Daws

on

Sem

inar

Sche

dule

Does any logical, thinking dentist believethat a TMJ with a completely displaced diskgot that way because the patient has a psy-chosocial stress problem? Or does anyonebelieve that a TMJ with a degenerative bonedisease should be treated the same as ahealthy, intact TMJ in a patient with masti-catory muscle pain? Are intracapsularstructural disorders all alike? Are all painsin the side of the face caused by the samedisorder? Unfortunately such conclusionsare often drawn by dentists who rely onsome all too common misrepresentationsand consequent misuse of the term “TMD.”As the term is used in articles, in research,in epidemiological studies, and from thepodium, TMD has become an umbrellaterm for so many different types of disor-ders, it is impossible to evaluate etiology,treatment effectiveness, or prognosis of spe-cific sources of pain or dysfunction thatdentists routinely observe. But the undiffer-entiated label “TMD” is still the norm inmost of the literature…and “psychosocialstress” is all too often the explanation for it.

So how do we explain the continuing use ofthe term “TMD” to include “pain in theside of the face or jaw” without differentiat-ing which specific structures (out of manypossibilities) are the actual source of thepain? And since by definition, pain is aresponse to tissue damage, does it makesense to ignore structural damage, even if it

is progressive, if we can dull the pain bydrugs or teach patients to cope better withtheir pain?

If we understand how damage or misalign-ment of one structure within the mastica-tory system can affect other structures, canwe justify watching the teeth wear intodentin as a collateral effect of condylarbreakdown just because we can mask thediscomfort? In other words, can we ashealth professionals accept an approachthat virtually ignores signs if control ofsymptoms can be managed?

As long as the term “TMD” continues tomean every type of pain in the head, neck,shoulder, back, and whatever else anyonedecides to label TMD, a logical approach todifferential diagnosis of the masticatory sys-tem disorders will continue to elude our lit-erature and lead to an impression that“TMD” must be in your head (the psy-chosocial explanation). The sad part of thisnegative scenario is that it doesn’t have tobe the way it is. Classification of specificdisorders is a reality. No clinician whounderstands this can accept the misguided

pronouncements in the literature that TMDis a multifactorial disease. It is not a multi-factorial disease. TMD is an umbrella termfor many different diseases, each one ofwhich may be multifactorial. They do notall have the same etiology nor do they allrespond to the same treatment. Treatmentsuccess will continue to be anybody’s guessfor those who fail to recognize this, and thus,they will be inclined to just helping thepatient cope with a problem that was neverdiagnosed (The psychosocial approach).

Until proper diagnosis and specific classifi-cation of disorders becomes the standard,the literature will continue to be seriouslyflawed, epidemiological studies will contin-ue to be meaningless, and psychosocialsolutions will continue to cover up symp-toms because doctors will continue toremain in the dark about how to properlytreat what they fail to diagnose.

The tragedy of the “biopsychosocial” stressagenda is that its belief in a predominatelyemotional explanation for symptoms hasled to less and less concern for the struc-tural integrity and harmony of the totalmasticatory system. If you can cover up thesymptoms, don’t worry about signs of pro-gressive deformation within the system.Don’t put any credibility on the addition of the “bio” prefix to the psychosocial

continued on page 2

“…can we as health professionalsaccept an approach that virtuallyignores signs if control of symptoms can be managed?”

Dawson SeminarUpdateA p u b l i c a t i o n o f G r e a t L a k e s P r o s t h o d o n t i c sA D i v i s i o n o f G r e a t L a k e s O r t h o d o n t i c s , L t d .

April 2000 Vol. III No. 1

The Tragedy of the Biopsychosocial AgendaPeter E. Dawson, DDSDirector, Dawson Center for Advanced Dental Study

Proper Doctor/Laboratory CommunicationImportant for Predictable RestorationsKathy Anderson and Ashley C. Johnson, III, JD

Predictable restorations will never happenwithout proper communication. The doctorhas to be able to communicate what hewants with his staff and then with hispatient. He must also be able to communi-cate with the laboratory technician. Thedoctor is the common denominator in allof this and ultimately the one responsible.Once the doctor has given the proper infor-mation to the laboratory, it is then the labo-

ratory’s responsibility to create the properrestorations.

