24/05/2024

Care Health

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How Dentofacial Orthopedics Can Benefit Your Overall Health, with Dr. Paul Peterson, DDS

How Dentofacial Orthopedics Can Benefit Your Overall Health, with Dr. Paul Peterson, DDS

In this episode, we discuss:

  • How evolutionary changes in the way our faces grow and develop, combined with a declining percentage of humans’ nasal breathing, is causing a host of problems not being adequately diagnosed or addressed by the medical community
  • Why it takes a multidisciplinary understanding to fix these problems
  • The challenges presented by a lack of training in the dental community on treating joint disorders
  • How the jaw plays a role in causing sleep apnea and why resolving jaw alignment issues can help
  • Treatment options including NightLase therapy, mandibular advancement devices, and sphenopalatine nerve blocks

Show notes:

Hey, everybody. Chris Kresser here. Welcome to another episode of Revolution Health Radio. I’ve done a few shows in the past with dentists and periodontists, exploring the connection between oral health and the structure of our jaw and face and [the] nerves in that area and our overall health. I would say there’s been a pretty dramatic shift in understanding in these fields over the past few decades. When I was growing up, the dentist was just a place that you went to see if you had any cavities and get those cavities filled, [and] maybe get a crown or something like that. We now know that the way our face develops from birth into adulthood, and even in utero, actually, [and] the structure of our jaw and our dental palate affects everything from how we breathe to how we sleep. It can be a major contributor to apnea and snoring, [and] to how we move our physical posture. Problems in the jaw and in the facial structure can cause pain throughout the body, digestive issues, [and] immune problems. There’s just so much to learn here. It’s such a rich area for exploration. And I’ve seen some pretty miraculous changes in overall health, sleep, musculoskeletal issues, chronic pain, etc., from people working with functional dentists or doing dental orthopedics or [any of the] various names that are used for this kind of work. I’ve benefited tremendously from this kind of work myself, as have my wife and our daughter and many other family members and patients.

So I’m really excited to welcome Dr. Paul Peterson as my guest today. He is a dentist [who] I met in Park City, where we were living at the time, and I worked with him for a couple of years. My wife also worked with him, and our daughter worked with him, and we all had pretty remarkable results. So I wanted to have Paul come on and share a little bit about his approach and the way he looks at dentistry from a functional perspective. I think you’ll really enjoy the show. Let’s dive in.

Chris Kresser:  Dr. Paul Peterson, welcome to the show. [It’s a] pleasure to have you on.

Paul Peterson:  Thank you, Chris. Happy to be here.

Chris Kresser:  I’m so excited about this conversation. [There’s] so much we can cover, and [there will] probably have to be a couple more conversations after this one because there’s no way we can cover everything in the time that we have. But before we jump in, I’d love to hear a little bit about your background. You’re trained as a dentist. How did you get interested in what we might call, it’s certainly not traditional dentistry that you’re doing now. So how did you get from dental school to where you are at this point?

Paul Peterson:  I did grow up in a dental family, so I [didn’t] really have a normal childhood in that regard. I joke with people that my perspective is different because I grew up hearing it talked about at the dinner table. And then, when I was 16, my mom went to work for my dad. So all aspects of the practice of dentistry, the patients and interactions, [were] just something I grew up with. I knew I wanted to go into medicine and healthcare, [but until] I was older [and] was in college, I didn’t start considering dentistry [before] that point. And I got in my dad’s office, and I saw the great relationships he had, and I really wanted that in whatever healthcare profession I went into. In school, I was fortunate that I was able to deal with a lot of complex cases, more so than most of my classmates. I spent a lot of time with the professors and the clinics that specialized in implant reconstruction. And instead of doing a crown here and a filling here, I was doing multiple teeth at a time, 10, 12, 20 teeth at a time, and it kind of gave me a taste for that. Following dental school, I started a prosthodontic residency, which would have been a three-year program, but I spent a year in that program and got a lot of great exposure and decided that [the] entire three-year program wasn’t where I wanted to go. But it did set the tone for my career. I got out and I started practicing, and I worked for an experienced dentist, and I was learning and watching from him. I got involved with Invisalign very early and just found that, even though I wasn’t in school anymore, I had a hunger to continue to learn.

