Occlusograms are Lying To Us! Don’t Trust the ‘Heat Map’ – PDP247

The essence of a scanning technology is that all the teeth are scanned with the patient’s teeth apart. No one’s biting. There’s no forces captured. There’s no contacts. There’s no gathering of teeth banging together or rubbing around. So it completely is falsely representing. These colour coded occlusograms have no force information in them at all.

Anyone who’s used articulating paper, which most of us do, and the T-scan, you still mark the teeth with paper, but you choose the contacts to treat based on the data, not based on where the paper marks look. And very often, the most pressure points of contacts are small, scratchy little marks that dentistry says are light force, which you’re completely wrong because again, the load is applied over area. So if you have a very small area, you have the potential for very high pressure.

Jaz’s Introduction:
Protruserati, the occlusogram is lying to us. Does that sound familiar? Well, we welcome back again, Dr. Robert Kerstein. If you remember way back in episode 109, we made an episode called, “Articulating Paper Is Lying to Us,” and you guys absolutely loved it because Arctic paper is lying to us.

You should totally listen to that episode if you haven’t already. And if you haven’t, essentially the arctic paper marks you see on teeth are flawed in the sense that you can’t look at a mark and accurately say that, oh yeah, that’s more force, or that’s less force, or that’s hitting first. You don’t get that data.

And not only that, but you also get false positives when it comes to articulating paper. Now, similarly, I’ve got Robert Kerstein back again talking about the occlusogram. Now the occlusogram is that heat map you see when you do a scan, when you do an intraoral scan of a patient, upper arch, lower arch, and then you do the occlusion.

Most modern scanners will give you some sort of a heat map of the occlusion and we call that an occlusogram. And we may all at the beginning make this mistake, this very simple error, that when you see red on the occlusogram that means high force. Well, we will absolutely and emphatically bust that myth today.

You see the heat map or the occlusogram is just a measure of proximity. How close in space is that cusp to that fossa? And if it’s very close, it’s gonna be red. And if it’s maybe a few microns away, it’ll be a colder colour. Absolutely does not tell you how much force or timing or pressure, none of that stuff. Just contact proximity. So we must be careful in how we interpret that data. It would be misinformation to tell a patient that a certain tooth is having more load because of the colour.

Hello Protruserati. I’m Jaz Gulati and welcome back to your favourite dental podcast. Today’s guest is none other than Dr. Robert Kerstein. Rob Kerstein is like the godfather of digital occlusion. When I was in New Mexico a few months ago with Dr. Bobby Supple, he described Dr. Kerstein as the Einstein of occlusion, and it’s an absolute pleasure to chat with him again.

It’s a different format of the podcast. We’re driving, well, I’m driving, he’s my passenger. And so one of the team members, when they were listening to this, they said, it’s like carpool karaoke vibes. And don’t worry, we will not start doing a little singing and dance in the middle of this episode, but something a bit different, a bit fresh. Me and Dr. Kerstein were on the way to some DTR training in the UK.

DTR is Disclusion Time Reduction, essentially, if you listen to that episode that we did with Nick Yiannios. We talked about frictional dental hypersensitivity, and essentially lots of friction between the back teeth could cause your teeth to become sensitive. So this posterior dental friction is also implicated in TMD, thus resurfacing that old debate: is occlusion a causative factor of TMD?

Now, we all know some CAMs and some reviews that suggest that occlusion has no relationship to TMD. Whereas my guest, Dr. Robert Kerstein, says that TMD is a neurological condition and has everything to do with occlusion, and particularly that muscular TMD group would greatly benefit from an occlusal adjustment or something to change about their occlusion, to reduce that sensory input and their noxious muscular spasms.

And I saw all this freehand. I can’t wait to share my experience of what I witnessed when Dr. Robert Kerstein came to my practice and I treated three patients. So I’ll leave you on that teaser if you like, ’cause we have another episode coming with Dr. Jeremy Bliss talking all about occlusion, TMD and Disclusion Time Reduction, aka DTR.

Dental Pearl
But for now, let’s enjoy this episode of occlusogram. And just before we join the main interview, I need to give you your Protrusive Dental Pearl. Every PDP episode, I’ll give you a top tip that you can use right away. And today’s one, like many pearls are, are from Dr. Mohammed Mozafari. Mohammed’s one of the most selfless and caring and giving people on our Protrusive app community, always helping our colleagues.

