Dan Jenkins

Principles of ear acupuncture: Microsystem of the auricle

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The Basic Rules of Oral Rehabilitation.

Many of us who treat TMJ disorders become really excited once our patient is relieved of their pain during phase one treatment. However, as we learned before kindergarten, after one is two. Phase two has several options for both the patient and the practitioner to decide upon. First, as in any case, the patient could do nothing at all and wait to see how it works out for them. Second, if phase one has determined a new occlusal position relieves their pain, they could have their occlusion changed through orthodontic treatment. Third, they could continue on with the same device used in phase one for as long as it holds up. The fourth option might be full mouth reconstruction with restorations at the new occlusal position. (I should add that options two and four are sometimes combined.) A fifth option could be dentures. In this book by Dr. Michael Racich of Vancouver, British Columbia, Canada, option four is the main emphasis. This is an overview of the full mouth reconstruction process. This is not just a technique guide. The author covers treatment philosophies from various modalities and encourages the reader to seek more advanced education and training than what they received in dental school. The concept of evidence-based dentistry is addressed and explained in basic easy to understand language. Dr. Racich also points out that, ‘...the lowest levels of evidence (editorials, case reports, in vitro studies, etc.) at times might be all that the practitioner has to work with.’ In essence, the idea is that the practitioner should strive to find the best information available and make a decision on treatment along with the patient’s desires. Preparation is important for the success of any endeavor. Dr. Racich is quick to emphasize this at the beginning of his book in the first of four sections. He writes of the importance of establishing a good relationship with the patient through kindness and respect. He writes of the importance in communication regarding the patient’s wants and needs and for the practitioner to evaluate whether he or she possesses the skills, physically and educationally, to achieve what the patient desires. I appreciated his comment; ‘... developing solid, open, respectful relationships with our patients is mandatory before setting course on a journey such as an oral rehabilitation.’ ‘... delivery of the definitive restorations or prosthetics is not the final destination but only part of the journey.’ I feel this philosophical statement alone explains Dr. Racich’s success! Throughout his book, Dr. Racich keeps each chapter short, (three to four pages), and makes it easy to not only reread the topic but to find a topic you may want to review at a later time. Section 2 deals with making out a plan through evaluation of the evidence-based care considerations, the problem, esthetics involved, occlusion, instruments, provisionalization, orthotics, and patient preferences on appearance. Of interest to the readers of CRANIO would be his comments in the chapter on occlusion and orthotics regarding TMJ positions. Dr. Racich seems to keep an open mind in regard to condylar position. He even states at times he will finish a case with the condyle on the slope – but he does not say how he determines how he arrives at his decision in those cases. (I’ll quickly add that I’m ok with that as well if that is where the patient is comfortable!) In regard to orthotics, he strongly recommends a nighttime orthotic or ‘night guard’ after reconstruction. He refers to these as ‘NADO’ (non-sleep apnea dental orthotics). My concern with the NADOs shown in his pictures is the lingual flange reducing room for the tongue, which may bring about some airway issues. The third section is labeled ‘The Process.’ Dr. Racich guides the reader through how he establishes the occlusion he has determined for the patient and communicates it to the laboratory. He calls the fourth section ‘The Payoff’ and explains his concept of a dental warranty and the importance of ‘playing by the rules’ to achieve the success you and the patient desired at the beginning. Many of us who have already sought out, (and are still seeking!), advanced education and training on reconstruction may find much of this book interesting in how it might differ from our own methods. Dr. Racich and I differ in our practice methods, but it seems we both are able to acknowledge that there are many other practitioners having success utilizing various methods.

