Are you still using long-term provisionals just to test OVD?

Is an occlusal splint really the best way to assess vertical dimension?

Could raising the OVD actually harm your patient?

Dr. Lukasz Lassmann joins Jaz and Mahmoud Ibrahim  this AES special episode to challenge conventional thinking around occlusion, vertical dimension, and full mouth rehab. Lukasz shares his unique perspective as a clinician, educator, and researcher, bringing clarity to a topic that often feels murky and divided.

They explore real-world questions like managing asymptomatic clicks before ortho, why occlusion alone won’t “cure” bruxism, and the number one reason not to raise the vertical without proper understanding.

Plus, Lukasz drops an incredible airway assessment tip at the end of the episode!

Protrusive Dental Pearl: Use a comprehensive TMD history-taking form to effectively triage patients into urgent (red), moderate (amber), or low-risk (green) categories—this allows you to prioritize care appropriately and build rapport by focusing on examination rather than data collection during the appointment.

Download the form: protrusive.co.uk/tmdhistory

Download the Patient History Evaluation Form

Need to Read it? Check out the Full Episode Transcript below!

Takeaways

Highlights of this episode:

Studies Mentioned:
Gut Bless Your Pain—Roles of the Gut Microbiota, Sleep, and Melatonin in Chronic Orofacial Pain and Depression

Randomised controlled trial on testing an increased vertical dimension of occlusion prior to restorative treatment of tooth wear

📅 Upcoming Talks & Courses

If you loved this episode, be sure to watch Myth Busting Occlusion and TMJ – PDP022

#PDPMainEpisodes #OcclusionTMDandSplints

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance. 

This episode meets GDC Outcomes B and C.

AGD Subject Code: 180 OCCLUSION (Occlusal therapy)

Aim: To enhance clinical understanding of occlusal principles, vertical dimension management, and red flag indicators that impact prosthodontic and TMD treatment, based on current best evidence and insights from Dr. Lukasz Lassmann. 

Dentists will be able to –

1. Identify common myths and misconceptions about vertical dimension increase and temporization.

2. Recognize red flag patient presentations that are not suitable for prosthodontic treatment.

3. Understand the airway implications of increasing vertical dimension and how mandibular rotation impacts it.

Teaser: This is insane. You know, I was always asking, what do you mean progressively you want to increase first like two millimeters and then you want to check if it's all right. If there is no joint pain or- I never start doing prostho or ortho when my patient has pain. I first want to turn my patient to be asymptomatic and then we go ahead.

Teaser:
On the first appointment, you are explaining on the second one you are justifying. We don’t want to tell our patients that this is because of the systemic disorders or some psychiatric disorders because we, ourself, we consider it is like showing the white flag that we just confessed that we don’t know the answer we do. If your patient has a problem with the bladder, you as a dentist, you’re not treating the bladder, but you just refer the patient to the proper doctor. Right? 

Jaz’s Introduction:
Stop placing your patients on long-term provisionals, or even worse, giving them an occlusal appliance. If the sole reason you’re doing it is to test the OVD.

Hello, Protruserati. I’m Jaz Gulati. Welcome back to your favorite dental podcast with an absolute superstar, Lukasz Lassmann. I remember meeting him in 2019 in Dubai on a course, and he just blew my mind. His cases are spectacular, and honestly, I have no idea how this guy does it. You guys say Jaz, how do you do it?

I look at Lukasz and think, how do you juggle everything, PhD, three kids, everything he’s doing in progressing education and occlusion. Absolutely inspiring guy. And yes, of course, we asked him how does he do it? This episode is one of the AES special episodes to shine a light on the AES 2026 conference where Lukasz Lassmann himself will be doing the closing act.

Me and Mahmoud, we got the paracetamol on day 2, AM but don’t worry, me and Mahmoud will try and keep you awake. But Lukasz is the main act and deservedly so. And this episode will give you an insight into his thinking, the work he does, the kind of patient he sees, including at the very end, he will just blow your mind.

It’s a way of checking your patient’s actual airway while they’re laying down in your dental chair, this video at the end, he shares it’s absolutely golden. For those audio listeners, that part lasts for 10 minutes, is on video only because I didn’t want you guys to feel alienated. But for those video watches you are in for a treat at the end.

So my friends, me and Mahmoud on this episode, we asked Lukasz so many questions. It was quite a broad overview and some were quite basic things and some were quite advanced things. And I’ll kind of like chime in now and again just to make a few things tangible because when we talk about occlusion, things can get a little bit saucy, a little bit too excited sometimes.

So we’ll just bring it back down a few pegs now and again with a little interject, which I hope will be helpful. And if it is, please comment below and let us know if it is we discuss real world things like if your patient has a click, does that mean we need to intervene before they have orthodontics, or is it okay for them to have a asymptomatic click?

You’ll also find out how many patients bruxism, me, Mahmoud, and Lukasz have cured from doing a full mouth rehab or an equillibration. Okay, tell you what. I’ll give you the answer. It’s zero. So find out why we believe that in our experience so far, that perfecting someone’s occlusion will not necessarily stop their bruxing.

And I know some of my dear friends and mentors are, are probably about to throw a brick at the screen here or smash their headphones. Let’s try and stay friends, everyone. I know everyone’s got different mixed views when it comes to occlusion, but everyone just take a breath. woosah-woosah. Take a breath. It’s gonna be okay.

Just hear us out. And of course, we’re gonna give you the number one reason not to raise a patient’s vertical dimension. Why by raising their vertical dimension, you might actually be killing your patient a slow and miserable death. All that, and much more to come in this episode.

Dental Pearl
Now every PDP episode I give you a Protrusive Dental Pearl. This one is kind of influenced by some of the things that Lukasz said in this episode. Like when he has these TMD patients that come from all over the world to see him in Poland, he needs a good way to categorize these patients. Who are the red urgent patients? Who are the amber patients and who are the kind of like the green patients, which are lower risk queries, which can be dealt with easier and they don’t need as much time?

And the way to do this is with a really good data collection or a history taking form, when you ask the right questions and you get a very detailed history, you are much more likely to be able to identify those patients that need to see you, ASAP, think of it like an evulsion, right? When a patient avulsed their tooth, they need to get to the office, ASAP.

So who are your TMD EVULSION patients? And who are the, oh, I’ve chipped a bit of enamel here. Can you please take a look? Kind of patient equivalent of TMD. Now, those of you who are watching this on Protrusive Guidance, our network, the history form that I use is ready for you to download below. That’s my gift to you.

But for the wider audience, I’ll put the link. But essentially it’s protrusive.co.uk/tmdhistory. That’s protrusive.co.uk/tmdhistory. And my team will email you the PDF that we use. It’s quite exhaustive and for good reason, so feel free to cut things out if you need to. But honestly, like when it comes to history taking and TMD, you can’t have too much information.

Some of the great physios I work with, they’re all about, again, the right information before they even come to the office. So you can focus on the examination and actually rapport building, which is so important when we look after our TMD patients. Once again, that’s protrusive.co.uk/tmdhistory.

But if you’re on the app already, scroll down below and you can download it. So now full circle to the very first thing I said at the start of this episode, which is why you shouldn’t be doing long-term provisionals and definitely not do a splint just to test that OVD. You’ll find out in great detail why that’s the case. Hope you enjoy a catch you in the outro.

Main Episode:
Lukasz Lassman. Wow. I mean, absolute rockstar and dentistry. We have rock stars like Pascal Magne, we have rock stars like Markus Blatz and Buddy, my friend. Let me tell you, you are right up there, man. You are right up there, Lukasz. And me and Mahmoud literally went offline for like one minute to set your screen share permissions and we were just like, holy crap.

How does this guy do it? Right? And so the whole world is just in awe of this superhuman that you are. So that’s a whole another topic to debate. But Lukasz, for those few people living under some sort of rock that haven’t come across your amazing cases or content and whatnot, please tell us about you. What drives you, Lukasz? What is your driver in life? 

[Lukasz]
Yeah. First of all, thanks for having me. I think it’s like comparing me to Markus or to Pascal is like, it makes me embarrassed because I truly believe that I’m on a good direction, but I think it’ll take years and years to get where those giants really are.

So what drives me is a progress. If I do not see the progress I’m burning out. It happens with my clinic, it happens with my courses. When I have to repeat the same course twice at the second time, it’s like, I don’t think I wanna do this again. So this is how I change all the lectures. This is how I split the courses, like step one, step two.

