利用先进影像技术治疗颞下颌关节紊乱病患者，与Drew McDonald博士对谈

如果你听这个播客有一段时间了，你可能会注意到我很少插广告，这是有意的。

If you've been listening to this podcast for a while, you've probably noticed that I very rarely include ads, and that's intentional.

我从来不想用一堆促销来打断你的收听体验。

I never want to interrupt your listening experience with a bunch of promotions.

但更重要的是，我不想为了赚点钱而推荐任何我自己都不相信或不用东西。

But more importantly, I don't want to recommend anything I don't personally believe in or use myself just to make a few bucks.

不过，确实有一样东西我想和你分享，因为那是我自己创建的。

That said, there is something I do want to share with you because I created it.

那就是 Elevated GP。

It's Elevated GP.

这是我自己的教育平台，它的使命很简单：赋能全科牙医。

This is my own educational platform and the mission behind it is simple: to empower super general dentists.

像你这样的牙医，想要保持专业敏锐，高水平执业，并坚持以证据为基础的护理。

Dentists like you who want to stay sharp practice at a high level and stay grounded in evidence based care.

在 Elevated GP 里，我们会深入探讨现代龋病管理、复合树脂技术、材料科学、种植流程等话题。

Inside Elevated GP, we dive into topics like modern caries management, composite techniques, material science, implant workflows, and more.

我们每个月会进行一次线上直播，进行协作讨论，你还可以访问我们不断扩充的课程库、所有课程录像，以及一个充满志同道合牙医的活跃群聊。

We meet live once a month for a collaborative session, and you'll get access to our growing course library, all the session recordings, and a vibrant group chat filled with like minded dentists.

所以，如果你想轻松跟上行业前沿，提升自己的临床水平，就去看看 theelevatedgp.com 吧。

So if you're looking for an easy way to stay on the cutting edge and grow as a clinician, check out theelevatedgp.com.

再说一遍，网址是 theelevatedgp.com。

Again, that's theelevatedgp.com.

我也会在节目笔记里附上链接。

I've also included a link to it in the show notes.

这是我非常引以为豪的东西，我很希望你能加入其中。

It's something I'm deeply proud of, and I'd love for you to be a part of it.

大家好。

Hey, everyone.

在开始今天的节目之前，我想花点时间跟大家聊聊 Net32，这是牙科专业人士的终极在线平台。

Before we dive in today's episode, I wanna take a quick moment to talk to you about Net32, the ultimate online platform for dental professionals.

如果你是一名牙医、牙科保健师，或者只是从事牙科相关工作的人，你一定会想听听这个。

If you're a dentist, dental hygienist, or just someone working in the dental field, you're going to want to hear this.

如果你厌倦了为牙科用品支付高价，或者因为要从多个供应商订货而头疼，Net32能帮你解决。

If you're tired of paying premium prices for dental supplies or dealing with the headache of ordering from multiple vendors, Net32 has your back.

它是最大的在线市场，牙科专业人士可以在一个地方比较来自顶级品牌和供应商的数千种产品的价格。

It's the largest online marketplace where dental professionals can compare prices on thousands of products from top brands and suppliers all in one place.

最棒的是什么？

The best part?

你不必非得是大诊所才能受益。

You don't have to be a giant practice to benefit.

无论你是刚起步，还是经营一家成熟诊所，Net32都提供有竞争力的价格和从设备到耗材的广泛选择。

Whether you're just starting out or running a well established clinic, Net32 offers competitive pricing and a wide selection of supplies from equipment consumables.

而且，他们易于使用的平台让你可以跟踪订单、找到折扣，并让所有你需要的东西直接送到家门口。

Plus, their easy to use platform lets you track orders, find discounts, and get everything you need delivered right to your door.

如果你担心质量，那大可不必。

And if you're worried about quality, don't be.

Net32只与值得信赖的供应商合作，所以你可以放心，你得到的是顶级产品，价格也是最优惠的。

Net thirty two only partners with trusted suppliers so you can rest assured you're getting top notch products at the best prices.

所以，如果你准备好节省时间、节省金钱，并简化你的采购流程，那就去 net32.com 看看吧。

So if you're ready to save time, save money, and simplify your processing process, head over to net32.com.

就是 net32.com，牙科专业人士在这里能找到他们需要的一切。

That's net32.com where dental professionals find everything they need in one place.

好了，我们回到节目中来。

Alright, let's go back to the show.

