Clicking & Popping in Your Practice

Episode #541 with Dr. Jim McKee

There's a quick way to build your practice — and no one wants to do it! Millions of patients have occlusal disease, and you can help them by adding joint and occlusion diagnosis to your practice. To help you become more confident in this space, Kirk Behrendt brings back Dr. Jim McKee from Spear Education with advice for rethinking occlusion and understanding its value. Don't shy away from occlusion — embrace it! To learn how, and to learn more about Dr. McKee’s Advanced Occlusion workshop at Spear, listen to Episode 541 of The Best Practices Show!

Episode Resources:

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Links Mentioned in This Episode:

Spear Education: https://www.speareducation.com

Dr. Gary DeWood and Dr. Jim McKee’s upcoming Advanced Occlusion workshop: https://campus.speareducation.com/workshops/advanced-occlusion/details/schedule

Chicago Study Club: https://chicagostudyclub.com

American Equilibration Society: https://aes.clubexpress.com

Main Takeaways:

It is more important now than ever to understand joints and occlusion.

Occlusion and joint diagnosis is the fastest way to build your practice.

Embrace joints and occlusion rather than being intimidated by it.

Recommend treatment to patients who are ready to hear it.

Not all clicking and popping is the same.

Learn to redefine occlusion.

Quotes:

“[I] got out of school after four or five years and didn't really understand occlusion. I saw a lot of cases that intimidated me. I started to pull away from recommending treatment planning on more complex cases because I really didn't understand how the teeth should fit together. But what I really didn't understand is when someone came in with a clicking joint or a popping joint, what that meant to me. So, I did what most of us are taught to do. I ignored it.” (2:30—2:57)

“My journey in this whole area of occlusion started out as most people do, from a pain-based perspective, because if a clicking joint didn't hurt, I basically ignored it. And sometimes, that's the right thing to do. But what I've learned over the years is every clicking joint is not the same.” (3:12—3:33)

“A clicking joint is basically a structurally altered joint. And part of the problem is, as dentists, we’re taught about occlusion in terms of how the teeth fit together. And while that's an important part of it, the reality is, occlusion today should be defined, I think, as how the lower jaw fits to the upper jaw. So, it’s not only how the teeth fit together, but it’s also how the right joint fits against the right joint socket with the disc in between, and the left joint fitting in the left joint socket with the disc in between. So, where I used to think of occlusion as primarily how the teeth fit, now, I'm thinking of it basically as a tripod and how do the three legs fit together. What I've learned over the years is that, many times, we have problems at the back end of the system because we have some type of structural alteration of the joint. And I didn't understand that in the early years. I was focused just on the teeth.” (3:40—4:43)

“When dentists really understand occlusion, what happens is we see how many patients occlusion touches in our practice. So, if a patient is going to come to you, let's say for an out-of-network service, it could be implants, it could be airway, it could be holistic dentistry, it could be esthetics — it could be any of those — I will tell you that most of the time, occlusion or joint diagnosis is the easiest way to build a practice because, quite frankly, no one wants to do it.” (6:47—7:23)

“I would really encourage dentists, especially young dentists, if you're looking to build a practice where patients are going to come to you for a specific reason and not necessarily because of the insurance company that you're affiliated with, if you can learn how to diagnose joints and understand occlusion, I know it’s the fastest way to do it because no one else wants to do it. That's the reality.” (7:59—8:25)

“Today, with especially the popularity that airway has, you have to know joints if you're going to do airway. Really, so many of the problems that we see with airway are at the maxillary level, and there's some constriction of the nasal complex so we don't have adequate breathing. We have a lot of collapsed pharyngeal airway space as well. And a lot of times, that's related to the joint. So, in order to treat airway today, I think you have to be an expert in occlusion as well because, so many times, those patients have both of those problems going on. So, I really think today, occlusion is the foundation for so many things that we do on a day-to-day practice. Regardless of the complexity of the case, occlusion touches everything.” (9:12—10:07)

“When I look back at my career, if I was a 30-year-old dentist and I had a 30-year-old new patient come in, a lot of those patients had large amalgams or were going to need crowns over the course of the next 25 years. So, a lot of my early production revenue was generated through doing crown work on old fillings. If I'm a 30-year-old new dentist today and a 30-year-old new patient comes in, they don't have that type of future restorative work that's going to be necessary to replace those composites or whatever would be filling the tooth today. I think, today, what you're going to see is a lot of those patients have had orthodontics that maybe now has relapsed and hasn’t been stable because there has been an occlusal component that wasn't recognized. So, today, I think as a practicing dentist, it becomes more important than ever to understand occlusion, especially to understand the joints.” (10:18—11:18)

