water. I started handing people-

[Jaz]
And you were doing this like way back when-

[Nick]
2008. 

[Jaz]
It start. But did you perhaps start, like the reason that you were doing DT at that time was not for sensitive teeth? It was for facial pain, right? Is that–

[Nick]
No, it wasn’t even for or facial pain, it was for me to improve my restorative. I’m like you, I’m a GP trying to serve my- I don’t want root canals afterwards. I don’t want them coming back, for a bite adjustment. I didn’t want things like that, I wanted to be more efficient. I wanted to be a better dentist. Cerec allowed me to cut less teeth. I would like half top a crown I do to this day. I mean, they’re onlays, they’re not crowns you. My margins, the majority of my margins are super gingival.

And if you get really good at Cerec, you can’t even see it. And if you know what you’re doing, you can get about a 25 to 50 micron tolerance versus 75 to 100 with lab made stuff. Back in the day we were just starting to get into some of the all ceramic things. But anyhow, I’m digressing. 

The point is I started noticing that I’m adjusting bites and the cold sensitivities going away with the water and air from the handpiece. So I started handing people ice water, had them swish, and then checked and all of a sudden I started throwing these up on YouTube. This is back, I don’t know, 2011, 2012, somewhere in there.

They were all about the T scan in the beginning. And initially there was no response, no one’s watching. I didn’t care, I was just trying to get it out there. I’m trying to get out to guys like you. And this is the Peaks, yeah. 

[Jaz]
The birds. But when I watched those videos years ago, Nick, it was like my headaches had gone, my joints were longer clicking, like I missed at that time about the sensitive teeth. I missed it. Completely. 

[Nick]
Yeah. Well, what got me into this was the sensitive teeth. So in other words, I’m just a GP. I’m not looking to be a TMD guy, I’m not looking to be an orofacial pain guy. So basically, I started applying these principles, and noticed that as I adjusted the occlusion, their cold sensitivity would go away much of the time. Not all, but probably most of the time. I called up Kerstein and I’m like, “Hey, what’s up with this? You ever seen this?” “No, I haven’t seen this.”

Well, he’s a researcher. I’m a real world guy. Robert, I’m seeing this. It’s real. Anyhow, long story short, a year or so later, maybe two, the YouTube videos are going up. I’m starting to get some, a few people looking, and it’s mostly guys like you and me bashing me. 

How dare you touch that version of enamel. You’re going to get sued. You’re going to perforate that crown that they did. You’re going to all this kind of crazy ****, and then it went kind of quiet for a while. Then all of a sudden the phone started ringing. And here’s someone coming in from Malta. Here’s a guy coming in from Australia. Here’s a guy coming in from Canada. Here’s a guy coming in from Mexico. And I’m like, what the hell’s going on here? 

[Jaz]
Did you feel a lot of pressure? 

[Nick]
Yeah. 

[Jaz]
Did that create a lot of pressure? because when I have someone, I’m like in London, right? And I get patients from like Birmingham, Newcastle. I feel the pressure. I’m like, okay, everything you need to do with your book, extra time, everything needs to go well. It’s a big thing. So for you to get these international patients that, I mean, that must have been a whole new level of pressure. 

[Nick]
It is. Because you don’t know, you’ve never met them before. Never treated a stranger, right? So anyhow, I started applying the DTR stuff. I started becoming more and more, I didn’t, not because I wanted to, but I’m starting to see all these TMD patients. Because most of them will have sensitive teeth. Then I would notice that there were many times that they would have their headaches would resolve too.

So Kerstein was right in a way. There were times where it was applicable. But then, over the years it got to where I’m starting to see people from literally everywhere and it’s starting to almost interfere with my practice because I’ve got locals I have to take care of. 

And to your point, it’s very, very hard to make time for those travelers. And you can’t predict and you’ve got an overhead, you’ve got to pay, you’ve got staff, you’ve got to pay, you’ve got a life you need to have, right? So I didn’t really sign up for that. It’s not what I was looking for. So once story- 

[Jaz]
Can I just stop you there? Because I’m really enjoying this, but I’m just kind of like, I’m relating a lot to what you’re saying earlier in my journey to where you are. But like, very relatable what you’re saying because at that time, when someone’s coming so far to you. What many people may not appreciate, but I know you will appreciate and you’ll be able to teach me on, is the level of communication. 

Like my TMD patients and I are emailing a lot. There’s long essays, there’s emails, there’s a lot of reading, there’s a lot of communication that goes into, there’s a lot of emotional trauma, there’s stories and whatnot. So did you feel that that was also like, wait, how do I fit all this in with your regular practice as well? Did you find that as well? 

[Nick]
Well, what I did was I put up a wall. I made it to where they couldn’t send me that, and it sounds uncaring. It was the opposite. I started getting into the BioPack. In other words, the bio pack, there’s an engineer named John Radke. John and I are good friends and back then, I didn’t even know him. 

Nowadays, we lecture together and we’ve published papers together. He’s the editor of Advanced Dental Technologies and Techniques. We just published last week. Mark Piper, Radke, myself, and a guy named Thomas Coleman out of Vermont. A new reason for sensitive teeth. We call it sympathetic Dental Hypersensitivity, SDH. We can go there a little bit too if you want. 

[Jaz]
We definitely will. 

[Nick]
My point is the biopack, there’s something called joint vibration where you can accelerometers, it is almost like a headset over the joints. The patient opens and closes multiple times and the sensors pick up vibrations, eminating from the joint.

[Jaz’s Interjection]
Hey guys, Jaz here with the second interjection. That’s a really quick one, right? What is JVA? It’s Joint Vibration Analysis. Essentially, it tells you how healthy or unhealthy the jaw joint sounds when it moves. So essentially when we open and close, and if you feel your TMJ area, it should be nice and smooth and it should be like a quiet car engine. 

But if you’ve got a clicking, popping crepitus, that kind of stuff, then it really rattles and knocks. And basically what the JVA captures is those rattles and it gives you like a little graph form so you can actually convert that to an objective data. You get these vibrations that can indicate an unhealthy joint. It’s a way of tracking joint health. This is some technology that I’m not using at the moment, so it’s good to get some insight into let’s rejoin the episode. 

[Nick]
Point and it gives you an idea of what’s going on with the cartilage because I started realizing a couple years into it that I need to have objective data here. They’re coming to me with all these subjective things, like to your point, they’ve got this long list of problems and this communication. I started realizing, “No, I need to start having– I’m not going to talk to them until they come. I don’t want to even hear why they’re here when they show up. I want to put together a protocol whereby I can objectively measure them.”

Okay? So this is about 2013- ish i’m starting to realize I have to put in place a protocol. About that time I got in my head, this stuff needs to get out there. I also got in my head that Hey, I need to stop applying DTR on everybody because I’d done it hundreds of times at that point and started realizing it doesn’t always work, right? 

So it doesn’t always take care of their headaches because there could be many things that are wrong with them. So Kerstein and I kind of split ways we were very tied for many years and I still love the man and I’m not ragging him. And I started going, I started chasing a guy named, Mark Piper, like TMJ Surgeon, like probably Yoda. The crowd here probably have never heard of Mark Piper. But Mark Piper is a badass, excuse the language– 

[Jaz]
Best mustache you’ve ever seen in your life. Like the best. 

[Nick]
Yeah, he’s got a heck of a handlebar. One of those old Western ones but unbelievably smart man. He was at the end of the Dawson curriculum for years. In other words, if he went through the Dawson curriculum back in the 70s, 80s, 90s, and he started with Dawson in the early 80s, he’s since retired about two years ago. He’s an Md dMD, Harvard Vanderbilt. So Physician, Dentist, General Surgeon, Oral Surgeon, ER Doctor I mean, brilliant guy.

