Prof. Tipton on Occlusion in the Digital Age

Dr Khalil Karam: Day, we’ll be hosting Professor Paul Tipton. My major area of interest, I think, is probably occlusion. Before that, my passion was cricket. The worst person I want to go and see is a dentist. No extension for prevention anymore. Everything that we do in dentistry is a compromise. And I asked them, How many times do you do gold on the molar that’s broken? And they’re saying, Never.

Dr Khalil Karam: ..with the help of Google and other platforms, they start looking and they do their homework before coming to you,

Professor Paul Tipton: Yes. Why are we getting more occlusal disease? One word, stress. Now,

Dr Khalil Karam: what about the curvy tools of ex vivo simulations,

Professor Paul Tipton: an AI driven simulation, and the computer model will be much better.

Dr Khalil Karam: What this trendy, hot topic of dynamic occlusion

Professor Paul Tipton: our teeth, when they come together, chewing wise, they only come together for maybe four to 15 minutes during the day. It’s a matter of trying to get that balance right. And the only person who can get that balance right is your patient.

Dr Khalil Karam: You get some certain insights, and these things, are you smiling? So supposedly,

Dr Khalil Karam: Hello, everyone. Dr Khaleel Karam.

Narrator: Dr Khalil Karam is a Digital Transformation Strategist as a creator of the Moz concept in Fujairah, UAE, he integrates technology with esthetic care to transform patient experiences, shaping the future of digital dentistry across the UAE,

Dr Khalil Karam: ..and today, we’ll be hosting Professor Paul Tipton.

Narrator: Professor Paul Tipton, acclaimed prosthodontist, founder of Tipton training and president of the British Academy of restorative dentistry. Through restorative and implant courses, he has mentored 5000 plus dentists, elevating standards in the UK, Europe and the Middle East.

Dr Khalil Karam:And I think he doesn’t need any acquaintance. He’s a very well renowned dentist with experience on all the fields of dentistry. Without further ado, we’ll start with Dr Paul to introduce himself, and then we ask him the right questions.

Professor Paul Tipton: Hi. Thank you very much for for having me. First of all, thank you. Thank you for being here. I am a prosthodontist. You can see from my my face, I’ve got a lot of experience. I’ve been practicing a long period of time. I qualified 40 years ago, so I’m now a professor in restorative cosmetic dentistry, a specialist in prosthodontics. And my major area of interest, I think, is probably occlusion. Before that, my passion was cricket. And I don’t know if anybody out there knows the game cricket, but I was professional cricketer. I played cricket for for Lancashire, many, many years ago as a professional and that was really my, my huge passion. And I think probably with any form of sport, if you get good at sport, you only get good at sport by working hard and trying hard and putting in the extra hours. And I think that’s probably what’s helped me as a dentist, by taking that work ethic from sport into dentistry. So I’ve worked very hard at my dentistry. Worked many, many long hours to get to a position where I may be starting to understand

Dr Khalil Karam: it starting. It’s very interesting to cricket, because I have a good idea about cricket as well. It’s a very, very It needs a lot of patience to practice, and it’s a very long game you have where you need to play it for one whole day to get it now I think, doctor, being a 40 year dentist, seeing all the changes from the different eras of dentistry, I think it will be very insightful for us. Doctor, how the timeline of dentistry went from where you have started and where we are today, actually, and sense of remarks, changes, challenges, all these things will be very insightful. Doctor,

