In this episode, Jaz dives into the complexities of Temporomandibular Disorders (TMD) management with Dr. Suzie Bergman, a US-based dentist and TMD sufferer. They discuss why treatments for TMD vary so much and examine the current state of evidence-based approaches.

https://youtu.be/r3QpkMYeTWk

Dr. Bergman shares her personal journey, highlighting conservative treatments, the role of occlusal appliances, and the power of multidisciplinary care. But just when you think you’ve got it all figured out—Dr. Bergman reveals a game-changing insight that could completely shift your approach to TMD management. Ready to find out what it is?

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

Highlights of this episode:

02:40 Protrusive Dental Pearl
04:32 Meet Dr. Susie Bergman: A Personal Journey with TMD
7:27 The Wild West of TMD Treatments
10:32 Challenges in TMD Research and Treatment
13:34 Suzie’s TMD Journey: From Trauma to Advocacy
21:42 Evidence-based Therapies and Occlusal Appliances
27:11 Orthodontics and TMD: A Complex Relationship
33:40 The Role of Occlusal Appliances
35:05 Debating Disc Displacement
39:17 Comprehensive TMD Diagnosis
44:09 Orthopedic Stability in Dentistry
51:04 Splints and TMD
53:52 Managing Bruxism Effectively
58:16 Suzie’s TMD Course and Final Thoughts

Listen to Dr. Suzie Bergman’s “Why is healthcare disjointed?” | TEDxStrathcona Women

Check out Dr. Suzie’s Course “21st Century TMD Protocols”

Looking for an Online course to allow General Dentists to treat 80% of TMD cases and 100% of Bruxists? Check out SplintCourse Online by Jaz Gulati

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: 200 Orofacial Pain (Diagnosis and treatment)

Dentists will be able to:

1. Recognize the multifaceted nature of Temporomandibular Disorders (TMD) and the various factors influencing treatment variability.

2. Evaluate current evidence-based treatments for TMD and their effectiveness, including conservative methods and occlusal appliances.

3. Discuss the importance of a collaborative approach in TMD management, integrating different specialties for optimal patient outcomes.

If you loved this episode, be sure to check out Deep in to TMD – An Orthopaedic Perspective – PDP172

Click below for full episode transcript:

Teaser: I tell them T. A. T. U., which stands for Teeth Apart, Tongue Up, so during the day as much as possible, try to keep your teeth away from each other so that you're not clenching. I tell them, we want you to do the three S's, which are-

Teaser:
I always tell people it’s unrealistic with chronic pain patients to think that there will be a day that you go to zero in pain. I don’t know what it’s like to not be in pain. Some days might be a little bit better, but there’s never a time that I’m not in pain. And part of that is because- When we have pain for so long, it can become a central nervous system issue. So when we have that central sensitization, our brain interprets non painful stimuli as painful.

We have patients who have discs that are either anteriorly and medially displaced, which is most common. It’s very uncommon for there to be a posterior displacement of the disc. We have to think about how that patient’s body has responded to the changes if the disc has been displayed. Some people will adapt beautifully and some people will not. And so, it’s really about the individual patient.

Jaz’s Introduction:
The management of Temporomandibular Disorders is like the Wild West. I know for a fact that for the same issue you can go to one dentist who will suggest orthodontics, you can go to a surgeon who may suggest some form of surgery, even if it’s like an arthrocentesis, you can go to another person they might suggest some botox to calm those muscles, whilst the next two dentists are still arguing about which splint to make for this patient.

And so why does this happen? You see, the number one reason I think this happens is because we still don’t have clear protocols and clear guidelines because there’s a lack of evidence and there’s numerous reasons for that that we unpack in this episode with Dr. Suzie Bergman. She’s a dentist from the US who herself is a TMD sufferer and she’s had surgeries and orthodontics and all sorts. Which is why she can truly empathize with her patients and I love the fact that she’s willing to share her journey. This journey of chronic pain, which so many of our patients suffer with as well.

From this episode, what you are going to gain is an understanding of how we can manage temporomandibular disorders in ways that are evidence based and what should be considered from the evidence that we do have, by the way, and in a way that is not irreversible and allows a patient to do more fringe treatments, let’s say, in the future, rather than going in for more irreversible therapies, and you get a good flavor of that.

Hello, Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast. Every PDP episode, I give you a Protrusive Dental Pearl. Can you believe, by the way, that we’re almost at episode 200? There’s actually almost 300 episodes when you count all the group functions and the interference casts, but that magic 200 number is coming for the PDP as well. If you’re a new listener, welcome. If you’re thinking, why I talk about onions so much, keep listening and you’ll find out. And of course, if you’re a returning Protruserati, keep chopping those onions.

Dental Pearl
The pearl today is kind of like an emotional one. One of my mentors, Michael Melkers, shared this with me and I want to share it with you because chances are if you clicked on this title then you may be used to seeing patients who suffer with TMD and oral facial pain and you more than likely have had this experience where the patient tells you their story, and disproportionately, this is a woman.

Disproportionately, this will be a woman, eight times more than it will be a male, and she will start crying. And this happens a lot in my clinics, and the nature of how we run things, and the referrals that we get with patients with long standing pain. And so what I used to do is me and Zoe would look at each other, and we’d get the tissues, and try to connect with the patient.

We’d we’ll be there for the patient at that moment. But what Michael Melkers suggested is that by giving the patient tissues, You’re kind of blunting their emotions. You’re kind of saying, actually, no, no, just dry your tears and let’s move on from this. You’re kind of not allowing the patient to express themselves.

So actually listen to that and I change what we do when a patient is vulnerable and they’re sharing such emotions and they’re getting a bit teary. I just listen. I just listen. I let them tell their entire story. And then at the end, I’ll help them with the tissues. But I really want to make sure I’ve listened to everything and I’ve connected and I haven’t missed an important part of their story.

And so like with everything, two ears. One mouth. Listen twice as much as you speak. I sound like my year eight history teacher. But it’s true for everything. This episode is eligible for CE and CPD. It’ll be worth one CE credit or one hour of CPD. You’ll be able to get that from the Protrusive Guidance app on the App Store or the Android Store.

If you haven’t already made an account, head to protrusive. app and join the geekiest and nicest community of dentists in the world. We’re sometimes a little bit slow by a couple of days to approve you because we actually manually approve each person. We want evidence that you are a dental professional joining our community because this needs to be a safe space. Anyway, let’s join the main interview with Dr. Suzie Bergman and I’ll catch you in the outro.