And probably my biggest mentor of all time. And I’ve had 4 or 5. But he’s number one. So I reached out to Piper and he had a little course going on. I went to it and he’d heard of me, pulled me aside. Because at the time, Kerstein had asked me to be a co-author in the textbook. They’d asked him to write on the T scan, and I came up with the name Frictional Dental Hypersensitivity, FDH. That was the occlusion, the speed bumps, all that caused the cold.

And I spent about a year in the literature trying to find out the reasons why, and there was no good reason as to why little speed bumps in the excursive movement would cause the teeth to be cold sensitive. 

He and I are talking about it and I’m giving you my theories as we’re walking to lunch the first day, and he is like, “Did you ever think about the sympathetics?” And I said, “Yeah, I did, but there’s nothing in the literature.” He goes, “It’s the sympathetics.” So that was about 2013. So here we are, what, 13 years later. It’s the sympathetics. 

[Jaz]
And so we got to figure out what that actually means in terms of making that tangible. Right. And, but what you’ve set there is you give some context of your history, your mentors I love learning about everyone’s journeys and mentors, is a regular theme that comes up and everyone who I admire and it’s so nice to hear who everyone’s their mentors were. I’m going to just bring it back to a basic experience I experienced when I was a Dental student, right? So this was probably 15 years ago.

I fit a bridge, it was a cantilever from a canine to a lateral, replacing a lateral. The patient comes back with extreme sensitivity on the canine. Now, this was a resin barn bridge. I know in the states they’re not very popular Maryland bridges, right? They’re not very popular in the States, but here, they’re super popular, right? 

And so that’s when I learned that by adjusting the pontics, which were way too high in excursion pontics, these kinds of bridges should not be an excursion at all. And that was a student rookie era. And I took it away, and then that was the first time I experienced it. When he came back a few weeks later, his sensitivity was completely gone at a macro level, something that we’ve all done at one time or another.

And then we’ve all experienced that, oh, the sensitivity’s gone. But then the problem we face, well, not the problem, but like when we go to the lectures, when we read the books, sensitive teeth. From my understanding, based on what we’re taught is down to having thin enamel, having an erosive diet, it’s a diet issue, it’s a reflux issue. It’s an exposed dentine exposed tubules issue, which is rectified by let’s say, if the abrasion and fraction is big enough with a composite or by rubbing Colgate Pro relief or Oral B the latest version or Sensodine whatever. Right?

And that’s really what we offer our patients unanimously, 99% of dentists will send their patients off with this. And for some patients it works. For many, it doesn’t. I’d love to know from you, from studying sensitivity and looking at this kind of link so deeply, so thoroughly with occlusion, with frictional, dental hypersensitivity and also now the sympathetics. Can you give us dentists an understanding of the etiology and say pathophysiology of sensitive teeth?

[Nick]
Alright. Yeah, let’s do it as quickly as I can. So everyone’s heard of Dentinal hypersensitivity? So I want you to think about the occlusal portion of the molar, and typically you’re worried about exposed dentinal tubules, you’ve got maybe some wear of enamel to where there’s some dentine exposed, right? 

[Jaz]
It’s like cupping. Would you say cupping, like erosive cupping? 

[Nick]
Yes that’ll apply. And yes, it could be chemical in nature, it could be gastric, regurge, things like that, it could be an acidic diet. It could be wear emanating from the joints, your orthopedic joints. Now don’t get me into my orthopedic realm, but two thirds of the human bites right here, 1, 2, 3 thirds, right? So biomechanically, the mandibles- 

[Jaz]
So those listing on Spotify and Apple Nick’s pointing as TMJ. So two thirds of the occlusion is the TMJs guys. 

[Nick]
Yeah. So basically, I want you to think of the mandible, like a door. And the TMJ is like a hinge to the door. The door has teeth connected. Right? And on top of the condylar, head of the mandible, you’ve got cartilage attached by ligaments on the lateral and medial pole. When you displace that soft tissue, that cartilage, you will very readily alter the occlusion. Okay. So it’s almost like taking a crowbar to the hinge of one of the doors, one of your TMJs bending it a little bit.

Does the mandible, the door, hit the jam? The maxilla a little bit differently? Of course it does. So the cupping, one of the possibilities, again, I’m digressed, but it could be biomechanical, it could be orthopedic, it could be the– look, the bottom line is sensitive teeth, it’s all a process of exclusion. In other words, you have to exclude fractures, faulty fillings, things like that. When you go through all these checks and everything pans out, there’s not a leaky crown. There’s what it is you got- 

[Jaz]
Caries free, obviously carry that’s the basic thing. Do the basics first. 

[Nick]
Yeah. Caries free. Dental hypersensitivity: the occlusal surface of a tooth, cupping to your point, exposed dentine. You’re activating C fibers via dental tubule flow. So these open tunnels that are pissing the nerve off they’re like popping the nerve, just irritating the hell out of it. There’s fluid flow. The neck of the tooth, which is the majority of the time-

[Jaz]
Can we talk about the dentine hypersensitivity just a little bit more? Right. So in this scenario, if that’s your diagnosis with no other source of sensitivity, what should you generally be doing? Is it a matter of restorative or is this the time where you say, okay, diet advice and use this sense of toothpaste?

[Nick]
Well, it’s the same reason on the cervical, that’s why I’m going down there that I was going to tell you. So you can have exposed dentine on the occlusal surface, open tubules. Remember, you’ve ruled out other possibilities. And then the most frequently you’ll find cervical dentinal where you’ve got it, where enamel at CEJ right open dentinal tubules.

That’s going to be different, more sharp. It’s a delta myelinated A delta fibers, basically that’s firing, that’s ding in the nerve pissing it off. But the treatment for both is the same, what I do and it works. I’m not going to say a hundred percent of the time because that’s not fair. But if I say 95 plus, that is fair. I’ve been doing this forever. 

[Jaz]
Before you reveal, because we had a little chat, and then what you do is very interesting, right? But Joe blogs, your doctor blogs, the average dentist is going to stick a resin in there your GIC or composite. Okay. And give some centers, toothpaste. And for a lot of patients that might work. Let’s face it for some patients that will work. Right. But your protocol I hadn’t heard of before so please tell us, where did you- was this like, where did you learn this protocol from? How did it develop and share? 

[Nick]
I spent years in literature. I still spend time in literature all the time. I’m reading things, I’m learning things, and I trust my eyes. I trust my hands and my eyes. And remember, I’m not an academian. I’m not looking for fame, I’m not looking for any of that. I’m looking to help the people that I serve. 

When you spend that much time in the literature and you’re looking for something you’re reading hundreds and hundreds of papers and you’re seeing different angles. You’re learning to identify that half the time, what they’re talking about is biased and BS. A lot of times it’s funded by no disclosures. Well, if you look deeply Google that name and this guy’s working for GlaxoSmithKline, it’s like, “Oh, okay. There we go.” Yeah. You’ll see this. You got to look.

You can’t just trust what they say in the paper. Authors declare no conflict of interest. Okay. But anyhow, my point is, so how I ran into these things was that way. So the typical doc is going to want to drop desensitizing agents, oxalates, ides, things like that. Don’t waste your time. In my world there’s a company called Fotana. They make a laser. It’s a dual wavelength laser called the Light Walker. 