I don’t think at that point I realized how much there was to learn and how little I knew. I probably didn’t fully grasp that until a few years ago. But it just gave me a hunger to learn. I enjoyed that part of it. I enjoyed looking at my patients and trying to get [to] the root of the problem. And those observations throughout the early years of my career led me to ask more questions. Then I had patient experience and I had personal experiences, and they led me to do more than simple continuing education. I started studying appliances just for snoring and kind of accidentally ended up in a wonderful course that was multiple days long and taught by a brilliant sleep tech. She really got into the science of sleep and sleep studies and what’s going on. And that was kind of accidental, but that was probably one turning point in my career when I started understanding that component. As I did more and more complex restorative cases, I wanted to understand, “How do people get in this condition? Why is one person’s dentition more damaged compared with another person’s teeth? Why is someone grinding their teeth so bad[ly]?” And those answers are out there. They’re not necessarily widely discussed or emphasized enough, in my opinion, or [weren’t] in my education. So going down that road got me where I am.

Chris Kresser:  [It] opened some doors, [got] you curious, and you [kept] pursuing those interests.

Paul Peterson:  Yeah, there you go.

Chris Kresser:  [I can] definitely relate to that. Let’s actually use snoring and breathing and apnea as an entry point here, because that’s how I met you. My wife was already working with you, and [my] daughter, [too,] actually, [which] we can perhaps revisit later in the conversation. But I came to see you because after we moved from the Bay Area, which is more or less at sea level, to Park City, which was [at] 6,500 feet, I noticed that I was snoring more, which is not typical for me. And I did an at-home sleep test, and I was having some moderate sleep apnea, which I had never had before. I’d had sleep studies [done] before in the lab, and I’d never had apnea. I had some transient low oxygen events, which were below the apnea threshold or what they would typically classify as apnea. I think most people today, when they are diagnosed with apnea or they hear about apnea, they don’t make a connection immediately in their brain to their jaw. And the common prescription, of course, is a [continuous positive airway pressure] (CPAP) machine if it’s severe enough to warrant one. But many people struggle with those and don’t enjoy wearing them, for obvious reasons. They’re very cumbersome, difficult to travel with, etcetera. And certainly, I’d say there’s some growing awareness that there are basic mandibular advancement devices or things you can do. But in my practice, for example, very few patients even knew that was an option until I brought it up.

So, talk a little bit about what’s happening there for people who are experiencing apnea and how their jaw can play a role in causing the condition and how resolving that jaw alignment issue can help.

Paul Peterson:  Yeah, absolutely. And I should probably start just by saying, I have seen plenty of patients [who] get a CPAP machine and do great with it. Is it the lesser percentage? Absolutely. But in all fairness, there are some [people who] get those and it addresses their apnea. I don’t know if treatment is quite the right word. And hopefully, that’ll become clearer as we talk about it. But they don’t fail all the time. And on the flip side, often they make improvements. One of the things that isn’t discussed is where you [were] when you started with any treatment, whether it’s CPAP or some other alternative treatment. Where were you when you started? And where are you now? And what does that mean? Those are discussions that I’ve found, I guess [it] was about 2010 when I first did that really good in-depth course, and I’ve been doing home sleep tests ever since for my patients. And [what] I found is [that] through all those years of talking with patients, so often that discussion has never [been] had with the patient [by] the provider, wherever they are.

But the other thing to bring up now is that when we talk about, if we use the term “functional dentistry,” for lack of a [better term]. [You] almost encouraged me to use [it], and I’ve given that a lot of thought since our discussion when I saw you last in the office. And it really has made more and more sense to me, terminology wise. I think it’s something that people relate to, [and] one component of that is understanding where these problems are coming from. And I think one of the big gaps, whether we’re talking about apnea, head and neck pain, jaw pain, or a whole host of other complications, is the public awareness and the medical and dental awareness of the foundational issue just isn’t there. And what is that issue? It’s that the human head just is not growing the same. And thanks to books like Breath by James Nestor, there is more and more awareness. We have people come in almost monthly, or multiple times a month sometimes, [who] have read this book, and they’re looking for a healthcare provider or a dentist [who] understands these concepts. But for tens of thousands of years, all of the skulls that are dug up and looked at by the anthropologists and the physiologists and the anatomists [are] very similar in how the upper jaw sits in relation to the cranial base or to the rest of the head.