Main Episode:
Dr. Suzie Bergman, welcome to the Protrusive Dental Podcast. How are you?

[Suzie]
I’m great. Thanks for having me, Jaz. And please just call me Suzie.

[Jaz]
I appreciate that, Suzie. Suzie, I’m so excited to speak to you. You’ve been on my radar for a few years. I know we emailed about some events in the past. And then you sent me recently your TED Talk. What a wonderful job. I’m definitely going to link that here. It’s something that every dentist should watch, but also there are some, unfortunately, so many patients who suffer with TMD who would also benefit from having that perspective.

And your story is so powerful. Could you spend a minute? Just tell us about you, your story. How did you niche into TMD? Are you still a general dentist or are you just like, have you niched into TMD? Tell us more about that.

[Suzie]
Okay, great. So yes, I am technically a general dentist, but I like to call myself a primary care dentist. And I really don’t, I’m not someone who picks up a hand piece and does fillings and those kinds of things. What happened was when I was a teenager, I was involved in a fluke accident where basically I got run over by my friend’s car. And I became a TMD patient even before I became a dentist.

And back then the treatments for TMD were archaic to say the least. And so I spent many years trying to figure out what to do and how to be able to continue my career. Because of the experience that I had, patients were drawn to me. So I started treating more and more TMD patients. And now the bulk of my practice is TMD. I also work at a university and do research and I’m involved in advocacy and infrastructure for TMD patients.

[Jaz]
It’s wonderful to hear your story. And then you obviously talk more about it in your TED talk, which I will direct everyone to. That was so well delivered. It’s a powerful message. And in terms of how I got into TMD Suzie, I mean, I am a general dentist.

I am happy to pick up a hand piece. I love doing fillings, rubber dam, crowns, that stuff I love, but I’ve dedicated like Mondays, for example, for me are my TMD days because I get great enjoyment fulfillment. I’m treating TMD, but I still, I just love dentistry. So I don’t want to limit myself just TMD and the way I got into TMD Suzie is when you start learning more about occlusion, the foundational thing about occlusion is, let’s assess the joint health.

And I started to feel more confident assessing the joint health. Then I started to realize, oh, this is health and this is not health. And then how can I help my patients become healthy enough to have the restorative care? And then I started to get some early successes, early wins, which really gives you a great boost.

Patients who tell you their headaches after 11 years are finally gone. Patients who have a positive outcome and you think, wow, this is really, really great. But then you get into the deep end of treating chronic pain patients. And wow, you have to like pain is such a fascinating beast. And I’ve had some really great learning experiences from lots of mentors.

And I’m really excited to have the chat with you because what I told you in that email, Suzie is something I truly believe is true, which is I think TMD care, even today is like the Wild West. in the sense that clinicians all over the world, and I see this a lot in the states, no offense to anyone right, but claims that are made of certain therapies and whatnot but we don’t have any evidence to back it up.

This is also partly to do with the lack of evidence and maybe there are good treatment modalities but they’re just evidence isn’t there yet and we need to figure out as a profession, how we can rectify that, how we can get that research. But what do you think about this analogy of the Wild West and how it applies to TMD?

[Suzie]
100% agree with you. And I say that as well. I’m from wild, wonderful West Virginia. And I can tell you the things that people have been doing for the past 30 or 40 years that have not been working or have caused patients to not improve and unfortunately, sometimes get worse, are things that we have to accept as a profession that when you know better, you need to do better.

And just because someone has fancy equipment doesn’t mean that it’s evidence based. So, I completely agree with you. And that’s part of my message. I went from specialist to specialist. Even when I was in dental school, they used to send me around to all the different departments because they thought it was funny that when I opened my mouth, it would swing over to one side and they would say, Oh my goodness, look what Suzie can do with her jaw.

But the truth was that I was very badly injured in that accident and did not really realize that. But I didn’t make the connection. I had bleeding in the joint space. I had, both of my discs were very anteriorly displaced. And I went through a lot of occlusal guards in the nightstand drawer, different treatments that people gave me.

And I was a dentist who really felt like I understood this. So, thinking about a patient who doesn’t have that background and that knowledge, sometimes they just get passed from provider to provider before they find someone who is knowledgeable and is also willing to say, there’s still a lot that we don’t know, so let’s be conservative in our management.

[Jaz]
I feel like you’ve taken the words exactly from my mouth when I say to my patients. So I’m a big fan in dentistry overall, not just TMD, but in dentistry, I’m a big fan of showing patients my working out. So when I recommend a plan, I always say, okay, this is based on the following facts because you have decay in this main teeth and you may want orthorhontics in the future.

Therefore, I thought this might be the best for you because X, Y, and Z. So when it comes to TMD, because we lack a lot of truth, I think, okay, because we don’t know which way you’re going, I think here’s the stuff that’s safe to do. That’s conservative as a first line before we escalate or do anything that’s irreversible, that sends to me.

And you know what, Suzie, sometimes I feel, sometimes I look at all the claims that are out there and clinicians that are perhaps a bit more aggressive and I think am I missing out in helping my patients? Am I missing out in serving my patients? Because perhaps I’m being a little bit too conservative.

Those thoughts do cross my mind. But I think it all stems down to, you mentioned the research, the evidence base. Where are we at in terms, cause you mentioned you do some research, where do you think TMD research is at both in terms of quantity and quality?

[Suzie]
So, first of all, let me say, I don’t think you should change your approach at all because conservative is safe and effective, and when we have to move to things that are a little bit more involved, at least we have tried the things that will not harm the patient, things that are self management type of thing.

In terms of research, that’s something that I really, really feel strongly about because last year in the U. S., we doubled the amount of dollars that we were spending on TMD research. So we had a whopping 35 million dollars of research dedicated to TMD as opposed to 2. 4 billion dollars for diabetes research.

So the problem is definitely a quantity issue and then the other problem is that we work in silos Unfortunately, TMD is kind of in a no man’s land where there are people who say dentists shouldn’t even be treating this. It’s multifactorial. We need physicians to treat it. But physicians say, I don’t want anything to do with this.

This is the only joint in the body that isn’t treated by orthopedists. When we’re doing our research, I strongly, strongly feel that we need to break down those silos and look at this from an orthopedic standpoint, because we’re talking about joints. So we’re not talking about a little click that has something to do with the way our teeth fit together.