嘿，欢迎收听《牙科文摘》。

Hey, welcome to Dental Digest.

这是一个播客，旨在帮助你始终站在循证牙科的前沿。

This is a podcast with mission of enabling you to stay on the cutting edge of evidence based dentistry.

我是你的主持人，医生。

I'm your host, Doctor.

梅丽莎·塞伯特。

Melissa Seibert.

本期节目，我们将深入探讨咬合与颞下颌关节紊乱之间复杂且常被误解的关系。

This episode, we're diving into the complex and often misunderstood relationship between occlusion and TMD.

不过这次我们不是讲那种常规的咬合话题，我们要深入看看证据怎么说，争议在哪里，以及你对咬合的理解如何影响你对TMD患者的诊断和治疗规划。

This isn't your typical occlusion talk though, we're unpacking what the evidence says, where the controversies lie, and how your understanding of occlusion can shape your diagnostic process and treatment planning for TMD patients.

今天请到的是

Joining us is Doctor.

Drew McDonald医生，他是认证的正畸专科医生，重点研究气道和颞下颌关节为中心的治疗规划、手术辅助正畸治疗，以及处理复杂的跨学科病例。

Drew McDonald, he is a board certified orthodontic specialist with a strong focus on airway and TMJ centered treatment planning, surgically facilitated orthodontic care and managing complex interdisciplinary cases.

McDonald医生

Doctor.

在国内和国际上都有讲座，并且为相关文献和教科书做出了贡献，这些内容也影响了我们今天对这些话题的理解。

McDonald lectures nationally and internationally on these topics and has contributed to the literature and textbooks that shape how we understand them today.

顺便说一句，如果你喜欢这个播客，支持它继续为你带来高质量、循证信息的最好方式之一，就是在Apple Podcast应用、Spotify或者你收听播客的任何平台上给我们评分并订阅。

By the way, if you enjoy this podcast one of the best ways to support it it can continue to bring you high quality evidence based information is to leave a rating and subscribe on the Apple Podcast app, Spotify, or wherever you get your podcasts.

那我们就来聊聊

So let's unpack a little

在诊所里使用核磁共振这个概念。

bit the idea of using MRIs in your practice.

我们来谈谈这个的实际操作吧。

Let's talk about the practicality of this.

首先，第一个问题是，我们知道用CBCT的时候，要注意辐射的问题。

So first of all, first question is, we know with CBCTs, we just want to be conscientious of radiation.

你知道，每次拍CBCT，辐射量其实很小，但也不能过度使用。

You know, there's such little radiation in the grand scheme of things, each time we take a CBCT, but we don't want to overdo it.

而MRI呢，对，完全安全。

With MRIs, correct, perfectly safe.

没有辐射，就像我们现在坐在这里聊天一样，没什么辐射。

No radiation as much as you and I sitting here in front of, you know, just in chairs and being alive.

你知道，那就像……

You know, that's a...

它不是CT图像。

It is not a CT image.

我经常听到这个，因为有些人以为MRI有很强的辐射，其实不是的。

I hear this a lot because some people think that MRIs are heavy radiation things, they're not.

它不是辐射。

It's not radiation.

基本上，它就是一个磁铁在旋转，作用于你细胞里的水分。

It is a magnet spinning in your water parts of your cells, basically.

所以非常安全。

So very safe.

所以在我自己的实践中，如果我看到足够的指征——再说一遍，不是每个患者都做核磁共振。

And so I do in my practice, if I see enough criteria, so again, not every patient gets an MRI.

我觉得大家都以为德鲁是个给所有人都做核磁共振的疯狂家伙。

I think everyone kind of thinks Drew's the crazy guy who does MRIs on everybody.

但最终，如果患者从检查中表现出咔哒声、弹响、下颌偏斜，或者我之前提到的明显咬合不良，或者他们的影像显示CBCT上关节有破坏，或者他们的……

But ultimately, if a patient meets from their exam signs of clicking popping, deviation of their jaws, you know, obviously the bad bites that I talked about, and or if their imaging shows that they've got breakdown of the joint on the CBCT, or if they've got a lack of space in their...

髁突和关节窝之间空间不足，这也可能是关节盘失去保护的迹象。

Between their condyle and fossa, that can also be a sign that the disc is not protecting.

如果我在X光片、外部检查等所有这些中看到这些情况，那我就会安排核磁共振。

If I see those things on x rays, externally, exam, all of that, then I'm ordering an MRI.