So if you just kind of think about your face that you look at in the mirror, how does that grow and develop from the time you’re born? Without getting too deep into that discussion, [it’s] changed because of the environment that we’re in. So with that understanding, it changes your perspective on [the] airway. If that upper jaw is growing differently, if any bone in the head, all these different bones that are in the middle of the head, the jaw bones, the plates of the head, if one of them [is] out of position, everything else has to shift and adapt. What happens with breathing is, if the upper jaw doesn’t grow out and forward—it should go 80 percent out and about 20 percent down from the time you’re born as an infant—if that happens, you have a big, wide palate, you have room for your tongue to sit up and forward. Not only that, but the floor of your nasal cavity is out, it’s wide, and you can breathe very easily through your nose. Not just when you’re sitting and talking, but all of the time. It isn’t a narrow space between where your soft palate hangs back in the uvula in the back of your mouth to the back of the throat. Your tongue moves forward. If the upper jaw was forward and out, then the lower jaw fits out and forward, also. And in this scenario, we don’t need orthodontics. Our teeth come in with plenty of room, there [are] no extractions, there [are] gaps between our teeth, our wisdom teeth come in, and, in many cases, there [is] room for a whole other set of teeth.

This was observed even after so much of the “civilized world” was dealing with crowding teeth and starting to have bad posture and all these problems. Well, when we found steady Native American populations, Amazonian populations, the Aborigines, they had these beautifully developed faces, they stood up straight, [and] they had room for their teeth. Not only that, but due to diet and breathing, they didn’t have the decay issues that we have. The minute you start breathing through your mouth, you decay.

Chris Kresser:  And they weren’t brushing their teeth or flossing three times a day either.

Paul Peterson:  Right. No fancy toothpaste, right? No super special floss or water picks or anything like that. So hopefully, I’ve made the point that proper jaw development is opening [the] airway.

Chris Kresser:  Right. So what happens when, let’s say someone’s snoring. What’s happening there when they’re [lying] down? What’s going on to cause that problem?

Paul Peterson:  Good. And let me add [really quickly] one more thing, in the nasal cavity, this is interesting because we see so many deviated septums, and people think it’s trauma. They’re almost never outside the fix. This deviation is internally in the nasal cavity. Because the nasal cavity didn’t develop fully, then we have all these deviated septums, and you’re not breathing well. So, snoring. What’s happening? It could be multiple locations. It’s not always the soft palate, the uvula. Sometimes it’s the tongue, [and] sometimes it’s coming from the nose. So when you’re treating it, you also need proper tools and diagnoses to identify the area where the [problem is]. [The] nasopharyngeal airway, the oral pharyngeal airway behind the tongue, is it lower? Are you having a collapse lower than the area of the tongue? What’s happening, and what tools can help?

Chris Kresser:  Right. So in my case, my airway in my neck was plenty large. That was not the issue. The problem was, if I recall, and correct me if I’m wrong, some of the tissue around the entryway had become slack over time, which happens with aging. So we did something, [and] you can explain that a little bit. But then also, just the position of my lower jaw, like if I’m [lying] on my back, was receding, or it was moving backward and closing the entrance to the airway. So it didn’t matter how large the airway itself was. If the lower jaw is not staying forward and in place, then it closes the airway. So we used an appliance, a nighttime [appliance], which I’m still wearing at night [and] which corrects that problem. So, talk a bit about those different interventions because that speaks to what you just said. It’s not the same [for everyone]. For some people, it might be the airway itself that is compromised. Whereas for me, it was a different issue.

Paul Peterson:  Yeah. And we can see large airways, but if you have trouble breathing through your nose or you never established the proper neuromuscular coordination to hold your tongue up in the roof of your mouth and your palate, maybe you just had really bad allergies as a kid; you don’t have them anymore, but you got in the habit of breathing through your mouth, well, then the whole load on your back, the whole lower jaw can fall back. When it falls back and the tongue goes with it, it can push on the soft palate, [and] it can close the airway. When you have any sleep-disordered breathing, the larger [and] more severe the obstruction, the longer amount of time, the more wear and tear it can have on the tissues of the throat. But those tissues are very friable. They’re mucosal tissue. They’re thin, they’re soft, [and] they get inflammation easily. So if your airway is closing, think of a hose, and you’re tightening it to make the water go faster out of the hose to squirt it. Well, when the airway is collapsing, and you get more friction of the air and the closure, you get swelling, and then it’s a self-feeding loop. Because now, you have more swelling, and the airway closes with more ease, and it continues to swell. And like you said, with age, there’s a natural breakdown in elasticity or collagen or elastin in the tissue.