And today it was our good colleague Yazan. And just yesterday on the group, Yazan had a query. He’s got these crowns, definitive crowns, temporarily cemented with TempBond.

Now we all know of that scenario that it could have happened to you or a colleague, whereby you put these crowns in temporarily. Even some colleagues, they try in a crown, let’s say a PFM crown without any cement, and they put the crown on and they just cannot take it off, and it’s like impossible to get off.

It’s not happened to me yet, but I’ve heard of this happening many times. So quite appropriately, Yazan was right to ask on the group, what’s the best way to remove a definitive crown that’s been temporarily cemented? Because you want to remove it in a way that you don’t damage the porcelain or the material itself, and you want it to be nice and easy and not very uncomfortable for the patient whatsoever.

Now, what I was going to say before I read all the comments was there are these like special pliers you can get with these, like these plastic ends, but they can be a bit hit and miss. Sometimes they do slip off, like they have got this like textured surface to prevent the slippage, but it can slip off.

So I really like what Mohammed suggested. So Mohammed suggested you get some bite registration paste, you put some buccal and lingual of the crown, then you put some gauze over it. You obviously let that bite registration paste set a little bit, and then you can get your hemostat or your mosquitoes and squeeze and try and wiggle the crown off.

The benefit is that the gauze and the bite registration paste are kind to the crown, but at the same time giving you enough of a grip. Haven’t tried this exact way before, but it just sounds amazing to me, and Yazan was able to report back that he was able to get the crown off. So thank you again, Dr. Mozafari. Really appreciate all the help and support you give to all the community members on Protrusive Guidance. Let’s now join the main episode and I’ll catch you in the outro.

Main Episode:
Dr. Robert Kerstein has entered the UK once again and we’re doing an extremely rare driving podcast. So, Robert Kerstein, welcome back to the UK. How are you today?

[Robert]
I’m good. Thank you for having me.

[Jaz]
Absolute pleasure. You know so many dentists around the world, around the world.

[Robert]
Yes.

[Jaz]
And you’ve done these trainings where I’m sure you’ve sat in lots of dentists’ cars.

[Robert]
Yes.

[Jaz]
And so therefore, I want to start by apologizing for probably the worst car of a dentist you’ve ever sat.

[Robert]
Oh, it’s very nice.

[Jaz]
No, no, no. Listen guys, as you guys know, I’m not into my cars at all. I literally googled what’s the cheapest electric car I can go buy for tax efficiency, and I landed on this Chinese car, the MG ZS EV. So I was trying to start by apology, but one of my, like a slight detail for you, talk about the good stuff, is one of my philosophies in life when it comes to spending money is things that I don’t value and I don’t love, I always skimp on.

But things that I value, I will spend mercilessly. I will save mercilessly where I can, but I will spend lavishly on the things that I value. And so one of the things I value so much is education. Education and investing in myself, which goes back full circle to why you are here in the UK right now. Myself, Riaz Yar, Shreyas Mhatre, Haider Raza, and then of course the previous group that you trained are also part of this, and you’re gonna do this one week intense tour around the UK with a didactic day on Thursday.

And we’re talking about Disclusion Time Reduction and the use of T-scan and all the benefits. And so previously we’ve done the episode on “Articulating Paper Is Lying to Us” that had about thousands of hits. You also very kindly shared lots of papers and that link is still active. If someone wants to download the papers that you kindly shared, that link is active. So I’ll link that episode there.

But now that I’ve done like a little introduction, I want people to really understand the scale of your education, the mentoring that you’ve delivered over the years around the world, ’cause it truly is an international operation. So tell me, how far and wide does it take you? How many dentists have you trained and what are you actually training on to help the younger docs understand? What are you actually showing chairside to dentists?

[Robert]
Well, I’ve trained dentists in many countries, so I’ve been very lucky to travel the world, see dentistry in Korea and Thailand and Japan and Russia and Europe. Many dentists in the UK and the United States, South America, it’s really Canada. It’s hard to–

[Jaz]
India being a hotspot.

[Robert]
India, many dentists in India. And so, it’s been a unique experience for me, for sure. But what we teach, what I’m teaching, is how to use the T-scan technology chairside effectively, and Disclusion Time Reduction is specifically to treat TMD muscular patients and how effective it is at resolving it.