[Jaz]
Well, there’s obviously a major funding issue there. But even when we look at the research, I draw comparisons to the research in even just occlusion, right? There is very little that we recommend in a practice of occlusion and full mouth rehab and that kind of stuff that is very well evidence based. And I think part of that issue is that there are so many of the confounding factors like tooth contact time during the day. Stress is variable in individual, the perception of pain varies by a factor of four individual to individual.

Differences between men and women difference between someone with a long ramus height versus a short ramus height like because there’s so many variations in an individual and also of course trauma history everyone’s trauma different type of trauma because I always thought there’s so many variables that we may never ever get the type of research that may be possible in other realms of health care. And that is sad, but it’s also something that we need to work with that to develop some sort of trials and protocols that we can perhaps draw some conclusions. Would you feel that way as well?

[Suzie]
I do. I completely agree with you. I think that besides the lack of quantity of research, there’s also a problem with researchers really having yet unraveled the etiologies and the pathophysiologies of TMDs or meaningfully translating that research into improved clinical practice.

[Jaz]
Would you mind sharing your journey, Suzie? Because I mean, I know that’s n equals one case history, which is the lower down the pecking order, but I would love to know where you are, if you don’t mind sharing, where are you at now with your TMD with your chronic pain? Is that still an issue for you now or is that something that you are managing well now and what steps worked for you? I’m not saying I’m condoning this for everyone. If a PMD patient is listening or watching this doesn’t mean that just because it worked for Suzie it’s going to work for you. You have to be mindful of that. It has to be an individualized approach. But tell us about what helped you?

[Suzie]
Absolutely. And I like that you said, it’s an individualized approach because my situation is very different from someone who maybe developed some problems from having a dental procedure where their mouth was open wide for a long period of time.

And everyone’s path is a little bit different. So I always emphasize that too. Now, my situation was that I was 19 years old when I had this major macro trauma, so outside the body trauma. And it was during the time that treatment for the kind of condition that I had was very controversial and there were implants that were being used that later were taken off the market at the pro class implant because pieces of Teflon would actually break off and go into the patient’s brain.

So there was open communication and giant cell body reactions. So when I started my journey, I was just constantly told, avoid surgery at all costs. Even though eventually, someday you may end up needing surgery, which did happen because eventually my joint ankylos, so I had no translation when I opened my mouth, I just had a very, very tiny opening.

[Jaz]
This is also known as a anchored disc phenomenon, right? Is that the same thing?

[Suzie]
No, so mine was a little bit different. What happened was the discs were completely gone. They were anteriorly displaced. I had two surgeries to have them reattached, like repositioned and attached, but unfortunately the surgeon that worked with me did cause more problems than he fixed because he did not follow an evidence based protocol afterwards. And so I was definitely emotionally traumatized by what I went through. I wasn’t allowed to pick my baby up for three months. He was 14 months old at the time. I wasn’t allowed to chew for over a year. I wasn’t allowed to sleep in a bed for four months. I had to sleep in a recliner sitting up.

I was only allowed to talk for five minutes per hour. These are not evidence based protocols. This was the surgeon’s idea of how he thought that I would improve, but I was wearing an appliance that actually atrophied my muscles because I had no lateral or protrusive excursions with the appliance. So after two surgeries that probably set me on a faster road to what eventually happened in 2019. I started the process of getting TMJ implants, so custom implants.

[Jaz]
Is that a total joint replacement?

[Suzie]
Total joint replacement, yes. And so the right side was so bad that I had to have that surgery done in stages. So for a period of about three months, I had no joint on the right side. And then I got the custom joint and then the pandemic happened and I went several years before I was able to get the left side done.

I now much better than I’ve ever been, but I always tell people it’s unrealistic with chronic pain patients to think that there will be a day that you go to zero in pain. I don’t know what it’s like to not be in pain, but I used to be-

[Jaz]
So you’re still in pain now, would you say? Like, would you, if I was to, yeah, you’re just about to give some scores now. Lovely. Please.

[Suzie]
Yeah, I would at a nine probably for several years and I would say these days I hover around three probably. Some days might be a little bit better but there’s never a time that I’m not in pain and part of that is because when we have pain for so long it can become a central nervous system issue.

So when we have that central sensitization our brain interprets non painful stimuli. as painful. And so I’m doing very well taking a medication called low dose naltrexone, which has helped me quite a bit. And I did a lot of physical therapy. I’m very mindful about my sleep hygiene. I understand that I have to modify the way that I do things just so that I can be productive and that I can help my patients and be there for my family.

[Jaz]
I think what you’re saying is so hard hitting, and I think it’s almost like to tell someone, look them in the eye and say that, there is no cure, right? Essentially you said that you went from a nine to a three. You have come to peace that you may never be a zero, right? And I think the first time a TMD patient may learn that, it’s not a nice message to hear, right?

That you can dial it down and there may not be a cure. And I think we’re chasing after this elusive cure. So maybe part of education therapy and then also cognitive behavioral therapy, how your coping mechanisms, did you have any psychological interventions either you’ve had or that you recommend to patients?

[Suzie]
Yes, absolutely. So when I was in dental school, I was very depressed and I had not made a connection between the fact that I was in pain and the depression. I really just thought that’s what happens when you’re a student. You’re studying all the time, your social life has to take a backseat, you’re tired, all of these things, I did not really make that connection.

It wasn’t until years later that I came to understand that anxiety and depression go hand in hand with chronic pain and I really recommend this triad of care for TMD patients. So a lot of times you hear people say there’s a bi directional link between mental health and medical conditions or a bi directional link between medicine and dentistry, but in my mind it’s not bi directional, it’s a triad.

So there’s medical, dental, and behavioral health that all have to go hand in hand to treat the whole person. And as I talk about in my TEDx talk, we can’t look at one part of the body, in one exam room and say this has nothing to do with another part of the body or with our mental health. It’s all related.

We’re all one person and if we take that more holistic view of things, we can have better outcomes for our patient. I do believe that CBT, Cognitive Behavioral Therapy, is an excellent treatment modality for anyone who’s dealing with TMD pain and that’s something that I’m incorporating into an interdisciplinary practice that I have started with some of my colleagues.

So we have behavioral health specialists, physical therapists, speech pathologists, primary care physicians. And we’re getting ready to add a nutritionist and a nurse practitioner to the team.