The importance of communication betweenthe doctor and the laboratory can never bestressed enough. This is where the use of alaboratory assistant can be invaluable. Oneof the roles of the laboratory assistant is tomake sure that all the proper steps havebeen taken before the case is ready to send

to the laboratory. The laboratory assistantis also responsible for making sure that allthe components are packaged properly forshipping.

continued on page 2

is also responsible for making sure that all the components are packaged properlyfor shipping.

For information about Dr. Dawson’sseminars, to register for any of thesecourses, or if you would like to add someone to our mailing list,contact: Center for Advanced Dental Study 111 Second Avenue, NESuite 1109St. Petersburg, FL 33701(800) 952-2178(727) 823-7047Fax: (727) 821-0482www.dawsoncenter.com

How to Put Your Practice in the Top 10%OCTOBER 26-28 LAS VEGAS, NVNOVEMBER 30 - DECEMBER 2 ATLANTA, GA

Seminar 1: The 10 “Must Know” Factors About Occlusion and the TMJMAY 11-13 ST. PETE BEACH, FLOCTOBER 12-14 ST. PETE BEACH, FL

Seminar 2: How to Master the Essential Elements for a Highly Effective Restorative PracticeNOVEMBER 9-11 ST. PETE BEACH, FL

Seminar 3: Advanced Problem SolvingFULL

The Center CoursesST. PETERSBURG, FLORIDA

Application 1: Diagnosis & Treatment of Masticatory System ProblemsJUNE 5-7 SEPTEMBER 20-22JUNE 26-28 OCTOBER 2-4JULY 12-14 OCTOBER 30 - NOVEMBER 1JULY 31 - AUGUST 2 NOVEMBER 29 - DECEMBER 1

Application 2: Equilibration: Diagnosis andTreatment of Occlusal ProblemsMAY 10-12 SEPTEMBER 27-29JUNE 12-14 OCTOBER 18-20AUGUST 23-25 NOVEMBER 6-8

Application 3: Perio-Restorative Case Planning: A Multi-Disciplinary Approach to Problem SolvingJUNE 21-23 SEPTEMBER 11-13

Laboratory Assistant TrainingMAY 4-6 AUGUST 9-11JUNE 15-17 SEPTEMBER 14-16

Piper Level 2: Core Therapy for Intermediate to Advanced TMDFULL

Piper Level 3: TMD Advanced ConsiderationsFULL

Managing for ExcellenceMAY 17-19

New Patient ExperienceAUGUST 16-18 OCTOBER 9-11

Dr. Frank SpearCourses & Seminars

CLINICAL WORKSHOP COURSESHeld at the Seattle Institute for Advanced Dental Education.Attendance is limited.

Diagnosis and Treatment Planning:Facially Generated Treatment PlanningFrank Spear, DDS, MSD FULL

Occlusion in Clinical PracticeFrank Spear, DDS, MSD FULL

Advanced Occlusion in Clinical PracticeFrank Spear, DDS, MSD June 5-7

November 6-8

The Exceptional Specialty Network: An Interdisciplinary Approach to Esthetic ExcellenceFrank Spear, DDS, MSD May 8-10Vince Kokich, DDS, MSDDavid Mathews, DDS, PS

Practice Leadership & Staff Development:Creating the Practice of Your Dreams(dentists only)Frank Spear, DDS, MSD July 10-12Brian DesRoches, PhD October 30-Nov. 1

SEMINAR SERIESRestorative Update 2000

Frank Spear, DDS, MSDChicago, IL (Ambassador West Hotel) June 15-17Anaheim, CA June 22-24

(Disneyland Pacific Hotel)

Las Vegas, NV (The Luxor Resort) December 7-9

“The Practice of Excellence”Frank Spear, DDS, MSDOrlando, FL August 17-19

(Disney’s Contemporary Resort)

Seattle/Orlando SeminarsFrank Spear, DDS, MSD

Seminar I: State-of-the-Art EstheticsSeattle (Bellevue Double Tree Inn) November 16-18

Seminar II: Occlusion in Clinical PracticeOrlando May 18-20

(Coronado Springs Resort, Disney World)