No appliances, no Botox, no TENS, no jaw repositioning, no appliances, no smaller guards, no acupuncture, no massage, no chiropractic care, no hypnotherapy. It’s the only treatment that’s neurologic, treats the central nervous system. That’s just why it resolves TMD, which is really the occlusal neurophysiology is at the core of TMD, even though there’s unfortunately many incorrect advocates around the world who keep teaching that occlusion has no role.

Occlusion is the number one cause of TMD, muscular TMD, and even some breakdown of the joints because of how the occlusion impacts disc position, lateral pterygoid strain, and therefore affecting the internal joint space.

[Jaz]
So what you’ll be teaching me today is we’ve got three patients booked in and some of these patients I’ve done orthodontic correction on because their occlusion was not conducive to any sort of immediate anterior canine guidance. It was a mess. So I’ve got a good foundation and that’s what you taught me is the macro occlusion.

What we’re dealing with today is the micro occlusion, not looking at just the dots and lines, but really the force and the timing being the most important thing, the timing. So as you said, and also something Nick Yiannios has also said recently to me is, as our jaw moves aside and there’s teeth contacts happening, they’re like little speed bumps. And so we want to eliminate these speed bumps.

Is that a good way to explain to a young doc who’s trying to understand what DTR is? ‘Cause trying to spread the message and patients will be tied up with this EMG, so muscle data coming from temporalis, masseter, anywhere else you can let us know now ’cause I’ve literally just got the kit in my car, haven’t opened it. So how’s a good analogy, a good way to explain to doctors what you’re training me on today?

[Robert]
Well, the speed bump analogy really discusses like the tooth contacts that rub together frictionally when people use their teeth. But it’s really the transfer of the neural information from the rubbing of the teeth through the pulp and the PDL that is what causes many occlusal problems.

And so the timing of that, the duration of these frictional speed bumps, if you will, sets off long periods of muscle firing. And the muscle firing is directly influenced by the teeth directly from the brain. There’s a single no-synapse pathway from the molars and the premolars, pulps and PDLs.

It goes directly to the centre of the brain and it enters a structure known as the reticular formation, which controls five or six different major body systems, mostly as it applies to this, your training today, is swallowing and masticating and pushing food down into your throat rather than into your lungs, because the teeth modulate all of those movements so that you don’t asphyxiate by putting food into your lungs.

So all these muscles that are involved in chewing, swallowing, and moving food into the digestive tract are controlled by the teeth. And this is why it goes on without us thinking about it. Nobody sits around and says, I’m gonna chew for a while and I think now I’ll swallow and maybe I’ll chew longer and no, I wanna swallow.

None of that happens. You’re just rubbing your teeth together and then all of this physiology takes place with neural control from the brain. And the tooth contacts can hyperfunction those muscles. So you can still use them to do all the things you’re supposed to do, but they get tired, they get sore.

They get tight because the tooth contacts create too much contraction information, and the Disclusion Time Reduction minimises the amount of contraction information that the teeth are passing on to the brain to control swallowing and moving food into the digestive tract with the least amount of muscle activity.

So when you disclude someone in a rapid timeframe, the least amount of muscle activity is used to perform these actions, and that allows the muscles involved to operate without pooling lactic acid, without becoming hyper-contracted. And then the symptoms that are associated with that: tight throat, facial pain, headaches, clenching and grinding, difficulty chewing, tired chewing, soreness after chewing, those things go away.

Because it’s neurologically resolved, not externally resolved with like splints and Botox and TENS and appliances. Those things don’t really work. They try to work, but they never stop the problem because the occlusion is still perpetuating all of this electrical activity that the brain is putting out into those muscles. So it’s a very powerful treatment. It controls how the central nervous system works, and that’s why it’s so effective.

[Jaz]
We were talking last night over dinner about centric relation, MIP now, but I would suggest that anyone interested in why the treatment we’re gonna be doing today is not an equilibration in the more traditional sense of seating the joints into centric relation and working from that position. The DTR is very much done, carried out, using MIP as a base.

And you covered that really well in the previous episode, but one thing I said to you last night is that, if only such a tiny percentage of the population are, have their centric relation coincident with their MIP, for example, as we know, then surely, why is that our goal? So we’re chasing the 1%, where actually we see physiologically that actually 99% plus are in MIP, which is further ahead, forward to their centric relation, right?

And so, but in the similar way, a lot of dentists may say to you, Robert, in terms of why maybe the number of T-scan users isn’t as great as other technology adoption, such as the intraoral scanner, for example. They’d be saying that, ah, I don’t need that level of precision because some dentists say that, accept what you say about MIP because of that.