In US dollars they’re about a hundred grand, they’re not cheap. But there’s about 80 things I do with that. Okay? And I have three of them. All right? And I use them constantly. It’s not just for sensitive teeth, it’s for surgeries, it’s for healing, it’s for biostimulation, it’s for root canals, it’s for extractions, it’s for laser-assisted periodontal therapy.

I don’t want to get off topic, but the point is basically on Dentinal or Cervical Dentinal Hypersensitivity, what you do is you spend about 30 seconds illuminating the cervical aspect or the occlusal aspect of the tooth with neo dium energy. It basically kind of, what’s the word? Discombobulated the pulp. And it also theoretically starts denaturing proteins that are sitting around in the tubules that you can’t see microscopic, because a lot of people you’ll find over time in the practical sense, you’ll see them for a checkup and they are cold sensitive. 

Then six months later they weren’t, even if they did nothing. Because a lot of times we’ll have deposits from salivary proteins going in there and clogging up the tunnels on its own. That’ll happen a majority of the time. Probably. 

[Jaz]
But isn’t that how also toothpaste market themselves work and they use the chemicals 

[Nick]
Yes.

[Jaz]
To clog it up and–

[Nick]
Yeah. 

[Jaz]
Block the pause if you like. 

[Nick]
Right? Yeah. So think of them like little tunnels that are open, you want to clog them. So that’s what they’re trying to do. And that’s what happens naturally out of your salivary, the stuff floating around your saliva. 

Well, in the times that it doesn’t happen, what I do is I hit it with neodymium energy, about 30 seconds off the surface. Let’s say you have an fracted area on a number, or I’m not going to say numbers because you’re probably international. Upper right first premolar. A very common area. Yes. The typical spots are going to be like upper and lower premolars. Okay. By the way, occlusally related. But anyhow, my point is let’s say there’s an infraction on that.

Upper right first premolar I will take the neodymium handpiece and I will spend about 20 to 30 seconds illuminating it. There’s certain settings that are not hard to find. They come with the laser. And then I pull out the Erbium, which is a different wave link. It’s 29, 40. Whereas the neodymium was 10 64 nanometers–

[Jaz]
They’re both on the light walker. They’re both in the same unit. 

[Nick]
It’s dual wavelength. So you buy that one dual machine, you got two lasers, right? Two tools. So basically then I hit it with Erbium and I spend about 10 or 15 seconds per area. Then that tooth, it would take me about 15 seconds. And then I take med grade ozone gas, which you’re taking from med grade oxygen through a converter. And all three are coming out at 50 gamma, which is a concentration and essentially kind of varnishing that shut.

And 95 plus percent of the time that will cure them of either DH on the occlusal or CDH on the cervical almost always. Until such time however, they may wear out more of the occlusal and expose new tubules or more of the cervical may recess and they may expose more tubules. So you always tell the patient, “Hey, this is lasting. It will be permanent until such time that happens.” Which it is. 

[Jaz]
But then as you alluded to just a few moments ago, actually, the root cause of that, it could be dietary, it could be occlusal in origin as well. So you’ve got to then address the root cause as well.

[Nick]
Yeah, the dietary, for example, we talked about proteins precipitating in and clogging the tunnel, right? In the natural sense, what if an acidic environment just allows that? So my point is, I know from experience for many years of doing this that it will almost always work if it’s true DH or CDH if I hit it with the laser and the ozone. So there’s your cure. 

Trust me when I tell you that if you’re like me and you’re deep into your technology, I know it sounds like a lot of money, and I’m not trying to sell Fontana, that’s not my point. I don’t care what brand it is. If you can get a hold of that kind of tech, you can do this now.

You can do about 80 or 90 other things that you can’t do otherwise too. It’s amazing tech. I’m a laser dentist too. I like big time into it, hard tissue and soft tissue lasers, basically. Erbium is hard tissue. Basically neodymium is more soft tissue. Okay? So 70% of the fillings I do in my office, no shot, no drill with the Erbium laser.

And I’m not exaggerating. I will pop my ears and ceramic crowns off with my laser. The less friction, the less trauma that I induce in the pulp of a tooth, the less likely I’m to have an necrotic problem, a root canal problem, an extraction, what have you. And again, I’m starting to tip into the sympathetic realm again because now we’re starting getting into sympathetics. Now I’ll get there. So I’ll take it from here if you don’t mind. So, DH, CDH. Right? So another possibility is FDH. FDH would be– 

[Jaz]
Can I please Nick before we get to friction because I think it’s really important to just touch on this point because what can we say? What can you say based on experience to the dentist who is not going to get access to lasers and maybe in their country they’re practicing in that it is just not going to happen in the foreseeable, right? Yeah. How can they serve that patient who has Dentinal hypersensitivity or sensitivity or Cervical Dental hypersensitivity, are the traditional restorative routes of composite or varnish that a useful or an acceptable alternative? 

[Nick]
It’s not worthless, but it’s not definitive generally. There are times, a example, I had one this week where she had cupping like a class six lesion on the top of a lower molar, and the first thing I did was I laced it and then I used my erbium angle after I desensitized with the lasers and ozone and I laced it to bond it. So I gave her an extra layer. I kind of sealed off the cupping, after I desensitized it. And by the way, when I initially hit her with water and air on that cupping area, it was uber sensitive.

By the time I was done desensitizing with laser and ozone, it was gone. But I wanted to close off the cupping to where it wouldn’t get bigger. So I dropped a composite in there. Now, had I done a composite only, maybe it would’ve worked, maybe it wouldn’t have. So I hate to say it, but I don’t have a great answer for you. If I was without that kind of tech, I would probably hit it with bonding. I would close off, I’d probably etch and bond and I might get some longevity out of it. HEMA, things like that.

Look, I use those for 20 years, the last 10 years I’ve been using lasers and ozone. I don’t even have desensitizer in my office. I’m not kidding you. I have a very big, large practice, seven operatories, very state of the art. There is no GLUMA , there is no anything in this practice. We do not tell people to go get Sensodyne, we do not use fluoride, we do not use fluoride. We’ll never use fluoride. That’s us personally, we’re more holistic. 

[Jaz]
Okay. 

[Nick]
I don’t want to get too deep into that, but– 

[Jaz]
No. That’s great to know. And I feel as though we just closed off that chapter for the dentist. It’s like, okay, but that’s great for Nick, but what do I do in my clinic? It just gives them something to think about. But we’ve opened their mind because the vast majority I’ve heard of ozone being used in root canals before. I haven’t heard of it in, used in this way. This is new information for me. 

[Nick]
Ozone machines are not expensive. You’re spending about $3,000 if I want people to learn, in my opinion, okay, I’m not that old, but I am old. Learn to open your minds and be a critical thinker. Learn to go into the literature, learn to spend time, spend maybe an hour or two a week when you run into something confounding in your office. Go jump in the literature and try to figure it out. Learn to identify the incorrect from truthful learning.

Maybe brush up on your stats a little bit. We all took it in school. Learn what a P value is, learn what a good N is. So things like that, maybe what I’m trying to say is open the mind to other possibilities. For example, ozone, if you jump into PubMed or Google Scholar, everyone in this audience guaranteed can get to Google Scholar scholar.google.com on your cell phone or your laptop, whatever.

Type it in. And I want you to type in Ozone in Dentistry. And you will see about 10,000 papers. And I want you to spend a little bit of time bouncing around example ozone, which is supposed to be this bugaboo and it’s dangerous. And I inject people with ozone gas all the time in abscesses. 

What am I doing? It’s antibacterial, antivirus, cidal, and anti-inflammatory. It also kills what are called Prions. Remember misfolded proteins? If you are a human, which is rare die of prion disease, you are a complete biohazard. They don’t even know what to do with your body. Cremation is not enough, but guess what? Kills prions.