Professor Paul Tipton: see the I suppose the changes, the major changes we see, are trends. And the trend has gone from when I first started as being reparative, the most important thing was to repair the teeth so the teeth lasted. It’s now trended towards more esthetic so we are doing esthetics. And the part about long lasting comes second. I think this is society. Generally. We live in a throwaway society, and we all know that if we have a hole in our sock, what do we do? We buy a new pair of socks. If a button comes off my shirt, what do we do? We buy a new shirt. So in years gone by, I’m still of the generation where my mother and father, if they had a hole in their sock, would don the sock. If there’s button missing, would keep the shirt and buy a new button and put a button on. So we live in a throwaway society. And I think that has also comes through into dentistry, whereby a lot of the trends are now for short term dentistry that not necessarily lasts. And I see this a lot, with composite bonding as a topic. Make the teeth look very, very nice now. But how long will that composite bonding last for maybe five years before it has to be redone again? And I don’t know about you going to the dentist, but the worst person I want to go and see is a dentist. Okay, so if somebody can offer me a solution whereby I go and see the dentist and have work done every 20 or 30 years, rather than every four or five years, then I would like to go and have that style of dentistry done. So we see the advent of composite bonding. We see the advent of a line of therapy and orthodontics becoming greater. It’s more minimalistic. So there’s nothing wrong in minimal, minimally invasive dentistry, but we have to go and look at the longevity of it. And I like to talk to my students about for any restoration that they are going to do for a patient, okay, there are three factors that you need to get into that restoration when you’re talking to a patient. You usually want your restoration to last as long as possible. You usually want your restoration to be esthetic as possible. And usually want your restoration to be as minimally invasive as possible. Those are three parts of the holy grail of doing restorative dentistry.

Dr Khalil Karam: No extension for prevention anymore.

Professor Paul Tipton: No, no those, those three factors. And here’s the crux. The crux is you cannot get those three factors into any restoration you do. So everything that we do in dentistry is a compromise, so we can’t have the most minimal, which will last the longest and be the most esthetic. I’m sorry there’s not a restoration out there. If you think of one, then I will give you another restoration which will either be more ascetic or last longer. So if we want the absolutely most minimal, most esthetic and longest lasting, it doesn’t appear to be out there yet.

Dr Khalil Karam: Very interesting questions I’m going to ask you, Doctor , are we are seeing more of invasive dentistry now, and sense of providing over treatment in terms of doing esthetic dentistry, or we are doing less invasive and sense of how big our cavities and our reductions are,

Professor Paul Tipton: again, interesting point. I see differences in different areas of the world. So in the Middle East, I see much more heavily prepared teeth. I see much more emphasis on zirconia, much more emphasis on the esthetic part, as opposed to minimal invasive. Back in my country, in the UK, I see a lot of emphasis on minimally invasive, and not necessarily that’s a good thing, because minimally invasive usually means that it won’t last, and therefore it has to be redone again and again. It’s a matter of trying to get that balance right, and the only person who can get that balance right is your patient. And so we have to talk to patients. We have to talk to patients and ask them, What is the most important two factors out of those three I’ve discussed. Now it’s an interesting one. If I talk to dentists here, and during my my lectures, we go through this, and I say, you have a an upper right molar tooth mod amalgam in it, and you’ve now broken the palatal cusp. What restoration Do you want? And it can vary between. You can have a glassonova, and some densities will just say, put some glass onoma in there. We can have another amalgam, a bonded amalgam. We can put a very big composite in, okay, and we’ll just make it so the boxes are sub gingival. We can go and put a zirconia crown on. We can put an emacs crown on. We can put an emacs onlay on there. We can put a PFM crown on we can put a gold crown. Go three quarter can go seven eighths crown, gold onlay. So that’s 11 restorations. All will have a different mix of longevity, esthetics and minimally invasiveness. And what comes to the fore, more and more, is, if I’ve got a class of 20 dentists there, probably 40% will go for gold. And I asked them, How many times did you do you do gold on the molar that’s broken? And they’ll say, Never, and it’s why do you want it yourself? But you’re not going to do for other people. And the question. And the answer is usually, well, they don’t want it. And what’s the difference? The difference is, you, the dentist, has got knowledge understanding of dentistry, and has therefore chosen to go for gold. And we need to be educating our patients again, that our patients decide. So when we talk about those three factors, it does need a lot of explanation to the patient, so the patient understands which of those two factors are the most important for him. So

Dr Khalil Karam: I think now, in this era, doctor, we data driven. Social Life is we all are driven by the data. So I think communication is based on your data you are communicating because people level of education is much higher than used to be, and with the help of Google and other platforms, they start looking and they do their homework before coming to you. Yes, so I think having what I called a patient specific communication to sustain a high level of practice is very important, and it needs to be supported by as well, softwares and different management applications which can help you to maximize this level of communication. So as I know doctor, you are also an economics part of dental businesses. I think it’s very important to our young dentists, the Z generation, to understand this part very profoundly, because that impacts their practice, their career growth as well. I