Yeah, you’re right, because such few people are in centric relation and they’re doing just fine. We can and should work at MIP, it makes sense for the patient. But then a similar group of dentists might say that, do we really need that microsecond data because yes, there’s a frictional rubbing of the posterior teeth.

It is happening. But if you were to T-scan and analyse most people, most population, you would find that the majority, especially after a certain age, are in group function. You’d find that there would be these posterior contacts. So really what we need to fall back on is, okay, there is the kind of patients that come to us as TMD patients, they’ve kind of self-selected themselves as they’re beyond their adaptive capacity.

And then that’s the ones that this treatment modality is for. It’s not for the asymptomatic cohort. Am I right in saying these ramblings?

[Robert]
Well, it’s a very interesting point because a lot of occlusal problems are not chronic TMD. They’re wear, recession, abfraction, mobility, cracking of teeth, chipping of incisal edges, isolated areas of wear or periodontal problems that arise around certain teeth because of occlusal factors, and those people are not complaining about anything really. They’re just slowly destroying their teeth.

[Jaz]
Which is the majority actually. The silent majority.

[Robert]
Well, exactly, because they’re not in pain, but they’re still losing tooth structure or root structure.

[Jaz]
They have signs but no symptoms.

[Robert]
Yes. And those signs are damage and the same and over. Well, it’s perceived as overload by like vertically. They’re making too much force, but it’s actually not vertical. It’s lateral movements that destroy their teeth. Friction, rubbing of teeth, milling of teeth for fractions of seconds.

That then overload the teeth because muscle activity is raised. And so there’s a lot of advantage to treating the asymptomatic patient who has signs of occlusal wear or damage or roots, abfractions. And those things only progress. They don’t go away. They just get worse day to day. And people who don’t address it early on, 10 years later, have a lot worse of a problem and may need reconstructive dentistry.

So there is an advantage to treating people that demonstrate occlusal problems in the same way. Because by treating the disclusion time in those patients, then they use their teeth with a lot less muscle-applied force, because the muscle activity is cut way down.

That’s what Disclusion Time Reduction does, is it relaxes muscles, it stops hyper-contracting muscles, so the load to the teeth is then greatly minimised while someone uses their teeth, and then the processes of damage are arrested and, or let’s say tremendously minimised, as opposed to continuing to wear their teeth, sand their teeth away, chip their teeth, cause root damage.

And those things are often patients don’t treat them or bring them up because they’re not in pain, they just are destroying their teeth. So enzyme reduction.

[Jaz]
So that’s a proactive, preventive treatment. But I imagine most of the DTR that’s carried around the world is delivered to the symptomatic cohort. Because to the nature of them being self-selecting and actually coming and having the sort of mindset that, okay, I need treatment and I’m willing to invest in this treatment for the result.

Whereas trying to have that conversation, like trying to sell aesthetics to someone like, hey, let’s do veneers and stuff, and that kind of stuff might be actually easier to give ’em what they want rather than what they need is just so a psychology. So that’s why whilst, yeah, DTR would help asymptomatic cohorts, because when we look at occlusion and the chewing system long term over time, that this sets ’em up in a better way.

And that makes sense to me. But yeah, I think majority of DTR is probably delivered for the symptomatic individual because of the fact that they are the ones who selected themselves.

[Robert]
It’s treatment for the symptomatic patient, but the application is far-reaching. But most of the dental injuries sustained that are not traumatic, like getting hit in the face with an accident, the dental damage, I should say, you know, again, the same things: wear, recession–

[Jaz]
Microtrauma.

[Robert]
Is microtrauma and it comes from the overload that the lack of disclusion creates. And the disclusion, people often think they have disclusion. Dentists will say, yeah, this person has good anterior guidance, but it’s the first millimetre of movement on either side of the central fossa that matters.

It’s not that they disclude at the end of their excursion. No one is chewing food with canine-to-canine tip-to-tip. Nope. So the person has to disclude within a very short distance from leaving MIP in all directions, and that’s what controls the muscle activity. And that control can only come from computer analysis.

It isn’t possible for us to measure the kinds of pressures that go on in a very short distance. We can’t pick it up in any other way than using the T-scan sensor, which is a highly sophisticated electronic device that is used all over the world in many, many industries. Dentistry doesn’t understand that. Dentistry doesn’t seem to really want the T-scan to succeed. And many people talk it down, but it’s the most sophisticated engineering tool available to dentistry to manage occlusal problems.