So we’ve seen amazing results. Since 2016, we were the first ones in the state to start using this technology. And I’m happy to say there’s a lot of people using it throughout Utah now. We’ve seen really amazing results with the NightLase technology from photon[s] or laser[s]. It’s a special wavelength of light that’s fractionated and micropulsed, and it’s used in multiple areas of medicine. It came from other areas of medicine. This company is in dermatology and gynecology, but they can tighten tissue. And we get surprisingly good results. So that’s one tool. The mandibular advancement device is an amazing tool. When I first started learning about them, we already had 15-year studies on some of the early, good appliances that are nowhere [near] as [high-]quality as what you’re using. But they said [with] mild to moderate sleep apnea, you can get as good or better result[s] with a mandibular advancement device than a CPAP.

Chris Kresser:  With a lot less intrusion for you and whoever you’re sleeping with.

Paul Peterson:  Yeah. And then it comes [down] to compliance, right? It’s easier to wear for the majority of people and the consistency of wear. The insurance guidelines to be successful to keep paying for the CPAP machines are really lax. I don’t know the exact numbers off the top of my head. I’ve heard them before. But how many days a week or how many hours of the night? Well, you put your CPAP on, and you take it off four hours into the night. You have more severe events in the later hours of the night anyway. So you’re only wearing it four nights a week for half the night, and it qualifies for insurance [to] keep paying for it, but, really, how well are you taking care of that human being? How well are you [really] treating the sleep-disordered breathing and all the associated complications of it?

The sad thing is that the mandibular advancement appliances didn’t get more traction. And I have to guess [that’s] for two reasons. There’s a lot of inexpensive appliances out there that may be working okay at first, but they’re more cumbersome, they’re not as comfortable, [and] they break. If something happens and [in] two years, you’ve got to remake one, no one wants to pay for it again. You don’t have warranties on them. They’re not well made. But also, it’s about, again, it comes to understanding the foundational issue and identifying the problem. While it’s true that [in] the majority of people, if you move that jaw forward and you hold that tongue out of the way, it’s going to help them. That’s not everybody. I’ve had people [who] got answers nowhere, and we put Breathe Right strips on them, and their sleep totally changed. They didn’t have surgery with the ear, nose, and throat doctor. You have to be able to look at everything. So I’m a huge believer in the cone beam [computed tomography] (CT) [scan] first, looking at the area and the problem. But the other issue is [that] in dentistry, there is not enough instruction [and] understanding on the joints. We talked about [how] the jaws don’t come out and forward, then the joints [are] the victim of that, if you just start randomly moving these teeth around. In other words, if you go to most general dentists, and they may have been to some good courses on how to make these things, quote unquote good courses, there’s not enough foundational understanding of what you’re doing. What have you done to that jaw joint? What have you done to the muscles? [For] so many people, even if they have a decent appliance, just the way that you move the jaw, the position you put it in, it hurts. So if you don’t know where the patient is starting, you don’t know how to assess it, [and] you don’t check it before you make an appliance. When we went through the process, we started with a CT [scan]. We knew where your joint was. We analyzed the obstructions, [and] we formulated a plan based on that. We didn’t just say, “I’m not sleeping [well], make an appliance because I don’t want to wear a CPAP machine.” We did follow-up studies, and we checked the position of your joint after, before I even had it made. I took a bite registration instead of taking models of your teeth, not relating them in any way, sending it to a lab and saying, “Build me something that moves their jaw forward.” Which, in simplicity, is what’s being done. So people aren’t comfortable in these things. And it’s unfortunate because they work really well if they’re done well.

Chris Kresser:  And I can attest to that personally.

Paul Peterson:  Sorry for my long rant on that.

Chris Kresser:  No, that’s fine.

Paul Peterson:  But it really is a frustration of mine. And it’s not that I’m doing anything super difficult or magical; it’s just that my career has led me to research these things and understand them. So now I can make something for you that you love and you can use.