And you know, without changing even a single slide, I would never, ever be able to repeat the same lecture. That would be much easier to have the same lecture, to repeat the same for 10 years. I would’ve saved a lot of time doing this way, but my brain couldn’t handle it. So yeah, the progress is something that drives me.

I know that there is a very thin line between the passion and workaholism and I’m sure that I have crossed this thin line many times in my life and I’m really trying to maintain this so-called work-life balance. Right? This is very important. The most important thing is not to regret anything at the end of your life, and this is how I try to live my life.

[Jaz]
I remember being at your lecture in 2019 in Dubai and obviously you just, even since then, you’ve just gone strength to strength and strength. I dunno if you remember this, I dunno if you still do this on your presentations, but you ended with like a really like human emotional bit. It was really, really nice and you pretty much summarized it beautifully just now about striving to better, let’s not compare to one another and the problems that social media brings about looking at yourself and wanting to be better and you’ve just described that beautifully.

Mahmoud, just wanna bring you in my friend. How are you doing, my friend? You’re at the clinic, you’re just finishing up some cases and you are as excited as I am to be sat here with Lukasz. They’re one of the biggest geeks in occlusion we know right now. 

[Mahmoud]
Oh, absolutely. Super, super excited Lukasz to be able to chat to you actually, sort of one-on-one, well, two on one I guess. Pick your brain a little bit. I absolutely love the content you’ve been putting out on Instagram through, Lukasz. So last minute education, which is the sort of the newer one and the stuff on there is amazing, so digestible. So yeah, which one are sort of try and get a few more, as we call it, sort of tangible bits. But yeah, I’m really excited to be here. I have no work-life balance at the moment, but you know, it’s hit the ground rocking. 

[Lukasz]
My last year wasn’t also the work-life balance, it was the toughest year in my life. Finishing PhD, finishing the book, finishing the clinic, having three kids and doing the courses and treating patients.

It was clearly too much. But finally I’m here and I would say that everything went right, but the level of the cortisol in my brain was very high this year. But I don’t not regret. 

[Jaz]
That’s the way to be. 

[Mahmoud]
There’s no point in regretting it, right. 

[Jaz]
Exactly. Well, today’s geeky topic, my friends, will be something that Lukasz talks a lot about in social media. Lukasz teaches a lot about in his courses stuff, which is the myths surrounding vertical dimension. And there are many myths. There has been some great papers published over time about this. I also want to touch on joint position, ’cause this could easily be like a fire hour debate, right on joint position.

So we’ll try and keep it brief. We’ll try and make everything relatable and tangible for our younger colleagues, right? Because let’s just pay homage to the AES which has brought us together, guys, AES February, 2026. I’ll put the link in. Lukasz, we’re all basically warming the stage for you. You are the last act, right and you are lecture title is Smile and Space Concept in Vertical Dimension of Occlusion.

So very much tying in with some of the small things we’re talking about, but it’s just a huge topic and one of the reasons I compared you to Markus Blatz what you both do so brilliantly is the dissemination of information. So that the masses of dentists can really resonate and collect ideas and understand.

And so a couple of the posts that you did on red flags are just so beautifully put together that it’d be an absolutely travesty if you don’t shine a light on those posts. And so together that will formulate the content. So really sometimes when I ask my guest these questions, sometimes you have to take a step back ’cause it’s such a big topic.

So if I ask you, Lukasz. What are the common myths that as young colleagues we’re learning about occlusion? What are some of the myths that you’ve ever come across when it comes to the vertical dimension or changing vertical dimension? Shall we pick one or two that you really want to highlight?

[Lukasz]
Yeah. The one that people very often ask me about the progressive, increasing vertical dimension of occlusion. This is insane. I was always asking, what do you mean progressively? You want to increase first, like two millimeters? Then you want to check if it’s all right. If there is no joint pain or there is no bruxism because of these two millimeters, and then if this is all right, you increase another two millimeters and then another two millimeters.

You do three set of wax ups, occlusal compass on every single tooth, three sets of condylography. Do you do the same when you do the full dentures? You also do three sets of full dentures, or you just use some basic rules and you put it in your patient’s mouth so that it looks good, it functions well, and your patient is happy, and you don’t wait for some deprogrammation in their brain because you know that if the form is good, if the function is good, if the appearance is good, it’ll be okay.

Some people just need a little bit more time. Some people need just a little bit less time, but they will all adapt. I will talk today about the red flags and some conditions where probably the adaptation could take a little bit more time than usual, but even in those scenarios, using prolonged temporization isn’t necessary thing, and we haven’t had any science for decades to support using temporaries for longer.

Now we got one paper which is a good paper, which says something totally against using the spleens or some kind of temporaries to let the patient adapt. I’m not saying that the temporaries are a bad thing. I’m not saying that we shouldn’t test mockup. I’m not saying that. I’m not saying also that if you have a patient that struggles with phonetics, for example, we shouldn’t use prolonged temporization because this is the condition where I would use it, definitely.

And if we want to shape the soft tissues with a soft tissue management, I get vertical preparation all over on every single tooth. We use the PMMA. We want to shape the soft. We’re gonna use this, but for checking the vertical dimension of occlusion, if only we obey the rules, the basic rules, and we screen the patients perfectly at the beginning of the treatment.

So I’m categorizing the patient for that red zone, yellow zone, and the orange zone. So if the patient is in a red zone, this is a patient that we don’t even start doing the prostho. We have to convert this patient first to be in the green zone and then you move ahead and then a treatment is easy. 

[Jaz]
Can you give a couple examples of red for our younger colleagues? What are a couple of examples that constitute someone has red? 

[Lukasz]
Especially the acute arthritis in the joint or any chronic exacerbated TMDs, centrally mediated myalgia. If you have a patient with the neuropathic pain, I mean, some people really believe that with the good occlusion we can get rid of neuropathic pain, which is totally against the science. So I never start doing prostho or ortho when my patient has pain. I first want to turn my patient to be asymptomatic. And then we go ahead. 

[Mahmoud]
Just to clarify again, for the younger listeners. When we’re talking about asymptomatic, we’re talking about pain, we’re talking about inability to function. However, things like maybe a click that’s been there for 10 years has never changed, hasn’t caused any pain. They can chew, they can eat, they can speak. That doesn’t constitute symptomatic, correct. 

[Lukasz]
Click is not a problem at all, but, function that when there is a big limitation in opening. Yeah, I would say that this may be the big problem because it may be because of the disc, acute, this displacement without reduction.

It may be because of the muscle trismus. And the other question is why there is a muscle trismus, probably because of some inflammatory reasons. It may be the elongation of the coronary process, which I have seen few times in my life. Those people got the deprogramation to let them open more. They got the physiotherapy to stretch the muscles while there was just coronoid process that was hitting the zygomatic.

[Jaz]
Mechanical obstruction. 

[Lukasz]
Yeah. That was a mechanical obstruction. 

Interjection:
Hey guys, it’s Jaz, interjecting to just explain how hyperplasia or an enlarged coronoid process can cause this mechanical obstruction. If you have a look at a normal size coronary process, and you look at the difference between that and an enlarged coronoid, for those of you whose anatomy is a little bit weak now is like, you know where the condyle of the mandible?

Well, it’s that fin shaped process, the top of the mandible. So the mandibles kind of like bifid if you’d like, right? It’s got the condyle, it’s got the coronoid, and the coronary process is like a little extension. It’s like a fin shaped extension on both sides. Now, when you have an enlarged coronoid or hyperplasia, what happens is that the coronoid gets stuck behind the zygomatic arch and the patient cannot open very big.

So it’s like a more rare thing. And there’s like articles online and case studies. It’s something to bear in mind. I think it’s always just nice to apply anatomy to our patients and anatomy is one of those things where we don’t wanna just memorize.

It actually helps you to get a deeper understanding of the human body. So I was worth just exploring this issue about coronoid process, hyperplasia and how exactly that causes a mechanical restriction. Back to the episode. 

[Lukasz]
If you try to do it too much, you could have broken this, the coronary process. Yeah. So, if you have those conditions, you should get rid of this problem pretty early. Also, when people have a hypermobility, you should also- 

[Jaz]
Very common, very common, in your TMD patients. I imagine Lukasz, like my TMD patients, a huge percentage. Obviously women, and then huge percentage of those are hypermobile. Is that what you found in your questionnaire and discussion as well? 

[Lukasz]
Yeah, but you always have to take a look at the side of the hypermobility because very often, the hypermobile side is hypermobile because the other side, the contralateral side is hypermobile. So this one is trying to compensate. So when you get the restriction over here, so in time, probably this will regenerate, but this one will try to catch up. We’ll try to compensate. 