Professor Paul Tipton: think what you’re discussing is success, okay? And for me, success has been built on in the past and will continue to be built on in dentistry. Three pillars of success. The first pillar is knowledge and theory, and unless you have good knowledge, good understanding and the theory of dentistry, understand it inside out, then you’re always going to have failures because you’re making the wrong decisions. You don’t know how to treatment plan. You’re doing this rather than that. So I think the first pillar, which is an obvious one, you get taught this at dental school, but at dental school, what you get taught is a very low level of what you can be achieving once you go into practice, private practice. So that’s the first the second part. And this may be replaced in the future, but at the moment, the second part is your hand eye coordination. Okay, to be a good quality dentist, you need to be able to prepare teeth, to do restorations. I’m talking now of a cosmetic surgeon, maybe not so much if you’re going to be an oral surgeon, or if you’re going to be involved in endodontics or orthodontics, but I’m talking about my actual field of prosthodontics. You need to be good with your hands. So you need to develop good clinical skills with your hands. And you get that from going on courses again, learning from people doing practical procedures again and again and again. And the third part is then the business skills. And the business skills and the communication skills come hand in hand, and if you are only good at two of them are not any good at the business side, or the communications Guide or the marketing side. You’ll be one of the top dentists in the world, but you’re sitting there going, nothing’s there, and waiting for your patients to come. So you’ve also got to develop that side of your business, the business skills, the communication skills, the marketing skills

Dr Khalil Karam: question, so I think you are the right person going to answer him. Where is the evidence dentistry? Currently, from both perspective, the knowledge itself and the practice, where we are actually,

Professor Paul Tipton: we’re getting more and more evidence based dentistry. But one of the things sometimes you cannot prove some things. Okay, the ideal model is the animal model. And medical ethics boards do mean that more and more we can’t do the ideal scientific style of test or examination, because we are now involved in medical ethics boards. I’ll give you, for instance, many years ago, we used to have the monkey model, and I’m not saying we should or shouldn’t do that’s a different story. But on the monkey model, we could go and test things, and we could test materials out directly on the pulp, and we could see what happened to the pulp of a monkey, and then what would happen if we treated that pulp in different ways, and what the response would be. And of course, we can’t do that anymore. There were studies done on students dental students in the States, where finally a dental. Students were given deliberately non working side interferences only for a small period of time. Okay, and just tested them over a month. What would happen if suddenly you or you or you were given non working side interferences? How is that going to affect you? Can’t do that anymore. So whilst the data is is getting more and more and more, some of the studies, the real, relevant ones we aren’t able to do,

Dr Khalil Karam: there was an interesting question this. Now, what about the tour, the the the tools of ex vivo simulations? So we are talking about materials and their physical properties. How accurate these simulation tools for research are getting, and we are getting more accurate data for these materials, compared on on the the longer or longitudinal studies are these? Are simulating these long term studies? What do you think of this?

Professor Paul Tipton: Well, I’m not a material scientist. Number one, so materials is probably on the weakest parts of my teaching. And I give that over to other people. However, all the tools that we’ve had previously on simulation, of chewing on, simulation of saliva and caries. They’ve not been great. They’ve not been great. I know that AI is coming in more and more an AI driven simulation, and the computer model will be, will be much better. However, again, I’m not a expert at AI and I, although I sit on one or two AI boards, it’s more those people telling me what is happening in the AI situation. But

Dr Khalil Karam: when it comes to now the practice of dentistry, we do all know that dentistry is becoming so diverse in terms of your practice, but how we can summarize dentistry today after 40 years of practicing it.