[Jaz]
Amazing. Finally, as you said, Ted Talk, putting the mouth back in the body, right? Putting the joint, putting the head back in the body. And that’s wonderful. I think an ideal TMD sensor, which is what we need. We need centers, right? We don’t need solo practitioners. I work very closely with a physical therapist and I have people to refer to nearby, but to have everyone in one house. Wow. In one setting, ideally is what we need to strive to.

Moving the conversation more towards perhaps clinical and also some of the conclusions that are safe to make. So for example, there was a recent article in, I think it was the British, it might’ve been the British Medical Journal. And it looked at the evidence base and actually the evidence base suggested that occlusal appliance therapy was the thumbs down. And there’s certain things that thumbs up and occlusal appliance therapy was thumbs down.

A lot of what I do is occlusal appliance therapy anecdotally. And also for my audit, I get good success. Is it 100%? No, but it’s reaching, 70%, 80% basically. So what do you think is a good first line approach? Now, obviously there’s a very difficult way to address this topic because TMD is an umbrella term and we have to just take a step back and appreciate, okay, what are we dealing with?

But then in terms of moving away from the wild west and going to like a, what is a safe zone? What are the proven evidence based effective therapies that are good to try as first line? If you could help me understand that and our listeners understand that a bit more.

[Suzie]
Sure. So the things that we do now are that self management is very powerful. Things that don’t sound that impressive, like hot and cold therapy that is safe. It is effective. Things like physical therapy. As you said, I feel my physical therapist, she has magic in her fingers. And I always say she makes me look good because patients come in and I tell them, I really want you to see my physical therapist and they come in the next visit with a huge smile on their face and say, I’m already starting to feel better.

I’m understanding that I have exercises that I can do. I give them lots of acronyms. I’m an acronym girl. So I tell them TATU, which stands for Teeth Apart, Tongue Up. So during the day, as much as possible, try to keep your teeth. away from each other so that you’re not clenching. I tell them we want you to do the three S’s, which are softer food, smaller bite, slower chewing, things that put less of a load on the joint.

We do sometimes need occlusal appliances. But recently, I was privileged to be part of a group that wrote a paper on the evidence that we now have regarding occlusal appliances, which types are safe, which types should be avoided, who needs one. In the past, we kind of just thought, oh, you have a click, you have a pop, you have pain, here you go piece of plastic, right?

It’s not that easy. It’s not that simple. So there are times when an occlusal appliance is warranted, but unlike we believed in the past that once somebody had that appliance, they needed to use it for the rest of their lives. Now we know that an occlusal appliance can just be something that’s used for the short term.

While we’re establishing occlusal harmony and our goal is orthopedic stability of the masticatory system. We can also use NSAIDs in certain cases can be used, so non steroidal anti inflammatory medication. I’m a fan of topical applications, the topical creams that don’t have a lot of side effects and the patient can decide when and how much to use.

And I am very, very much against things that are irreversible until we have tried the conservative management. So even though I’m a surgery patient, I don’t recommend surgery for the majority of TMD patients. I also don’t like to see patients come in who have been told, we need to put a crown on every tooth in your mouth.

I know that can be unpopular. There has been a battle between the occlusion camp and the non occlusion camp when it comes to TMDs, but they came together to have what we call a meaningful discussion, as my friend, Dr. Jeff Okeson said, and that meaningful discussion looked like the battle of Braveheart.

Yeah. So we have to understand that anytime we change something, we’re introducing a variable that may be difficult to piece out, if things have changed in a way that’s not easy to go back to what the patient had before treatment.

[Jaz]
Two modalities you haven’t mentioned yet, which also quite controversial and maybe higher up in the, I use a pyramid. So at the bottom is where we start the foundations. It is self-management. It is physiotherapy or physical therapy as you call it, there basically, and much, much higher up, the plans and much higher up box room toxin and a higher up is like adjustment orthodontics, that kinda stuff. So tooth adjustment and orthodontics. Where are we at now with the evidence base?

[Suzie] Okay, so I will just start by saying I am an orthodontic instructor also, so I do a lot of orthodontics and I do orthodontics on patients who are stable. Orthodontics for me is not something that should be a modality to address a TMD complaint.

If a patient has some TMD issues and they stabilize and they have an unstable malocclusion, then orthodontics may be necessary. But in the same way that we don’t move teeth in the presence of inflammation, when it comes to periodontal health, we tell our patients we can’t start ortho until you have no deep pockets, no areas of bleeding on probing.

We don’t want to make the periodontal condition worse through our orthodontic treatment. The same thing is true of the joint. So if we have someone who’s coming to us and saying, I heard that if I get braces or Invisalign or aligner therapy, my TMD should improve or go away. What we know from evidence is that orthodontics does not cause temporomandibular disorders, but orthodontics also does not cure temporomandibular disorders.

And when I say this, sometimes people tell me you are dead wrong, but I actually have research to support that. Now, the caveat is that all of the research was done on growing patients and also in a very controlled environment in universities where the orthodontics was at a very high level.

So when patients are growing and adapting, the joint is a very adaptable joint. And if we’re careful with it and we don’t move teeth too fast, the body system can keep up with that. But with patients who are not growing and with sloppy orthodontics. We do see problems and we have to understand that that’s very similar to, let’s say someone did an MOD composite and they hit the nerve and now the patient has to have a root canal.

Do we say the decay caused the root canal? No. What caused the root canal was the fact that overtreatment was done or incomplete or incorrect treatment was done. So we have to understand that with orthodontics, we should never make promises to patients that we can’t keep. And I would never tell a patient, when you’re done with ortho, you’ll be cured from your TMD.

But I can tell them that there are instances where fixing their unstable malocclusion could be helpful. A lot of people are walking around with stable malocclusions, right? There are lots of people who have crowded teeth, they have class 2, or maybe they have spacing between their teeth, all kinds of different situations that aren’t the ideal occlusion, but they aren’t having issues because they have enough contact on enough teeth, they’re able to chew well, they’re not heavy loaders.

They don’t have a lot of parafunctional habit, and because of that, they are able to walk around without the perfect straight smile, but then the people who have malocclusions that are unstable are going to have instability in the entire orthopedic masticatory system. If that makes sense.

[Jaz]
It does. And I’ve just got some more follow up questions. It’s a very hotly debated topic. This is the kind of stuff like in occlusion camps, people get into fist fights. So it’s really sad, we should really be open dollar, like even some things you said there, I respectfully would say, you know what, I’m slightly, I’m not in the opposite spectrum at all.