[Jaz]
Well, talking of sophisticated tools, a lot of dentists, and then I love how you just came to the topic of this very short snippet today, is ’cause we’ll do some more content on Thursday and whatnot.

And today, hopefully I’ll get to record some of the DTR that we’re doing through my loupes actually, which will be pretty cool. But sophisticated technology, a lot of dentists, they feel that the data they see from an occlusogram–

So for the younger docs, occlusogram is when you take a scan, let’s say PrimeScan, iTero, 3Shape, whatever you use, and then you record the occlusion, and then you get this like heat map of occlusion, and some dentists may be fooled into thinking, why do I need the T-scan? Because this is telling me where the forces are highest. This is telling me already.

And then what we need to talk about is why, whilst that has some very basic data, we have to be careful how we interpret that data. And the example I want to start off with before I hear your sort of way you expect the dentist that, okay, just be careful with this occlusogram data.

But one of the cases that I teach in our foundational occlusion courses is a case where this lady, late fifties, early sixties, she had a history of having Invisalign, had a fixed retainer, and on the upper and behind the upper anteriors, and this fixed retainer snapped in half along the centrals.

And every time she bites together there is very clear fremitus, i.e. when she bites together, the front teeth literally move out the way, mobility, then the back teeth are able to come together, which makes sense as to why the wire fracture is, okay. So when you take the scan of that static position, when the teeth come together, you would see that, oh, everything looks okay.

Because what you’re seeing is the end product. Once the teeth are fully come together, once the front teeth have overloaded and moved out the way and the occlusogram would fool you into thinking that there is good distribution of load around the arch. But I think even the younger colleagues can understand that, in this example where we have fremitus, that actually that, how can that be true?

Because the front teeth were early contact, they had to move out of the way. And that’s not gonna be good for the PDL, ligament, long term. And then the back teeth were able to come together. But that story, that timing is not captured in occlusogram. It’s not telling us that kind of stuff.

And when I showed that case and how I treated it was we did some Invisalign, we gave the correct overjet to allow the jaw closure to happen. And then now, three years on, I checked the teeth now and they are solid, okay, because now, and then you look at the occlusogram, it doesn’t look much different.

But the first occlusogram and the second, they might look the same, but it’s the timing data you miss out on. And the force data is actually coming from how close the teeth are together, which is not telling you about the actual force itself because, as you said yesterday over dinner, pressure is a force over surface area. And when it gives us the red, the blue, yellow, it’s not measuring the force.

So it cannot tell us the pressure. So tell us about the nuances of being careful with the occlusogram and where it fails in the face of something more sophisticated, like the T-scan.

[Robert]
Well, the essence of a scanning technology is that all the teeth are scanned with the patient’s teeth apart, right? No one’s biting. And so there’s no forces captured. What happens is the software algorithmically puts the scans together spatially–

[Jaz]
Stitches them, yeah.

[Robert]
Right, spatially. But there’s no impact pressures. There’s no contacts. There’s no gathering of teeth banging together or rubbing around. So it completely is falsely representing. These colour coded occlusograms have no force information in them at all. And a recent study showed that clearly they don’t measure pressure.

There’s a comparison of the T-scan, force mapping to PrimeScan. And there was way too much overestimation of what appears to be high force in the PrimeScan. But it’s not force at all. It’s distance and tooth proximity, contact intimacy, which is not pressure.

And just because you have a good contact, low intimacy, meaning very small distance between opposing teeth, doesn’t mean that tooth generates extreme pressure. That’s a completely false representation that the scanning companies are proliferating and misleading dentists in a very unfortunate way because there’s no impact pressures captured when you scan someone because the teeth are all apart. So that’s a very big difference between–

[Jaz]
But what do you actually scan? The bite, the teeth have come together, and then held there, and then stitching that. But you’re right, because the actual arch itself is taking the arch in isolation, the lower arch in isolation, that’s scanned when the teeth are apart.

And therefore you don’t have the stressors into the teeth. And when the teeth do come together and you scan the left and right bite, and obviously teeth will intrude a bit, hence why you have like minus figures in terms of, someone has intrusion and whatnot, but that’s not giving you force and timing data.

So I think that a key lesson for dentists is don’t look at the occlusogram and start doing adjustments on teeth by occlusogram, thinking, oh, the first molars are looking red on the PrimeScan. That means they must be proud. I need to adjust. That would be a very false way to view it. Would you agree?