“When we talk about occlusion and joints, it’s a ball-and-socket joint. The top of the lower jaw fits into the base of the skull, and muscles contract to open and close the jaw. So, if it’s a ball-and-socket joint, we don't want the ball or the condyle to grind against the base of the skull with a joint socket. So, we’ve got a disc in there that attaches like a bucket handle, and the disc has attachments on the outside lateral pole, inside medial pole. And if those attachments tear, that's how we start to click or pop.” (11:21—11:55)

“We've made joints way too complicated. Part of it is because we never saw them. Everything that we saw and our knowledge about jaw joints was basically an artist’s drawing based upon what a dentist told them they thought it looked like. When we started to image, back when imaging came out 30 years ago, we realized, ‘Mm, that's not really an accurate representation of what we’re seeing anatomically.’ Many times, the structural breakdown was far greater than the drawings in the textbooks. And that's why occlusion became an unpredictable discipline in dentistry.” (11:58—12:35)

“If we can understand the structural changes at the joint level, the discussion becomes so much easier. So, basically, structural alterations generally start at the soft tissue level. If you've got hard tissue bone and soft tissue disc, we generally don't see bone issues if the disc is protecting the bone. So, the tipping point or the first domino that has to fall is a ligament tear. And that can be a ligament tear at the outside, the lateral pole, which would be a partially displaced disc. If we were looking at the literature, it'd be called the displaced disc with reduction, which means we get back under the disc when we open. But I'm going to add a qualifier. I'm going to say at the lateral pole.” (12:37—13:22)

“The other type of disc displacement we have is if the ligament tears at the medial pole. Easy enough to think about. Partial disc displacement of the lateral, complete disc displacement at the lateral and the medial pole. So, that's the first part to think about, is it a partial disc displacement or a complete disc displacement? Now, the reason why that's important is because if we look at the joint socket, we talked about bite forces. And when we bite down, we have a lot of muscle force that we can generate when we bite down. The muscles are positioned between the teeth and the joints. Forces are going to be distributed between the teeth and the joints. At the tooth level, what we try and do is to make sure that every tooth touches with the same amount of force. We don't want to overload one, two teeth. They break, they wear, they loosen. So, basically, we’re trying to get an even bite to distribute to all the bite forces through the roots of the teeth and into the bone.” (13:23—14:24)

“Generally, what we’re seeing is we’re seeing injuries at the joint level earlier than we ever thought. When you really think about the jaw joint, it’s an orthopedic joint. The problem is, orthopedic physicians don't look at this. There's not an orthopedic physician that I know that thinks that this jaw joint is an orthopedic joint. So, now, it falls to the dental world where normally it would fall to the oral surgery profession, their specialty. Oral surgeons are plenty busy taking wisdom teeth out, doing orthognathic surgery, placing implants. So, from a patient’s perspective, it’s an area that's kind of fallen through the cracks in terms of trying to get diagnosis and treatment.” (16:39—17:23)

“If you can be the dentist in your community who can recognize these problems and give people answers, they will beat a path to your door. And that's exactly what happens in clinical practice. It really is.” (17:25—17:38)

“When we talk about managing occlusion, I think people are living longer. People are also getting injured earlier. If I look back, when my mom was younger, she didn't drive until she was 30. She wasn't playing travel soccer, travel basketball, getting elbowed in the jaw. She wasn't having the amount of facial injuries, trauma, whatever you want to call it, to growing patients, especially females, who are in a subset of patients who are least able to adapt to an injury to the joint. Females tend to have a more lax ligament system to account for childbirth. And what happens is, especially today in growing patients, we see more joint injuries than we used to.” (17:39—18:23)

“The easiest thing to think about clicking and popping, number one, is it a partially herniated disc or a completely herniated disc? Because if it’s clicking and popping, it’s herniated. Now, I'll give you a tiny exception that's an outlier just so we have a little bit of context here. You can also get a click or pop if you open really wide and maybe open past the eminence. You might get an opening click at 40, at 42, at 45 millimeters. But that's exceedingly rare. That's probably one to two percent of the cases. Most of the cases, if a patient comes in with a click or a pop, the question is, is the ligament torn at the lateral pole, or is it torn at the lateral pole and the medial pole? If it’s the 60-year-old patient who has been clicking for 30 years and never had a problem, I'm thinking it’s probably a partially herniated disc. Because discs that are completely herniated, generally, if they have problems — because they all don't. Some will adapt. But the problems generally are in that population. If they do have problems, they generally present in one of two ways. Something hurts, which is a low distribution issue, because the soft tissue isn't present and now the bone is grinding against the joint socket, or something doesn't fit, which is namely the teeth because we've lost the gasket and now we have a bite that doesn't fit together because we don't have stability at the back end of the system. And as that changes, now the front teeth don't fit together either.” (21:41—23:29)