Well, they’re not alive. Guess what? Destroys prions. They’re misfolded proteins. Ozone in your life’s experience so use your critical thinking forget the politics. After a big thunderstorm, you walk outside, you smell what? Ozone. What’s nature doing? It’s scrubbing stuff. Getting rid of the dead stuff. 

What else? When the sun’s out UV. What’s that doing? Destroying bacteria and viruses, right? Right. So my point is ozone, there’s massive applications. Now, if I didn’t have a laser, I could grab an ozone machine for about 3000 US. Will it work definitively? Not as well as the combination, but it’ll probably work pretty well.

And if you start chasing the Ozone World. You start realizing you’re going to start realizing you can start using the heck out of that thing. And it can actually make a little bit of money off of that thing. It’s a very inexpensive piece of equipment and the only disposable is you need to be able to replace refill the the oxygen tank med, great oxygen. So that would be my advice. 

My advice would be, look at the literature, get yourself an ozone machine you can use it for all kinds of Perio, Endo, Hypersensitivity things. That would be my advice, that’s a cheap in. And I don’t care where in the world you are, you can probably get med grade oxygen if you’re a health professional. And that would Well–

[Jaz]
That’s great. I think it’s good. You mentioned the fact that everyone should do their, carry out their due diligence and look at the literature. And I think that’s it is very clear that, we even before we hit record that you have been deep into literature in many ways and takes us nicely into the next bit, which is frictional. I think that you were talk about Frictional Dental Hypersensitivity, which is the speed bumps and how the occlusion has a link. And I just want to love to hear about that now. 

[Nick]
So basically back in the day, around 2008. 2009, 2010,, Kerstein and I were on the phone and I’m like, “Man, I’m adjusting bites in the water, in the air. After I adjust the occlusion, it gets less and less sensitive, even though they’re exposing more of the dentine.” I am doing so sometimes right. Depending on the wear patterns. Anyhow, so that I called that FDH, and I put that in the literature. So Frictional Dental Hypersensitivity, basically the speed bumps, the excursive speed bumps.

So initially, the initial thought, the best I could do in the literature at the time was there’s something called an A beta fiber in the pulp of a tooth, A beta if you have a mosquito or a fly land on you and you smack like your neck or wherever he is at, you feel it, right? Those are proprioceptive, A beta fibers, they’re all over the epidermis. We have them everywhere.

We even have them in the pulp of teeth. Okay. So when I went to school back in the 90s they told us that we had C fiber, A delta, and that was pretty much it. Okay. Innovation wise. And so the C fiber was the unmyelinated slow, dull pain. The A delta was the fast myelinated pain.

Well, come to find out, probably around 2000 ish, they started discovering histologically that they had A beta fibers, a few of them in the dental pulp, and they were responsible for proprioception. And they were also linked up to the sensory homunculus. 

The sensory homunculus is that part of the brain that has that really weird, we all saw it in school. Weird representation of a hemisphere of the brain and this is the arm, this is the leg, this is the this is that. So the A beta allowed them to add the dental pulp to the sensory humunculus. I don’t want to get too deep. This is geeky stuff. Long story short, I don’t believe it is A beta. I used to think it was the teeth being flexed excessively and the A beta intra pulpal. 

[Jaz]
Because the theory I’ve had as well. Yeah. 

[Nick]
Yeah. That was the theory. Right? Well, it’s not that. In my experience, I can tell you with almost a hundred percent certainty, it’s not based on what we’ve been doing the last few years with the research. Okay, so that’s FDH. So theoretically, I walked into with Piper at that lunch and we were talking about A beta. And that’s when he looked at me, he said, “Do you think about Sympathetics?” I said, “Yes, but it’s not the literature.”, He goes, it’s the sympathetics. And I think he’s a hundred percent right. Okay, so that’s FDH.

So basically, if you eliminate Incursive movements in the, say the crown that you just placed on tooth number 19, they come back a week later and they’re exquisitely, not exquisitely. Let’s say they’re, yeah, I drink something cold and it’s a six out of 10 and it goes away pretty quick that’s likely FDH.

Okay. If they’ve got the margin sealed, if everything’s decent, you’re not too close to the pulp. You pull out your T-Scan, if you have one and you track for in time, now your next question’s going to be what about for the guy that doesn’t have a T-Scan? Well, it’s kind of like if you don’t have the laser it, it might work, it might not. Articulating ribbon, this is important. 

Articulating ribbon, depending on the study, is about 12 to 33% accurate. Relative to force in time. All the big stiletto heel things that we learned about in school and all this stuff, and the 99.999% of us, all we ever use is that if you start going to digital and you start seeing force in time and 3000 of a second increments, it will change your world.

[Jaz]
Absolutely. 

[Nick]
The T-Scan will change your world and I’m not trying to sell T-Scan either. Just like I’m not trying to– 

[Jaz]
It’s changed my world. It’s been Yeah. 

[Nick]
Well it’s huge. I use it on– this is important too. I use the T-Scan on every patient that walks in my office that it gets restorative. Every patient that gets aligner therapy, I’m getting ready to do oral.

[Jaz]
Same. 

[Nick]
Yeah. I always have a record of before and after. Let’s say you walked in, you’re my patient and I’m doing two fillings. Let’s do something real basic two occlusals on eight on lower- let’s say lower left first and second molar. The first thing my girls do is they have you clench and grind on the T-Scan sensor. So all of a sudden I walk in and I’m looking at the proper reading and I’ve got a record of their bite. 

Now they’re probably 70% of the time when I’m doing that filling for you, I’m just using the Erbium laser. No shot, no drill. And then I’m having you bite and grind, checking and comparing before and after. I’m using ribbon two to mark, but I don’t trust ribbon. I trust the data, the T-Scan, the literature is about 95% accurate relative to force in time across the board, 12 to 33 95. Which one would I rather use? Most are completely unaware. 

[Jaz]
Well, it’s the objective data for me Nick, I was always worried about equilibration.Whether, whichever definition you use, whether you’re doing it to CR or just getting a bite bouncing, adjustment. Occlusal adjustment. 

[Nick]
Occlusal Adjustment. 

[Jaz]
Absolutely. And so I was worried about occlusal adjustment because in my notes occlusal adjustment and then I was missing that objective data. Now that I have objective data that I had pre-op, this was the actual force in time data and post-op, I have objectively improved the occlusion. Right? 

[Nick]
Yes. 

[Jaz]
And then no one can argue with that. And for me, that really was the license to, okay, now I can do it in a way that I mean control.

[Nick]
Well, let me give you another hierarchy. Remember the door analogy with the hinges? You’ve got to be able to get a read on what’s going on with the joint, if you really want to know. Every single patient that we ever see, even their periodic exams, when they come in for their six month cleaning, we slap the joint vibration on them and we’re comparing it to past JVA readings.

Joint vibration remembers listening for tears and cartilage. You can cross reference the data with Flowsheets and get an idea of the Piper classification. There’s Piper’s name, how deranged the joints might be, and that matters, like we alluded to that earlier. If you bend the hinge of a door, the way the door, the lower jaw with teeth connected is the jam, upper jaw with teeth connected.

And that in itself can be problematic. And also another thing you can track with T-scan, let back, jump back to digital occlusal. If, let’s say I did those two fillings on you, I numbed you, or I didn’t numb you, I checked the after. And let’s say you’re Cooley didn’t come back, or let’s say you come back a week later, you’ve got a little bit of sensitivity problem to cold. 