Chris Kresser:  It’s much more complete. It’s analogous to the difference between Functional Medicine and conventional medicine, where it’s like, the conventional approach is, “Oh, do a blood test; your cholesterol is high. Now we’re going to give you a statin, [and] that’s going to lower the cholesterol on the follow-up blood tests. Problem solved.” Well, not really, because why was the cholesterol high in the first place? What’s going on under the hood that’s leading to that problem? And if you do a little bit more digging up front, you’ll find maybe a way of addressing the problem at the root so that you’re not using a drug to just suppress the symptoms. And with the CPAP machine, okay, what’s the problem? The problem is low oxygen. So you give oxygen. Okay, well, that makes some sense in a way, but you’re not answering the question [of] why is the oxygen low in the first place? So, what you’re doing is analogous there, where the first step is diagnosing the problem.

Paul Peterson:  Where is the obstruction?

Chris Kresser:  Where is the obstruction? And for those [who] aren’t familiar with the terminology, the 3D cone beam scan is just a much more comprehensive way of imaging the structures in the head and the neck.

Paul Peterson:  It’s a 3D X-ray that doesn’t have the high radiation that you’d get at a hospital CT [scan].

Chris Kresser:  Yeah, and I had this in the Bay Area when I was having some issues with sleeping. I did some research, and I can just look in the mirror and see my jaw is narrow. I’m a classic, industrial, Western civilization face. If you read Weston A. Price[’s] Nutrition and Physical Degeneration, like you referred to earlier, you see the comparisons of people living in the industrialized world, with [a] very narrow jaw, narrow dental arch, [the] lower part of their jaw is [farther] back than it should be, all the classic signs. So I suspected that my jaw [misalignment] and malocclusion was contributing to my problems. I went to a dentist who was just listed as someone, I think I went to the mandibular advancement device website, and they had a directory of dentists that were using it. And I went there, and it was exactly what you described. They took [a] mold of the teeth, [and] they made an appliance that was based on that. It was super uncomfortable, [and] it was bulky. It did the job in the sense that it mechanically moved my lower teeth forward, but it was not something that was sustainable.

Paul Peterson:  Somebody forgot to consider that [the] teeth in this model of your mouth [are] connected to a human being.

Chris Kresser:  The rest of the body.

Paul Peterson:  You can’t just put it into some random position.

Chris Kresser:  Exactly. Yeah. And then, working with you, we had the better, much more sophisticated appliance, [and] there was a night or two of discomfort just getting used to it, but that quickly passed. And now, I sleep with my mouth taped shut with the appliance in, and I wake up with the tape still there. So I’m 100 percent sure I’m not breathing through my mouth at night. I’m breathing through my nose the entire night. And I feel more refreshed and rested, and [I] don’t wake up with headaches or anything that was happening with the apnea before. So it’s a pretty big difference. And with the NightLase, that helped a lot. But it also, as you suggested it might, helped even with my VO2 max and oxygen availability when I’m exercising. I was living at 6,500 feet and often exercising at [9,000] or 10,000 feet. So the ability to get oxygen when you’re breathing through your nose …

Paul Peterson:  It’s tough, man.

Chris Kresser:  Yeah, it’s tough, and it’s important, right? Because there’s a lot less of it. And I’d also read James Nestor’s book, and he talks about some training that he was doing trying to breathe exclusively through your nose, even when you’re doing [a] pretty rigorous cardiovascular type of activity. So I would be riding my bike up the Armstrong loop in Park City and just trying, with tape on my mouth, to breathe exclusively through my nose. And I was able [to]. Not immediately, it took a while to build up to it, but I was able to do that. And I think the NightLase helped because it created more space and more ability to breathe because those tissues pulled together and tightened instead of being sort of slack and obstructing the airway.

Paul Peterson:  Yeah, it’s really cool.

Disorders such as TMD and sleep-disordered breathing can wreak havoc on bodies and lives. In this episode of Revolution Health Radio, dentist Paul Peterson explains his multidisciplinary approach to looking beyond the teeth and gums to the musculoskeletal and nervous systems of the head, neck, and jaw to address the root causes of these issues. #chriskresser #functionaldentistry

Chris Kresser:  Let’s shift gears and talk about [temporomandibular joint dysfunction] (TMJ), because this is a whole other window into how a lot of issues that we’ve already been talking about, like, kind of maybe short-sighted or narrow view that the conventional medicine or dentistry look takes at TMJ. And then what a more holistic way of looking at this is. And I know, I mean, this is a huge issue. So many people suffer from this.