But for example, do I think orthodontics? I think you made a good point that, okay, if it’s sloppy orthodontics or perhaps some features weren’t accounted for. Could that lead to temporomandibular disorders in the future? Possibly, and whilst the evidence is in support that there is a true link, I’m open that, okay, this could be possible.

We just need more research. I mean, the example I can give you is when orthodontics is finished and the orthodontist may not be someone who’s actually checking the masticatory health. So the patient actually isn’t like the patient’s one side temporalis is firing, but the other one isn’t. And then, but they’ve got nice straight teeth.

Okay. And at macro level, the teeth look like they’re hitting together, but at a micro muscular level, things are unbalanced. So there’s compensation that has to happen. Now carry that forward many years. Plus the patient’s poor adaptive capacity. plus the patient’s hormonal, whatever. Like, I’m not saying it’s just orthodontics, but orthodontics contributed to various other factors may be a part of it.

But I agree that doing orthodontics, I like your perio analogy that we don’t move teeth in the presence of inflammation in the periodontal ligament. So we don’t do an active perio, no ortho. I agree, active TMD, whereas some colleagues will say, no, no, no, you have a deep bite. We need to fix this to cure your TMD.

I don’t adapt to that. There’s a really good lecture I saw by Daniele Manfredini once, who looked at different occlusal features. And he said, actually, deep bite is protective of TMD. We look at the odds ratio, right? That was actually fascinating. We actually look at it. So malocclusion definitely does not equal TMD, but potentially orthodontic treatment that, like you said, may be sloppy, may in the future.

But it’s not that itself is many other issues. I have a young patient who came in and his diagnosis was unilateral disc displacement without reduction to our colleagues who are younger colleagues who don’t know that sound like gobbledygook. Okay. So on one side, okay, let’s say the left side, the disc is out of place and as the patient’s tries to open up, that’s not coming back into position.

So typically you’d find reduced opening, especially if it’s acute. And then the jaw kind of deflects that side on opening. So, he was in a lot of pain, a lot of issues and not able to play basketball, not able to open big, a lot of issues and pain. And then therefore, what that affected was it also affected his occlusion in a negative way.

So we often think, as Jim McKee says, think not about how the occlusion causes TMD, think how the TMD causes a change in the occlusion. So because the disc was out of place, his bite was completely out of kilter. It wasn’t balanced. There was no harmony. Use that wonderful word harmony. So a patient with a little harmony, they bite together and their muscles are not there.

You don’t feel that healthy clench, right? You don’t feel that masticatory system firing. And so with him, I gave him an occlusal appliance to get the muscles happy. Once his pain decreased, And he was happy. We found that, okay, without the appliance, he’s actually in pain again because the jaw shifts again.

That’s the patient I’ve referred to orthodontics. He’s happy to take a break for a couple of years because he’s happy with the appliance at the moment, but because he’s not able to actually physically bring his teeth together, there’s complete malocclusion there, and therefore, there’s no harmony. Basic, a very foundational level, that kind of patient may benefit from orthodontics.

I think we can agree on that. And then the other thing you mentioned, Suzie, I just want to highlight to make it tangible is you mentioned that occlusal appliances for the short term may have a role. And sometimes when I say this to my patients, I give them an appliance, okay, they wear it. And then six months has gone, they’re feeling better.

And I say, okay, now you can stop wearing it. And they look at me like, no, no, no, I need this. But I think most TMD patients that I’ve seen now, they’re not necessarily the severe bruxist. The severe bruxist, they often are able to withstand all the load and they have an adaptive capacity that’s brilliant.

Their teeth have taken all the damage, their joints seem to be fine, right? You see lots of people with lots of wear, but no joint issues. A lot of patients that I see, they have complete unharmonious fight together. The muscles are all over the place, they’re dysfunction. You give them an occlusal appliance, their muscles start firing better.

Okay. And then you take off the appliance and the muscles are still happy. The muscles are able to adapt to their own bite again. And then we wean them off. There are some schools of thought though, Suzie, that actually, if you have a disc displacement, that absolutely needs correction. Like you need to have that corrected.

Whether it’s an anterior repositioning splint, or through surgical means with disc plication. So where are you at on this debate of on the disc or off the disc? Do you think it is insufficient treatment to help someone’s pain, but they are still off the disc?

[Suzie]
The latest research that I have read is going away from displacement being an important issue. I know a lot of people don’t like to hear that because that’s what they’ve looked at for so long. There is feel like the disc needs to be recaptured, but the latest research is telling us that the position of the disc is not as important as we thought. The body that used the word adapt several times, and adaptability, the body does an amazing job of adapting.

And we do know that sometimes patients will be in a great deal of pain when they’ve had an anterior disc displacement until the body forms what we call a pseudo disc, because the innervation is on that posterior attachment. When the patient is functioning on the posterior attachment where the nerves are, that’s very painful.

But after a period of time of pseudo disc conform, which is kind of like when we get a little callous on our, let’s say we cut our hand and it’s painful while the cut is open, but then when a little, callus forms there, it’s fibrous and it’s not painful anymore. So I don’t like disc plication. It didn’t work for me in the two surgeries that I had.

The second time I had a disc plication was going to my physical therapist and she was out of town and another therapist came in to see me and was too forceful and the disc placation surgery failed within seven months of having the surgery which was terribly disappointing, right? So the disc was out again and the surgeons that I know who are very, very experienced will say it’s so common for that to happen.

You can put it back where it belongs. You can even use my peck, anchors. But if the disc goes out again, then what was the point really of recapturing it? And so as you said, this is a hot topic. There’s a lot of controversy. I think that part of the problem with TMD is that people spend more time arguing about things than they do looking for result or evidence that we need. I think you made a really important point, Jaz, when you said that the patient that you mentioned, he was at a point where he was stable, right? And that’s my metric for doing orthodontics. I don’t do orthodontics while a patient is unstable or in a lot of pain when the TMD is their primary complaint.

But if a patient has some TMD symptoms, but they’re pretty well controlled. That’s kind of like doing ortho on a perio patient. If the perio is stable, we can move forward with ortho, and the ortho can actually improve the perio condition at that point in time. So I love that analogy because I feel it’s easy for dentists to understand, and I think that we just have to, like you said, you have to start with conservative modalities.