The whole topic of this podcast, I’ll pull out my T scan again and I’ll check again. Maybe I missed something for about 3 or 6 or 9,000 of a second. Maybe there’s a little excursive rub, a little speed bump and I’ll hit it with the bur, that one little spot. Then all of a sudden I’ll have you swish ice water as you walk in. You were a seven, you swished a minute later, you’re a one. I do this all the time. I’ve done this for— 

[Jaz]
That’s so fascinating because a minute later the upper teeth don’t know what’s happened to the lower teeth just yet. because they haven’t had enough time to even meet. So do you see what I mean? Like, they haven’t had the time to like trial it, to see to, to, for the weather it’s flexor or sympathetics, which we’re going to come to. 

[Nick]
Now let me leave FDH for just a second and let me take you guys to SDH now. 

[Jaz]
Okay. 

[Nick]
So you either have DH occlusal of the tooth where you have CDH, the cervical aspect, maybe recession exposed, Dental Tubules, like just like you would on a DH, right? Remember, laser ozone is the cure most of the time, almost always. Or you could have FDH, which is the bite. The little speed bumps in the incursive movements.

[Jaz]
Okay. I’m really sorry to interject, but I really need to know this, Nick. Okay. Yeah, because one of the questions I need to understand, and for sake of everyone, is when you are not sure— Okay? So I think what you’re saying is to follow as a hierarchy. Look for the DH first and deal with that. Look for the CDH first to deal with that before you jump to the frictional, because there’s no point then doing like adjustments and whatnot until you’ve actually taken care of the previous two, right?

[Nick]
Yes. But here’s the point. You need to have the objective metrics. I’m sorry, there’s no cheap way into this. You’re not going to be able to do what I’m doing with your ribbon. It’s not going to happen. You might get lucky. You’ve got about a one in four chance of hitting it. Okay? This stuff gets really deep and I don’t want to get too deep, but the bottom line is, the reason I’m trying to take you to SDH is because SDH is why FDH happens.

[Jaz]
Yeah. Yep. Let’s hear about it. 

[Nick]
So over the years, as I’m seeing people from all over the place I have a large database. So I decided to jump into the database. I had my head assistant look and she spent about a month there. And we were looking for things. We were — because we’re starting to give neck blocks. We started doing that years ago. Maybe Piper taught me this net block, basically that’s a lecture in itself. But their nerves–

[Jaz]
What are you injecting? 

[Nick]
We’re injecting anesthetic. Typically Marcaine 1:200,000. Basically the upper C spine, their cervical sensory nerves that make their way from the neck, they cross over the sternal cloud of mastoid, that big bulging muscle. When we turn right below the skin, it comes very superficial. It’s called the great auricular nerve. That nerve in particular is one of the ways that’s a cervical sensory nerve from C2, C3 ventral. That comes very superficially right by the SCM, where you can drop anesthetic about two millimeters below the skin.

The anesthetic will essentially throw up a roadblock, not because you’re trying to block the greater auricular nerve, but because that cervical sensory nerve is a way that sympathetic nerve fibers make their way to the lateral face and teeth from the neck autonomic sympathetic. So what’s the point? Well, if I have a sympathetic response, I want you to just remember this one thing: Sympathetics Vasoconstrict, parasympathetic dilates blood. 

Okay. So if I have ramped up sympathetic tone, I’m constricting blood vessels. If it’s always on, they’re always constricted. If I don’t have enough blood flow, might I kill tissues? I wonder why that crown prep I did last week that was nowhere near close to the nerve, needed a root canal this week because you stimulated sympathetic flow.

[Jaz]
So this is why some good or endodontists, they advocate when you’re doing a deep restoration or crack to you to dissect a crack, for example, to use an anesthetic without epinephrine or artane. So without adrenaline, sorry. 

[Nick]
That’s fair. Yeah. The only reason I use the 1 to 200 is because I want to last a while and it’s not, and honestly, the only time in my practice that I use any epi at all is when I give a neck block. Or if I’m doing say, eight or 10 veneers up front or something like that. Because we do, when we do veneers, we’re using Cadcam Tech. 

We’re doing Cerec same day. Like they walk out finished. We call that CAD Smiles. We do that about every three months, I ship in a lab tech, he works the lab side of it, and I do the preps. And we do two patients a day like 16 to 20.

I’ll use Marcaine there, I’ll use Marcaine up on the neck block. And honestly, I can use Prilocaine, I can use Citanest plain, whatever. I can use Procaine. If I want to get really holistic and no epi, I’ll drop Procaine in there. 

Okay. And if you understand the holistic realm in dentistry, a lot of the patients and dentists that are in that realm, they’re using Procaine, which is the old fashioned Novocaine, which is supposed to have an allergic reaction. Every 20,000 people. I know a lot of holistic dentists, and I’ve never even heard of one. So we’re getting into that money thing again, in other words, corporations pushing certain things that are more profitable. 

But the bottom line is , whatever. Here’s the point. The sympathetics, if they’re ramped up, and why might they be ramped up? Well, too many tap, tap taps, too many speed bumps. Now we’re pulling back to FDH, but I introduced the sympathetic idea if I have excessive sympathetic tone. Here’s another thing to know. The dental pulp, if you look histologically, 10% of the nerve fibers are sympathetic, originating from superior cervical plexus, which is neck.

Anyone who took dental, anatomy, histology, whatever in Dental School, look it up online look it up right now on Google Scholar, whatever. It’s, I’ll say that one more time. It’s very important of the innovation of the dental. Pulp is sympathetic in origin. The other 90% is trigeminal. 

[Jaz]
Okay. 

[Nick]
Now, of that 10%, that’s sympathetic in origin. Some of it’s sensory and some of it’s motor. What’s the difference? Well, afferent, efferent, right? Sensory brain feels something. Motor brain’s telling something to do something. Gland, muscle, whatever, right? So if you have sympathetic nerve fibers in the pulp of a tooth, what the hell are they doing there? And why are they coming from the neck? It’s not the trigeminal this is very important.

In other words, we all think trigeminal, our realm is trigeminal it’s V2, V3. Well, the reality is this is a big deal. It’s going to be a very big deal probably after I die. But who knows? It takes time for these things, right? But this is important. This is the topic of our most recent paper we published about a week ago. So Sympathetic Dental hypersensitivity was the name of the paper. Look it up in Google Scholar, SDH novel Etiology. 

[Jaz]
I can share it with this in the— 

[Nick]
Please do 

[Jaz]
–show notes. 

[Nick]
Please do. And I’m dead serious. It’s worth reading. The authors are myself, Piper, Radke,, the guy who created BioPack and another dentist who’s a kind of an expert in the old school of sensitive teeth. But the bottom line is the sympathetic efferent fibers, the motor fibers coming from the neck. The reason they’re there is to constrict the arterials in the dental pulp.

Now here’s the kicker. Most every other part of the body, we have sympathetic and parasympathetic nerves to counter them. And the dental pulp, guess what? They can’t find histologically. Parasympathetic, five parasympathetic. So when you or I prep that crown, it was an easy one nowhere near the nerve, no cracks, no problems, just a broken cusp, no big deal. They weren’t symptomatic, they needed a crown.

And then a week later, they are really in pain. When your bur hit that tooth, you ramped up a sympathetic tone. You caused excessive constriction. There’s no parasympathetic way to counter it. The constriction got so bad, it choked off blood flow. You get hypoxia, ischemia, potential necrosis distal to that point. So if you guys have ever wondered why it is that. Good guy that was a routine filling a routine crown. The caries was nowhere near, there’s no crack, no nothing. And now I’ve got a root canal problem. I’m telling you what. 