Professor Paul Tipton: So dentistry is getting bigger and bigger, and it’s more and more difficult to keep up with the topic which is yours. And so my dental topic has been more and more going from restorative dentistry into prosthodontics and then into fixed prosthodontics. So fixed pros is my particular field. And over the years, I think that the major factor which I look at, which has been the Keystone, the cornerstone of success is occlusion. And occlusion drives everything. And again, when I do my my lectures, my small group lectures, here in Dubai, in the UK, we lecture all throughout Europe. The one factor which comes through is that their occlusion teaching is very poor, and so we need to educate dentists more and more on occlusion, and we say, why is the occlusion teaching so more so poor? Because occlusion is taught by older dentists who’ve been through a lot of experience. It’s very difficult for newer graduates to understand occlusion and work with occlusion without a certain amount of experience as well. We teach occlusion. Occlusion in my hands, I feel, is very simple to teach. It’s a matter of getting the bike right when we do this up and down, the bike right when you go forwards and backwards, and the bike right from side to side. That’s all occlusion is about. There’s five principles, and once you understand those principles and break occlusion down, it becomes very simple. And the problem with the occlusal teaching is that it’s poor. And occlusion affects every part of dentistry. If you don’t get the occlusion right, then your endo is not going to work. You’re going to get relapse. Don’t get the occlusion right, and your perio won’t settle down, and you’ll still have mobility. You don’t get the occlusion right, and your orthodontics is going to not necessarily fail, but potentially cause problems elsewhere. So occlusion is the one thing that ties all of dentistry together. It’s the lifeblood that goes through all of dentistry, and that’s the bit that I try to teach after 40 years of experience and 40 years of going on courses, et cetera.

Dr Khalil Karam: Now it won’t come Dr and all these different let’s say the evolution of dentistry itself, are we are going to more diverse selection of different treatment modalities and materials, or we are approaching to more unified or universal practice of dentistry and sense of the materials and the approaches? I think

Professor Paul Tipton: the materials are getting more and more. More. So I think we’re probably getting more diversified with that, with occlusal teaching, occlusal teaching stayed the same. Okay, those principles are still the same as they were 30 and 40 years ago. Yes, we’re getting into a more digitally driven age where we can maybe finesse the occlusion, or we can maybe get a bit closer to the shapes of restorations with our dental technicians before we put them in the mouth, but the principles and theories of occlusion are exactly the same as they were 3040, years ago.

Dr Khalil Karam: So we are still practicing the old occlusion we have to practice because that’s the human being is. There’s no much changes in your

Professor Paul Tipton: physiology. Those are fundamentals. There are certain fundamentals in dentistry, and that’s a fundamental. Now,

Dr Khalil Karam: you mentioned the digital dentistry. Now myself as being very exposed to digital dentistry. There’s a lot of tools and facilitations happening in this practice. Are those things helping us to practice better occlusion? Or you see that still, we need more profound understanding for the occlusion by specialists and other things, because now, with the digital scanners softwares, you get your occlusion mapping there, you get some certain insights. And these things say, Are you smiling? So, supposedly, so I think, and there’s AI platforms as well, for example, byte finder. So how do you feel that occlusion, from the registration till adjustment, is being captured by these digital means.

Professor Paul Tipton: The first thing is that we need to have an understanding, a comprehensive understanding of occlusion before we can start to work with these tools. That’s the first thing. You can’t take a beginner and give him all these tools, these lovely AI driven digital tools, scanning, etc, and expect him to understand the occlusion. So we have to learn analog first before we can learn digital. And at the moment, we have to ask ourselves, is digital going too quickly? Are we teaching people too much digital? And from my point of view, I think again, this is for most people. This is not for the extreme 1% or 2% of top class prosthodontists in the country, in the world, who has all these tools and uses them, they would probably be just as good if they didn’t have the tools. We’re talking about the younger generation, the younger generation who is trying to find a way of working with occlusion, they’ve got to understand analog before they move on to digital. Now, a lot of the the work that I see out there in our country, and again, I can only speak for the UK, probably similar elsewhere, average age of a dental technician. Give me an idea, what you think average age of a dental technician in the UK,

Dr Khalil Karam: 50 maybe 57 Okay,

Professor Paul Tipton: okay. So what does that mean? That means that in 10 years time, five years time, those 57 year olds will be dropping off the edge. And you have to say, Who are the people coming forwards, the people coming forwards again have got great digital knowledge, but very limited knowledge in the mouth of the analog techniques. And therefore something does go wrong, as it can do with digital very easily. We’ve all had problems with our phones, with our laptops, etc, with bookings online. So these things happen. They don’t have the experience to go and check to see if the end result is actually what we thought it was going to be. So it’s the same thing with with dentists, we have to understand the analog before we can go to the digital. And one of my problems that I see a lot is that the dental world is pushing digital scanners, for instance, okay? And we talk about, I talk to my technicians, and they say, Yes, we can scan the byte, okay, yes, you can scan into cuspal, okay. What about how do you place the models that you have your digital models? How do you place those into your digital articulator? Now we know that in order to do that, we need to have a digital face bow. Now there are very few companies at the moment that have digital face bows. So I say to a lot of I have a feedback from technicians who say, Well, we put it sort of here. So. Now, of course, if you’re not putting it into the right part in your digital articulator, then the angle of approach of your lower jaw to your top jaw is going to be wrong when you’re close together, because you’re starting from the wrong point. So your intercuspal is always going to have a slight problem in terms of premature contacts. It’s like using a simple hinge articulator. So until we get to the stage where we have digital face bows throughout dentistry, and we can use them, we still need to find this point here, terminal, hinge axis.