Interjection:
Okay. It’s Jaz again, just interjecting on hypermobility, right? So many of our TMD patients are hypermobile. They’re just built differently. We know about the correlation, if you remember from a few episodes ago, between TMD and how so many TMD patients have an undiagnosed connective tissue disorder.

Think of things like Ehlers–Danlos syndrome. We call them “bendy”. Someone asked me, Jaz, are you bendy? When I had my pneumothorax and yes, I am bendy. I’ve been told when my physio, I’m hypermobile. I’ve got quite stretchy skin and all those things. But to just drive the point home clinically, right?

It’s wanting to appreciate how hypermobility specifically of the TMJ may manifest in your patients. It’s those patients who, when they open, they sometimes get locked, open a bit, right? And then they just have to wiggle their jaw and then they fix it. So they kind of locked open. Typically like when they’re yawning, they yawn and then they get like stuck open for like a few seconds and then they wiggle their jaw and they are able to close again.

It feels a bit tender when they do that. And so these patients know not to open too much or just be careful when they’re yawning. And that’s called a subluxation. If someone subluxes their TMJs, they’re probably hypermobile. And the extreme end of that is that they kind of sublux and then they don’t go back to normal, in which case that’s a true dislocation and that’s more rare.

That’s like you have to go through the emergency department or dentist who knows what they’re doing, try and get the condyle back under the articular eminence again, and back into the glenoid fossa. So top tip to patients who sublux a lot and they kind of get stuck for a few seconds is tell them they should not be opening their mouth more than three fingers.

There should be no reason to open more than three fingers and tell them, just be careful when they’re yawning, right? So when they’re yawning, I get my patients to put their hand underneath their chin. And lastly, sometimes you hear a click. So as they open and as the condyle gets over the articular eminence, just like when they’re about to sublux, that can sometimes make a click sound, right?

And that’s called an eminence click. So don’t think that’s like a click of the disc. That clunk. It’s more like a clunk actually. And that’s called an eminence click. Anyway, just trying to shower this episode with as many real world nuggets as possible and arm you with knowledge that you can actually apply day to day and help your patients with.

[Lukasz]
And then you got a patient, you know what? You’re gonna see, you do the CBCT or something and you see the arthritic joint over here, and you are almost sure that this is the one that is painful, but your patient’s telling you, no, no, no, doctor, I got my pain over here in here nothing is clicking, in here is clicking.

But then you realize that it’s not even this clicking, it’s just jump over the eminence. It’s the sublux joint and those cases are pretty tough for dentists if they don’t recognize it because those patients will tell you that they struggle to keep their mouth open with prolonged dental appointments.

And we think this is about the muscles. Yeah, it may be because of the muscles, but because of the protective mechanism, try to imagine that you do the endo in your lower third molar, the worst scenario, and you ask a patient to open as much as they can and you do endo for one hour. And if this is a normal patient, the condyle should stop on the lowest level of damage, right?

With a hypermobile patient, it’ll jump over here and would stay here for one hour. And this is where the protective co-contraction starts. This is why they start feeling the pain. So the solution for those people is always to, first of all, to put the support between the teeth to bite on it. But do not let the patient bite on it when the condyle is displaced.

So let them open only when they feel that it is not displaced. And you can, as a dentist, you can also feel it pretty easily because we can feel it under the skin. So you tell them only to open up, up here and then you give them the piece of plastic to support and then- 

[Jaz]
The mouth prop. 

[Lukasz]
Yeah. How you call it?

[Jaz]
We call it the mouth prop. 

[Lukasz]
Okay. Mouth prop. Okay. Alright. So then you leave it for one hour and you would be surprised that just a small difference, five millimeters less opening and it makes a huge difference for the symptoms for the patient. 

[Jaz]
I always say, ’cause sometimes patients find it like quite often it’s the first time they’ve ever had it when I’ve offered it to them, right? And so I always say to the patient, it’s a bit like me holding my elbow out for like an hour like this, whereas me leaning against something and then patients get it and I say, look, the first 90 seconds it’ll feel strange to swallow, but then you get used to it. And I found, I tell them, don’t bite hard into it, relax into it.

And I’ve found that, it’s made my dentistry easier, it’s made our patients comfort levels easier. And I’m hugely a big fan of mouth props. But some clinicians have been a little bit reserved or worried about using them. Anything you wanna add to that Lukasz, in terms of communication or your use of it?

[Lukasz]
You mean why do you worried about it? Because they worry- 

[Jaz]
Dentist- 

[Lukasz]
The person will swallow it or what? 

[Jaz]
I don’t know what it is, about it, but usually they see it as something that you did in hospital, but then you don’t do, like, they associate it with like patients under general anesthetic and they feel as though most clinics I speak to, they don’t even have it in their clinic, operatory in general dentistry.

So I’m like, this is such a simple and good thing to use. Whereas in dentistry, because they don’t see it so much on social media, they don’t see other dentists using it. They feel as though maybe it’s frowned upon. And I’m always saying, no, it’s okay to use, especially on this acceptable patient. 

[Lukasz]
I feel like I have to record a video with this one and show it on my Instagram. When you spoke about Markus Blatz, I must admit that he was the biggest inspiration for me to open my Instagram channel with educational content because I only then realized that Instagram is not only show off, it’s not only showing before and after pictures. On Facebook, I could have used 100 slides and put tons of knowledge over there.

And now on Instagram we can use 20 slides. But back then when I started, it’s like more than one year ago, I think I opened it like three years ago now. But then we had only 10 slides. So deciding what is important and what is not is was very tough, not putting too much words on the slides, not to distract attention.

We have to realize how the young brain works. I mean, like we are also young, right? But people that are watching us are 10 years or 20 years younger. So this generation, what I see, they don’t really like to read books. They like shortcuts. They need algorithms. They say, don’t tell me why, just tell me what to do.

And this is scary. This is very scary. But, at the same time, only the people who can adapt will survive. And if you’re gonna be stubborn and you’re say no, I will not even try to explain it with 10 slides because this is oversimplification. Nobody will listen to you. So we have to balance between putting things in a very simple way, not too comprehensive, because if you’re gonna be too comprehensive, nobody will read it anyway.

But also, if you have a big message, why don’t you split it in three posts with big picture and main message? Big picture and main message. This is what I’ve seen for the first time in Markus Blatz Instagram. And this really inspired me to do so. 

[Jaz]
Well, you definitely maintained that. You’ve recreated it for occlusion and more power too, man.

[Lukasz]
Yeah. To occlusion, to temporomandibular joint, it was like, I’m doing form of reconstruction almost every day when I do not do fu of reconstruction. I’m doing TMD patients. So like yesterday we had 25 TMD patients one day, and those were- 

[Mahmoud]
I’ve got a headache speaking about that. Oh my God. 

[Jaz]
And these patients are traveling a long way to see you.

[Lukasz]
Oh yeah. They are traveling. I had patients from Switzerland and so on, but how did we do this that we had 25 patients? It wasn’t like every single patient for 10 minutes. I’m collecting the questionnaires that I have done this year for the purpose of the book. I’m very proud of those questionnaires.

This is one of the things that I’m proudest of with this book, that I’m sending all those questionnaire to my patients. I’ve got a huge list of patients, like 700 patients waiting with TMD, with the pain, this is sick. You know? How can people wait two years for an appointment with pain?

So at certain point, I realized that within those several hundred people, there are people with this really severe pain and there are people that are waiting two years because orthodontists said, if Dr. Lukasz doesn’t see your clicking joint, I will not put the braces on your teeth. And after two years they’re coming and I’m saying, oh, we don’t care about it. Just leave it like it is.

Well, the way to resolve this huge line of patient was sending all those people, all those questionnaires. So I’m like once a month I’m getting the package of 70 questionnaires and then I know who is my patient. Is this a patient with myofascial pain or neuropathic pain or some central intimidated myalgia, neuropathic pain. So yesterday, and I’m tagging all those patients. So yesterday I had a whole day with red, red, red, patient. 

[Jaz]
Urgent. 

[Lukasz]
Only neuropathic pains, neuralgia and all those. It’s like terrible stories. I was very exhausted. At the end of the day, they- 

[Jaz]
Mostly drained. These patients, I dunno how you do it, but they drain you. 

[Lukasz]
Yeah, they do because, and this is very sad because when patient is telling you that they had several suicidal attempts- 

[Jaz]
Very sad. 