[Jaz’s Interjection]
Okay, interjection number three, guys. Okay. I know it was a lot to take in. So a quick little summary. That’s all this injection is, right? Remember Dentinal hypersensitivity, I think we can all understand this type of hypersensitivity. Typically occlusal surfaces expose tubules, right? You blow your 3 in 1, your air on it and it’s, ooh, that’s sensitive. Okay? So we can all understand and visualize that.

Now, CDH, just Cervical Dentine Hypersensitivity, think of those abrasions, abfractions, where the CEJ is, and again, loads of our patients get that. The ones that you may not have heard of are Frictional Dentine Hypersensitivity. Those are the occlusal speed bumps that he described so like posterior friction, it’s the back teeth rubbing, getting in the way, stimulating this nerve response, causing this hypersensitivity.

So essentially it is hypersensitivity due to occlusal cause. And now lastly, something that was new to me was a sympathetic dental hypersensitivity, which say nerve driven response. Now we’re going to delve deeper into that, but remember that when you find someone, a patient who’s got sensitivity, obviously, check for cracks, carries the usual stuff first. And then once you rule that out, then you check, okay, is there some exposed dentine occlusally? So that’s your dentine hypersensitivity. And if not, you check for abrasions and a fraction.

So your Cervical Dentine Hypersensitivity, do you see any of those lesions that when you’re blowing air near the neck of the teeth and they’re super sensitive and you see those abrasion areas. Now, if they don’t have that. Then maybe think, could it be frictional? Could there be too many occlusal speed bumps? And if it’s not that, then it’s just fascinating what Nick’s saying with the Sympathetic Dentinal Hypersensitivity. 

[Nick]
So when you do a neck block at the greater occipital nerve, the sympathetic fibers, that’s one of the main highways by which the sympathetics make it up to the lateral face. And ear the oracle is the ear great auricular nerve. It runs to the angle of the mandible, innervates parts of the parotid, parts of the ear lobe and the mastoid area. Look it up online. Look it up in Google Scholar you’ll find the only thing you’ll see on Google Scholar relative to the dental world is stuff about wisdom, teeth extractions. Helping people get numbers on V3. And I’m telling you why, because the sympathetic nerve stuff is still active even though you’ve given a block. 

Remember, 10% of the dental pulp is sympathetic and mostly efferent fibers, which can constrict blood vessels. So why we’re giving the nerve block is because we’re trying to reduce the amount of sympathetic flow. All right? This is how the sympathetic guys, let’s call them the bad guys. This is how the bad guys make it into the lateral face and the teeth themselves, it’s a big deal.

So here’s the point. So our end was 194 in the paper and we basically, I’d injected all 194 of those peoples, and I had a ice water swish before and after, and we’re looking at their responses and basically there was like quartiles, I don’t want to get too deep into it, but about 124 of them it affected. And there was about of the 190, I think it was a hundred ninety four, a hundred twenty, yeah. So there’s about 70 people where it didn’t do anything. In other words–

[Jaz]
And just to clarify now for people following along in this study, it was a, the nerve block into the neck and it was just before and after ice water, just from that one intervention, right?

[Nick]
Yes. 

[Jaz]
Okay. 

[Nick]
Yes. So in other words, 124 of the 194 thereabouts had a complete change matter of degrees. Some of them, it went down to almost zero from say an 8 or 9 out of 10. 

[Jaz]
So statistically significant change. 

[Nick]
Huge. The P was less than 0.0000000000. 

[Jaz]
Perfect.

[Nick]
Anything less, if you know anything about P values 0.05 or less is statistically significant, right? Our numbers were like unbelievably significant depending on which quartile you’re looking at. So the bottom line was, here we are injecting in the neck, which has nothing to do with trigeminal, and their two sensitivity went away on a very large subset of those 194 people. 

Okay, so what does that prove? Well, that, does it prove anything? Well, we need controlled studies we need people in a university setting, taking this on. We need them doing like saline injections instead of anesthetics, seeing if there’s a change. Right.

This is a clinical retrospective study, so it’s the poorest. It’s not a randomized controlled study. I’m sorry, I’m a GP I don’t have time for that. I’m giving the best I got. But the bottom line is, I can tell you, because I’ve been doing this for years, and I, there are many times where they’ll come in for screening, like the TMD patient that’s traveled a long distance to see me.

Remember we were talking about this about 20 minutes ago, what you do or what I’ve done over the years, and I integrated and put that into my teaching center the cno doctors.com thing centered for neural occlusion. 

I created the neural occlusion screening protocols, which mean they come in, they don’t even tell me why they’re here. We run them through a normal thorough dental exam. Then we send them off for MRI and CT. Then we start doing electromyography readings of various iterations.

Then we do jaw track and kinesiology, heart rate variability monitors, things like that. All this kind of stuff very objective data. I run them for two to three hours through all that data, the MRI, the CT, the EMG reading is a T scan, the this, that, the other. And then I look at them about three hours into it and I’m like, so tell me why you’re here.

By then, they’ve spent three hours looking at the data. As I explain as we go, they already have, and now all of a sudden, for the first time, they’ve seen where their discs are. They’ve seen if the bone is alive or dead. About every six patient, by the way, has an AVN Avascular necrosis on average over the years to stuff, I’ve seen that.

Now if you travel to see me from where you live and you’ve been to 30 different doctors, there’s a pretty good chance you’ve got something really bad going on, right? 

[Jaz]
Yeah. True.

[Nick]
The patient pool that I’ve seen some stuff you would not believe. Okay. So the vascular necrosis, I literally see probably, I don’t know, four to five a year. Now, can an occlusal adjustment fix that? No. Not even close. Okay. So my point is you have to make them own their problems. 

And how you make them own their problems is you give them objective data and you educate them. And then all of a sudden that big, long communication problem that you’ve had over the years, when you’re dealing with people that live a long ways away, you shut it down.

And I started throwing that out in my videos about seven or eight years ago, saying, Dr. Nick doesn’t want to know why you’re here. And people initially were kind of taken aback by that. Like, oh, he doesn’t give a damn. He’s just out for my money. No, I’m not. There’s a reason for it. because we don’t have time to go through all the subjective BS. They all told me it was in my head. And I’m like, yeah, it’s probably in your head, your neck. It could be the autonomics, it could be the trigeminal or the cervical that’s messing with you. . So, bottom line, this cold stuff led to TMD world, which I did not expect nor plan or want. I don’t want any piece of that.

[Jaz]
See, I thought it was a TMD that led to the cold stuff, but now I’m learning your journey. There we are. 

[Nick]
My journey was the opposite. The cold stuff, trying to be a better dentist led to craziness where I’m starting to see people that couldn’t get help. They could. Here’s the bottom line. If you can just help them diagnose themselves, you’ve done them a massive service. 

If you can objectively help them understand you have an AVN on your left joint, you have a fusions bilaterally in the joint itself. Your sympathetic tone’s ramped up. You might have complex regional pain syndrome type one. Your hypotonic on this muscle, you’re hypertonic on that one, your occlusion times are terrible here.

So what, what happened after I initiated a neural occlusion screening protocols over 10 years ago, only about 40% of the time maximum did I apply occlusal adjustments because the other 60% of the time it was not indicated. What was indicated was, you need to go see Mark Piper. You’ve got an AVN, or you need to go see the chiropractor. 

Your C-spine is jacked, or you need to understand your neurologist is a little misinformed when he says complex regional pain syndrome or RSD, old school Reflex Sympathetic Dystrophy, which means ramped up sympathetic tone to the point where you want to put a bullet in your head. They call crips type one, the suicide disease.