[Robert]
Yes, correct. Very, very true. Meaning it’s false. It’s the distance scale does not predict the pressure mapping. And that’s what scanning technology offers is distance between opposing teeth and you know how close or how far apart various surfaces are, and this is not gonna give you pressure mapping because no impact pressures are actually measured in any way at all. So it’s completely false when it comes to force, timing and pressure.

[Jaz]
So what are the benefits to actually measuring the pressure? So what decisions is a dentist able to make once they know about the timing and pressure data that they weren’t able to do before? Because before, without it, we’re relying on the occlusogram and relying on articulating paper. Now, we talked extensively about why the articulating paper is lying to us.

But feel free to revise those concepts for someone who may need to listen to it another time. But what’s the, I guess what I’m trying to say, what’s the advantage of, fair enough, we have data, but it’s the application and the use and how you choose to use the data to help benefit your patient. What is the benefit of the pressure data?

[Robert]
Well, it allows you to make intelligent decisions about what to adjust and what not to adjust, instead of looking at ink marks that don’t measure pressure at all, or scanning technology which doesn’t measure pressure at all, so that you treat very minimally and definitively without misrepresenting where you should be treating.

And of course, anyone who’s used articulating paper, which most of us do, and the T-scan, you still mark the teeth with paper, but you choose the contacts to treat based on the data, not based on the way the paper marks look. And very often the most pressure-responsive contacts are small, scratchy little marks that dentistry says are light force, which you’re completely wrong because again, the load is applied over area.

So if you have a very small area, you have the potential for very high pressure. It’s very much like the high heel, the lady’s stiletto heel, right? She steps on that, on your foot with that, it’s gonna hurt you. But if she was wearing a flat sandal and would leave a big imprint, it wouldn’t hurt you as much. So the T-scan data allows you to choose wisely what to adjust.

[Jaz]
And so, I mean, I think to make it really tangible for dentists is like prosthetics, right? When we are working prosthetics to help our materials, that if you’ve done like multiple crowns, or even nowadays very on vogue is treating wear cases interceptively with composite, and you do a full-arch or majority-arch composite restorations and you check with arctic paper and you see ink everywhere and you think, okay, I have good distribution.

But without the pressure data, you know, when you start using, you might see that, oh, 38% of the force is going down one molar. And then the other molars are hardly doing any work. So without that data, you don’t know to lighten it. And the other scenario we talked about last night was the patient that says, you know, I had this work done or whatever, and then these three teeth on the left side, they just feel really proud.

And every dentist who has kind of attempted to lighten the occlusion on it, and then still the patient says it’s proud. And then you told me that, okay, when you checked, and this was in front of everyone, you checked it whilst the forces were low on those teeth, it was the timing. They were the first teeth to touch.

And it was very subtle. They rise first and then everything comes. And when you adjusted those exact points, led by this data, so not just pressures, timing here obviously we’re talking about, then the patient was able to say, oh wow, now I feel comfortable. And that was a real amazing moment, which I’ve experienced myself.

I’ve been using it for a few years, including on some dentists. So shout out to Nikhil Kanani who came to my practice and he wanted me to take it. He was interested in T-scan, so I had a look and I made some minor adjustments and he bit together. Not only did it sound better, which I liked, to listen to the bites as well, but then he actually felt like, whoa, wow, that feels so much more comfortable.

[Robert]
Yes. Yes, no question about that.

[Jaz]
There’s no occlusogram that will give you that. Well, as we sort of, we’re about to get to the practice now and start a day of training with you, my last request is any sort of nuances that you want dentists to consider when they’re planning their next case or checking the occlusion and considering about, thinking about technology, digital occlusion, and actually implementing kind of this T-scan technology.

Like we discussed yesterday, the adoption of T-scan, whilst it has gone worldwide, to the level that dentists invest in loupes, the level that they invest in intraoral scanners, the level that they invest in so many more bits of equipment, yes, there is a cost to it, but when you look at some of the costs of the other things that we widely purchase, so I don’t accept that it’s the cost barrier because we’re also buying, you know, $80,000 CBCT machines.

We’re buying $50,000 intraoral scanners. Why is it that this, 10, $12,000, whatever it is, a T-scan. So I’m not, I don’t think it’s just financial. What do you think’s going on in terms of why are dentists not understanding the benefits of seeing objective data?