I do like injections, just to go back to that. I do a lot of trigger point injections for myofascial pain with referral, or having these taught bands of muscle fibers in the masseter, the TMJ, a lot of times at the insertion of where the temporalis inserts at the coronoid process. And I do Botox for patients.

I’m doing less and less Botox now, but when patients have comorbid migraine, Botox is very helpful. Or when they have trismus, when they have the big, huge masseter muscles. So there are lots of things that we can do for our patients. We just have to make sure that we’ve started with an accurate diagnosis because TMD is, as you said, not just one thing.

It’s an umbrella term for 30 different disorders. So the first thing we have to do is come to an accurate diagnosis. So we know what we’re dealing with, and then we have the tools in our toolbox to deal with that.

[Jaz]
You mentioned about your experience with getting disc plication. Jameson Spencer once taught me that it’s like a, it could be the peanut in a salad and then suddenly it could be off the disc again. Like the stability, there is concerns about the stability moving forward with that and therefore, be careful it’s no silver bullet. Now, interesting question. When you said you were at a lowest point, you were a nine out of 10. Now you’re a three out of 10. When you had the displication, was that a curative for you at the time? Did that help a lot? Or where were you at in that regard? Because a lot of people will claim that, ah, yes, have this treatment modality. It will be the cure.

[Suzie]
I have never been out of pain since I was 19 years old. So I know everyone is different. I had one patient that I referred for that surgery that did very, very well for several years, but she’s also now in pain again.

She’s also looking at possibly another surgery. And I know patients who have had 20 surgeries. So I think the problem is they say TMJ surgery is like a potato chip. You can’t just have one and that’s what’s very unfortunate because when patients get desperate, they want to be out of pain. And if the surgeon says you need surgery, they’ll say, let’s do it tomorrow.

And so I do think we have to be very, very cautious with over treatment or treatments that could end up progressing, causing the disease to progress more rapidly than it would have naturally. And when there are patients who have acute TMD who could go back to normal and it could be like it’s a college student who’s under a lot of stress and during the time that they’re in school they have this displacement with reduction and then when their stress levels decrease, their TMD symptoms go away.

But when things become more degenerative in nature and more chronic in nature, we cannot reverse it. Just like to go back to periodontal example again, when we have gingivitis, we can do things to get rid of our gingivitis. We can brush and floss and water pick and get our teeth cleaned and be more mindful of the foods that we’re eating.

And gingivitis is reversible, but once it becomes periodontal disease, what we’re trying to do is slow down the progression and keep things from getting worse. And that is a very good analogy for me, in my mind, of how things work with temporomandibular disorders. Once somebody has degenerative joint disease in the joint itself, we don’t put them back to a state of complete health again, but what we try to do is maintain mobility for as long as possible. Keep them comfortable and keep the joint lubricated so that we don’t get the situation like I had where you couldn’t tell the difference between my fossa and my condyle.

[Jaz]
Wow. I mean, I think that’s another, continuing this analogy is really wonderful because in that scenario where you do have that patient who’s maybe lost 50% bone, but we know that, okay, with really good oral hygiene, regular care.

We can maintain that and slow it down so that they’d have to live until age 200 for them to lose all their teeth, for example, to slow it down a rate whereby they can outlive their teeth, basically, which is what we want. And so when you apply that to a joint, it’s about good practices early on. I strongly feel that early treatment.

So we as clinicians listening to this young colleagues listen to this, knowing about diagnosis and early intervention to stop it becoming chronic. is something that should be, I think, foundational. I also just want to ask you to go back on to hotly debated orthodontic stuff. I have several colleagues who are dear friends of mine, and we have slightly different opinions, and I’ll share them with you.

I will not suggest orthodontics without first doing occlusal appliance. It’s just my way of doing it. Only if I can get them out of pain, then also have cosmetic concerns as well. Well, does that help me to suggest? Okay, we can do the line therapy now that you’re not in pain. We’ll straighten your teeth and I’ll try and set it up so that everything is harmonious and very rarely do I go down the orthodontic pathway.

Whereas a lot of my colleagues will say, okay, I can see that your bite is locked in. Like you have muscle pain because you’re trying to grind your teeth at night. Your teeth are in the way, your muscles are going crazy. We need to do some orthodontics to give you a bit more over jet to give you more this.

What do you think about that? Because logically speaking, some of the characteristics that you give in the splint, these colleagues of ours, they want to give it through the medium of teeth. So they try and create the occlusal appliance through the teeth. I’m too chicken to go through that step because I know pain is a funny beast, right? So, but what do you think about this kind of thought process?

[Suzie]
I agree with you, Jaz. I need to clarify something I said earlier. I treat a lot of patients orthodontically, but they are not my TMD patients. So those are the only two things I do in dentistry anymore because of the pain that I experienced even when wearing lube, it’s not feasible for me to do clinical dentistry. But because I know how important it is for us to treat the temporomandibular joints conservatively as much as possible, I don’t recommend ortho for many of my TMD patients. I will do it after we’ve treated and stabilized the joint.

If I think it’s absolutely necessary, if it’s not absolutely necessary and it’s just for cosmetic reasons, then I let the patients know we have to tread lightly. We have to be careful here. There’s a difference between having a class one occlusion, straight, white, beautiful teeth, which is what society wants us to have, and what is healthy for us as an individual.

So we really need to look at the patient, I come back to this phrase so often, the orthopedic stability of the masticatory system. That’s what’s important. We need to have joints that are happy as well as muscles that are happy, right? And we have to think about that so that what we’re doing for the patient is really keeping everything in balance and harmony.

And there are people who have very strong muscles of mastication. Our brachyfacial patient, those are patients who are their muscles will become unhappy very quickly. We need to think about more than just the teeth. We need to think about their adaptability, and we are learning more and more about adaptability through the COMT gene, which I am not sure if you’re familiar with, but at some point in the future, we’ll be able to have our patient give us a little saliva sample, and we’ll be able to determine whether they are highly adaptable.

Or if adaptability is a very big problem for them and the patients who have a lot of stress in their lives or who are anxious, nervous, have a lot of comorbid conditions, they may not be good candidates for ortho. So we have to choose the patient wisely, and we have to understand that occlusion is one of several possible etiologies.

Stress is another etiology that we believe has a lot to do with the patient adaptability. And we have other things that we have to keep in consideration, such as how heavy of a loader the patient is. Do they have a lot of parafunctional habits? Are they grinding their teeth, biting their fingernails, chewing on a pen, doing things that, introducing non nutritive things into their mouth, you know?