[Lukasz]
They’re telling your doctor, if you don’t help me, I will commit suicide. This is such a heavy burden. And what I was trying to say, how did we do this, that we had more than 20 people was because I had my postgraduates students after my TMD courses and we had it in four offices. So we all knew the patient before, so it was accelerated and I had the biggest authority in the pain treatment.

The professor from my capital city from Warsaw, she also came, she’s anesthesiologist and she was helping me with all those people. So I was just going from one office to another, to another. And then coming back, they were taking impressions, they were doing the tropical ology injections, some we were prescribing some pills.

We were talking about the lifestyle changes because this is so important. They are so disrupted at so many levels. This is like, this experiment with slowly cooking frog when you put the frog into the water. Yeah. And it increase the temperature.

[Jaz]
Just for those who haven’t heard it, just explain it. ‘Cause we’ve had this on podcast before in a pediatric episode actually. But just tell us about the frog because it’s so relatable. It’s like dentists listening to this frog analogy, even in their career, their life, their family. This analogy can apply in anything. So please just share that for us for a moment.

[Lukasz]
Yeah, that was in famous experiment. I don’t even know if that was a true experiment or is it just an anecdote. But if you put a frog into the water and you just slowly try to increase the temperature, the frog will not even realize that something bad is happening until it dies. Until it’s just boiled.

And the same happened with people. So we are sleeping very badly, and this is ridiculous because we are doctors and we are not trained how to improve people’s sleep. We sleep for one third of our life. This is the most powerful regeneration in our life, and we only learn how to take the Zolpidem.

We only learn how to take pills to sleep better. But there are so many tools how to improve sleep that I’m also sharing with my patients. We have never learned. I don’t know, I was in the uk, but in Poland, we are not learning about a diet. 

[Jaz]
Oh no, not at all. 

[Lukasz]
We learn how to eat pills. And this is crazy because I remember six years ago when I was never an expert in dietician, but at certain point I realized that maybe there is something that we are missing.

So I had a patient and she was a violent player and she came saying that she had pain for eight years and nobody could help her. She had tons of dentistry in her mouth. You should have seen this. The appliances, unbelievable. When she showed me those terrible appliances, I was not surprised that she still had this pain.

But long story short, I asked her, has anybody ever tried to change her diet? And she looked at me like suspicious eyes. I was like, oh my God. Again, shaman will try to treat me with energy, you know? I was like, no, no, no, no, seriously. Has anybody ever tried to eliminate something from your diet? She said, no.

And just because I wasn’t so good about those different forms of diet. We have this kind of a diet in Poland from one pretty famous doctor. This is diet that is based on the fruit and vegetables and mostly the juices made of fruit and vegetables. You eliminated basically everything else. So I told her, go on this Dr. Dąbrowska diet for two weeks and we’ll see what’s gonna happen.

After two weeks, she came to me and she said, doctor, you will not believe. Everything is gone. And I didn’t know, was it because of what she was eating or what she excluded from her diet? Maybe it was just, I dunno, gluten, maybe it was a casein, maybe it was lactose, maybe it was, I don’t know, tomato skin. God knows.

So with my patient, I sometimes do it, like with the kids, when the kid has a green poo, what do we do? We eliminate everything and we start with one ingredient, and another day we add another one and then another one. So at the end of the month, you just have a normal diet. But then you know what made it worse?

The way the diet, the big problem is that we can have a cross allergies. And we can have also delayed onset with the allergy. So sometimes you feel badly two or three days after you eat something. So I will just tell you one private thing. I used to have the geographic tongue and this lesion on my tongue was always appearing on the same right side of my tongue.

I was always Googling, was there any new signs about the geographic tongue? I was checking chat, GPT, research, everything, nothing. I stopped drinking coffee in September. No more geographic tongue at all. This is why I’m drinking now  yerba maté. I don’t know what the connection, but there was some immune response to something in the coffee.

Some people tell me, pick up the specialty coffee. It’s called specialty because, I dunno, they have some special grains. They say that this is maybe because of the fungis in the coffee. It may be and maybe I have some like- 

[Mahmoud]
Preservatives or something. 

[Lukasz]
Oh yeah, it may be. So what I’m trying to say, many people think that they have a very healthy lifestyle, but just because something is generally healthy doesn’t mean that this is healthy for you. You may have completely different reaction to healthy ingredients. Even vegetables or fruits. 

[Jaz]
It’s fascinating because my wife, oh, I bought this blood test for myself to see if I’m allergic to anything. There’s food intolerance. And I bought it, but actually, and she won’t mind me saying this, I hope we will find out- 

[Mahmoud]
You’re allergic to her.

[Jaz]
Well, I found out I was allergic to my wife. No, I made my wife do it because God knows she needs it more than me, with her diet and stuff. So she did it. Severe allergy to dairy, severe allergy to casein, which is the main protein in dairy and mushrooms and cashews and like, there’s a whole 20 other things in here.

I’m like, damn. And so I think one of my, just, before we just circle back to the occlusion topics is that everything you’re saying is really relevant, especially in the world of TMD and healthcare in general, because two things that Lukasz mentioned guys is sleep and diet. And my mentors have taught me in TMD as well that you could do everything right, but if the patient is not sleeping well.

Or they’re in systemic upset, then they will not heal the TMD as Lukasz’s story quite rightly pointed out, and that’s really important. Taking it all the way back to that red flag. Patient’s got acute jaw issues. Make them green first before doing anything with their vertical dimension, and then going back again to the whole progressive changes and vertical dimension, right?

Mahmoud, in the UK we have this old school group. I mean, I don’t know if they teach us anymore, but there’s a Eastman philosophy. Put everyone on a Michigan or a Tanner Appliance for six months, 12 months, make sure their head doesn’t explode. Then give them that vertical dimension. The other things that Lukasz actually mentioned in his Instagram posts and agree with so much is the acrylic material or the material that the temporary is made of. It’s not even the same as your ceramic and there’s a whole adaptation that has to happen. Lukasz, tell us about that. 

[Lukasz]
Yeah, so you have to know that there are at least 10 reasons why does plane work? People think that if patient is getting better because of the appliance, it is because of the occlusion that is different now that there are many, many reasons and you have to know that one of the reason is regression to the mean.

And one of the reason is also placebo effect, which is very powerful, especially for the people with myofascial pain and some mental disorders. And usually within six months, this is what science says, 60% of your patient will recover no matter what kind of crazy appliance we’re gonna use. And so when I hear that in some occlusal schools, they have to use an appliance before prostho, before ortho, like, MAGO appliance, and they are happy that they have a huge success rate.

You know why the Indians were so effective at the rain dance? Because they were dancing until it start raining. So it’s just sometimes to wait enough and the symptoms will just go away. And you can have a patient that just got your appliance and the next day this patient’s going on a Hawaii for vacation and they have a less stress, they got an appliance.

I always tell my patients, even if now is all right, especially those with the chronic pain, you have to know that those symptoms may fluctuate. You can sometimes have a bad weather and there is a big correlation between the bad weather and chronic pain. Not with acute, not with inflammation, but with chronic pain, with oversensitization of the cortex.

Yeah, there is a correlation. Some hormonal disbalance, bad night’s sleep. This is not without the reason why women are four times more frequent patient within the TMD practice. But we have the same bite, right? The same occlusion. But we have completely different lifestyle. And I was trying to connect the dots also when I wrote the paper.

‘Gut Bless Your Pain’, but not the gut, but gut, you know? So it was about the connection between gut microbiota and the chronic orofacial pain and the role of melatonin in sleep and chronic or facial pain. And when I was reading all this, I was shocked that for so many years we didn’t look inside the guts.

I was always hearing that this is our third brain, but for me it was just a saying, it was like, ah, everybody knows that this is true. But actually, for years it was considered to be the pseudoscience. The same as a leaky gut syndrome, you know? There are things in our life when they are considered a pseudoscience until someone finally shows the proof that this is not a pseudoscience.

But I’m not saying that this is a bad way to practice medicine because if we didn’t do this, we will have a lot of shamans, chakras. I dunno, maybe chakras turns out to be truth in the future. We don’t know what we don’t know. In 2018, we found the biggest organ in the human body, and it was published in nature and it was interstitium.

Come on with anatomy. We know everything. Maybe we have to work with the quantum physics, but with anatomy we have already seen everything. We haven’t even seen the different part of the masseter muscle, which we found pretty recently. It was one of the findings.

[Jaz]
Even in anatomy, we’re finding new things. So just to highlight that, so basically testing your patients virtual vertical dimension increase purely to see if they will adapt is perhaps not a great idea. However, you mentioned brilliantly that if there are other reasons like soft tissue development, phonetics and stuff, that may be a reason to keep them in temporization for longer.