And probably every third, I’d say every third or fourth patient I see has Crips. And I knew nothing about Crips until I learned about it from Piper. So, bottom line, trigeminal, cervical, sympathetic, and this all ties into sensitive teeth because it’s not just trigeminal, it’s also sympathetic. 

So when I make occlusal adjustments, and this is what I want Robert Kerstein to hear, I want Batman to understand what I’ve learned over the last decade when you have fewer speed bumps, as you’re making those adjustments, those discursive adjustments. Every tap, tap, tap, every bump, every bump in a bump in a bump, ramps up sympathetic tone causing hypoxia inside the pulp of a tooth.

Hypoxia causes ischemia, not necessarily a necrosis, but ischemia to the point where it’s kind of hyperpolarized. And all of a sudden that coal insult is just like unbelievably bad when you get rid of some of those speed bumps and you decrease the tap, tap, tap, which ramped up sympathetic tone before and now there’s fewer taps. It’s not about timing, because in my opinion, you cannot reproducibly do that. On the T-Scan, there’s a center of force icon. 

It’s like a little kite, when you bite down, you see this little graphical deputation, and when they clench, you’ll see that kites hold real still, and then you’ll have make a right excursion movement and the kit will start floating off and zinging around straight in that line.

When they’re going right, make it go towards the upper right nice and straight all you got to do. The timing will be different, patients if they have dystonia, if they have problems like that, they’re going to be slower, faster, this, that, and the other. 

I love Robert and I love his research and the Disclusion time and all this, but in my experience, I’m far better chasing the center of force icon. I want to straighten that line. If I straighten that line, which is the path of breadcrumbs, whereby the all the average force percentages at that given moment on the graph, when I straighten that out, that’s when the magic happens. In my world, I don’t even look at timing. 

[Jaz]
Okay. Interesting. 

[Nick]
Okay. I’m getting too deep because most of the audience has probably never even seen a tcam.

[Jaz]
But this just gives us a flavor of how much there is to learn and how much there is. No, you’ve already spoken about the fact that if you’re relying on articulating paper, you are relying on what is largely false data or rather missing data. Right? We think the big mark or the small or the bullseye is indicative of force, but it isn’t. And a very low percentage of time. And we know that, we’ve discussed it. In fact, Rob Kerstein was on this podcast. So we titled that podcast episode articulating paper lying to us. And that was a good one. But what you are building on here with relation to two sensitivities for me is very new.

All these protocols are suggesting, but also this input and involvement of a sympathetic let’s talk about, because final bit now I’ve only got a few minutes left, but in terms of narrative, right there, there are different narratives. Nick, like for example, some academics or some theories of TMD is, it’s very much emotional, it’s stress related. The occlusion is irrelevant, anatomy is so irrelevant. So the Bio-psychosocial with the emphasis on the psychosocial. 

[Nick]
Yep. 

[Jaz]
Then there’s our friend Rob Kerstein, who has taught me that, A lot of these, if you do the imaging and the joints are okay, then a lot of these issues are occlusal. Okay. And if you’ve fixed occlusion, you get that Disclusion Time Reduction you get that time below 0.3, 0.2, whatever it was for that individual then, with the correct EMG data. And then you’ll cure that patient. What would you say is your narrative and your legacy?

[Nick]
My narrative? My legacy? The bios–

[Jaz]
Today, because things are always developing, as you’ve said that, and I wrote, I really respect about you, is you said that at once upon in time, you thought this about the flexing of the tooth. And now you think different. And I admire that about was open— 

[Nick]
My mind, I could be dead wrong. But the data, look, you’ve got to chase the data. And you got to trust your eyes. So if I read something and I try to vet it as best I can, make sure there’s no conflicts and I try to apply, said research or results or what have you in my practice, if I’m not seeing that either I suck or I’ve done something wrong.

Now the bio-psychosocial thing, you know what that is? The autonomic sympathetics. This is deep. Now we’re getting into deeper neurology. I want your audience open up that Google scholar and I want you to see how the autonomic sympathetics affect the pene gland melatonin. I want you guys to look into that. 

So the next time you start hearing this bio-psychosocial stress thing I want you to think sympathetics, I want you to think hypoxia. I want you to think melatonin levels. I want you to look for yourself, and then I want you to maybe learn how to do the neck blocks. Come to the center for neural occlusion. This is not a sales pitch. This is my passion this is not a money maker. Trust me. We’re lucky if we break even. 

[Jaz]
Yeah.

[Nick]
My wife always reminds me, I need to quit this. But I’m not going to. My point is, I’m sorry. I love it. I’m passionate about it and let me tell you why I’m passionate about it 2 reasons. It makes me a better dentist. And if you’ve seen the kind of patients that I’ve seen with the kind of problems they’ve got, and you’re able to at least help them figure out what the heck’s wrong with them, that’s when you get your endorphins rushing. 

That’s when it doesn’t matter. That’s when you’re really there for the right reason, that you’ve actually accomplished something. So what’s my legacy? My legacy would be to pass what I’ve learned onto others and hope they will take it up and prove me wrong. Prove me right. Learn, spend some time. 

A lot of doctors will go out and they will and I think it’s great. They’ll go volunteer their time in Africa. They’ll go on a mission trip. How I give back is this, the videos, the research, the publications, it’s all thankless there’s no money. I get paid when patients come to see me, but it’s the least profitable thing we do. My wife reminds me of that all the time too. Love her for it. But I’m not quitting because I’m passionate about it. Because when you can literally change people’s lives, which I’ve done innumerable times, 

[Jaz]
I’ve seen it, it’s been brilliant to see your videos over the years. 

[Nick]
Then there’s times where you can’t, but at least they understand why, based on my limited understanding of their set of problems because it’s never one thing. All right, last thing that I should get into real fast. There’s a concept called The Beaker of Pain. I call The Beaker of Pain this like you or I sitting here right now, our masticatory system, our stomatognathic system is not problematic. You and I aren’t hurting we’re not thinking about our pain in our jaw or our headaches, right?

So our beakers likely not empty. The point is when the beaker, the number of problems, when the beaker fills up and it overflows, that’s when we’re seeking help. But there’s lots of things filling the beaker. It could be a neck problem, it could be a bite problem, it could be a tooth problem, it could be a muscle problem. It could be a sympathetic problem, it could be a psychological problem, pineal gland. It could be a whatever. So the goal, my goal when I screen people is to try to understand what the hell’s in their beaker.

They’re in my chair, they’re obviously overflowing. I have to try to diagnose as much as I can. There’s going to be 10, 20, 30 things in that beaker. I need to objectively identify as many of those possibly that I possibly can. I need to take whatever I can do treatment wise as a dentist, Turkey based, or suck that up to where it doesn’t overflow anymore. There are times where the occlusion is enough of that beaker, when you suck it out, you’re not thinking about it anymore. They’re walking around like you and I. 

[Jaz]
I work with a TMJ physio, her name’s Krina. Give her a shout out and she talks about it in the form of a bucket. So say the same thing as, see there’s so much in their bucket. It’s about how can we help reduce the bucket. And so, it is great that you mentioned that. It’s a great point because it’s never just one thing. Absolutely. 

[Nick]
The bottom line is understand there’s a beaker of pain, a bucket of pain, whatever you want to call it. Understand they always have multiple problems. Understand the top three are trigeminal, cervical sympathetic. Learn these guys. We already have a pretty good handle on trigeminal. We suck at necks and we know absolutely nothing about the sympathetics, the average dentist 

[Jaz]
Until now. 

