You don't "have TMJ."

I was well aware that the biggest drawback to creating my blog was the fact that I would actually need to update it with new entries on a somewhat periodic basis. However, it's not everyday where I feel inspiration to share my thoughts with you (no offense, of course). That being said, it has been awhile, but I am glad to be back. I hope that everyone is having a safe, relaxing, and enjoyable start to their summer. I spent the first week of June in Lexington, Kentucky participating in the one and only Dr. Jeff Okeson’s mini-residency program on Orofacial Pain & Temporomandibular Joint Disorders. Dr. Okeson is the author of the “bible” of TMDs and Orofacial Pain, so learning from him was a true honor and incredible experience.

It is usually during these week-long explorations where I find time to reflect and discover potential inspiration to share my ideas with the world at-large. The program had approximately thirty participants (ranging from anesthesiologists to oral and maxillofacial surgeons) from all over the world (Norway, Australia, etc.), so I felt lucky to be just a short five hour drive away from the UK campus.

Anyway, enough of all that, let’s get straight into it. I am going to do my very best to stay focused on the topic at hand (I have a lot on my mind). But, before we begin, allow me to give a quick “shout-out” of inspiration to Mr. Mark Twain, who will be our tour guide for this entry.

How we learn.

"A full belly is little worth where the mind is starved." -Mark Twain

Certainly, I learned lots of invaluable information that continues to layer advanced, evidence-based science that I continue to incorporate in my practice in order to provide my patients with optimal, individualized, and personalized care. The residency taught elements of restorative dentistry, pain management and control, advanced sleep medicine, behavioral sciences, physical therapy, and interdisciplinary medicine from leaders in their respective fields to help professionals treat TMD and muscle pain patients most appropriately. But, Dr. Okeson, recognizing the abundance of perpetuating myths that fellow colleagues tell patients about TMDs when they simply do not understand, gave us a very interesting synopsis in “ways in which we learn.”

So, how do we learn?

Here are different ways in which we learn:

  1. Trial and error
  2. Sometimes we learn from our own personal experiences
  3. Sometimes we learn from others, but cannot remember why
  4. Sometimes we learn from others, and repeat the same mistakes
  5. Sometimes we learn from others, who then become our mentors

My experience is that many dental professionals make treatment decisions based off of a pre-conceived set of “beliefs” that are not supported by modern-day science (physiology, evidence-based research, methods of imaging, etc.). This is a major disappointment to me. Undoubtedly, I will have conversations with other dental professionals who tell me they are treating “Mrs. Jones for TMJ.” I simply cannot imagine a fellow orthopedic surgeon telling his or her colleague that they are treating “Mrs. Jones for knee.”

However, we have allowed this in our profession. If we speak this way, how can we expect our patients to understand their conditions? We have taken our sophisticated masticatory system that is controlled by our joint (and muscles) and over-simplified it because we do not want to take the time to understand (I will explain why I believe this is the case in a future entry).

So, what do I think causes the confusion?

Let’s draw a quick picture:

Surprisingly, many United States dental schools teach very little about the jaw-joint (TMJ) in their formal pre-doctoral programs. Therefore, it is left to those to explore and learn on their own journey after they have begun the clinical practice of dentistry.

In dental school, we learn diagnosis and treatment planning on a limited basis. We learn how to identify a cavity, remove it, and place an appropriate restoration. Most dentists are accomplished at this task to some degree of clinical acceptability. We learn how patients present with a conventional toothache, and form diagnostic boxes based upon this formal training. Ask any dentist about someone who has extreme throbbing in a tooth with prolonged thermal (cold) sensitivity keeping them awake at night, and I guarantee they respond that this patient "needs a root canal" (yes, they might need root canal therapy). By the way, the "toothache" is the 7th most common complaint of pain in the United States.

However, in dental programs, we also learn anatomy and physiology of other systems of the body in the medical sciences. We learn all of this information in order to be able to assist our physician colleagues in treating our patients comprehensively, and address any potential systemic issues that may exist. All of this information results in an incomplete and hazy picture of our complex head and neck systems.

So, we leave dental school, and things are simple. We “fill cavities” and treat periodontal disease. Patients come in with toothaches, and we treat them. We become narrow in our thinking, because things are "working." We are practicing dentistry of the past. Let’s face it, at this stage, we are unaware of sophisticated dentistry. Some people remain in this stage for their entire years of practice. It is a safe, easy place to practice (far left on the graph above). Patients are (unfortunately) accustomed to this, like giving your identification and credit card to the check-in staff in a hotel lobby.

But, if you are like me, you strive for more. You begin to know yourself and understand how you want to treat your patients. You need to learn more if you aspire to treat people appropriately. And you need to learn from the best. And it comes at a cost when you’re learning from the best, but it does not matter, because the strive for excellence trumps any other form of motivation.

We learn something new on an entirely different level than the majority of our colleagues understand it. We begin to isolate ourselves from the way the majority of our colleagues think. We view things as complex, and look at an entirely different set of risk factors and methods of treatment based upon sound science.

Patients (even some practitioners) may view us as “different,” even though we are incorporating data based upon the literature in our diagnosis and treatment planning decisions. Unfortunately, however, patients have been given misinformation for so long (many times from purported “experts”), that we become the practitioners who are almost hard to believe.

