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The Return of Centric Relation

September 12, 2017

Filed under: Technical dentistry — Tags: , — Barry @ 10:11 PM


A long time ago in a galaxy far far away…you know that line from Star Wars. Well, in dentistry we had our own version and we called it Jaw Wars.

Many of you who practiced years ago are familiar with the occlusion wars between neuromuscular occlusion, centric relation and some of the lesser known philosophies. I remember getting caught up in endless debates about which occlusal method was better. Then the wars seemed to die down.

Other trends seemed to dominate dentistry. Boy—those were the good old days.

A few weeks ago on one of the more popular Facebook groups I saw a post that discussed the impossibility of being able to find and record a true centric relation position. The comments flowed—just like the old days.

The biggest difference that I noted was that many of the dentists weren’t arguing about which philosophy of occlusion was better but rather the difficulty of finding the position was leading many of the dentists to throw the baby out with the bathwater and abandon any occlusal philosophy.

I wondered why? The principles of occlusion hadn’t changed. But dentistry has changed. The way dentists practice today has drastically been altered. 

For whatever the reasons, it’s not a good idea to abandon a philosophical approach to dentistry because there are forces that are difficult to control...like the economy, third parties or corporate policies.

I remember debating with a “cosmetic dentist” about his article The Truth About CR. It was a heated debate that was carried on in the dental trade magazines. Today, I look back and wonder if it was about centric relation at all…or was it really about a philosophy of practice.

I liken it the question people ask about “what is the worst breakfast you can eat?” The answer is “no breakfast” is the worst breakfast. In dentistry – what is the worst occlusal philosophy? That’s right…no philosophy is the worst philosophy.

Occlusion is the foundation of complete dentistry. Too many dentists have focused on tooth dentistry and the current trends as they have relinquished control and their freedom of choice to the third parties.

A coherent philosophy of practice – and of life is still within the control of each and every one of us. If we all exercised that right, then maybe we can do something to bring dentistry back to the good old days.


Dental Yoga

August 10, 2015

Filed under: Technical dentistry — Barry @ 12:48 PM




Can a dentist be a yogi?

I practice hot yoga three days per week.  I have reaped the rewards.  The word “yoga” means “to join” or “to yoke.”  What gets joined is the body, mind and the spirit.  First comes the body, then the mind, and then the spirit.

Physical, mental and emotional benefits.  Harmony!  Balance!

When the owner of my hot yoga studio, a yogini, came to see me, she was in acute pain.

She had been reluctant to see a dentist for years because she found it difficult to keep her mouth open for cleanings or x-rays.

But pain is the greatest motivator, and she could no longer avoid the inevitable.  She was skeptical, but when I explained that the jaw followed the same principles of muscle physiology that governs the body, she agreed to having an occlusal splint made.

The occlusal splint, as most dentists know, quiets the major muscles of the face – like a perfectly executed Yoga posture.

Jess wore the splint.

When I showed up for my next Yoga class, she greeted me at the entrance with a huge smile on her face.  She demonstrated that she was able to freely move her jaw painlessly, in all directions.

I pride myself in reading people’s emotions.  That’s a skill dentists get good at over time.

I can read pain, I can read fear and I can read frustration.  That is how Jess presented that first day.

On this day, I was reading pure joy...as if she were being let out of prison.  As a matter of fact during our class she admitted to always feeling reluctant about going to the dentist because of the jaw pain.

I told her many people suffer from facial pain and headaches due to TMJ dysfunction – and even those who don’t have the acute symptoms, get relief of subclinical symptoms they never knew they had.

Just like Yoga.

Mild constant chronic pain can effect us mentally and emotionally.  We tend to adapt to not feeling well.  Since I began doing Yoga I have become pain free, I have more energy, and yes I am happier—the union of the body, mind and spirit.

People walk around with subclinical pain.  They accept it as being normal and make life choices based on not feeling well.  It’s amazing how pain relief can affect the mind.

So many people walk around with chronic pain, and accept it as part of their life.

Taking care of the body goes way beyond the cosmetic…it’s life changing in many ways.

With all of the emphasis these days on cosmetic dentistry…I still feel better about getting a yogini back to the mats than doing a big cosmetic case.





Overnight Sensation

April 13, 2015

Filed under: Technical dentistry — Tags: — Barry @ 10:28 PM



No one can argue that a dentist’s best friend is a patient with symptoms.  Symptoms represent the highest level of motivation for patients to get treatment.  The other day I noticed my lab technician rubbing her jaw.  I asked her what the problem was and she explained that her jaw had been killing her lately.  I did a quick examination and saw plenty of signs that revealed occlusal disease but the discomfort was taking center stage.  So I made her an occlusal splint.