But purely to test, will my patient adapt to this vertical dimension? And that’s the main reason that perhaps we should go sooner to the definitive or sooner to the more transitional restoration. Like, composite injection molding is quite popular nowadays to get their aesthetics, phonetics and stuff, and then that will be served them well for many, many years.

Before we’re trying to be minimally invasive and stuff. Do you do that kind of treatment, Lukasz, or do you believe more and less go straight to ceramic? ‘Cause that’s longer lasting and better value and better investment for the patient. 

[Lukasz]
Provided that my patient has no speech issues or doesn’t need any soft tissue management, they got temps for two weeks because this is the time my dental technician needs to make a full mouth ceramics.

So they just got as a teeth protection and they also have those two weeks to get adapted to the new form maybe sometimes with a speech. I will talk about it much deeper with my presentation. But in general, even if you let your patient adapt on the composite and then you try to change it in ceramics, your dental technician, even if they try to do the copy paste, they will never do 100% accurately as it was before.

Even if they do, you can cement your overlays, you can have occlusal seat, your cement will just increase the video on this particular overlay and everything changes. The softness of the material will be different. Softness and hardness, right? So you had the composite, your patient was feeling good with the composite, now they got zirconia, right?

And this is not the same. You use the something mock that is splinted. All the teeth are splinted not separate. And now you put separated teeth. And the perception and the periodontium is completely different. So we very often torture people with few adaptations and they struggle with each one the same.

Instead of giving them the temporaries just for two weeks and explaining. I always say on the first appointment, you are explaining on the second one you are justifying. So if you have a patient that you suspect to have a bigger problem with adaptation, like a patient with mental disorders, I’ll speak about it.

You have to tell this patient that they may require more time. Taking into consideration the drugs they take, their mental history and so on. Don’t talk too much about it because we don’t want to create a nocebo effect, which is the opposite of placebo effect. But yeah, we have to explain those things to our patients for sure.

[Mahmoud]
I think one point our listeners need to take away is the amount of information you seem to be able to get out of patients in terms of just history, right? Like you already mentioned that with these questionnaires you’re sending out these patients you’ve never met and yet you’re able to categorize them really, really well.

Just highlights the importance of history taking, like we’re dentists, we want to get our hands on the patient, we wanna get our hands on the teeth and do stuff. But how that history can then possibly inform how adaptable or not adaptable the patient might be. Therefore you can then create a customized temporary phase. But if you go into the phonetic side, what are the common things you see people struggle with and what are your some of the possible solutions to particular problems? 

[Lukasz]
So the most common is of course, the S sound. But as many studies proved that the speech fanatics is the least predictable thing in our job. And this is also something you have to tell your patient. And what people usually struggle with is the S sound. But with every language we have a different pronunciation. So in Polish language, we say, just, whereas in Spain, they will say [sound like “ith”], right? So they are kind of lisping . In Mexico, they will say [inaudible], right?

And in some languages you would say that they have a phonetic problem, but it’s just a language. So when we and Riaz decided to do the research. Riaz has many cases done with the post and the before and after rehabilitation and with the S sound trying to trace the changes and trying to predict what the changes are, depending on the bite, depending on the incisal relationships.

There is no classification for this, and we are trying now to make this classification, but then I realized that it may be restricted to English language. Not to all the languages around the world, right? But with the S sound, what we always have to know is that this is the closest speaking position. So if your patient struggles to keep this position, the same with the people with the open bite, they’re trying to compensate, putting the tongue between the teeth, right? This is why sometimes you don’t even hear them lisping. This is why the phonetics is so unpredictable. 

Interjection:
Okay? It’s me interjecting again. And remember, I have asked, I’ll ask you at the end of this episode, how are you finding these interjections? Are they helpful? Are they not? Please guide me guys.

So closest speaking position. How can I make this very clinically relevant to you? I remember when I was early on my career doing my first few DAHL cases, right? When you add composite to worn anterior teeth, but you leave the posteriors to kind of settle occlusally. So dento-alveolar compensation, the anterior is intrude, the posterior extrude, if you like, and that’s how the DAHL technique works.

You’ve got some episodes on that already, but when you add the palatal contours of the upper incisors, imagine a wear case, the palatal incisors, acid erosion. Typically they’re worn and now you want to increase the vertical dimension. You want to add some composite there, but then the patient comes back with a lisp.

Okay? So every time they say S or the S sound, basically what could be happening is that you’ve breached the closest speaking position, right? So everyone has a different way they make the S sound. Some people’s lower incisor comes like just at the cingulum of the uppers, whereas other people’s lower incisal edge comes near the upper incisal edge, right?

So you gotta kind of see how they’re making it. And if you breach this position and the patient is not able to adapt, then the patient will be contacting, right? When they’re making the S sound, the teeth will contact and there’ll be a lisp. So what to check at this point is, I like to get 200 micron paper, right?

So 200 micron, that thick blue paper, yes, it does have a use, right? And I pop it in between the patient’s teeth, between the front teeth specifically, and I get the patient to say 66. 66. 66. And now that they’re saying this, they’re reproducing that closest speaking position. And then where you see blue or wherever you see the ink of the arctic paper, that tells you, okay, this is where the closest speaking position is being breached and probably where you need to adjust.

And this could be palatal of the upper or maybe the lower incisal edge. And there are ramifications of all this. But I just wanted to give you a little trick in case you ever do a buildup of these teeth and you find that you’ve breached the closest speaking position back to the ep. 

[Lukasz]
Because people can adapt between the teeth, between the lips and teeth, between the tongue and teeth. And finally most of them will adapt. But if at the beginning you struggle with S sound phonetics, sometimes it’s because of there is a two big space, but sometimes it is just because there is not enough space. This is when I put the 200 microns paper. And I tell them to say S sound few times. And when they are hitting on the upper incisors, I just know where to take a little bit of the material to create this proper space for speaking.

Sometimes you’ll see people destroying their teeth just because the only position when they can say the S sound properly is when they go, for example, to the left and they find the space between two attrited, worn down, canines. I saw many cases like that. So they keep on destroying their teeth and in those cases.

You’ll have to reeducate them how to speak properly because you don’t want them to destroy the ceramics. Again, this is why in my clinic we have not only dentists, we have speech therapists as well. In Poland, we say logopedas, I dunno how you’ll call those proficiency. 

[Mahmoud]
Speech therapist. 

[Lukasz]
Speech therapist, okay. So D sound. D sound is a problem when you have two bulky palatal, wall of the upper incisors. F sound, sound is problematic when you have two long incisors. Yeah, there are many, many sounds that may be disrupted because of the new material in the mouth, but usually it’s very fast to adapt and I see bigger problem with the class two patients rather than class three patients.

I was a little bit surprised because when you think about the edge to edge, worn down dentition, and this is the space which they use to say the S sound. Now when you increase video and you put two completely new incisors and you change the incisal relationships completely, I out of expect that those would be the people who would struggle most with the S sound, they’re not.

What the people that I struggle most are the people with the class two. And when you increase video, you create even bigger distance to say the S sound. So those are the most difficult patient to treat. Increasing video in class three patients is so nice. You improve everything. 

[Jaz]
Vertical chew is much easier, but that’s a whole another topic. I’m just gonna ask you two quick questions before we go into red flags, right? Because I think you’ve got a lovely presentation that we can just go deeper into maybe a couple of those red flags. Maybe in the interest of time, this is really shining a light on some of your amazing work and some great tips you’ve given already.

But I wanna just really excite everyone for AES, right? So maybe tackle the two most prominent red flags that you think there are. Before we get to that, Lukasz, I have two fun controversial questions for you, right? Which I know you love to talk about and I think it’s gonna be quite fun actually, is how many patients of bruxism have you cured from a full mouth rehab in centric relation?

[Lukasz]
Have I cured? You mean it stopped bruxing? 

[Jaz]
Yes. 

[Lukasz]
I think maybe zero. 

[Jaz]
I thought you might say that. So this is such a huge thing, right? People are claiming that bruxism is because the occlusion is not right, and when you get the occlusion right, you’ll fix the bruxism. Now, in my own experience, Lukasz, when I’ve done a bigger case, when I’ve done the full mouth rehab and I either give them a splint, I see where on the splint, or I give them a brux checker and I see that, okay, they’re still moving their jaw.