"Nothing so needs reforming as other people's habits." -Mark Twain

We are healthcare professionals. It is not appropriate to learn from trial and error. It is not appropriate to simply tell patients what they desire to hear, because they have been told for years by those who have not done their due diligence to read the literature and convey scientific evidence to them in fear of rejection. How can we fail to recognize, utilize, and incorporate the incredible advances we have made to treat people in maximum comfort and aesthetics using scientific principles?

For example, it may seem out of sorts for a dentist to inquire to you about potential cervical spine issues when you show up in his or her chair with a toothache. But, what if science has proven that certain cervical spine issues refer pain to the chewing muscles that can present almost identically to a toothache? How often does a dentist inquire about Vitamin B12 levels when a patient presents with an unexplained burning feeling in their mouth? Are we helping our patients to the best of what modern day science offers? No longer does “no cavities” equate to “comprehensive” or a “healthy” oral cavity.

Eventually, we implement systems and acquire enough education and knowledge to make our decision making processes simpler, but at a highly proficient level. We strive to be at the furthest point to the right on the graph above. We become truly competent providers (so competent that we are again unaware of treating people any other way). And things are simple again.

Very few practices achieve this level of competence. Patients invited by others to a practice like this understand the systems well, and come to expect the level of thoroughness and intellectual integrity that is distinctly different from the “usual” routine.

Healthcare Marketing.

I am currently in the process of creating a website for my practice. This has been a few years in the making, and I realized I had to do it when one of my patients said to me: “You know, you really ought to at least be in the phone book.” Point well taken.

Honestly, I just cannot stand external “marketing” for healthcare. It pains me to see what much of our profession, which has the potential to be so extraordinary, puts on the internet for patients to read.

So, during this process, it physically saddens me when I browse different dentists websites explaining their practice and their “philosophy.” This is your page, and the public can view it at anytime! A 24/7 reflection of you, your values, and your philosophy.

  • “$50 cleaning! $100 whitening! $1,000 crown!”
  • “Free exam and x-rays!”

Really? How did we get here? ($100 whitening and we don’t even know each other yet…)

  • What about care, skill, and judgment?
  • What about maintaining our mouth in comfort, beauty, and aesthetics?
  • What about building relationships based on mutual trust and respect?

I went to this course with an exceptional restorative dentist, Dr. Ryan Mizumoto, who practices on the other side of town. He is a great colleague and friend, and sometimes the learning outside of the classroom proves to be more valuable than in the course itself (we literally listened to the 2014 American Equilibration Society’s annual meeting on the drive home). For more information, feel free to visit the AES here.

"To eat is human... to digest, divine." -Mark Twain

While in Lexington, we decided we needed a change in the normal cuisine we were having. We also decided that we needed a break from tasting authentic Kentucky bourbon, so we searched for a unique restaurant in Lexington. Finally, somebody told us about Yamaguchi’s. Yamaguchi’s has recently become my most respected restaurant for two reasons:

  1. Yamaguchi’s is in a strip-mall with no signage (see picture). You cannot find this place unless you know about Yamaguchi’s. It looks like a total dive.
  2. I need to quote the menu: “Our phone number is not listedand the phone is turned offall the time to provide a hideaway experience for our guests.”

Yamaguchi’s is not about advertising the quality of their food. Yamaguchi’s understands that the people who appreciate their quality will find their way to their restaurant and bring other like-minded folks with them. And, it works. It works really, really well.

The second you walk into Yamaguchi’s, you forget you are in a dingy, old, almost abandoned strip-mall. You surely forget you are in Lexington, Kentucky. We were not let down with the experience. The fish was delivered overnight, never frozen, and hand selected. Every single tapa dish was exceptional. The owner works diligently, solely concerned about the quality of his food and experience of his guests... not the volume of his customers. He knows that people will find his restaurant, somehow, someway, because of the excellent cuisine and ambience (enhanced by the fact that you never hear a phone ring while dining). Nobody accidentally leaves their cell phone ringer "on" in Yamaguchi’s.

Can you imagine telling a restaurant owner that it is a decent idea to never turn your business phone on? Sounds like a ridiculous idea, I know. But, Mr. Yamaguchi knows that his level of commitment provides cuisine so far superior to anyone else that people will come. And, people will know what to expect. They can expect an education in properly crafted tapas. His commitment to exceptional tapas and service is enough to drive success, despite what appears to be a difficult location for a high-end restaurant.

I want to try and (succinctly) bring all of this together.

Conclusion.

"Always do right. This will gratify some people and astonish the rest." -Mark Twain

"The man with a new idea is a crank until the idea succeeds." -Mark Twain

Wrapping up, we covered two important issues. We discussed ways in which we learn, and that we must be careful to use sound principles of science as healthcare practitioners in our decisions while treating patients with complex problems. We also observed how certain types of marketing may be a distraction from the sophisticated services we are able to provide for our patients. We conclude that if we stay committed based solely on altruistic motives, people will find us.

It is our duty, as professionals, to approach our careers as a journey that lies along an infinite continuum of learning, growth, and personal development.

I believe that true commitment to being the very best one can be is enough to harbor trust, growth, and respect amongst colleagues, peers, and patients. I would advise anyone in any profession to simply immerse themselves in the highest level of professional growth they can, before their habits overtake their hunger for learning.

Be a life-long learner.

Learn from the masters.

And, aspire to surpass them.