TMJ & Airway-Directed Orthodontics

Episode #494 with Dr. Drew McDonald

As an orthodontist, it’s easy to just focus on moving teeth. But most of your ortho patients have underlying joint and airway issues — and they’ve had them before being in your chair! And to shift your thinking so you can recognize and treat these patients, Kirk Behrendt brings back Dr. Drew McDonald to explain the connection between airway, joints, and teeth. Straightening teeth is the easy part! Take your practice to the next level by screening every patient for joint and airway disorders. To learn more, listen to Episode 494 of The Best Practices Show!

Episode Resources:

• Dr. McDonald’s website: https://www.mcdonaldortho.com
• Dr. McDonald’s Facebook: https://www.facebook.com/drew.mcdonald.984
• Dr. McDonald’s social media: @drdrewmcdonald
• Email Kirk for Dr. McDonald’s Master Class: kirk@actdental.com 
• Subscribe to the Best Practices Show Podcast
• Join the To The Top Study Club
• See our Live Events Schedule here
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Links Mentioned in This Episode:

Spear Summit: https://content.speareducation.com/2022-summit

Chicago Study Club: https://chicagostudyclub.com

Main Takeaways:

Recognize joint and airway issues before starting on a case.

Most ortho patients have underlying joint or airway issues.

Don't focus on just the teeth or esthetics.

Help patients prevent relapse.

Screen every patient!

Quotes:

“Whenever it came time to apply to dental school . . . I didn't get in the first time. For any predental students listening . . . it’s competitive out there. And I know for anybody listening that's applying to school or applying to residency — if you want it, go after it. And if you don't get in the first time, do it again. Because ultimately, this profession gives back to you in so many ways.” (3:47—4:19)

“I was tired of not having an answer for something that was commonly coming up in my orthodontic practice as to why patients were relapsing. And what we stumbled upon, or what I feel I stumbled upon, was that most orthodontic patients are there because they’ve got a joint issue, an airway issue, a tongue issue, or minimal other things — it’s not just teeth. And we’ve got to get to the bottom of why that patient is in our chair to understand how we do treatment and how we keep it stable.” (8:07—8:35)

“Recognizing joint issues, airway issues before you get into the case helps you navigate those cases and be successful. And ultimately, you also change the lives of your patients. That's the biggest bit, is people come in with problems they don't even know about.” (8:43—8:58)

“In ortho school, we tend to cling to old research that basically divorces us from both situations of airway and joints. I go into this in my lecture, but there are some pretty dogmatic thought patterns in orthodontic education that basically says we have nothing to do with joints. And a newer set of research white papers that was done in 2018, 2019 basically said we’re cleared of having to worry about the airway. ‘We don't make it better. We don't make it worse. Why should we care?’ was kind of the consensus of a lot of that paper. What the details were in both of those papers, on the airway side, it really did say we’re involved in this. We need to be screening as soon as we see kids, adults — anybody. We need to be at least screening for patients.” (9:44—10:39)

“What lands 90% of patients in my orthodontic chair is an underlying airway issue. If they're a mouth-breather, if they have poor tongue posture because they can't breathe through their nose, if they have tongue thrusting patterns to breathe better, all that stuff, teeth move, and they get out of place. And so, it looks like an ortho issue. Really, it’s an airway issue that's bringing up the secondary problem with the teeth. Same thing with the joints.” (10:57—11:21)

“These patients had joint issues before they ever entered our chair. And basically, if we don't recognize or know how to recognize a joint issue and diagnose it properly at the front end of treatment, then that makes the middle and end of treatment a nightmare if that patient starts having symptoms, or if you start spinning your wheels with your orthodontic mechanics trying to correct a bite that’s really uncorrectable with conventional things.” (11:48—12:15)

“The joint issues and airway issues, they're a huge part of our world. And we have to recognize them before you get on the case rather than after they become a problem.” (12:17—12:25)

“How you can diagnose the airway and joint issues, it all basically comes out of the imaging that you see with the patient. We’ve got to be doing CBCTs. We’ve got to be doing MRIs to be able to see the enemy under the surface. And so, without a CBCT, how do you expect to visualize the airway? How do you expect to visualize deviated septums or turbinates? How do you expect to see the joints and what's going on there at the heart tissue level?” (12:56—13:25)

“You can't see soft tissues on a CBCT. You can't see inflammatory things on a CBCT. So, if there are joint concerns with clicks, pops, deviations of the jaw to one side, essentially, we've got to get to the bottom of that. And what we know through decades of research on the joints is that joint issues cause bite problems. And that is the opposite of what you were taught in ortho school, which is that bite problems cause joint issues. So, I think that's the biggest mental leap that we all need to make as orthodontists, is that under-the-surface issues cause the bite problems, whether it be joints or airway, versus the opposite of what we were taught, which is that teeth problems cause joint issues or airway issues. We’ve got to flip our thinking here.” (13:28—14:16)