Seminar III: Tooth Replacement in Clinical PracticeSeattle (Bellevue Hyatt Regency) July 13-15Orlando September 7-9

(Coronado Springs Resort, Disney World)

For additional information or to register for any of these courses,contact::Seattle Institute for Advanced Dental Education600 Broadway, Suite 490, Seattle WA 98122(888) 575-0370 (206) 322-0370 Fax: (206) 328-5447www.seattleinstitute.com

4

Inside This Issue…• Upcoming Courses/Seminars• Featured Products

proponent’s terminology. All you have to doto clarify that is to read what the psychosocialadvocates are still putting in the literature.Use of the Research Diagnostic Criteria forTMD, while a small step in the right direction,is woefully inadequate for structural analysisof the TMJs or the teeth, and fails completelyto properly analyze the relationship betweenocclusion and the TMJs. Yet the RDC/TMD isbeing touted as the “scientific” criteria fordiagnosis of TMD. To illustrate its heavyemphasis on a battery of psychological instru-ments, a recent article in JADA used graduatepsychology students to do the TMD exams fora research project.

We could write off such nonsense if it werebalanced by more logical analytical methodsin the literature, but such balance has notbeen in evidence, even in juried journals.This is partly so because advocates of morecomplete analysis have also been guilty of thesame lack of clarity in using the all inclusiveTMD label in their claims regarding occlusaltherapy. Neither have they been specificenough in defining and verifying position andcondition of the TMJs when reporting onocclusal methods including use of occlusalappliances.

It is also obvious that the majority of studiesthat propose to analyze the effect of occlusalsplints (occlusal appliances) are carried outwithout adequate regard for the precisenessrequired for adequate occlusal applianceeffectiveness. I have not been able to find asingle negative study regarding occlusal appli-ances in which joint position and conditionwere clearly defined and verified in the study.And positive articles are usually as unscientif-ic as well. Note, it is not enough to just saythe TMJ is non-osteoarthritic, and just sayingthe joint does or does not click is not a diag-nosis.

The above scenario begs for correction, but itdoes not give license to anti-occlusion pro-moters to claim scientific evidence they donot have. Absence of evidence can not bemisconstrued as evidence of absence, butread the literature and you’ll see how oftenanti-occlusion sentiments are expressed as“scientific” when the most important criteriafor correct occlusal treatment has not beenstudied. Fortunately, I definitely see the tideturning toward more complete analysis bymore and more educators and researchers. If you are convinced of the importance ofocclusion to masticatory system harmony,don’t make the typical mistake that the psy-

chosocial advocates make when they criticizeocclusion advocates. That mistake is to con-sider analysis of occlusion as being exclu-sionary of any analysis of emotional stress asa factor. This assumption is incorrect withoutan understanding of what I have been preach-ing for many years—do a complete examina-tion of the masticatory system in addition toan analysis of the patient’s level of stress andother possible contributing factors, includinggeneral health considerations, behavioral pat-terns, nutrition, and whatever other consider-ations may be needed for completeness (TheTMD scale has consistently been recommend-ed as a standard part of the examination oforofacial pain patients.).

But just as important, don’t make the mistakeof jumping to conclusions that TMD is pri-marily a psychosocial disorder without doinga complete examination of all masticatory sys-tem structures.

The real tragedy of the exclusionary psy-chosocial agenda is that it has excused educa-tors from teaching a full measure of under-standing the role of dentistry as physicians ofthe total masticatory system. Dental gradu-ates who do not understand the TMJs cannotunderstand occlusion and visa versa. Failureto understand occlusion results in misseddiagnoses, failed restorative dentistry, fringetype treatment approaches and either grossovertreatment or lack of effective treatment.It definitely results in failure to diagnose and treat the most common cause of the most common type of TMD–occluso-muscledisorders.

It is time that dentists who know the difference should start challenging both the literature and the lecturer who woulddeprive patients of the kind of care that dentists should and can be rendering on a regular basis. Let’s start with a completeexamination.

It is also time to commit to a better under-standing of the scientific methods for present-ing evidence pro or con. Learn and usedefinitive classification systems when dis-cussing masticatory system disorders, includ-ing TMJ disorders, masticatory muscle disor-ders, occlusal disease, or any orofacial painconditions. It is part of the responsibility oftrue professionals.•

Biopsychosocial Agenda cont.