Dr Khalil Karam: No, that’s very interesting. Question statement, Doctor, I have read articles where there is faces can driven alignment, yes, and you have a CBCT, driven alignment of your your jaw. And the initial insights, they are very promising, that we are good to very good alignment. But the over the question is, even we do the best alignment, we will take the patient or the human and we digitalize them. Still we do how much reliable that occlusion in both static and dynamic is becoming.

Professor Paul Tipton: So when we talk about facially driven and doing scanning, facial scanning that can get around it, and cbcts, but we’re talking about using occlusion for the masses. And again, the one to 2% who are doing that are getting good results. We need to look down and say, for the average dentist, it’s very easy to take a face bow. And therefore, if you take a face bow, you’re at least going to get your models put into the articulator, approximating to where terminal hinge axis is, which is your starting point for your restorative work, by the dentist, by the dental technician. So that’s our basic okay. And until we have the digital face bow, then we can’t do that. So the method that we teach, and remember, we’re not I’m not teaching the top one to 2% I’m teaching the masses here how to do good dentistry. Good. Okay, so the basic we teach is you take a face bow for your restorative work. You use a semi adjustable articulator. That’s the best way to get your restorations to a situation where they need the least amount of adjustment in the mouth. Okay? And so again, we are now waiting for digital face bows in the meantime, therefore, we’re doing our scanning, we’re printing the models. We’re using an analog facebow to put into an analog articulator, and then we’re going to make digitally our restorations. So we’re using a hybrid approach. It’s a little bit like when, when Tesla and cars came out, everybody went and started to buy Teslas, okay, electric cars. There was no chargers. Yeah, yeah. All problems. Now, what’s happened? Everybody seems to be more into the hybrid mode. Okay, the electric cars will come again, but everybody’s into hybrid. And I look like and the same thing with our digital analog dentistry. The digital has been pushed a little bit too far. Come back just a pace and go into a hybrid approach, where there’s some digital and the some analog, and that will give you day in, day out. For most dentists, the best,

Dr Khalil Karam: what this trendy hot topic of dynamic occlusion, digital.

Professor Paul Tipton: Dynamic occlusion is hugely important, and dynamic occlusion is important when we brux so we our teeth when they come together chewing wise, they only come together for maybe four to 15 minutes during the day. Okay, so when you swallow, your teeth come together when you’re chewing. Maybe there’s the odd little path here, touch here and there. But when we brux at night time, then our teeth can come into contact for three to four hours. So the dynamic occlusion is when we brux, and we have to put an occlusion for our patient as though he’s a bruxer. We develop an occlusal scheme for that patient for when he does brux, because that’s when the damage is

Dr Khalil Karam: done. I think. What do you think to which is the ideal occlusal scheme? So should we, or, let me rephrase it, should we find choose our occlusal scheme, or should we choose our material first? What come first?

Professor Paul Tipton: Occlusal scheme, always. Occlusal scheme. Okay? Because your exclusive scheme is basically saying, I want the temporomandibular joints to work with the muscles, to work with the periodontal ligaments, to then finally, work with the teeth. Okay, so our starting point for any restorative work is your condyles. Okay, put your condyles either. Into the best position possible, or into a position where the patient is comfortable and has been comfortable for a period of time. So our starting point is, do we work to what I would call recruited axis position, or centric relation, and we take the condyles into that position first, or do we accept the patient’s existing conduit position, which is the position that’s dictated by intercuspal position? Our problem with most dentists is that they think they’re working to intercuspal position, but because they don’t record that position and work to it more accurately then intercuspal position moves, and as intercuspal position moves, the condyle starts to move.