现在回到这个做法的实际可行性。

Now back to how practical that is.

我以前在新墨西哥州的阿尔伯克基执业，那里可不是什么医疗创新的中心。

I used to practice in Albuquerque, New Mexico, not exactly a hotbed of just, you know, medical innovation.

我不是说那里不好，但你可以在这种地方做到这些，不是大城市，也不是医疗圣地。

I'm I'm not saying that poorly, but you can do this in not so, you know, not a big city, not a big medical mecca.

你完全可以建立这些东西。

You can establish these things.

再说说我是怎么走到这一步的。

Again, here's how I even got here.

派珀医生。

Doctor.

和麦基医生。

Mark Piper and Doctor.

吉姆·麦基，我想你应该认识他们。

Jim McKee, I think you're familiar with them.

我在阿尔伯克基有个很好的牙科朋友，他参加过他们的研究小组，专门研究关节问题。

I had a good dental friend in Albuquerque who had gone through and was part of their study club looking at joints.

作为阿尔伯克基的一名正畸医生，我拥有自己的诊所，业务主要侧重于正颌手术。

Me as an orthodontist in Albuquerque, I've had a practice or I owned my practice that was heavy on orthognathic surgery.

我出来的第一年，我和医生一起。

The first year I came out between myself and Doctor.

约翰·科内利，我从他手里买下了诊所，那一年我们做了大约三十到四十例正颌手术。

John Cornelli, who I purchased the practice from, we did somewhere between thirty and forty orthognathic cases that year.

他退下来之后，我每年仍然要做二十到三十例。

After he kind of stepped back, it was still between twenty and thirty a year for me.

所以这意味着，在我去之前，已经有好几年的患者，你知道，做了很多正颌手术，偶尔会有患者出现关节退化，甚至可能……

And so what that meant was, even before I got there, there were several years of patients that, you know, a lot of orthognathic surgery had been done, and every once in a while a patient would pop up that was having breakdown of their joint and potentially...

或者复发。

Or in relapse.

而我除了说“这是特发性的”之外，没有别的答案。

And I didn't have an answer for them other than, oh, it's idiopathic.

那挺好的。

Well, that's great.

你知道吗，如果你去看医生，跟他说，嘿，我遇到这个问题，他们却说，哦，别担心。

You know, if if you go to your doctor and and, you know, you say, hey, I'm having this trouble, and they're like, oh, don't worry about it.

这是特发性的。

It's idiopathic.

这等于什么都没说。

Well, didn't answer anything.

那只是告诉我，我……

That just told me I just...

你知道，随便吧。

You know, whatever.

所以最后，我的哥们儿戴维·蒙西纳里斯，他参加过道森的课程，也上过马克·派珀的课，他在学习小组里，他说，嘿，你不如跟我一起去，看看这个事儿？

So ultimately, my buddy David Montsinaris, had been through Dawson, who'd been through Mark Piper's courses, he was in the study club, he's like, hey, why don't you come with me and maybe just check this thing out?

而最早的几个病例，是医生……

And the very first cases that Doctor.

马克·派珀展示的是一些二类正颌手术复发案例。

Mark Piper was showing at this were class two orthognathic surgery relapse cases.

那些做过大型下颌前移手术、多次颌骨手术的人，反复失败，一次又一次。

People that had had big time MMAs, had multiple jaw surgeries, all of this thing, and they were failing and failing over again.

那才是让人害怕的地方。

That was the scary thing.

有些病人做过多次颌骨手术、多次前移，结果还是复发了。

Some of these patients that they've had multiple jaw surgeries, multiple advancements, and they've relapsed.

他展示的，是我第一次看到的核磁共振图像，那是2018年，我完全不知道自己在看什么。

And what he showed and this was the first MRIs I ever saw, this was back in 2018, I had no idea what I was looking at.

你知道，就像在看墨迹图一样。

And you know, it's like looking at an inkblot.

就像在牙科学校第一次看X光片，你会想，哦，那些白色的东西。

You know, it's first time you saw an x-ray in dental school, you're like, oh, those white things.

其他的东西我就不知道是什么了，好吧。

I don't know what the other stuff is, okay.

不是说您，但那就是我当时的状况。

Not you, but just that was how I was.

但说到底，从核磁共振来看，这些患者的关节盘都不在正确的位置上。

But ultimately, the MRI side, you know, again, these patients did not have the disc in place.