2

“…don’t make the mistake of jumping to conclusions that TMD is primarily a psychosocial disorder…”

3

Proper Steps for Predictability:• Accurate alginate impressions• Accurate facebow registration• Accurate bite registration• Accurate facebow / CR mounted

pre-op models (If this is done the doctor does not have to send the facebow registration.)

• Accurate final impressions (to include margins that are visible 360 degrees)

• Esthetic checklist

Predictable Packaging Process:• Line the inside of the box with

bubble wrap• Place the bite registrations in an

orthodontic retainer case• Wrap everything else individually

with bubble wrap• Verify that you have included

prescription, photos, etc.

The amount of information given tothe laboratory varies with the size ofthe case. In almost all cases the fol-lowing should be sent to the labora-tory. In a single tooth replacementthe laboratory needs a good finalimpression, a good opposing model,a facebow registration, and an accu-rate bite registration. If the tooth isan anterior tooth, or multiple anteri-or teeth, the doctor should send apre-op model, a diagnostic wax up,or a model of pre-approved tempo-raries. An incisal guide index shouldbe included. If the case is a fullarch, all of the above should beincluded.

When a full mouth rehabilitation isbeing done, some extra bite registra-tions should be taken. There shouldbe a bite registration between upperprovisionals and lower prepped teethand one between both upper andlower prepped teeth. To get accu-rate gingival embrasures, and thecorrect pontic to ridge adaptation, asoft tissue model is absolutely neces-sary. The laboratory can fabricatethe soft tissue model, custom guidetable, and the putty silicone incisalindex.

The doctor must include propershade communication. He shouldprovide the laboratory with a shadeselection and a diagram of any mav-erick colors or separation of colors.

Proper Doctor/ LaboratoryCommunication cont.

Stain Kit for TemporariesAllows you to match almost any toothshade. Bonds chemically to temporaries,and won’t fade or wear off. Eight shadesto choose from.

Perfect Stain®

Several photographs should beincluded. A picture of the chosenshade tab (or several pictures ofdifferent shade tabs that matchdifferent parts of the tooth) beingheld adjacent to the tooth to berestored. Make sure the shadechoice on the tab handle is visiblein the photo. If taken from theproper camera angle, a close-upof anterior teeth will show thetexture and lustre of the labialsurface. Another photo takenfrom a different camera angle canbe used to communicate randomcolors, interproximal colors, andgingival colors. It can also showthe technician where to place theincisal porcelains.

When your communication takesplace on this level, the results aregoing to become predictable! •Kathy and Ashley work togetheras a consulting team. Theirpurpose is to help dental prac-tices transition to the Conceptsof Complete Dentistry bybecoming Physicians of theMasticatory System, putting inthe proper protocols and com-munication on a clinical andadministrative level.

Kathy Anderson is the presidentand creator of The KathyAnderson Consultant Group inTampa, Florida. Her dental jour-ney, with selected practicesaround the country, offers cus-tomized solutions that helprefine and develop a practicevision. This foundation allowsher to help build a team envi-ronment that supports excep-tional patient care, laser beamleadership, and astute businessand clinical systems. Contactthem by mail at P.O. Box 18266,Tampa, Florida 33679, or e-mailto kander3608@aol.com. Youcan reach them by phone at 800-963-8222.

Ashley C. Johnson, III, JD, is afaculty member at Dr. PeterDawson’s Center for AdvancedDental Study in St. Petersburg,FL. He is the owner of UltraCraft Dental Lab, Inc. He can be reached at 800-227-4258.

Featured Products

For more information about theseproducts, or to place an order, call

1-800-828-7626

This convenient tapered wafer is thinner in the posterior section and thicker in the anterior, taking the arc of closureinto consideration. Results in an evenindexing of teeth into the wax.

Tapered Delar Wax

Ideal for incisal edge indexes, provisional matrices, checking occlusalregistrations of mounted casts, andother laboratory applications thatrequire utmost accuracy.

Putty Silicone

The same shape as regular bite fork waxrims, these were designed in response tothe many requests for a single thicknessbite fork wax rim.