Like I told you something yesterday, which I say all the time to colleagues who ask me about T-scan, is I felt uncomfortable adjusting teeth without having data, just medico-legally. If I can see that the bite is way off, even in a prosthetic case, or any type of case, and I can do some adjustments to really measurably timing and pressure improve the occlusion, I feel so much safer. But I dunno why that doesn’t translate to worldwide. But obviously you might have a perception or an insight into this.

[Robert]
Well, the biggest resistance to the T-scan is political. It’s that the T-scan has disproved every occlusal theory. You don’t need to TENS anyone, you don’t need to neuromuscular treat them.

You don’t need to put people in CR. CR is a very compromised position that constricts the airway and definitely is not a physiologic position. Putting people there is unnecessary for most dental treatments. And so just by disproving all of these basic principles that people really believe in, no one wants to face that. And the most important one is the carbon paper paradigm, right?

T-scan has absolutely disproved the carbon paper paradigm. The big marks aren’t always big force. The little marks always aren’t light force. And making the marks look a certain way doesn’t give you a balanced bite. So there’s a lot of things that dentists have been holding onto politically because they’re teaching these things in continuums and–

[Jaz]
Can I talk about that? Because it’s something that in my teaching, so I’m involved in teaching occlusion, and so feel free to disagree with me, Rob, I take it, I’m happy to talk about these things, right, is what I teach is centric relation is a position of restorative convenience. It is a utility position.

So whilst my patients whose occlusion is generally working for them, I don’t, I work within the MIP. But when we have the opportunity or need to open the vertical dimension, it may be a position of reproducibility and convenience, then I’ll look to use it. ‘Cause when we have lost all references and that’s how me and Mahmoud have been teaching it. What do you think about that?

[Robert]
Well, the value of finding a reproducible position helps greatly in doing restorative dentistry. I’m a prosthodontist, so I worked a fair amount in centric relation where indicated. But I also found that I could open the bite in MIP and treat the person directly.

[Jaz]
Didier Dietschi does that. My old principal, Dave Winkler, used to work with, he is now, maybe you know him. Do you know Dave?

[Robert]
I’ve heard the name.

[Jaz]
Yeah, so he used to practice here in Windsor. He’s now gone retired in Denmark. Wishing you well, Dave. Hope you’re well, buddy. And so lots of dentists I really respect, you know what, they work in MIP and even when the vertical, like obviously when you open the vertical dimension, MIP is gone. But like what you’re trying to say is like, you’re not really seeking the CR, you just open the bite arbitrarily.

And then just trying to create the correct occlusal scheme led by the T-scan in that arbitrary position. And that works well, has worked well for many dentists.

[Robert]
It works extremely well, actually. And you can mount the casts and then raise the articulating pin and mount them in MIP and raise the articulating pin, and then work in that new vertical dimension, essentially the same way you would in centric relation. So it’s very possible to do. It’s not, let’s say, academically principled that you shouldn’t do it, right, but it’s a reality.

[Jaz]
A hundred percent.

[Robert]
And so there is a lack of need for concepts about jaw position being the key to success. You can put someone in CR, but if their micro occlusion isn’t well managed, they’re not gonna be comfortable. It’s not about the position. No jaw position manages the micro occlusion.

It’s the micro occlusion that brings about patient health, accurate, not accurate, but physiologic muscle physiology, as opposed to excessive muscle physiology and occlusal comfort for the patient. It’s all about the micro occlusion. That’s why you take a beautiful outcome like Invisalign.

The teeth line up beautifully and the patient comes in and says they’re not comfortable. It’s because the micro occlusion isn’t good. The macro occlusion doesn’t make the micro occlusion, and that’s where the T-scan is the huge advantage for finalising cases. That’s the most important thing I would say that the average dentist struggles with is extra visits after delivery.

The biggest problem is a patient coming back complaining, saying their bite isn’t right, and then randomly grinding. The T-scan virtually eliminates that. It doesn’t eliminate it in total. Nothing eliminates it in total. But you send the patient out the door with a high quality micro occlusion, there’s a lot less for them to complain about.

[Jaz]
And also less stress on the materials, ’cause if we’re working with prosthetic materials. Going back to prosthetics now, I’ve had these scenarios whereby, over time in the last few years of using T-scan, patients like, well, some of them, many of them actually, are very accurate. Before the T-scan data comes through, they can tell me that something over here.