关节盘偏得离谱，离正常位置差得远，而且他们的状况一直在恶化。

It was way off in left field, nowhere even close, and they were continually breaking down.

每次他们调整好咬合，就会复发。

Every time they'd fix their bite, they would relapse.

调整咬合，又复发。

Fix a bite, relapse.

问题就在于关节这个后门一直开着。

Well, the back door has been left open with that joint.

所以这立刻引起了我的注意。

So that immediately had my attention.

然后我就想，天哪，我得开始做核磁共振了。

And I go, crap, I gotta start taking MRIs.

那我该怎么做呢？

How do I do that?

比如说，我现在处于什么位置？

Like, where am I?

我到底该从哪里开始着手这件事？

Where do I even start this this thing?

所以我回到了阿尔伯克基，完全不知道该怎么办。

And so I went back to Albuquerque, no idea what to do.

基本上就是，好吧，我想我得给一些私人的MRI成像中心打电话，看看他们愿不愿意跟我合作。

And basically was like, alright, I guess I'm going to call around to some private MRI imaging centers and see if they'll work with me.

你知道，一开始我联系了大概三家不同的地方，我就不点名了，但作为牙医，你面临的困难是，这些MRI中心主要是针对膝盖、髋关节之类的，而且有固定的时间安排，也就是说，这种图像需要十分钟，那种图像需要三十分钟。

And you know, first I went through about three different places, I won't name names, but you know, what you're kind of up against as a dentist is that these MRI centers are geared towards knees, hips, other things and that are set timeline, meaning that you know, this type of image takes ten minutes, this type of image takes thirty minutes.

但是，要看到我想看的关节活动范围，按照标准流程，一个好的技师大概需要三十到四十五分钟。

Well, the protocol for the joints to see the range of motion that I want to see takes about thirty to forty five minutes for a good technician to do.

如果技师水平不行，不知道自己在做什么，那可能得花一个半小时，而且他们也不知道该怎么收费。

When they're not good and don't know what they're doing, it can take an hour and a half, and they don't know how to bill for that.

所以最后的情况是，我找到他们，说，我有很多病人会介绍给你们。

So what ended up happening was I approached them and said, I have a lot of patients I'm gonna be sending you.

能不能商量一个现金价，不走保险的价格？

Can we work out a cash rate, non insurance rate?

因为那是另一回事。

Because that was the other thing.

大家都想用医疗保险来支付这些，你也可以这么做，但这会给你的前台带来巨大的负担，他们得做术前准备，然后你作为医生还得跟进电话，或者跟保险公司的人沟通，所有这些，你知道，会变得非常麻烦。

Everyone wants to use their medical insurance for these things, and you can, but it becomes totally a huge burden on your front desk and that they have to pre op things, and then you as a doctor end up having to do follow-up calls or, you know, just kind of talking with the insurance people, all this, you know, it becomes very burdensome.

而且我们还发现，病人虽然被批准做核磁共振，但他们会去做检查。

And also what we found was patients would be approved for their MRI, but then they would go get their MRI done.

然后基本上，到了最后，他们的保险公司会说，嘿，我们出了这么多，你还需要为这次核磁共振付2000美元。

And then essentially, the end of the day, their insurance would say, hey, we chipped in this much, you still owe $2,000 for this MRI.

他们就会说，我为什么要付2000？

And they're like, why do I owe 2,000?

所以我在阿尔伯克基谈好的，以及现在在佛罗里达这里做的，就是那个现金价，就是说，嘿，我们不走保险。

So what I worked out back in Albuquerque and what's been done elsewhere out in Florida where I'm at now, is that cash rate that says, hey, we're not going to utilize insurance.

病人最少需要付多少钱，才能覆盖你的时间、放射科医生、技师的时间，还有所有这些费用？

What is the bare minimum for your time that the patient needs to pay to cover, you know, the radiologist this, the technician time and all this stuff?

最后算下来，病人自费差不多不到500美元。

And it ended up being just shy of $500 was what patients would pay out of pocket for this.

这总是比他们用保险之后自付的费用要便宜。

That was always cheaper than what anyone would would pay out of pocket, you know, after their insurance.

所以这对病人来说是有好处的。

So that was beneficial for the patient.

而且安排病人做检查也很高效，因为他们不想等一个月才排上，结果预授权还被拒了，各种麻烦。

It was efficient in getting patients scheduled because they're just like, I'm not going to wait a month to get in because I got a pre auth and then have it denied and all this stuff.