The very next day…after a good night’s sleep with the splint, she came in smiling and thanking me for helping her get out of pain.  I was a hero.  It felt great to be an overnight sensation.

We all know how easy it is to treat symptoms and help people get out of pain…physical and emotional.  There’s nothing like an easy pulpotomy or a Class IV composite on a central incisor to turn that frown upside down.

It’s the signs of disease that I am concerned about, because can we really cure an asymptomatic patient?

When there are no symptoms we must rely on our extraordinary communication skills to build trust and motivate the patient toward proper treatment.  This is a great source of frustration for many dentists, because we see signs of disease all the time and have difficulty persuading patients to take action.  That’s why we love symptoms.

And that is why splint therapy should be a big part of the dentist’s armamentarium.  The splint helps patients to realize that there are subclinical symptoms present.  In my lab tech’s case, she realized that the splint uncovered more than just muscle soreness.  It exposed the clenching she had been doing (now we could talk about the signs), and the headaches she had been getting which were leading to a few bad moods.

The point is that our examination should go further than finding signs…it should expose symptoms from the overt to the covert.  A starting point for that is a full understanding of the role of occlusion and the use of splints.

When I first employed splint therapy into my practice, I never fully understood the behavioral component of the splint.  I made many splints for patients who never fully understood “why” I was recommending the splint.  Needless to say I had some very unhappy patients.  Knowing how to make a splint and why “we” use splints doesn’t help the patient understand its value unless they “feel” the importance.

Including an occlusal examination for every new patient is a great starting point for helping the young dentist explain complete treatment better and building trust.









The Motivational Power of Splint Therapy

October 16, 2014

Filed under: Mastery,Technical dentistry — Tags: , , — Barry @ 10:05 PM



I check my splint patients at their hygiene appointments.  Imagine how I felt when I asked a patient if she was wearing her splint, and she said “yes,” and when I asked to see it she handed me her old orthodontic retainer.

She looked up at me and said, “Oops, you caught me.”  She hadn’t worn her splint in a long time, because she didn’t feel she needed it anymore.  Somewhere along the line my message didn’t stick.

That’s not the first time a splint patient either stopped wearing their splint, or lost the splint, or maybe even fed the splint to the dog.  It’s the same feeling I get when a perio patient goes back to the same bad habits that caused their disease in the first place, or I find out that their very expensive partial denture is lying at the bottom of their night table drawer.

The consequences for the patient are pretty grim, but for me I feel as if I am not doing my job because I place a high emphasis on doing meaningful work.

The key to meaningful work is to gain commitment from the patient.

Dentistry that changes people’s lives isn’t, and should not be restricted to, cosmetic dentistry.  Changing people’s lives in meaningful ways is about health, comfort and function as well.  Function is the one that lies under the radar.  Function is the one that requires more education, and splint therapy is the educational and motivational tool.

Let’s face it when people enter into comprehensive dental treatment some level of commitment is necessary in order to get the best long-term benefits.  People weigh the benefits of treatment against the consequences of treatment…the result is the level of commitment.  When the benefits far outweigh the consequences…the cost, the time, the levels of discomfort, real or imagined…then there will be commitment.

And the work will be more meaningful for all.


Many cosmetics dentists use a technique called a trial smile or cosmetic mock-up.  The purpose is to show the patient the benefits of cosmetic dentistry.  In sales they call that demonstrating the solution.  You see demonstrations on TV all the time.  The famous pitchman Ron Popeil would wow viewers with demonstrations of his Chop-o-Matic hand food processor or his Veg-o-Matic slicer.

Think of a splint as a way to demonstrate to the patient problems they never knew they had.  They will accept your splint like people accepted the Pocket Fisherman.  Just kidding of course.  The point is that dentists need to educate patients when they are not aware of the problem.

People will never accept a solution to a problem they don’t understand in their own mind.  Many will nod yes because of the positional authority of the dentist…only not to follow through with treatment or put the partial in the drawer and never come back.

Here are a few guidelines for using a splint as an educational and motivational tool:

  1. Splint therapy can be the gateway for patient’s accepting long-term comprehensive dentistry.  Become an expert in diagnosis and splint treatment options.
  2. Take the time to educate the patients as part of your new patient examination process.  Make sure they thoroughly understand the problem before treatment is presented.  Make use of photography, muscle palpation, diagrams, TMJ trainers, and of course mounted study models.
  3. Relate your findings to any signs and symptoms.
  4. If they do not acknowledge a problem…don’t treat through the occlusal issues.
  5. Once they own the problem…the splint becomes the ultimate demonstration.  The next natural question for them is “where do we go from here?”
  6. Slow down the examination-presentation process.