Now when I check with the arctic paper, everything looks okay. But when I show the T-scan, I can see the early rise or the high point. And they often, for these patients who are very “princess and the pea,” which is amazing. So it’s very validating to them. And the trust aspect is there, but also the flip scenario.

Well, the patient says, yes, it feels proud, but I’m going, I’m checking the T-scan and reproducibly, I’m seeing that there’s no timing issue. There’s no pressure issue. Then I feel okay to say, ah, let it settle, kind of thing. You’ll get used to it, or whatever it could be. And then rather than praying and wishing that, oh, hope it’s not proud, and let’s see. So it gives me that again, objectivity, which is why, the reason why I went into–

[Robert]
Extremely objective and highly repetitive. A user has to learn how to use it. It doesn’t work by itself. You can’t buy it and make it work. You have to take training like you’re about to go through. And didactic training is helpful, but it doesn’t make someone a chairside effective T-scan user. You have to be–

[Jaz]
It’s a bit like, when you go into implants and you buy implants to use in your patients, there’s a lot of training that comes with implants to be able to do it, right? Same with when you pick an aligner system and you go with them and you go on the two-day course to learn to use the technology.

So, fair enough, when I got the T-scan installed, it was like being given an aligner system. But until you learn ortho and diagnosis and actually treatment planning in ortho, and then troubleshooting and retention or everything that goes with the education of orthodontics. So that’s a good analogy to think that, okay, the T-scan is like the aligner system. It’s like the implant, but you need to have the protocols in place to be able to actually get the best results from it.

[Robert]
And you need to have clinical experience under guidance. It’s not something you can pick up on your own. And this is why people struggle with it. They purchase it. They don’t seek out the training that you’re about to have.

That’s what makes someone a chairside effective user. It’s not possible to become chairside effective because you read a book or you read a paper that I wrote about, for example, the disclusion time. Even though it’s well described what to do, it doesn’t make you a clinician. It’s like reading about a crown prep.

You can read about a crown prep, but until you’ve cut 50 crown preps, you don’t have the skills to cut predictable crown preps, right? So T-scan is a chairside learning technology that once you understand what to do with it, how to record, how to read the information, how to understand the force versus time graph, which is a critical software feature, and how to apply the information to make intelligent decisions about what to treat, then you can become effective with it.

But you have to learn those three things. Recording well, understanding how to read the data, what matters in the movies, what doesn’t matter, what parts of the movies matter, what parts don’t matter, and then how to apply the information by mapping the pressures using carbon paper.

But you don’t look at the carbon paper and say, yeah, it’s that one because it’s big, or that one’s too small, we’re not gonna treat that. It’s all data driven. That’s the difference. By doing that you control the micro occlusion and get much more predictable outcomes.

[Jaz]
Well, excited to walk into the practice now and let’s get into the micro occlusion of it. Well, thank you so much. Alright guys, I hope you’ve got some insight there into the nuances of occlusogram and why that is to be taken with a massive bag of salt, and also a little bit more about the details of micro occlusion, what T-scan does. Uh, and yet wish me luck on my training today. Be kind to me, Robert.

[Robert]
Yes, of course.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. A few different themes touched here from joint positions to muscular harmony, and of course the main event, which was all about the occlusogram. And now I hope you’re convinced that it’s lying to us, which doesn’t mean it can’t be useful to us.

We can still use that information. Just don’t think it’s giving you something that it isn’t. We are a PACE-approved education provider. You need to be either on the Podcast CE Plan or the Ultimate Plan of Protrusive Guidance. If you’re on the Ultimate Plan, you get access to all the masterclasses, including the recently added Splint Course, everything occlusal appliances, and the 21 Day Photography Challenge.

Head over to protrusive.co.uk/ultimate if you’re interested in that. Even just to join the community for free, we need to verify that you’re a dentist first, by the way, and we will do that. It’s very important to us that it’s a safe community, we do not want any members of the public on our special forum, so we do have a verification procedure. But if you head over to Protrusive app and request access to Community Plan, we will get you in.

So you can see all the good stuff that we have in the chat and the main feed and all these podcasts are on there. And some bonus ones that are not on YouTube or Spotify. Watch this space for that DTR episode that I promised you. And as ever, I want to thank Team Protrusive who do a wonderful job behind the scenes to get these episodes published and allow me to still practice dentistry, support the community, and serve my family, and essentially be a dad.

So thanks again, and thank you, the listener, watcher, once again for watching all the way to the end. I’ll catch you same time, same place next week. Bye for now.