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A new calm: A story of breakthrough neuroscience technology patented to quickly and naturally reduce stress and improve performance

All practitioners, in treating patients with TMJ disorders, frequently are confronted by patients who are nervous – so nervous, it makes treatment difficult and takes more time than a normal appointment. Each practitioner deals with this type of difficulty in his or her own way – maybe even by referring the patient to someone else. Historically, reducing the apprehension of a dental patient has been approached by alcohol, gas inhalation (nitrous oxide), drug ingestion, and drug injection. Other methods, such as “white noise,” selective operatory music, dogs, cats, comedy, and psychological counseling have also been utilized. Each of these methods has its advantages and disadvantages when it comes to dental procedures. For TMJ disorder procedures, many practitioners prefer the patient be able to cooperate with the practitioner and respond to voice requests and that their masticatory muscles be relaxed with their sarcomeres in a neutral position. In this book, A New Calm, a neuroscience method of utilizing the sympathetic nervous system to achieve relaxation of a person’s nervous system and muscles is explained. The history of the discovery of this technology is interesting in that initially, the discoverer, Dr. G. Blake Holloway, was simply seeking some treatment method for alcoholism. Along with the neuroscience of NuCalm and how it relieves stress and its associated side effects are many stories of how it has been utilized by various practitioners, athletes, and whole championship sports teams. For dentistry alone, there have been over 700,000 patients across five continents who have experienced this technology. The medications used in this system are amino acids that help with GABA levels to reach their intended targets to control the stress response in our brains. Another part of the technique is acoustic in nature; the patient wears a headset while listening to music with calculated wavelengths, binaural beats, to help calm the nerves. The wearing of a blindfold helps to eliminate visual interferences while the patient is achieving a state of calmness. Interestingly, the medications can be taken either orally or as a topical cream to be absorbed through the skin. As one could surmise, there should be many applications for this type of technology. For general dentistry, it would be a godsend for those anxious patients who cringe and cry at any sensation experienced during treatment. For TMJ practitioners, this would mean having a relaxed patient after undergoing the NuCalm treatment, and better results could be expected in a shorter period of time. I’ve purposely avoided mentioning the many celebrities and sports teams who have utilized this technology, but they are mentioned in the book. They felt it provided them a more restful and restoring sleep and helped them perform better – without illegal drugs. I do have many friends, both dentists and non-dentists, who have used this technology for personal reasons, such as “jet lag” and nervousness of public speaking, and they are very happy with it. My recommendation is to read this book to learn more details, and then decide if it would be a benefit for your practice, your patients, or yourself.

The Basic Rules of Facially Generated Treatment Planning.

This is the 3rd book in Dr. Racich’s series on dental reconstruction following The Basic Rules of Oral Rehabilitation and The Basic Rules of Occlusion. He intends for these books to be “short, concise references” for dental practitioners and their ancillary support networks. This book is divided into three sections: (1) The Basic Rule introduction to patient care – Dr. Racich’s Triad Algorithm, (2) the facially generated treatment planning mantra, as the body of the book, and (3) the general maintenance planning considerations, as the conclusion of the book. As in Dr. Racich’s previous books, he encourages practitioners to consider the whole person when considering dental treatment. This fits into his use of evidence-based dentistry, where the patient’s values conjoin with the evidence found and the clinician’s bias or experience regarding potential treatment. The Triad Algorithm is the pathway to completion. Its first step is the aforementioned evidence-based dentistry evaluation. Next are the ABC steps. ‘A’ is the pre-treatment consideration and evaluation of the ‘patient’s wants, needs, and expectations.’ ‘B’ is the clinical treatment; and ‘C’ is the post-treatment, which involves a non-sleep apnea orthotic device (NADO) and post-treatment home care for the patient. Inside the ‘B’ section of the Triad Algorithm, where the actual treatment takes place, are what Dr. Racich calls the ‘1, 2, 3s’ of dentistry. Step 1 is his starting point, in that he feels there needs to be a ‘Consistently Reproducible position’ (CR) of the mandibular condyles. As he indicates in his earlier work, he does not quibble over where this position is or how it is achieved. He seems more concerned with it being consistently reproducible to build the rest of the occlusion. From here, he addresses vertical dimension being obtained either through an orthotic or temporarily bonded composites. Step 2 is where the incisors are positioned in a manner such that the patient is comfortable and that is esthetic. He includes cuspid/incisor-protected occlusion in Step 2. Step 3 involves what he calls ‘filling in the blanks.’ He calls for a mutually protective occlusion between the posterior and anterior teeth, with a plane of occlusion relatively parallel with the horizon. In Chapter 2, the author stresses that practitioners should know not only their patients, but also themselves! He states, ‘Knowing who we are is the primary cornerstone to success no matter what vocation or profession we choose.’ He goes on to say,