Paul Peterson:  I mean, this issue was the rabbit hole that changed my career in my life. In dental school, I remember being in the clinic and going to get my instruments, and there was a lady working there. Apparently, we had a specialist in the dental school. No one ever saw him. We didn’t get any lectures from him. But he saw people there. So we saw this lady [who] we talked to almost every day when we were in the clinic seeing patients as students, and one day, she had this crazy bunch of acrylic in her mouth. And everyone [was] asking, “Hey, what is that? What’s going on? Tell me about it. Who is this doctor [who’s] treating you [who] happens to be here at the dental school [who’s] never lectured to us?”

You talk about our traditional view. And I don’t know if there ever has been a good one. One of the really sad realities of dentistry is in modern dentistry, I don’t even know how many. There [have] been six or 10 different definitions of how the joints should sit in the fossa. What does that mean? The temporal bone is the one on the side of your head that the bottom of it forms the roof of the joint. And dentistry has always been very mechanically minded about where [it] should sit. Should it sit up and forward? Should it sit up and back? So there [have] been all these techniques over there, where you grab the jaw and you try to force it into a position if you think there’s a problem, or you’re doing something. You’re manhandling it into some position based on some definition. Well, the dental school that you went to on one side of San Francisco is teaching it different[ly] than the one on the other side of San Francisco.

So historically, it hasn’t been well taught to anybody. And then there [have] been surgical interventions that sometimes work, and sometimes they don’t. Nothing has been really great. And again, you’re missing the point. Like I said in the beginning, if you understand the foundational cause, you look at it differently. If you understand that it’s clear as day that all the anatomists and anthropologists agree the face isn’t growing the same. And if you understand that and if you understand the upper jaw [is] in a different position, now the lower jaw has to adapt. The trouble with the TM joint is it’s bilateral, and the lower jaw is victim to where the upper jaw ends up, which is a victim of the industrialized world. So the lower jaw gets moved back, it changes position, the joint gets compressed, and the disc gets kicked out. I’m going to guess a traditional definition is [that] the disc is popping and clicking. That’s a dislocating disc. And people don’t even think about it like that. And dentistry has never talked about functional space. You talk to an orthopedist, you talk to a physical therapist, they understand joints need functional room.

And if you have a corrupted skeletal development, then the musculature is going to be off, and this joint gets really victimized because your teeth still have to fit together and the muscles still contract, and there’s just this huge cascade of symptoms that result—lots of inner ear issues, lots of head and neck pain, [the] trigeminal nerve is in this hyperaroused state all the time. But then, if it’s affecting your airway, too, then it’s affecting you not just through pain in the area of the joint, or the head and neck and the face, let alone the neck, because now you have poor head posture from your bad jaw position. But if you’re not sleeping right, now you have disrupted sleep. You may have apnea, and now you’re at risk for a heart attack and stroke. You may just have upper airway resistance syndrome, which is hugely overlooked, [and] which is just on that spectrum of sleep-disordered breathing. So you’ll go get a sleep test, and they say you’re normal because you don’t have this high apnea number, or they call it mild, which is crazy, but you have lots of disruptions and you feel crummy. Well, if you’re disrupted in your sleep all the time, and you’re in fight-or-flight all night long, the hormone and metabolic functions of your body are thrown off, and now you’re going to be even more sensitive to pain.

So there can’t be a disconnect between them. They’re both so interrelated. And the numbers that I’ve been taught are around 80, 85 percent of people [who] have TMD have sleep-disordered breathing or vice versa. So, why? Well, we said it multiple times. Because it’s the same cause the majority of the time; it’s the same reason. If someone’s morbidly obese, you might have a perfectly fine joint. But that’s also a big misnomer not to circle back around sleep. I see large airways on thin people; I see tiny airways on thin people. You can’t tell from the outside what it’s like on the inside. I don’t know if I answered your question.

Chris Kresser:  Yeah. I mean, we talked about how nutrition and other influences in the modern world are leading to differences in facial and jaw development and how that relates to breathing and apnea. I assume that’s a similar pattern with TMJ and some of the joint issues.