Obviously I don’t have any polysomnography data, but all the camps who are telling me that the bruxism has stopped, they are not proving it. I’m proving that they’re still bruxing after the full mouth rehab in centric relation, but no one’s proving to me that they stopped bruxing. So what’s your thought process that you wanna explain to dentists about why the occlusion or quote unquote fixing the occlusion may not necessarily stop the bruxing?

[Lukasz]
It all started with great dentists, but with a pretty bad science. I think it was in sixties with Mr. Ramfjord who wrote the papers that when they equillibrated the teeth, patient stops grinding. And the methodology was pretty awkward because they asked them if they stopped grinding. Can’t imagine, you know?

Did you grind last night? I think I didn’t. Yeah. All right. So we got a success with equilibration. People think that people are grinding because they are trying to destroy the obstacle, the premature contact to the centric relation. And you see those people with completely worn down dentition, completely flat, no premature contacts at all. They are already- 

[Mahmoud]
No grinding. 

[Lukasz]
They’re still grinding. And now they’re asking, Daniele Manfredini was describing pretty nicely, he was just reminding his old professor, his first mentor, that he said that those people have the memory of the obstacle in the past. This is why they- 

[Mahmoud]
It’s like phantom limb syndrome, but for your premature contact. 

[Lukasz]
Maybe. Yeah. Phantom, there is something that’s called phantom bite anesthesia, right? Some people say there’s a mental disorder. Some people say there’s too many receptors and the periodontium. 

[Jaz]
Lukasz, I’m gonna ask you the other, ’cause that was just me being controversial, right? So the second controversial one, I’m gonna ask you now just to set the scene before we then just cover one or two of your favorite red flags in the interest of time is, do you believe that you can palpate the lateral pterygoid in your clinic? 

[Lukasz]
No, no, it has been disproven. I mean, the science is split. There were papers that described it is possible. There were papers with the EMG that described that it is impossible. When you look at the anatomy, you cannot put your finger so much backwards.

So usually you can palpate the lateral pterygoid muscle indirectly through the medial pterygoid muscle. The question is, what for? Why should we do this if it is almost always painful? So I got a hyper diagnosis, which leads to overtreatment, right? And I always ask myself a question, whenever I put this muscle, it’s always painful.

Why should I even touch it? What should I do with this piece of information, we always have to correlate the history with examination. Because what we should treat is the familiar pain, the pain that replicates the symptoms, not the accidental findings. If you put your finger over here and you ask your patient, Mr. Jones, do you feel the pain? And the patient says, yeah, I do. Do you think it matters?

I always say, if patient has time to think whether he feels pain or not, this pain is completely relevant. When you put your finger here and the patient says, oh, oh, don’t do this, it matters. But usually those people do not come up for veneers and they’ll say, oh, doctor, by the way, yesterday something clicked in my joints a terrible pain and I cannot open my mouth.

No, they’re coming with pain. So you just confirm with examination the symptoms. No reason to do any treatment because of accidental findings. We can test the patient from the head to the feet. It’s like, what for? Are we trying to correct the posture for everybody? Like I think 99% of population has a bad posture. We can be- 

[Mahmoud]
If you’re over 40, you’ll find something that hurts somewhere. 

[Lukasz]
Limit of being holistic dentists, you know. 

[Jaz]
Well said, mahmoud. I’ve got one more controversial question. Have you got any controversial questions for Lukasz before I ask my new one that I have now? ‘Cause I’m quite enjoying these controversial ones.

[Mahmoud]
No, you ask yours and I’ll mull it over all. 

[Jaz]
So here’s my controversy, Lukasz, right? We’re very similar in thinking. Obviously I’ve been to your courses as well, so maybe that’s molded me. Let’s talk about e equilibration and centric relation as a joint position and as a goal, right?

So the beef I have with equilibration and centric relation is this, that if we accept the vast majority, now, whether you believe this is 90%, 93%, 95%, 97% of patients, their conal is not in centric relation in their day-to-day life. Their condyle is not in centric relation, it is probably slightly anterior, and that is, i.e. most people have a slide, and then our goal is, oh, I want to- 

[Lukasz]
99.5.

[Jaz]
There we are almost a hundred percent right? And so, why are we saying that these patients are diseased? Whereas actually the people who are diseased are the ones, the 0.5% who are in centric relation, they’re the ones who are diseased. So I always like, there are some clinicians who I respect, dear friends of mine, who will say that, look, every one of my patients, if I find a slide, I will offer an equilibration because there’s X, Y, and Z benefit.

But I’m thinking just like lateral pterygoid, if a hundred percent of your patients will feel pain, if the vast majority of patients have a slide, then surely they are physiological and normal. 

[Lukasz]
Of course. So we do not need to be in cr. CR is a technical position. If we want to increase vertical dimension or we want to do the reconstruction of both arches because it is easier for us.

And it is more predictable and more stable for the future. It’s just this, it’s not the vaccine for TMD. Not at all. We can have the best cr, we can have the best occlusion, and if your patients clenching in the joint, there is all the time immobilization. There’s gonna be the adherences, there’s gonna be adhesions, and there’s gonna be clicking and everything.

Interjection:
And, okay guys, Jaz again with my final interjection. Remember I do want feedback in the comments in terms of how you found these interjections and so centric relation, right? How can we not tackle this. Now, Lukasz described this as a technical position, and I like to think of it as a practical position, but a great paper by Daniele Manfredini is called Centric Relation, a Biological Perspective of a Technical Concept, and it uses the term maxilla mandibular utility position. The key word here being utility position, i.e. It can be useful to us when we are reorganizing, so we need space. We’re gonna open the vertical dimension. Where should we put the condyles?

Well, why not put the ball in the cup, right? If you liken the TM joint, extremely simplified as a ball and cup. Well, the most orthopedically stable position is having the ball in the cup, i.e., the condyle in the glenoid fossa. And that’s a repeatable and comfortable position. So why don’t we use that to our advantage, specifically the repeatability of it.

Can you imagine doing a full mouth case and the patient keeps changing where they’re biting, but now you can guide them or get them to guide themselves into this repeatable position. And so if you lose your bearings, you know exactly where to go. Think of those complete denture patients, right? So centric relation, the whole thing about sticking your tongue all the way to the back, curl your tongue to the back as a crude way to get this patient in what we used to call retruded contact position.

Well, it helps us, right? It’s a utility position. It helps to guide the patient and we are choosing to use that joint position because it’s gonna be repeatable. And so when a patient no longer has a normal bite anymore, the MIP is not repeatable, it’s not comfortable, and you want to restart. We want to restart the bite.

Then many occlusal camps will use centric relation. Other positions are available, but with the vast majority of occlusal camps, use centric relation and let’s think of it as a utility position and not so much as a vaccine for TMD or a position where all your ailments, your erectile dysfunction goes away and that kind of stuff. It’s useful, man. It’s a useful position for prosdontics. Back to the ep. 

[Lukasz]
You know, most of my patients with TMD, they are women between 20 and 40 with a beautiful bite. They don’t have malocclusion. They don’t have attrition because people with TMD usually do not have attrition. People with TMD usually are clenchers, not grinders, and clenching is not healthy.

Immobilizing any joint in your body is not healthy. This is why having any appliances that immobilize the jaw is very bad thing. And soft appliances that stimulate clenching even more is also not a good appliance. 

[Jaz]
Mahmoud, have you thought of one before we pick a red flag that Lukasz wants to present? Have you thought of any controversial things that what we can get out of our system today? 

[Mahmoud]
The thing is that every time Lukasz speaks, like he is talking so much sense. And it’s so interesting. I don’t have time to think of other stuff. I’m just listening. Right. I’m just listening. 

[Jaz]
Okay, Lukasz. 

[Mahmoud]
But it is amazing, isn’t it? That you know, ’cause I was on a podcast a couple of weeks ago. I was, and I got asked this question about centric relation and people grinding away their premature contact to get into centric relation. But it’s just, you take the two facts that we know that are, most people are not in centric relation.

That includes the people that are grinding, guess correct. But guess what? They have ground bejesus out of their teeth and yet they’re still grinding. So logic isn’t logic and- 

[Lukasz]
Yeah- Even opposite because if you look at the data, it turns out that if you incorporate the premature contact intentionally, they’ll brux less, not more. And those are the papers from /inaudible/ and a few others. And this is counterintuitive because I would’ve thought that when you get the two high crown, you will try to smash it to destroy it, to get the good MIP. But it’s not. 

[Mahmoud]
I wanna disagree with Lukasz.

[Lukasz]
The obstacle. Of course there are people- 

[Mahmoud]
I disagree with Lukasz.