Dr Khalil Karam: Very interesting question, because I have started seeing these things a lot of my patients, Doctor, are we seeing a lot of premature interference in the central relation because of the stress related TM deviation and occlusion, because we always do the post, especially myself. It comes very often when you do the procedure, tooth preparation, and we are you did your all depth, guys, everything, and you come to take the bite by the rejection is gone, and it’s it’s getting more and more often, unfortunately. So we are we seeing this? Yeah, central relation interferences more

Professor Paul Tipton: Well, I think we’re seeing occlusal problems more and more so in the UK. The survey was done fairly recently, and it showed that occlusal disease, inverted commas, was more prevalent than decay and periodontal disease. Okay? And again, I ask my my dentists, wherever I am in the world, I go through a series of signs and symptoms of occlusal inverted commas, disease such as temporomandibular, joints, clicking, popping or pain, muscular pains, headaches, tooth wear, tooth fracture, restorations, wear restorations, fracture periodontal mobility or recession, where we have no periodontal disease. And I ask them all, and ask anybody listening here now who’s a dentist is think about your adult population that you see in your practice, and what percentage of your adult population have any of those signs and symptoms. Now the usual response I get is somewhere between about 70 and 90% 70 to 90% of your patients don’t have periodontal disease. 70 to 90% of your patients don’t have caries, unless we are living in maybe a different country to the ones we’re talking about here. And so it’s the most prevalent. And therefore we are getting more occlusal disease. Why are we getting more occlusal disease? One word stress,

Dr Khalil Karam: stress. I think, I think we there is one final thing we need to highlight it the cranial cervical adjustments, emergence and how it interacts with our occlusion, because now everyone’s bragging about it and giving it in their occlusion courses. So

Professor Paul Tipton: yeah, they may be giving it in occlusal courses. But again, I’ll come down to basics. Get your masticatory system right. First of all, okay, other joints, other issues, breathing difficulties, those are fine. Do those afterwards? But get your masticatory system working well. And the masticatory system is comprised, as we know, of jaw joints, muscles, Periodontal ligaments and teeth. So basics of starting anybody’s restorative work is choose your conduit position, and that’s based simply on four aspects. It’s based on the patient’s slide from retreated contact position to intercuspal position. Is it a large vertical? Is it a large horizontal? Next one is the stability of intercuspal position. You can’t work to intercuspal position unless it’s stable. Third one signs and symptoms of temporomandibular joint problems or wear. And the fourth one is the amount of restorations you’re going to do. Those four factors will determine whether you should work reorganized. We call it around our AP, or con-formatively around ICP. Once you’ve chosen your conduit position, okay, then we must stick to it. And we have to work rigidly to that position. And what we must not do is let the condyles just move and drift.

Dr Khalil Karam: I mean, is there any objective way, doctor, of registering your CR? Your best condyler,

Professor Paul Tipton: lots and lots of ways. And we teach it on our courses all the time. You know that you’re on CR? Or our AP by a door. There you open and close the door. You know what it feels like to open and close close the door. It’s a hinge, okay? And the second part is that you are opening and closing the door. So it’s the same thing. Here we take a a position of our fingers. That’s the dorsum by manual manipulation position. We take that position, and we by manually, start to move the condyle up and down. And once we feel this muscular release, and we feel the joint moving, and we feel as though we are managing that movement and it’s hinging, then we’re in our AP or centric relation, and that’s been reproducible for 40 years. The trouble is, who’s teaching it, who is teaching that and the other secondary part of it, and again, I have this when I teach students, this is not dentistry, as far as there were aware. What is dentistry? Dentistry is drilling teeth. Dentistry is putting fillings in teeth. I’m now trying to teach them something which is more orthopedics, chiropractor, physiotherapy, but we’ve got to learn that particular part which is not taught at university to be able to get our starting point if we want to work reorganized, if we don’t, we just want to work con-formatively, forget it. Don’t don’t bother manipulating mandibles. But in that instance, you’re going to be treating a lot of patients the wrong way.

Dr Khalil Karam: Dr Tipton, thank you very much for wonderful insights. Thank you everyone for watching next dental podcast series, and we hope we can see you with more of about dentistry.

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