I started this post with a description of the uncommitted patient, but in reality nothing, except maybe cosmetic mock-ups and pulpotomies, has done more for educating and motivating patients than splint therapy.

That’s how you can continue to do meaningful work that patients thank you for.

How do you use splint therapy for education and motivation?  Leave your response in the comment section.






5 Reasons Ryan Loves the Dentist

August 9, 2010

Filed under: Business of Dentistry,Technical dentistry,Uncategorized — Barry @ 2:52 PM

Ryan is like so many of our dental patients: he has some fear but he wants to get his work done when necessary.  Let’s face it, not many people line up for treatment, hence all those root canal jokes.  Ryan takes care of his teeth for many reasons, one of which is to stay away from me.

So when Ryan came in with a small chip on his upper front central incisor, he would have been fine to leave it alone…but not Grandma.  He hated needles, he didn’t want me to touch his teeth and he was kind of vain so he needed a perfect shade match.  When we were finished doing our magic (I promised him I would use only Weapons of Minimal Destruction), Ryan (and Grandma) loved us, here’s why:

1. No Needles

Although I only had to use the drill to do the least amount of shaping necessary, and to roughen up the surface.  Ryan felt nothing (he was amazed…I wasn’t).  I didn’t have to go anywhere near his gum tissue…I will explain that below.

2. No Mutilation

Who wants to get their teeth cut down for crowns and veneers?  I understand the price of vanity, but Ryan would have lived with his chip.  Don’t we all have patients like Ryan.  And in the center of the mouth getting one tooth shade corrected can be one of the most difficult things in dentistry…dentists today are jumping at the chance to prepare teeth.

3. No Shade Discrepancies

Okay, this is really where the lab takes over.  It’s pretty tough to make veneers that are this thin and esthetic.  We can match the underlying shade of the tooth by using feldspathic porcelain.  Note the contact lens effect in the center.

4. It’s Invisible

Both Ryan and Grandma were happy because it truly was invisible.  It was a case of under promising and over delivering.

5. Now We Love Ryan Too

The best part of this is that Ryan and Grandma have developed a strong trust in our practice.  It showed how competent we were to deliver on our promises.  They realized that we had really listened to Ryan and his latent objections.  Our intent was to do the very best for our patient under his circumstances and objectives (not ours).  This is how we build our practice.


There are many ways to do minimally invasive dentistry.  I believe the success of this minimally invasive veneer case was due to the expert use of feldspathic porcelain by Niche Dental Studio, and the use of fine Dialite polishing wheels which helped to make all of the margins invisible.

One Change Leads to a Yes

August 4, 2010

Filed under: ARTICLES,Technical dentistry — Barry @ 2:20 PM

One moment she was okay, and the next she was one the ground holding her mouth.  She just got out of a taxi after the theater on a bitter cold March night in New York.  Her feet tangled as she stepped on the curb and down she went.  In that instant her circumstances changed.

The  driver put her back in the cab and took her to the emergency room.  After cleaning the wound which did not require stitches she was left with two broken central incisors, one of which moved into a new position, at least thirty degrees from the other.  But it took her weeks to visit my office.

Helene was a patient in my practice for over ten years.  I had tried to convince her to close a Terry Thomas type of diastema (okay…Lauren Hutton, if you insist), every chance I got.  Helene wouldn’t budge.  Talk about a resistance to change.  Most turtles are faster.  After a while I just never mentioned it.  Approaching seventy years of age I resigned myself to the old saying about old dogs.

Then came the fall.

Even after weeks of walking around with two broken teeth, she was resistant.  She never wanted to change her smile.  She said she liked the space…but now she said she had never seen crowns that looked like real teeth.  She hated that white square look, and she feared getting artificial looking teeth.

The first thing we did was a smile mock-up but this was difficult because of the gross malposition of the teeth.  We also had an endodontic consult and the teeth tested vital. So we did a wax-up.  Helene was still unconvinced.  She wanted to keep a small space.  Reluctantly she went forward because I promised not to finish until she was happy with the provisionals.

Helene had a tight neutral zone and a very long narrow envelope of function.  We worked out her occlusion in the provisional.  For a further discussion of this go to http://nichedentalarts.blogspot.com/  It was amazing to see how she responded to the tiniest adjustments on our Radica provisional.  Take a look at the wonderful job Sooji Lee from Niche Dental Studio did.  Our patient was so happy that she went down to the Reading Terminal in Philly and brought us three dozen chocolate chip cookies and a for me a gorgonzola cheese and fig bread.

So what can we learn from this?

1. For some people change is tough.

2. Even in the face of injury some people just hold on.

3. Never assume.

4. Get to the bottom of the problem…it wasn’t totally the diastema.

I am sure you have had similar issues in your practice…please share.