“It’s easy in ortho, especially, to focus on the teeth part and the esthetics. That is 100% our world. We’re good at it. Everyone, as an orthodontist, knows how to move teeth. People who aren't orthodontists know how to move teeth too. But essentially, if you land the plane in the wrong spot regarding the airway and the joints, then basically, what did we do? Did we help that patient from a bigger standpoint than just having a nice cosmetic result, or did we miss an opportunity to do more for that patient?” (15:11—15:45)

“If we recognize the issues, we can do a lot, orthodontically, to help. Maxillary expansion is a huge part of our world, orthodontically, that we've known forever that helps with nasal breathing. All of our new technologies in ortho have been allowing us to bring that to a new population of adults.” (15:51—16:11)

“Nasal issues are the most common thing I think I see in orthodontics. And patients go, ‘Okay, I'll go see the ENT. They didn't say it’s surgical, so I guess I don't need to do anything. Right?’ I go, ‘No, you still have an issue. And because they're telling you they don't want to do surgery, that doesn't mean you don't have to manage this the rest of your life.’ And so, having that conversation with the patient, they clearly start to own their issue, and then they also start to take it on that they want to be in charge of it. And they know, ‘If I don't do these things, then I can expect that I'm not going to see the maximum benefit that we talked about.’” (22:00—22:36)

“A lot of times, if patients still have an underlying airway issue or a tongue issue at the end of treatment, we’re going to see relapse. Because the same thing that got us in the problem in the first place is still present. And no matter how well they wear that retainer, they're probably going to have a tendency towards relapse that shouldn’t be there, and we need to take care of the underlying [issue].” (22:57—23:15)

“The straight teeth part is easy. Looking at the big picture and trying to help the big picture is where we can make the biggest difference.” (25:16—25:23)

“We can't be in a camp and ignore all the other stuff. I've been to a lot of different CE, and I love learning the different perspectives or the pieces of the puzzle. But I feel like sometimes in those different CE, it becomes easy to go, ‘Well, that's it. That's the answer for all these patients.’ And then, you go to a different one and go, ‘Oh, wow. That sounds amazing too. That sounds like that might be the answer.’ What I've come to see in orthodontics, especially, is that this is the hot garbage fire of all issues of dentistry. Which is, if somebody’s in your ortho chair, they’ve got all of the above going on. And it’s our job to know how much of what is diving into this case.” (27:39—28:23)

“We have to look at it all, and we have to be masters of it all. Because if we’re missing one of the fires that's burning, it’s still going to rear back up and cause issues for these patients. So, that's where the imaging side sets us free. Because if you're able to visualize what's going on with your patient, if you're able to do sleep studies or CPC studies at home to see how they're sleeping, that's data. If we’ve got data on our patients showing imaging, sleep patterns, heart rates, and then MRIs on top of that, man, we can see through the dark.” (28:28—28:58)

Snippets:

0:00 Introduction.

1:51 How to watch Dr. McDonald’s Master Class for free.

2:54 Dr. McDonald’s background.

6:04 How he got into ortho and TMJ.

9:18 What dentists get wrong about ortho and TMJ.

12:28 Why imaging is crucial for ortho.

14:16 Ortho is not just about teeth and esthetics.

17:05 Managing outside forces and managing expectations.

23:17 People will seek out experts for answers.

25:23 Resistance to building a support group.

27:01 Look at it all and master it all.

29:50 More about Dr. McDonald’s courses at Spear Summit.

31:26 More about Chicago Study Club.

Dr. Drew McDonald Bio:

Dr. Drew McDonald is a board-certified orthodontic specialist with a strong focus on airway and temporomandibular joint-focused treatment planning, surgically facilitated orthodontic treatment, and providing complex interdisciplinary care for patients. He lectures internationally on these topics and has contributed to literature and textbooks in these areas. He is dedicated to advancing the profession of orthodontics and dentistry as a whole.

Born and raised in Tucson, Arizona, Dr. McDonald’s love of baseball brought him to Albuquerque, New Mexico, where he played as a catcher for the Lobos from 2006 to 2008. While attending the University of New Mexico, he met his wife, Emily, a New Mexico native. He also fell in love with the Sandias, green chile, and the near-perfect weather. He graduated from the University of New Mexico in 2008 with a Bachelor of Science degree in biology and a minor in chemistry.

Dr. McDonald attended dental school at the prestigious Creighton University in Omaha, Nebraska. Known for its rigorous academic curriculum and intense clinical training, he received many academic accolades while at Creighton, including inductions into Omicron Kappa Upsilon (National Dental Honor Society) and Alpha Sigma Nu (Honor Society of Jesuit Universities). He also served in leadership positions as class president and student body president, and on alumni relations committees.

After graduating cum laude from Creighton, Dr. McDonald was accepted as one of only three residents nationwide into the University of Missouri-Kansas City Orthodontics program, a renowned two-and-a-half-year, full-time residency known for its clinical excellence. He graduated in December of 2016 with his certificate in orthodontics and master’s degree in Oral and Craniofacial Sciences.

When away from the office, Dr. McDonald is a “girl-Dad” to two daughters, a self-proclaimed grill master, and minimally talented yet enthusiastic golfer. You can find him taking in a Lobos game and spending time outdoors with his family.