就是很快，很快，最终病人得到了正确的诊断。

It was like boom, boom, boom, it ultimately gave the patient the right diagnosis.

这样一来，整个流程就变得常规多了。

So by doing that, it became much more routine.

就像我说的，第一步是找到一个愿意这样合作的中心，然后跟他们谈，我会送很多病人过来，能不能定一个现金价？

Worked, like I said, that was step one, was finding a center, wanting to work that way, and then approaching them about I'm going to send a good amount of volume, can we work out a cash rate?

所以在那之后，事情确实变得简单多了。

So after that, that really kind of just made it easier.

而且对我来说，那时候我也在进步，我越来越能看出这些关节盘移位患者的细微差别，所以我送检了更多不同类型的咬合样本去看。

And for me, I was also evolving at that time going, I'm seeing more and more subtlety to these disc displacement patients, so I was sending more and more different types of bites for these things to see.

而且，你知道，我注意到的是，患者确实想要这个。

And also just, you know, what I noticed was patients wanted this.

怎么说都不够，我知道你一直强调这一点，但患者想要一个诊断，他们想要知道该怎么办的选择。

Like, I can't say enough and I know you espouse this all the time, but patients want a diagnosis and they want options for what do you do about it.

吉姆·麦基说得比我好，但归根结底，他们来找我们，不是想听那些在别处也能听到的老一套，对吧？

Jim McKee says that better than me, but ultimately, they don't come to you and I and say, I just want the same old thing that I could get anywhere else, right?

他们通常把我们当作最后的希望，或者我们有点像……

They usually we are the end of the road for these patients or we're kind of...

他们对之前没解决的问题感到沮丧，他们就想知道答案。

They're frustrated by what they haven't gotten done and they just want to know.

如果你给他们真正需要的信息，并且解释清楚，比如为什么这个核磁共振很重要，它怎么和你的咬合联系起来，又怎么影响你的牙齿和未来，他们就会很接受，而且会成为很好的患者，也会好好配合治疗。

And if you are giving them information that they really need and explaining it to them like why this MRI is important, how does it extrapolate to your bite, how does this extrapolate to your teeth and your future, They're here for it and they will be great patients and they'll take care of what they need to treatment wise too.

所以最终，这成了患者来我诊所的一个动力，而不是让人望而却步的东西。

So ultimately, it became a driver for patients to come to my practice, not something that scared people away.

我这么说是因为那是我最初的想法。

And I say that because that was my first thought.

我当时想，我会成为那个让所有人都做核磁共振的疯狂正畸医生，然后他们都会觉得那家伙疯了。

I was like, I'm gonna be that one crazy orthodontist that makes everyone do or makes people do an MRI and they're all gonna be like that guy's crazy.

我周围一英里内其他九个正畸医生都没提这个，我为什么要去找这个人？

The other nine orthodontists within a mile of me didn't say that, why should I go to this guy?

而且我为什么要多花那么多钱？

And why do I want to pay that much more money?

但我看到的是，这并没有把人吓跑，反而吸引了更多人，因为他们在别的地方得不到答案。

And what I saw was it didn't scare people away, it actually attracted more people because they weren't getting answers other places.

所以这……

So it's...

总之，我不……

Anyway, I don't...

我觉得如果你在听这个，别担心这会吓跑病人。

I think if you're listening to this, don't be afraid of this being something that drives patients away.

其实，如果你懂得怎么识别和理解这些问题，这反而能让你脱颖而出。

Actually, this is something that can differentiate you very well if you know how to see these things and understand them.

跟你说，有一段时间我真的很不喜欢牙科。

Listen, there was a point in time when I really did not enjoy dentistry.

有些日子我甚至特别讨厌它。

Some days I even downright hated it.

我觉得我的牙科学校没有为真实世界做好准备。

I felt like my dental school did not prepare me for the real world.

当你不知道发生了什么的时候，牙科就没那么有趣了。

Dentistry is not a lot of fun when you don't know what's going on.

我能有今天，全靠导师、三年的住院医师培训，还有好的继续教育。

I am where I am today because of mentors, a three year residency training, and good CE.

所以我想把这个带给你：加入Elevated GP，让你通过能力获得自信。

And I wanted to bring this to you: Become a member of Elevated GP, so you can get confident through competence.