So those are all things that have to be considered. And then we also need to look at their overall medical health. If you have a patient who has temporomandibular disorders, it’s very likely that they have other coexisting conditions.

[Jaz]
IBS, fibromyalgia, depressive illnesses, unfortunately.

[Suzie]
Yes, there are 10 recognized chronic overlapping pain conditions. And beyond those, we see things like Ehlers Danlos syndrome, a hypermobility issue, and those things have to be considered. Before we just jump in and say, I know how to give you straight teeth.

[Jaz]
I’m asking some tough questions here. I hope you don’t mind. You’re doing great. I’m really enjoying talking with someone who’s very experienced in this field and also thinks similar to me in terms of conservatism, but also I’m happy to have a healthy debate here. You say orthopedic stability. Now, one person who’s also taught me is a Patrick Grossman, who me and him, we don’t 100% agree, but I respect everyone who’s taught me something. But he would say that to have orthopedic stability, you need to be on the disc. So what is orthopedic stability look like for you?

[Suzie]
In my understanding, and I follow the teachings of Dr. Jeff Okeson very closely, and my understanding is that what we need is for the joint to be seated fully. And I don’t like the term centric relation because centric relation has had 30 definitions since I’ve been a dentist.

So instead of saying centric relation, I just like saying having the joint seated with proper support with the condyle in the fossa with the muscles also in balance. And the question of whether or not the disc needs to be seated there is something that even though it has been debated a lot, we’re starting to see good evidence.

We’re starting to have research supporting the fact that the position of the disc is not as important as we once believed. And so, even though we have patients who have discs that are either anteriorly and medially displaced, which is most common, it’s very uncommon for there to be a posterior displacement of the disc.

We have to think about how that patient’s body has responded to the changes if the disc has been displaced. Some people will adapt beautifully and some people will not. And so it’s really about the individual patient, whether or not they have a full range of motion, if they’re able to open at least 40 millimeters, maximum incisal opening of at least 40 millimeters.

If their condyle is rotating and translating, then if that’s happening without pain, then that patient is okay, even with an anteriorly displaced disc. When there’s pain, we need to address the source of the pain rather than the site of the pain. And that’s very strongly supported by research.

[Jaz]
You mentioned someone who I highly respect, Jeff Okeson, reading his book, listening to many of his seminars. I get the impression that he’s not a big proponent or advocate of anterior repositioning. It’s like he’ll do them, but it’s not a mainstay for him. Whereas other clinicians I’ve learned from, they use that very heavily.

And I’m in this phase of my career now where I’m a sponge that has absorbed a lot already. And I’m really just trying to apply this philosophy of listen to everyone and do what feels right to you. And right now what feels right to me is be conservative and escalate. But I’m also over the last few years as the kind of cases I get referred are more and more complex. There is a time and place where I’ve had to use mandibular advancement or anterior repositioning splints basically. Where is that in terms of your protocols? Is that something that you use as well?

[Suzie]
So to be honest, even though I was a part of this writing this paper about occlusal appliances, and I know that there is a place for anterior repositioning appliances, I’m not a big fan of them because I have seen clinicians who don’t understand how they work or patients who are not compliant.

And with an anterior repositioning appliance, you need both of those. It’s very, very important that you don’t try something like that on a patient who could be lost to follow up, right? That patient has to be really committed. And the clinician needs to know how to adjust the appliance when the appliance has done what the goal was of recapturing the disc or making the patient more comfortable, allowing them to have a greater range of motion.

But in my hands, it’s not a super useful tool. I really prefer a plain splint, a hard acrylic splint with one point contact per tooth. That just works very well for me and I’m not saying that other people are doing something wrong by using an anterior repositioning appliance. I would not recommend an NTI because I’ve seen too many situations where an NTI has caused in the anterior open bite.

It’s irreversible when that happens. And then we do have to do orthodontic treatment. I, sometimes-

[Jaz]
I just want to point one thing I can share with you is that I’m a big fan, not of the NTI specifically, but anterior midpoint stop appliances, but applied in a way that covers all the teeth. So I give them that benefit of reduced muscle contraction.

And that seems to help a lot of my patients are primary muscular brachyfacial and another point is where a lot of patients, I will wean them off the splint. Cause I don’t think it’s a lifetime thing. There is a cohort of patients who are are pathological bruxist and they’re causing microtrauma. And for those that are more likely the ones that when they sleep, they’ll wear the appliance because they will end up destroying that appliance. If they don’t destroy the appliance, the load’s going to go somewhere else. What do you feel about that cohort of patients who most severe bruxist who wear appliances?

[Suzie]
Yes. So I was going to say, just in terms of the NTI, there are times when I’ll make a little NTI in house. I have a little kit where you just put some blue mousse and just try it while the patient is in the chair, let them wear it for a few minutes and see if it helps their headache.

I’m fine with that as a diagnostic tool, but then that’s the time when we realize we’re probably dealing with headache as the primary diagnosis, and so then we need to address the headache first. Now, in terms of bruxism, there’s a really great new tool. You mentioned Dr. Daniele Manfredini. He and Dr. Stephen Bender and a few other doctors came up with a Brux Screener, I believe it’s called. We might have to look that up. But they’ve done a lot of work on looking at bruxism as we used to call it nocturnal bruxism and now call it sleep and awake bruxism because you can be asleep during the day too.

So, what we’re really talking about is not bruxism that happens at night, but bruxism that happens while we’re sleeping. We definitely do need to prevent microtrauma when patients are sleeping. We can use occlusal appliances for that. We can also sometimes give them injections, like if we give them some botox in the masseter and we’re reducing the intensity and the duration of the clenching, that can be very helpful.

The goal is to reduce the bruxism, right? And I think that the problem is that a lot of patients have been told you’re getting this appliance to protect your teeth, which we do need to protect the teeth, but we are actually trying to stop a habit that is harmful. So it’s the habit that we’re trying to work on. I don’t know if that’s clear.

[Jaz]
It’s clear, but do you feel as though bruxism is something that we can stop? Because here’s my viewpoint and then happy to share different viewpoints. But bruxism is like if you find the trigger for that bruxism. Great. But often that’s very, very difficult to do. Whether it’s smoking, whether it’s caffeine, whether it’s their stress levels for those patients who I’ve been following up for occlusal appliances for years and I color them in, I do the parafunctional analysis.