At times it is desirable for the patient notto have wax on the bottom of the bitefork. It is also easier for the operator tomanipulate if a bottom rim is desired.(24 per pkg.)

Delar Single ThicknessBite Fork Wax Rims

proponent’s terminology. All you have to doto clarify that is to read what the psychosocialadvocates are still putting in the literature.Use of the Research Diagnostic Criteria forTMD, while a small step in the right direction,is woefully inadequate for structural analysisof the TMJs or the teeth, and fails completelyto properly analyze the relationship betweenocclusion and the TMJs. Yet the RDC/TMD isbeing touted as the “scientific” criteria fordiagnosis of TMD. To illustrate its heavyemphasis on a battery of psychological instru-ments, a recent article in JADA used graduatepsychology students to do the TMD exams fora research project.

We could write off such nonsense if it werebalanced by more logical analytical methodsin the literature, but such balance has notbeen in evidence, even in juried journals.This is partly so because advocates of morecomplete analysis have also been guilty of thesame lack of clarity in using the all inclusiveTMD label in their claims regarding occlusaltherapy. Neither have they been specificenough in defining and verifying position andcondition of the TMJs when reporting onocclusal methods including use of occlusalappliances.

It is also obvious that the majority of studiesthat propose to analyze the effect of occlusalsplints (occlusal appliances) are carried outwithout adequate regard for the precisenessrequired for adequate occlusal applianceeffectiveness. I have not been able to find asingle negative study regarding occlusal appli-ances in which joint position and conditionwere clearly defined and verified in the study.And positive articles are usually as unscientif-ic as well. Note, it is not enough to just saythe TMJ is non-osteoarthritic, and just sayingthe joint does or does not click is not a diag-nosis.

The above scenario begs for correction, but itdoes not give license to anti-occlusion pro-moters to claim scientific evidence they donot have. Absence of evidence can not bemisconstrued as evidence of absence, butread the literature and you’ll see how oftenanti-occlusion sentiments are expressed as“scientific” when the most important criteriafor correct occlusal treatment has not beenstudied. Fortunately, I definitely see the tideturning toward more complete analysis bymore and more educators and researchers. If you are convinced of the importance ofocclusion to masticatory system harmony,don’t make the typical mistake that the psy-

chosocial advocates make when they criticizeocclusion advocates. That mistake is to con-sider analysis of occlusion as being exclu-sionary of any analysis of emotional stress asa factor. This assumption is incorrect withoutan understanding of what I have been preach-ing for many years—do a complete examina-tion of the masticatory system in addition toan analysis of the patient’s level of stress andother possible contributing factors, includinggeneral health considerations, behavioral pat-terns, nutrition, and whatever other consider-ations may be needed for completeness (TheTMD scale has consistently been recommend-ed as a standard part of the examination oforofacial pain patients.).

But just as important, don’t make the mistakeof jumping to conclusions that TMD is pri-marily a psychosocial disorder without doinga complete examination of all masticatory sys-tem structures.

The real tragedy of the exclusionary psy-chosocial agenda is that it has excused educa-tors from teaching a full measure of under-standing the role of dentistry as physicians ofthe total masticatory system. Dental gradu-ates who do not understand the TMJs cannotunderstand occlusion and visa versa. Failureto understand occlusion results in misseddiagnoses, failed restorative dentistry, fringetype treatment approaches and either grossovertreatment or lack of effective treatment.It definitely results in failure to diagnose and treat the most common cause of the most common type of TMD–occluso-muscledisorders.

It is time that dentists who know the difference should start challenging both the literature and the lecturer who woulddeprive patients of the kind of care that dentists should and can be rendering on a regular basis. Let’s start with a completeexamination.

It is also time to commit to a better under-standing of the scientific methods for present-ing evidence pro or con. Learn and usedefinitive classification systems when dis-cussing masticatory system disorders, includ-ing TMJ disorders, masticatory muscle disor-ders, occlusal disease, or any orofacial painconditions. It is part of the responsibility oftrue professionals.•

Biopsychosocial Agenda cont.