Paul Peterson:  Yeah, exactly the same. And one complicates the other.

Chris Kresser:  Exactly. In the case of my wife, she didn’t have TMJ. But she had pretty intractable pain in her neck and upper back that she’d had for 20, 25 years. And she’s a Feldenkrais practitioner and a somatic awareness practitioner and has a very developed, refined body awareness. So it certainly was not from lack of trying to resolve and unwind those patterns. And the thing that eventually made the difference to the point where she could be without pain in those parts of her body was fixing her jaw [through] doing the work with you. She started with a couple of other dentists who were helpful in some ways, but were not able to bring it across the finish line, I guess I would say. I think there was some awareness there for sure of how the jaw was contributing and where the jaw needed to be for her to not have pain. That was actually her first experience of not having pain, after her jaw was adjusted. But they were not able to keep it in the right place without the appliance being there anymore. So what’s happening there, where just the alignment of the jaw can cause such severe and widespread pain in other areas of the body?

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Paul Peterson:  Yeah, and there is no one answer for one patient. And this is why you need thorough diagnostics and comprehensive evaluation, and you need a team. And that’s why, as far as I’ve come in the last decade, I still feel like there’s always more to learn. There [are] people [who] have been working with patients longer than I have, and I go to meetings and I learn from them. But why is there so much pain? Or how many problems? Well, there’s a lot of energy expended when your body’s not in alignment, is one way to look at it. Certainly, pain can come right from the joint. Maybe there’s not popping and clicking, but if the joint is not sitting properly, there are nerves and blood vessels in there that can be compressed; there [are] tendons that connect to the inner ear that can cause problems. The breathing and the dysregulation of the autonomic nervous system as a result of that is so interrelated. The trigeminal nerve going to all the functional structures of the face also is just this superhighway, and just like chronic pain anywhere else, the sensitivity after long periods of chronic pain can become extra sensitive. And some of the techniques or some of the results that people get are based on normalizing the muscle position and downregulating the neural activity.

One of the really useful tools that I don’t think is wide[ly] enough known is sphenopalatine nerve block. I’d have to go back and see if we utilized that with Elanne. But it is really beneficial. I’ve had teenagers; my youngest was 13 years old. This poor girl came in, and she started having horrible migraines. You’ve got to know where to put it, of course, but it’s simple 2 percent lidocaine, you put it in the right place, run it into the nasal sinus, you hit this nerve bundle that’s not far separated from the trigeminal ganglion, and you can calm down the hypersensitivity that’s happened in that nerve pathway. Just like nerve blocks are used in pain anywhere in the body. Super, super useful, super easy to do. Not expensive. I’ve had people [who] have suffered from migraines for years and years and years. So it really is a complex answer because every patient is different. Some patients you’re able to get better really quickly, [and] some take more time. There’s not just muscle, but the fascia that’s included. Improper breathing is a big player in this and how sensitive people are to pain.

So one of the things that we’ve added to our repertoire is I have a physical therapist [who] works for me, and he works with preparing people for me to do oral tether releases like tongue ties and lip ties. Some people have had really big relief by just addressing a tongue tie and how that’s interconnected to the hyoid bone and all those structures. But the point I’m getting at is the fascia. We do the same thing with dry needling. We can get into muscles and help with the fascia, and I have a soft tissue specialist [who] comes in and works on that, too. So it’s not just my dental tools; it’s not just what I’m doing. I’ve tried to bring in a team to help these patients, to find the things that are most relevant and most helpful. So, now, it’s nice not to have two tools in your toolbox. It’s nice to have half a dozen. And I hope in two years, I’ll have half a dozen more.

Chris Kresser:  Yeah, yeah.

Paul Peterson:  Did I get to your question, Chris? It’s just not a simple answer.

Chris Kresser:  Exactly, that’s what’s challenging in general about this. Functional Medicine has come a long way since the early ‘90s. I feel like, let’s just use for lack of a better term, functional dentistry is kind of at the stage that Functional Medicine was 20 years ago, where there’s less awareness, but it’s growing, and growing quickly. There’s no established residency or board certification for this. As far as I can tell, there’s not really even any formal training programs that are like beginning, middle, end, go through this whole thing, and you’ll get this whole curriculum and program. It sounds like you’ve done more of the Mr. Miyagi style kind of apprenticeship, finding people [who] teach some part of it [who] you really respect and learning from them, and then going on learning a different piece from someone else. And I think that’s fantastic. You’ve been able to put that together. My sense is [that] it’s also what makes it frustrating for patients and frustrating for dentists who want to get more training like this.