[Lukasz]
Yeah, no. 

[Mahmoud]
‘Cause I don’t think it’s counterintuitive because to me, think about this, if I’m walking around and I put a pebble in my shoe on purpose. 

[Lukasz]
You’ll avoid it. 

[Mahmoud]
I’m gonna stop. Yeah. I’m gonna avoid it. I’m not actually gonna try and stomp my foot down to get the feeling to get disappeared. 

[Lukasz]
There are some people that would do it the other way around. Most of the people will try to avoid it. But people with some specific mental disorders, they will react completely differently and those will be the ones who try to eliminate the obstacle. Right? Those are the nervous people. I’m using aligners now and every week when I change my aligners, I feel like I’m clenching more, but probably because of elasticity of the aligners.

There is some new research that says that the EMG activity is not increased because of aligners. I always say, we are human beings. We are not statistics. So every human being reacts differently. But in general, I could agree that orthodontics has nothing to do with the TMD. The other thing is that mostly those research is done at the universities where the level of orthodontics is a little bit higher in most of the countries.

So I can imagine that very bad ortho can cause TMD. So I’m not the one that will tell you that occlusion is never a reason for TMD. I’m the one who will tell you that it’s so rare that I would always recommend to think about something else at the outset of the treatment and never, ever start with the irreversible treatment at the beginning because equilibration and 24 hour splint therapy is often irreversible treatment.

So if I tried lifestyle changes, maybe nighttime splint therapy, maybe collagen injections, maybe physiotherapy, that is so popular in Poland and we are very happy that we have so many physiotherapies in Poland that deal with the TMJ. I have two in my clinic that do only this.

And if I tried everything, maybe I would consider 24 hours splint therapy. But most cases it is just the diagnosis was wrong initially have to rethink the diagnosis because maybe there is some other problem. Maybe there is some systemic disorder and this is completely new story. And very often people don’t even think about doing blood tests and everything when we have the TMD patients.

We are just grinding teeth because we are trained to do so and we want the teeth to be the reason because if this is the reason, we will be able to help. We don’t want to tell our patients that this is because of the systemic disorders or some psychiatric disorders because we, ourself we consider is like showing the white flag that we just confessed, that we don’t know the answer, we do.

If your patient has a problem with the bladder, you as a dentist, you’re not treating the bladder, but you just refer the patient to the proper doctor, right? And it’s not like showing the white flag. You have to know how to refer the patient to the proper specialist and not to try to do everything with what we know.

[Jaz]
Well said. I think it’s- 

[Mahmoud]
Nail. Everything’s a hammer. 

[Jaz]
That’s it. You nailed it, Mahmoud, and I think you mentioned this point that we can want a patient to fall into a specific basket, but we should be open to the holistic nature of them. Now, you mentioned about 24/7 splints, and I agree with you, that’s a very serious thing, 24/7 splints.

The longer you wear it, the bigger change it has. And I will only reserve that treatment when you’ve done everything else in the pyramid. But also I try and reserve if patients who already don’t have an occlusion, who already have a messed up occlusion that really you can’t get any worse and sometimes they need just some stability.

Before we get into the deep dark realms of TMD, I would like you Lukasz, just maybe share your screen and share in the interest of time, one red flag that we haven’t discussed that you think general dentists ought to know about when it comes to changing the vertical dimension, which is the most interesting one that you think we haven’t touched on yet that we can discuss now for the last part of this podcast, when it comes to changing the vertical dimension, which is the red flag that you want to discuss.

[Lukasz]
If I would pick up only one, I would pick up probably the one that you don’t want me to talk about, because you have the other speaker to talk about it. I mean the airway. 

[Jaz]
That’s okay. Jeff Rouse is gonna come on. We’re gonna go deep. But what I like then is you’ve now wet everyone’s appetite for Jeff Rouse episode as well, so that’s great. Let’s talk about that.

[Lukasz]
So one of the most important red flags, when you consider increasing vertical dimension of occlusion, you have to ask yourself, why do we want to increase video? In most of the cases, we don’t increase it because the patient has lost the vertical dimension. In most of the cases, they do not lose vertical dimension because they have a dento-alveolar compensation, right?

So also the question is if you want to recreate the previous video, how do you know how high was it 20 years ago? Do you have a pictures or what? How do you know that we are recreating some? We do not. So when you have a patient that has a teeth wear and we know that there are some correlations with the sleep apnea.

And the bruxism, in one year, they’re stronger and one year they’re weaker. I believe that the problem and confusion with the data is that we put the whole sleep apnea into one back. We do not separate different reasons for sleep apnea because we can have a central sleep apnea and we can have obstructive sleep apnea.

We can have a obstructive sleep apnea because of the restriction in the nose, the tonsils, larynx, the tongue base, and I believe that the restriction in the larynx would appear much more correlated with the bruxism because if we consider bruxism as a protective mechanism, moving the jaw forward would unlock the airway at the level of the larynx, not at the nasal level, right?

So I think that this may be one of the problems with the methodology. When you see people with sleep apnea, very often they have this special appearance of the neck with the forward head posture because this opens the airway over here. And they have a low hyoid bone with a special kind of neck.

But, in the past it was rather disease of old obese males. Nowadays, it’s not anymore. This is why the STOP-BANG questionnaire is not useful for me anymore because it is mostly for those obese and older guys, and I have very slim young women having the sleep apnea nowadays.

So, whenever I have my patient with bruxism, even if I put an appliance to protect their teeth, my first choice of diagnostics is polygraphy, not polysomnography, the hospital. Polygraphy is the home sleep device. So they can order it via the internet. They just sleep with that for two days and we see what is their  Apnea-Hypopnea Index. And only then I would give them the night guard because if they have sleep apnea and I would give them the night guard, something bad can happen.

And we know that increasing vertical dimension of occlusion can exacerbate the sleep apnea. And this may be because as we know, that if you increase video, you get the rotational axis in most of the cases. And if you increase one millimeter at the back, it’ll increase about two millimeters in the front, but at the same time, you’ll have the posterior rotation of the jaw.

It’s not distalisation. It is posterior rotation of the jaw. So your airway at the level of the larynx can restrict even more. Of course, this is generalization that this is the one to two ratio. It could be the one to two ratio with the normal pre-industrial skull. Nowadays we have the epidemic with the modern skulls.

This is called a dis evolution because we have a case that are mouth breathers. They eat very soft diet. So there is a dis-evolution of the skull. And if you look at this high gonial angle, patient probably increasing one millimeter over here would increase at the incisal level about three to four millimeters with the much more pronounced posterior rotation of the mandible.

So we know that when we look at the level of the larynx, increasing video can be harmful. Here I’ve got my click that when we increased video of the leave gauge during the course for her, she said that the bite, she felt comfortable in this position, but not in this position. 

[Jaz]
So chin up positions those listing like neck extended up.

[Lukasz]
It was helpful for her. Ever since she went down with the chin, she couldn’t breathe and look at the neck. This is clearly sleep apnea patient, but during the courses which I do, we trained also on manipulation. So I do it on my participants and they do it on me just to be clear that they do it right.

And once I did it on one of my colleagues and what I’ve seen was pretty astonishing. Take a look. So this is his maximum intercuspation. As far as remember he has been treated by his wife with ortho.

[Jaz]
Dangerous. 

[Lukasz]
So this is his MIP. And now I do the dose and manipulation for him and this is his cr. And now you wonder what should we do? 

[Jaz]
So just to describe for the audio listeners, Lukasz, is a huge slide. So it looked like everything was like class one, but now he has a huge, no terrible class two and AP slide, basically. Huge Class two. Absolutely. 

[Lukasz]
Yeah. So for many people going into CR would be going distally, and for some people it would not be just one millimeter. It may be even six millimeters like you saw in here. Now, I would say in most of the cases, centric relation is a very helpful position for doing prostho for increasing video and much the most repeatable, the most stable. But in some cases, I would think twice. What do I want to do? If this was my brother, I would say, bro, if you really want to have it very stable for your lifetime.

Probably would have to do it in cr, but then you would require orthognatic surgery. If you want to do it in MIP, we can go on. You would not have to cut your jaws, but you are at risk of relapse in the future. If somebody ever decide to put you at an appliance, you may end up with this open bite. If you ever get very, now, if you get a lot of anxiety, you’ll get a post-traumatic stress disorder and you’ll be all tensed.

Maybe your muscles will pull your condyles into cr and I’ve seen many cases like that, and this is very common reason for relapse after ortho. If it wasn’t done in cr. I’m not saying that every case must be done in cr, but if you are far away from cr, and let’s imagine that in 20 years somebody would decide to increase his VDO because he has attrition.