2

“…don’t make the mistake of jumping to conclusions that TMD is primarily a psychosocial disorder…”

3

Proper Steps for Predictability:• Accurate alginate impressions• Accurate facebow registration• Accurate bite registration• Accurate facebow / CR mounted

pre-op models (If this is done the doctor does not have to send the facebow registration.)

• Accurate final impressions (to include margins that are visible 360 degrees)

• Esthetic checklist

Predictable Packaging Process:• Line the inside of the box with

bubble wrap• Place the bite registrations in an

orthodontic retainer case• Wrap everything else individually

with bubble wrap• Verify that you have included

prescription, photos, etc.

The amount of information given tothe laboratory varies with the size ofthe case. In almost all cases the fol-lowing should be sent to the labora-tory. In a single tooth replacementthe laboratory needs a good finalimpression, a good opposing model,a facebow registration, and an accu-rate bite registration. If the tooth isan anterior tooth, or multiple anteri-or teeth, the doctor should send apre-op model, a diagnostic wax up,or a model of pre-approved tempo-raries. An incisal guide index shouldbe included. If the case is a fullarch, all of the above should beincluded.

When a full mouth rehabilitation isbeing done, some extra bite registra-tions should be taken. There shouldbe a bite registration between upperprovisionals and lower prepped teethand one between both upper andlower prepped teeth. To get accu-rate gingival embrasures, and thecorrect pontic to ridge adaptation, asoft tissue model is absolutely neces-sary. The laboratory can fabricatethe soft tissue model, custom guidetable, and the putty silicone incisalindex.

The doctor must include propershade communication. He shouldprovide the laboratory with a shadeselection and a diagram of any mav-erick colors or separation of colors.

Proper Doctor/ LaboratoryCommunication cont.

Stain Kit for TemporariesAllows you to match almost any toothshade. Bonds chemically to temporaries,and won’t fade or wear off. Eight shadesto choose from.

Perfect Stain®

Several photographs should beincluded. A picture of the chosenshade tab (or several pictures ofdifferent shade tabs that matchdifferent parts of the tooth) beingheld adjacent to the tooth to berestored. Make sure the shadechoice on the tab handle is visiblein the photo. If taken from theproper camera angle, a close-upof anterior teeth will show thetexture and lustre of the labialsurface. Another photo takenfrom a different camera angle canbe used to communicate randomcolors, interproximal colors, andgingival colors. It can also showthe technician where to place theincisal porcelains.

When your communication takesplace on this level, the results aregoing to become predictable! •Kathy and Ashley work togetheras a consulting team. Theirpurpose is to help dental prac-tices transition to the Conceptsof Complete Dentistry bybecoming Physicians of theMasticatory System, putting inthe proper protocols and com-munication on a clinical andadministrative level.

Kathy Anderson is the presidentand creator of The KathyAnderson Consultant Group inTampa, Florida. Her dental jour-ney, with selected practicesaround the country, offers cus-tomized solutions that helprefine and develop a practicevision. This foundation allowsher to help build a team envi-ronment that supports excep-tional patient care, laser beamleadership, and astute businessand clinical systems. Contactthem by mail at P.O. Box 18266,Tampa, Florida 33679, or e-mailto kander3608@aol.com. Youcan reach them by phone at 800-963-8222.

Ashley C. Johnson, III, JD, is afaculty member at Dr. PeterDawson’s Center for AdvancedDental Study in St. Petersburg,FL. He is the owner of UltraCraft Dental Lab, Inc. He can be reached at 800-227-4258.

Featured Products

For more information about theseproducts, or to place an order, call

1-800-828-7626

This convenient tapered wafer is thinner in the posterior section and thicker in the anterior, taking the arc of closureinto consideration. Results in an evenindexing of teeth into the wax.

Tapered Delar Wax

Ideal for incisal edge indexes, provisional matrices, checking occlusalregistrations of mounted casts, andother laboratory applications thatrequire utmost accuracy.

Putty Silicone

The same shape as regular bite fork waxrims, these were designed in response tothe many requests for a single thicknessbite fork wax rim.

At times it is desirable for the patient notto have wax on the bottom of the bitefork. It is also easier for the operator tomanipulate if a bottom rim is desired.(24 per pkg.)

Delar Single ThicknessBite Fork Wax Rims