Because if someone hears this show, and they’re like, “Awesome, I want to do this. I want to work with somebody like this,” there’s no directory that you or I can send them to that has a list of people [who] are combining all of these things in the way that you are. And of course, I’m very familiar with this problem. That’s why I started my ADAPT Practitioner Training Program in 2016. But we chatted about this before we decided to do the podcast. I’m almost reluctant to do podcasts like this just because I know people are going to hear it, they’re going to get excited, [and] they’re going to want to be able to access this kind of care, which, of course, is perfectly logical and understandable. I was there myself. And if they’re near you or can travel to you and can afford to do that, I would highly recommend that. So in a second here, [I’ll] let you give your information. But for many people, that’s not going to be possible or feasible. And that’s nothing you can do anything about personally today or I can, but I do take some solace in the fact that this is a really different field even than it was five years ago. I was kind of surveying this landscape. It seems like there are changes happening there.

Paul Peterson:  Yeah, you’re right.

Chris Kresser:  There’s a lot more going on now.

Paul Peterson: Yeah, there [is]. There’s more collaboration [between] groups. The [Academy of Orofacial Myofunctional Therapy] (AOMT), which is a myofunctional therapy group, [is] doing brilliant work and great education and lots of multidisciplinary collaboration. The Breathe Institute is doing great things. There’s more and more appliances that are based around addressing these issues that are dental in nature for expansion in one form or another. It’s growing, and there’s a growing understanding that, historically, the problem has been a lack of training, a lack of knowing. As things like this develop, we’re in this period where I feel like there [are] people [who] are focusing on one thing or another, and I’m sure they know many things that I have yet to learn. But when I listen to them speak and I participate in their trainings, I see gaps in their understanding, based on my experience. So we still have a long way to go. But I agree with you; I think your observation is accurate. It’s much different than it was five years ago.

So it is promising that in five more years, it will be much better. But it’s challenging. What you said about how much it takes to get this understanding and study, it’s very true. And it self-limits because there isn’t a residency for this. I feel like based on what you learn in dental school or in a specialty, you don’t understand, at least at the time that I went through. It’s been a minute, if I’m being honest; it’s been almost 20 years, but you didn’t understand the importance of it. You didn’t understand the significance and how profound the problem is and how much people are suffering. So there’s probably some change there. But if you’re going to treat and treat well, there was a point that I was a few years into this, and I had to make a decision. Am I going to continue to forego family vacations and spend so much money educating myself and time away from family and work to continue doing this? Because I had to get a couple [of] years in to realize how much there was to learn. And that’s only grown, which is good. There’s more interdisciplinary, multiple groups sharing information. But it’s really hard. As much as I try, if you’re a full-time clinician, it’s hard to keep up with it all. It’s a challenge.

Chris Kresser:  Absolutely. Well, thanks for your contribution. I really appreciate your multidisciplinary approach. That’s definitely my orientation and what I think is often necessary, especially in complex chronic cases. So where can people find out more about your practice and your work? Especially if they’re local or want to come travel to see you.

Paul Peterson:  Like you said, we’re in Park City, Utah. Our website is AdvancedCosmeticDentistry.com. You can look up Dr. Paul Peterson, and you will find that. We’re launching in the next couple of weeks a new site that hopefully does a clearer job of getting this message forward. But for now, the URL will probably be the same.

Chris Kresser:  By the time this comes out, it’ll probably be past that, so that’ll be great.

Paul Peterson:  Yeah, yeah, it should be up and working. So that’ll be good. And they’ll even be able to see Elanne on there and some of her changes.

Chris Kresser:  Awesome.

Paul Peterson:  She’s been kind enough to say [we] can use [her] before and afters, and it really speaks to what can be accomplished.

Chris Kresser:  Absolutely. Well, thanks again, Dr. Peterson. It’s been a great conversation.

Paul Peterson:  Thank you, Chris. Thanks for what you do.

Chris Kresser:  Thanks, everyone, for listening. Keep sending your questions to ChrisKresser.com/podcastquestion. We’ll see you next time.

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