这是一个会员项目，你可以随时观看课程，还能参加我们的月度学习小组，也就是期刊俱乐部。

This is a membership program where you'll have access to on demand courses and our monthly study club, also known as journal club.

要注册的话，就去 elevatedgp.com 网站。

To get registered, go to the elevatedgp.com.

希望能在那里见到你。

I hope to see you there.

你或者你诊所的同事，是不是有一套固定的说辞，就是跟病人解释这个？因为我毫不怀疑，有一部分病人已经知道他们有问题了。

Do you or someone in your office just kind of have a pre sort of described spiel, if you will, just explaining it to the patient because I have no doubt that there's a contingent of patients that they already know that there's a problem there.

他们只是想知道，为什么他们做核磁共振检查时没有遇到任何问题。

They just want to know why they have no problem moving forward their MRI.

但其他人可能会觉得这是多余的。

But then others will feel like this is superfluous.

我觉得不幸的是，而且我认为这是应得的。

And I think unfortunately, and I think that this is deserved.

我觉得我们确实生活在一个我们的职业有

I think that we do live in an era where our profession does have a

有点名声，就是总想

bit of a reputation for trying

从病人身上榨钱。

to squeeze money out of patients.

我不是说所有人都是这样，绝对不是。

I'm not saying that's everybody by any stretch.

我觉得我们这个行业确实有些地方需要改进，需要重新赢得公众的信任。

I think we as a profession have some work to do, I think to gain back some public trust.

但你们是怎么跟病人介绍这个的，让他们愿意接受那额外的500美元费用？

But how do you all kind of pitch this to patients just so they do feel comfortable with that additional $500 fee?

对，完全同意。

Yeah, absolutely.

我非常同意你的看法，我觉得我们这个行业确实需要重新赢得信任。

So and I can't agree with you more, I think that we've got some trust to regain as a profession.

但我觉得部分原因是要做好诊断，而不是老一套——说我收费更高因为我更好，或者我用不同的支架之类的说辞，你懂的。

But I think part of that is being good diagnosticians and not just being the same old thing, but I charge more because I'm better and I use different brackets or some spiel like that, you know.

总之，这个我就不多说了。

So anyway, I'll digress on that one.

但说到底，回到那个话术脚本，这很重要。

But ultimately, back to kind of scripting, this is important.

从我的角度来看，这是慢慢学来的，因为一开始我也挺犹豫的，真的花了好几年时间才明白，每个来找我看病的成年患者，他们身上都有很多长期积累的问题。

And from my side of things, this was learned over time, because same thing, I was a little hesitant, and it took a couple years really of just being like, you know, every adult patient that comes and sees me, they've got a lot of stuff that's gone wrong for a long time.

尤其是作为正畸医生或全科牙医，你会看到这些成年患者，他们的牙齿有磨损，还有其他各种问题。

And especially the level of difficulty that you see as an orthodontist, or as a general dentist, you see these adult patients that they have wear and tear on their teeth, they have, you know, other things.

我的工作就是要搞清楚为什么会这样，因为我要知道怎么修复并保持稳定，就得先诊断出最初的原因，并且解决根本问题。

My job is to understand why is this happening, because me knowing how to fix it and keep it stable relies upon me diagnosing why it happened in the first place and addressing the root cause too.

所以回到话术脚本，很多打电话来找我的成年人，我举个例子，我经常看到一些下颌后缩的患者，男女都有，他们对MMA很感兴趣。

So back to scripting, on a lot of these adults that are calling to see me, they've got, I will say, I'll just use a common example, I will see patients with, you know, male or female, recessed jaws that are interested in MMA.

他们来了，特别兴奋，还有MARPY，他们就说，嘿，医生，我想要改善呼吸，我想睡得更好，我一直在看这方面的资料，我很喜欢这个，我们能做些什么？

They come forward, they're really excited too, and also MARPY, and they're just like, hey, aspect, I want the breathing, I want to breathe better, I want to sleep better, I've been reading about this, I love this, what can we do?

但在这种对话里，他们很少提到关节疼痛。

Well, that conversation, they're not very often talking about joint pain.

很遗憾，在牙科领域，我们总是把关节问题跟疼痛挂钩。

And I know that we make the joint conversation about pain sadly, in dentistry.

就是……

It's...

你是因为疼痛才成为颞下颌关节患者，而不是因为发育不良或咬合不好？

Are you a TMJ patient because of your pain, not because of bad growth or bad bites?