They’ll be surprised, right? And they’ll be very confused which bite should they use to increase vertical dimension of occlusion. So for some people, going into CR is not only posterior rotation of the jaw, it’s also distalization of the jaw. And I have checked some papers if anybody has ever talked about digitalization of the jaw while getting into cr.

And there is zero papers. There’s only one paper from 2023, which says that there was no papers. So that was basically the conclusion. There is a theoretical risk, but there are no papers, right? So the thing is that if you look at the normal patient. This is the normal patient with a very wide airway. And this is the patient with the sleep apnea, with the very narrow airway.

So this is even worse if you put the patient in a supine position. And let’s look at this area because in here, we got the attrition and anterior area. And in here you got the airway. So now if we increase vertical dimension, look what gonna happen. So you will restrict the airway. But now let’s say you had a patient with bruxism and this patient also had a sleep apnea.

Your reconstructed teeth with ceramics, it may turn out that you got the patient with a bigger sleep apnea, and if it correlates well with his bruxism, you’ll have a patient with a bigger bruxism. And so now you don’t want your patient to destroy your ceramics, right? What are you gonna use? You will use the night guard, which will increase video even more.

So we went from here up here, right? And there are many papers showing this correlation with adverse effect of the night guard on the sleep apnea. So, very often the solution is to use the mandibular advancement device for those people because then it works like head and shoulders two in one.

You protect the teeth and you protect the airway. But to have this, you have to know that the restriction is over here. This is why after doing polygraphy, we very often do DISE, Drug-Induced Sleep Endoscopy. We put our patient on the propofol and we put the endoscope into the nose to check where is the restriction, because if the restrictions in the nose, this appliance will not help at all.

So if you ask me if there is a patient, that increasing video would exacerbate the sleep apnea, I would tell you that this should be not only one factor, but combination of factors like patient that already has a sleep apnea patient that has significant elevation of video. And what does it mean significant?

I don’t know. It’s like I would say one millimeter increase. Three millimeter increase is not significant. But for this patient that you see on a screen that they very often describe on during the lectures, big case, we increase I think 10 millimeters. So this is significant. If at the same time there is a big shift between the maximum intercuspation and centric occlusion, the risk of increasing sleep apnea is even bigger.

If at the same time this patient already has restriction in the larynx. The risk is even bigger. If the same patient has a high gonial angle, probably the risk is even bigger. So this is like plane crash. They say that it must be at least seven reasons for the plane catastrophe, not a single one.

So this is why for many patients, we just use this appliance and we use DISE at the end. I will just show this a short video to let you know. 

[Jaz]
That’s because I saw on your Instagram as well, and this is the highest level of diagnostics, man, like you are actually making sure that actually bringing the mandible will actually help your patient. A, not just then putting them through the risks of a bite change and also immobilization. That happens to a degree with these appliances. I mean, kudos, man. 

[Lukasz]
This is called the precision medicine, right? Because I had so many patients that had the surgery of the soft palate. They have surgery of the nose, they cut off everything, and then it turns out that, oh, it didn’t work.

So let’s try to check if the restriction is not in the larynx, we cannot do those surgical procedures blindly because those are irreversible, right? This is why we do the DISE first. But in this video, you’ll see that we can actually also set the appliance at the proper protrusion using DISE. This is not something I do regularly.

Usually we use just subjective, symptom-based protrusion. So we give this appliance and every day we tell our patient, if you feel very sleep in the morning, if your wife says that you are still snoring, just make two screws more protrude, the jaw half millimeter forward. Some people say very subjective things, so they are asking, how did you decide that you don’t want to go even more forward? And they said, Doctor, I got a morning glory again as a teenager. So, this is not objective data. This is clearly- 

[Mahmoud]
I think you should write a paper, Lukasz, I think there’s a paper in that somewhere. 

[Lukasz]
Probably, many patients will not confess. But I think I had at least three guys that said, so. Take a look at a video.

I want to invite you to the operating room where, where we perform very special procedure, diagnostic procedure for the patient that has just received their prosthetic work from me. So the procedure is called DISE, so drug induced sleep endoscopy. So we start with the injection of the propofol so that the patient is sleeping and then my ENT doctor is placing the endoscope into the nose so that he can clearly see the upper airways.

We see the soft palate, we see the the tonsils, we see the larynx, and now what I’m doing, I’m turning the special key that is moving the mandibular advancement device forward. So we are setting this appliance under the control of the endoscope, which is not typical procedure.

Now, the patient stopped snoring, so I do not have to move this device anymore forward. So we have the ideal position, not only for the TMJ, not to overload it, but also for the airways so that the patient will be very happy.

Yeah, so this is it. 

[Mahmoud]
Very happy. 

[Lukasz]
Yeah, I had all those other red flags, but I will save it for the other. 

[Jaz]
To have a conversation with superstar like you, like you have to, you could speak for like 20 days in a row and it’d be like, honestly, the amount of research you’ve done, your PhD, everything is so much of value.

So I just wanna thank you for spending this time with us and really excited to see you again in Chicago next year. But I also wanna just take a moment to just highlight. 

[Lukasz]
That’s gonna be my first lecture ever in US. So I’ve been lecturing like all over the world and all the continents. This year what we are gonna have. Actually, I’m gonna have many people from UK on our summer camp this year. We do like eight days. But yeah, the event in Chicago will be probably amazing. I’ve never been on the American Equilibration Society, but I’m really- 

[Jaz]
Dude, it’s amazing, man. But man, the videos of summer camp look absolutely amazing. I would come this year myself, but I know you’re teaching in Malaysia the same group. I’m doing a little bit in August, the same date.

So maybe next year. I mean, your summer camp just looks like a great festival of occlusion, man. Like me and Mahmoud, like when we see the videos, like I messaged him like, dude, man, Lukasz’ summer camp looks so good and you have great speakers like Calita and Riaz and stuff. Amazing man. Honestly, hats off to you for making- 

[Lukasz]
I feel like, again, like a teenager on the camp, on the high school. 

[Jaz]
Definitely send that vibe. Lukasz, thank you so much for your time, for your contribution to dentistry and occlusion to temporomandibular disorder. Really excited to see you grow and grow and grow and, and put more stuff out there.

So from us as a profession, thank you. And thank you for geeking out with us. See you in Chicago at AES next year, but hopefully we meet sooner than that as well. To me and Mahmoud are going into Copenhagen next month. There’s Occlusion conference there. Are you going there by any chance? 

[Lukasz]
No, no, no. I actually, I don’t have any free weekend until the end of the year, so I really have to be busy with the events and usually I’m at the events where I’m speaking, so this is how it- 

[Jaz]
Exactly. I thought that might be the case, but anyway, it would’ve been nice to you. But we’ll see you next year for sure. Anyway, but we’ll keep in touch my friend. I’ll let you know when this episode’s out.

Well, there we have it guys. Thank you so much for making it all the way to the end with an absolute superstar, Lukasz Lassman, and thanks to my partner in crime, Dr. Mahmoud Ibrahim.

I do wonder if you enjoyed those interjections, like did I annoy you? Please let me know if it was annoying. For me to interject now and again, just to bring things back to basic again, I really would love to know if you find that helpful or not. So please do on protrusive guidance YouTube or wherever you’re catching this, DM me on Instagram @protrusivedental. I really would love that feedback.

As this is an AES special episode, please do join us next year. That’s Wednesday 18th, February and Thursday 19th, February, 2026, in Chicago. The website is aes-tmj.org. That’s aes-tmj.org. If you are in the states, you have no excuse, right? This is plenty of warning. Come and join the most comprehensive organization when it comes to dentistry.

Geek out with us for a few days. It’ll be great to you there and around the world. What a great opportunity to go to a tax deductible trip to the US of A. Let’s try and not focus on Trump and all the bad things happening in the world. Try and focus on the good things, i.e., the dentistry, the education, and it’s no secret that I’m a little bit partial to the US junk food.

Anyway, thanks again for listening. This episode is eligible for CE credits. We are a PACE approved education provider. If you’re on our app, that’s protrusive.app. The website is protrusive.app. On the paid subscription, you can answer our quiz, and my team will send you your CE certificate. Thanks to everyone who supports Protrusive and validates their learning through reflection and certification.

Man, that was a lot of fun I have to say and I enjoy geeking out with the Lukasz today, and I hope you did too. I’ll catch you same time, same place next week. Bye for now.