I’ve also been using the brux checker on my patients. A really cool little thing they wear and they come in and they rub away the ink and stuff. So even if I did a full mouth rehab for restorative reasons and they have this, or they have an appliance and they have some botox as well, there’s still a degree of bruxism that happens.

Yes, it’s a less amplitude, less muscle contractions, but I have not found an effective way yet to stop my patient’s bruxism. Is there anything that you found that helps decrease bruxism? Like if my patients come back to me, if I didn’t tell them the bruxism still happening, they say, Oh yeah, my bruxism has stopped. But actually their pain has stopped. The bruxism is still continuing. They’re just now bruxing in a more dentally beautiful way. As I like to say.

[Suzie]
Dentally beautiful. I like that too. Well, I know that there has been some research about physical self regulation as a tool for decreasing stress. And when stress is lowered, it seems that sometimes that can help with bruxism.

There are patients who are always going to brux and there are patients who are going to need that appliance to protect their teeth. And I do agree with that. Anecdotally and empirically, I’ve seen a lot of patients who have told me, I used to grind my teeth. Like when I was a students or when had a very stressful job and my sleeping partner tells me they don’t hear me grinding my teeth anymore.

My stress levels have gone down. I don’t think that I currently grind my teeth. And someone I can’t remember who said it, but someone gave me a really good analogy. They said when you identify wear on a patient’s teeth. That’s like an archaeological finding. You know, like it is telling us we see there is evidence that the patient at some point in time in their life was a bruxer.

But do we know? Unless we sleep beside them and watch them while they’re sleeping, do we know that they’re still bruxing? So a lot of it comes down to the patient report. And I like to ask them if their muscles are sore when they wake up in the morning. I ask them, when is your pain worse? Do you feel comfortable when you wake up and then your dog gets tired as the day progresses? Are you waking up feeling like? Oh my goodness. I was running a marathon with my masseter last night.

[Jaz]
I think that’s stiff in the morning as well. Also noises in the morning where you get clicking in other times, basically headaches in the mornings could be a sign as well. I think we’ve covered a lot there, Suzie. Look, I have asked you some tough questions, lots of questions. And what I like is that. You answered everyone with such a nice balance, respecting the other side. And I think we need more clinicians like you that respect all the different views. And so well done for being so respectful to all the different views out there.

I know that you do some teaching. I know you’ve got a course coming up. I’d love for you to plug it because for me, it’s all about helping dentists become better with their TMD patients and how we can serve our patients. So please tell us about your hybrid event. Suzie, tell us more.

[Suzie]
Okay, great. So I teach for an organization called McGann Postgraduate School of Dentistry. It’s located or headquartered in Orange County, California. We have locations all around the world, and we have a sister company called Progressive Orthodontics Seminars, and I’m going to be giving a course that I wrote called 21st Century TMD Protocols, which is a two day course. It’s going to be a hybrid event, so it’s live in Aliso Viejo, California, and also via Zoom, and I go through pretty much everything you could imagine from review of anatomy, the history of what we have done, what we’ve learned from the things that haven’t worked for us.

I go through how to do a comprehensive initial exam for doctors who aren’t comfortable treating TMD patients, letting them know at least how to do a good referral, how to work with multidisciplinary teams. I share some case studies and really fun exercise where we watch a patient go to different video that was pre recorded, go to different providers, and then we analyze together what was good about each appointment and what could have been been improved.

And how this relates to our clinical practice and it’s just full of practical advice and we do some hands on exercises, which for the people who are not in the room, you can still participate in the hands on exercises by just asking your girlfriend or your aunt or your brother or whoever is around, come over here and let me practice palpating your muscles so that I can learn if I’m doing it correctly.

And so I would love to have as many people as possible who have listened to this podcast join. We’re going to offer you a 15% discount if you mention the podcast. And that’s something that is very near and dear to my heart because I wrote this course for patients like myself and for providers like myself.

[Jaz]
Wonderful. I just want to make clear. I have no financial interest in your course, but I do wish people join you to learn more. Anything we can do to learn more from different individuals, because your experience and background is so unique. I really love that. So I’ll put the link in the show notes. I think the date you said was 23rd and 24th of November, right?

[Suzie]
That’s correct.

[Jaz]
Perfect. Brilliant. So I’m going to guys, I’m going to put the link in the show notes. Please do reach out to Susie. I’m also going to put the TEDx talk as well. I’d love for you guys to watch that. Hope you guys like Suzie’s very kind style and the diverse background she has and the great people that she’s learned from. And I’m very grateful that you shared that with us on here. Suzie, thank you so much for giving up your time to talk TMD, some tough questions, but I think ultimately we’ve done a little tiny bit today to advance in the field of TMD.

[Suzie]
Thank you so much, Jaz. It was a great experience and I look forward to continuing our conversation.

Jaz’s Outro:
Absolutely. Thank you so much. Well, there we have it guys. Thank you so much for listening all the way to the end. Let’s face it. There were some tough questions in there and this was a controversial episode. Especially if you’re in the sphere of managing TMDs some of the things that we discussed you may violently disagree with them. And that’s okay because we still don’t have the answers I hope we inch closer to the evidence base that we need. But in the absence of high quality evidence we do need to be cautious and perhaps sometimes guilty of being a bit too cautious.

And certainly I’ve seen success from more aggressive therapies, orthodontics, various types of directive splints that bring the jaw in a certain position. But if there’s one thing that you take away, try and manage it early before it needs any of those more advanced therapies, let’s say. Make sure you answer the quiz if you want CPD.

Protrusive Education is a PACE approved provider and the subject code for this one was 200 which is oral facial pain. Please do check out Suzie Bergman’s TEDx talk and I’ll put that in the show notes as well as any education courses from her. If you have absolutely no idea about splints and TMD and you really need a crash course, please do also check out splintcourse. com which is my course for those beginning in TMD and those who want to help protect their dentistry from that high force bruxist patient. And if you want to be able to do splints like stabilization, splint, B splint and the various types of deprogrammers, like I said, I’ll put the links in the show notes below and thank you so much for making it all the way to the end.

I do want to thank my team. This one was produced by Gian and for the show notes, I think Krissel and Nav the CPD and the CE certificates, I thank Mari. And lastly, I thank you, the Protruserati who stick with us, even with these very geeky and niche episodes. Thank you. And I’ll catch you same time, same place next week. Bye for now.

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