“In terms of clicks or pops, number one, is it a partially herniated disc or a completely herniated disc? Number two, does it present as something is hurting or something is not fitting? Now, one of the things you have to do as a dentist when you're checking whether it fits or not, we can have the patient close down and see how the teeth come together and look at it that way. What we also should do, though, is not only check from a dental position but also check from a skeletal position. So, if we can seat the joints in the socket, whether you use bimanual like Pete Dawson talked about, whether you use a leaf gauge like Frank Spear talks about, whether you use an anterior deprogrammer like John Kois talks about, what we want to do is to position the condyle skeletally, and then look at the bite. And here’s the take-home: if the bite is uncoupled greater than the thickness of the disc, let's call it two millimeters, then the likelihood increases that we’ve lost the gasket at the back end of the system. That's the easiest way to think about it.” (23:30—24:40)

“[There is] an old tool that Mark Piper called reading the bite. Basically, what you're doing is you're looking at the anterior tooth relationship in a skeletal position. And really, what you're doing is you're now comparing that space to the thickness of the disc. It’s an easy clinical skill to look at. I think, honestly, it’s probably the easiest clinical screening tool that we have, along with understanding the history.” (24:41—25:06)

“I used to present treatment plans or discussions like this before the patient had enough information to make a good decision. What I have changed is I have frontloaded my educational discussion with the patient earlier in the appointment than I ever did in the past. So, generally, this discussion starts by taking a history. If they say they click, if they said they had ortho because they had a large overbite, if they say they had ortho with headgear, I know right off the bat that, likely, there was a joint-based problem. So, if they're coming in specifically for a joint-based issue, I'm going to educate them early so that by the time we get to the end of the clinical exam, all that's doing is verifying what we talked about initially before we even looked in their mouth, based upon what I learned from their history.” (27:31—28:26)

“I learned this at the Pankey Institute, that if I could build a patient base of patients who valued the type of dentistry I was offering, it was more likely that they would say yes to treatment, or that we would do treatment, but we may have to phase it. My mistake early on is that I was presenting treatment plans to patients who weren't ready to hear it. They didn't value it, so the first question that came out of their mouth is, ‘How much does insurance cover?’ And a lot of the stuff I was doing wasn't covered by insurance, so I had a lot of noes.” (30:03—30:39)

“In terms of implementing, my best advice to a young dentist is take a morning a week and make that your comprehensive dentistry day, whatever you want to call it. And I'm talking about joints and occlusion. But really, what I think the practice of the future is going to be is the diagnostic practice. You're not going to have, as I said before, as much restorative dentistry to do as we've had in the past simply because people are taking better care of their teeth and we have better materials. So, I think what you are going to have is a diagnostic practice that might be joint-based, that might be occlusion-based, that might be airway-based, that might be orthodontically based. It could be anything like that. But what we have to do, I think, is become diagnosticians. Because so many times, the patients who I have seen who have problems have not had treatment plans that have been developed with a comprehensive thought process.” (30:48—31:53)

“I still see patients today that come for insurance reasons, so I'm not saying you have to get rid of that or you shouldn't do that. But I'm saying if you can develop another side of the practice, a diagnostic practice, I always think of it almost as a diagnostic subspecialty in my neighborhood practice. And the beauty of that, from a practice management perspective, is I have a column for my production, and I have a column for the assistants’ production. And if we can create a diagnostic practice, whether it’s airway, whether it’s joints, whether it’s restorative, whether it’s implants, our assistant now can produce revenue through diagnostics. And all of a sudden, now, you start to build a practice that has some sustaining numbers, and you have enough money now to go to some CE that will allow you to implement more.” (32:44—33:30)

“When I look back at my practice, there's nothing that I have done that has had a greater return on investment than continuing education. That's what allowed me to treat patients that I never would have treated otherwise.” (33:33—33:47)

“There's an old saying, if you're a baseball player, you can hit for average and hit for power. That's kind of what I did for my practice. I had a regular practice. I would do single-unit crowns. I would do direct restorations. And as my skillset started to increase, first in recognizing problems and then being able to provide treatment, what I started to do was to do bigger cases. I still had the bread-and-butter stuff going, but I started to add to that. That was my pathway.” (35:21—35:54)

“A lot of times, if I look back at my mistakes, it’s because I was recommending treatment to patients that simply weren't ready to hear it yet. Technically, the treatment was correct. But I hadn't prepped them well enough so that they can make a good decision and accept the treatment.” (37:40—37:59)

“Realistically, you're not going to get everyone. There are going to be people that no matter how well you explain it, they're not going to be able to do it, for whatever reason it may be. But I think that your case acceptance rate can increase dramatically based upon how we explain things to patients and how we give them choices to move through a case, either all at once or on a phase basis, based upon if they need to do that.” (38:01—38:28)

“I'm hoping that the people listening to this podcast will redefine occlusion. And if we can redefine occlusion to include not only the teeth but also the back end of the system of the joints as well, all of a sudden, now, occlusion becomes very predictable. And with occlusion, so