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The Piper Education and Research Center (PERC) was opened in 2003, to fill a void in the true understanding that doctors have about temporomandibular disorders, facial pain, and occlusion. Through our contact with thousands of patients and doctors we realize that many misconceptions remain in these fields. At the Piper Clinic, we have been in the business of treating these patients for over twenty-five years. Our concepts of diagnosis and management have been developed at the Piper Clinic because there were no other resources that we could use for our patients. Most often our patients have been those who did not respond or oftentimes worsened with established dental and medical theories of management. During this time we maintained a healthy skepticism of many of the concepts that had developed during the 19th and 20th centuries. Our discoveries through detailed modern imaging have shown that old concepts have benefit today, but we also know that there is much more that we can be doing to assure even greater success in patient therapy. While developing our concepts and our new science on Joint Based Occlusion, we have seen predictable responses from doctors.

Some doctors have made a point of avoiding treatment of "TMJ patients." Conceptually this is ludicrous. If a doctor provides any type of rehabilitation to teeth, then they are already treating patients with temporomandibular problems, whether they are aware of this or not. Any physician treating ear pain, migraines, or tension headaches is treating TMJ patients as well. In fact, any dentist providing major dental restorative, orthodontic, or orthognathic surgery is already treating complicated TMJ patients. Although the definition of a "TMJ patient" to most doctors is a patient who is in pain, 21st century imaging with CAT and MRI scans shows that there are far more patients with TMJ damage than we ever before appreciated, and many of these patients never develop pain. Furthermore, many of these will have instability of their occlusion.

Some doctors might question the importance of any concerns about the temporomandibular joint. After all, some dentists will claim to have practiced for decades without ever having run into a patient that they could not handle with occlusal therapy. Yet orthodontists and surgeons see these same patients, and they know better. Similarly many orthodontists believe that their work is always stable and that the occlusion will function adequately for the lifetime of the patient. Restorative and general dentists and oral surgeons see the same patients, and they know better too. Surgeons treat bite and skeletal defects with osteotomies, and many rarely admit to any problem with relapse of the occlusion afterwards. Restorative and general dentists and orthodontists see the same patients, and again they know better. A neurologist or family doctor might claim high success in treating headache patients with endless anti migraine therapy. Dentists see the same patients and resolve the headaches with bite therapy. This begs the question why we look at the same patients and we can see the errors made by our colleagues, but we ignore those caused by our own hands.

There are also "mysterious" circumstances that are seen in some patients. Take the child for instance with multiple relapses of their occlusion requiring several episodes of orthodontic treatment. Another child may seem to develop progressive asymmetry in their chin. Still other children have a very retrognathic mandible, even though this may not be a family trait, and in spite of a malocclusion they never develop pain. Some have significant wear on the first molars, and yet these teeth may be totally out of contact.

Adult patients may show mysterious developments that are oftentimes explained away. A patient is equilibrated only to return time and time again with new posterior tooth interferences. (The prior manipulations must have missed "centric.") After fully seating a permanent crown, the restoration may seem "high" even though the bite registration for the lab was felt to be accurate. (The high restoration must have been the lab's fault.) An older patient with severe wear and an Angle Class II bite has extreme parafunction after "full mouth rehabilitation and placement of a stronger anterior guidance." (They must be a "delta stage bruxer.") A mandibular first molar is replaced by an implant, and after the restoration is complete the second molar contact opens and the implant is no longer in occlusion. (The implant must be "submerging" or the second molar is "over erupting."). Veneers are placed on the maxillary anterior teeth, and the patient fractures them at the incisal edge. (Perhaps veneers should never have been used in the first place.) A child is placed into vertical elastics to close a mild anterior open bite, but the malocclusion just keeps getting worse. (The child must be non compliant with the elastics.)

Other mysteries may be cosmetic. A patient may complain that their chin is receding, and yet there is no bite change. Or a patient has a minor procedure and they suddenly develop a significant shift of their bite and chin to one side. In spite of splinted restorations through a whole quadrant on both sides of the maxilla, a diastema keeps reappearing between the central incisors. Perhaps the occlusal plane is canted, requiring "periodontal plastic surgery" and full mouth restorations for correction. Maybe when a patient uses a splint their anterior bite opens, and the occlusion is "better" when no splint is worn.

Pain or the lack thereof is also a mystery in some patients. One patient may have extreme tooth wear and large mandibular lingual and maxillary buccal tori, but they have never had any pain. The next patient shows the most minimal second molar prematurity, and yet they suffer from extreme "occlusal muscle" spasm. TMJ pain gets better after removal of the wisdom teeth even if they are not in occlusion, but the reason is not clear. A minor procedure is done on a tooth, and the patient gets extreme pain necessitating a root canal. The root canal fails and the tooth is extracted assuming that a root is cracked. The scenario then repeats itself in the next tooth, and the next, and the next.

Most of us seek answers to patient problems, and if a patient improves with a given procedure then we are conditioned to believe that the therapeutic answers that we have learned are true. This in particular is how things are in dentistry. We have developed as a tooth based profession. We treat teeth directly, and we assume that we are treating other conditions such as temporomandibular disk displacements directly through our repair of teeth. Although this may seem intuitively correct, there are still significant numbers of problems that persist or progress in spite of our treatment of the teeth.

At PERC we are looking at dentistry from a different perspective. We can explain why some therapies actually work quite well- in part of the patient population. We can also figure out why two theories of bite management that are seemingly in conflict do work about the same- in some of the population. And we can tell you why one technique or the other or both fail dramatically- in a percentage of patients. You see we have moved away from thinking that the teeth or periodontium are the foundation of the bite to a realization that the ultimate foundation for the skeleton, basal bone, alveolar bone, periodontal structures, teeth, and bite relationship is the temporomandibular joint.

Again this may not seem to be a new revelation to some, but in fact it is, considering that even minute alterations in the growth, development, and maintenance of joint tissues may have serious impact on the other structures that make up the patient's occlusal scheme. Our approach at PERC, to prioritize the diagnosis of the bite from the exact condition of the joints, is a new dental science that we call Joint Based Occlusion. Furthermore, though we are in agreement with most dental techniques of the 21st century, we also know, from the condition of the joint, that some dental therapies are better than others in any given patient. Knowing the type and timing of dental therapy based upon a primary consideration of the status of the temporomandibular joints is a new way of practicing Joint Based Dentistry.

Our role in your education is to lead you into 21st century testing and analysis to develop your skills and to position your practice for 21st century dentistry. A PERC education will help you to understand everything about the temporomandibular joint and the occlusal schemes that are supported by any given joint foundation. A PERC education will clarify the usual mysteries of dental practice. Joint Based Occlusion and Joint Based Dentistry will be the guiding sciences of the future of dentistry, and at PERC we are fully prepared to lead your practice into and through the 21st century.

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