[Nick]
And by the way, the sympathetic stuff brings us big time into medicine. This is our realm and I’m ready for the day. My medical board in my state may say, why are you sticking people in the neck? I’m totally ready. Put me in front of whoever you want, the neurosurgeon. I don’t care. I’m ready. Yeah. 

[Jaz’s Interjection]
Hello. Geeks it’s the fourth and final interject, and I use that word geek intentionally because if you’ve made it this far, this episode, oh my goodness, you are a geek. This is one of the geekiest episodes we have ever done and wow. Just well done for making it this far. Right? So I actually forgot to ask him a question and I emailed him, I said, one thing I didn’t get to ask is the greater auricular nerve block, if it reduces the sensitivity, thus it kind of points to a sympathetic etiology, right?

So it’s a Sympathetic Dentine Hypersensitivity, right? So if you give those neck injections and they’re, they swish ice water and they’re completely fine, that points to the etiology, right? But once the block wears away, the sensitivity returns. 

So I asked, what’s the long-term fix for these patients? So what he told me is the dentine hypersensitivity, the cervical Dentine Hypersensitivity, to remember the occlusal and the cervical and the Frictional Dentine Hypersensitivity, they usually have a definitive fixes, okay?

But you can’t always cure the sympathetic endotype. So sometimes a cure is occlusal corrections. He says even for the Sympathetic Dentine Hypersensitivity. And for those ones you have to vet the orthopedic. So you have to make sure that the joints are healthy or adapted and they need bilateral stable or adapted joints for you do any occlusal corrections.

So like MRIs and CT’s and sometimes the etiology actually arises from the C spine and sometimes etiology is further down the spine because sympathetics can arise from T1 to L2. 

So sometimes the damage and injury is somewhere along the sympathetic pathway, and that can be the cause. And sometimes the etiology is just a ramped up sympathetic tone, and it’s a combination of the above. And therefore this sympathetic dentine hypersensitivity is the least predictable to fix. Now, isn’t that just absolutely fascinating? 

[Nick]
And by the way, there’s precedence in the literature by yours truly about the neck block. Multiple papers now, chapters and textbooks, and we’re going to be publishing more and more and more and more. And it’s a huge deal, and if you jump onto the YouTube channel, type in Dr. Nick DDS on YouTube, you can start seeing, especially the last year or two, you’ll start seeing some really strange stuff the cold stuff, the this. If you look back five years ago, it’s big MRI stuff. You look nowadays as big sympathetic stuff.

And by the way, last thing, you joined yesterday, Facebook. I am not promoting Facebook. Don’t really like Facebook, but we’ve had a forum on Facebook for over 10 years now. Center for Neural Occlusion it’s a private one. There’s also a public one don’t join that. You can if you want. The private one is for doctors only. Highly recommend that we all come together and ask each other questions. 

And one of these days, if the CNO ever grows in my retirement, I might spend time on it to make it grow. I’m planning on having my own dedicated website, my own forums where people like you and me can like interact and ask questions, try to learn from one another. So that’s– 

[Jaz]
I’ll put the link to that. I’ve been on it for a short while. I’m just, maybe there’s some hidden video stuff on there, if you like. And it’s incredible honestly, what you’ve done with patients and what I’m seeing has been great. It’s been great to learn from you and what I’m looking forward to. 

Next paper they’re going to write as well, and I’ll be able to share the paper that you have and what you mentioned towards the end is about. Integration to medicine, how this unlocks that. Well, it greatly brings together the AES conference in February where you’ll be speaking, as well, the oral physician. And I just really want to plug that really hard because it’s thanks to the AES who’s connected me with you and Dania Tamimi and all these great guests I’ve had on. And so— 

[Nick]
I know Dania’s mentor, Hatcher, he’s part of the CNO. 

[Jaz]
Yeah. She talk about–

[Nick]
He’s like a badass, Oral Maxillofacial Radiologist. One of the best in the world. At least he used to be he’s not active anymore. But when I formed a CNO we formed a board of advisors, not directors, and we’ve got like TMJ Surgeons, Med Radiologists, Maxillofacial Radiologists, Periodontists Orthodontists, GPS researchers, Blood guy, Rick Myron, if you’ve ever heard of him, the PRF guy, you need to interview him. He’s the guru. PRF plate Rich fiber. 

[Jaz]
Yeah. 

[Nick]
Amazing. 

[Jaz]
I’ve heard of PF in surgery and wound healing and that kind of stuff in implant world, but don’t know much more about it. 

[Nick]
This guys’ published 10 textbooks and 350 plus publications on that topic. 

[Jaz]
Amazing. 

[Nick]
Yeah. Rick Myron. Okay. Yeah. So watch out guys.

[Jaz]
Yeah. Yeah. I’m always, I’m guess, like I said, I’m a sponge, right. I’m here to share so just final things. I’ll look forward to meeting you in February in Chicago. And I want to encourage as many colleagues to, to come to that as well. And obviously the websites c and know everything I’ll put in the show links and the Facebook group is probably the best way for someone to connect with you and show some love or debate and discuss. 

[Nick]
Totally easy. And do you have to wait for me to let you in? We ask are you a medical or dental professional just to answer the questions. because a lot of times we’ll have patients trying to sneak in and Nope, nope. This is just for us. Yeah.

[Jaz]
I can imagine. I can imagine.

[Nick]
And by the way on AES the way I understand it. Mark Piper says this is his last time to lecture, so you better show up. And here’s another quick tip on Mark Piper. I want you guys to jump on YouTube and I want you to type in Dr. Mark Piper, AACP, American Academy Craniofacial Pain. I want you to learn from the best in the world, in my opinion, on this stuff, on the sympathetic angle.

I’m his student. He taught me, and I still have a thousand times more to learn before I can get to his level. I filmed that when he and I spoke at the American Academy of CranioFacial Pain back seven years ago. He hit them with the Sympathetics and Crips Complex regional Pain syndrome. And then I followed with practical stuff and Occlusion World to dental World, specialty GP stuff. But that one lecture, I’ve listened to it probably at least 10 times over the years. 

[Jaz]
Amazing. I’m going to stick that on. I’m going to, I can’t wait to, can’t wait to watch it and stick it on. A hundred percent.

[Nick]
That’s worth your time. 

[Jaz]
It’ll be made available to all what we call the Protruserati. Nick, absolutely a pleasure to host you and speak with you. Learn so much, with our short time together today. I can’t wait to learn more from you over the years. Keep doing what you’re doing, please. Right. Keep doing what you’re doing. Keep, I’ll see you in Chicago. Next year, my friend.

[Nick]
Thanks, man. 

Jaz’s Outro:
Well, there we have it guys. How fascinating was that? I really appreciate you listening all the way to the end. Big shout out to Dr. Yanos. It was a complex topic and like this guy knows so much and I always noticed that with my guests who just know so much, it’s often difficult to get the right bits across, so hopefully together I was able to interject at the right times.

I love him for his storytelling and the admission of the fact that you know what? He changed his views and theories and he’s amenable to changing your mind and how something works and he thinks very critically. I think we can all learn from that and appreciate that anything that was promised in this episode, the team try their very best to put it in the show notes.

If you are watching this on protrusive Guidance App on iOS, Android, or on the web, scroll down, answer the quiz, get 80% and we will send you a CE certificate. We are a PACE approved education provider. I’m going to thank my team for the hard work they do. And one more request. 

Protruserati, have you hit the subscribe button yet. If you haven’t, it really does help us to get more reach, to attract more guests in the future and to keep doing what we’re doing. So don’t forget wherever you’re listening or watching from, hit that subscribe button. Thanks again. I’ll catch you same time, same place next week. Bye for now.