所以我觉得我们需要改变这种看法。

So I think we need to flip that script.

但回到跟患者的沟通上，你知道，如果有患者打电话来说，嘿，我对气道导向的正畸很感兴趣，想做Marpe，或者我知道自己有深覆合，真的很想解决这个问题。

But back to scripting to the patient, you know, if a patient calls in and says, hey, I'm really interested in, you know, airway directed orthodontics and doing Marpi or potentially I know I've got an overbite, really want to address that.

那么，从前台的角度，首先要说的是，嗯，为了全面诊断你描述的情况，医生确实需要，或者麦克唐纳医生需要。

Well, from my front desk, the first thing is, well, you know, in order to fully diagnose what you're describing, the doctor does need or Doctor.

麦克唐纳医生需要看到表面之下的东西，才能理解背后的原因。

McDonald does need to see underneath the surface to understand, you know, the reasons why.

而且我把前台培训得很好，经济方面也处理得不错，你知道，如果他们描述这些情况，那么……

And I've taught my front desk very well, the economic turkey out here, just, you know, if they're describing these things, then...

如果是成年患者，还需要做核磁共振。

And if they are an adult, they need an MRI.

所以我们要跟患者解释清楚，为了看清表面之下的情况，麦克唐纳医生需要……

And so we need to start talking that, okay, in order to see underneath the surface, Doctor.

他会安排拍摄三维锥形束CT（CBCT），用来评估你的关节，同时检查气道和颌骨结构。

McDonald will will order a three d x-ray CBCT to evaluate your joints, to also look at your airway, and also to look at the structures of your jaw.

基本上，X光片能显示骨骼结构，也能看到鼻腔内部或舌头位置等部分软组织的情况。

And basically the next thing is the x-ray tells the bone structures and it can also show some of the other soft tissue structures like within your nose or where your tongue is.

但为了看清全貌，麦克唐纳医生

But in order to see the full picture, Doctor.

考虑到你的颌骨结构，颞下颌关节往往是问题的一部分，也是进行颌骨前移或MTPD类治疗的基础。

McDonald and given your jaw structure, very commonly the jaw joints are part of this problem and they're the foundation of doing an advancement of your jaws or doing a mark b type procedure.

为了全面评估颞下颌关节并分析你咬合的基础，他会安排你做关节的MRI检查，以便在制定新的咬合重建方案之前，看清软组织状况以及关节的稳定性。

And in order to see the full picture of the jaw joints and analyze that foundation of your bite, this is where he would also order an MRI of your joints to be able to see the soft tissue and how stable your joints are before we start making the plan to build your bite to a new position.

患者听到这种解释时，通常都能接受。

Patients generally seem to be just fine with that when they hear it that way.

再说一次，我觉得患者们其实都挺理解的，他们会预约，接下来呢，X光在我们办公室做，诊断也在这里完成，但你知道，MRI必须去别的机构做，费用方面我们已经和那家机构谈好了，但你要直接付给他们。

And again, I feel like patients do, I mean, they schedule, the next thing is, you know, the x-ray is done at our office, we will do our diagnostics here, but we, you know, the MRI is something that does need to be done at a different facility and the cost of that is something that we've worked out at that facility, but you pay that directly to them.

我觉得这点很重要，因为这样患者就不会以为我在MRI上赚钱。

I think that's important because then the patient doesn't think I'm getting paid for the MRI.

从我的角度看，他们会想，好吧，这家伙没从我做的MRI里赚钱，所以他只是觉得这是必要的。

That, you know, from my standpoint, I think that they go, okay, this guy's not making money off me doing the MRI, so he just thinks it's necessary.

不过你也可以有另一种做法，因为我认识一些医生，他们把MRI费用包含在总费用里，然后医生也付钱给影像中心，这样做在安排时间和其他方面确实有些好处。

You can go two ways on that though, because I know some doctors who wrap the MRI into the overall fee and then the doctor does pay to the imaging center too, which there's some advantages to that I will say for scheduling and for other things.

但最终，不管你怎么做，我觉得话术必须是：MRI很重要，它会决定你的治疗方案，以及你做这些手术的安全性。

But ultimately, however you do it, I think the scripting has to be that the MRI is important and it's going to dictate your treatment and how safe you are to do these things.

如果MRI显示你咬合的基础有更大、更实质的问题，那通常需要先处理这些问题，或者和咬合矫正一起进行，才能保证稳定。

And if the MRI shows that there are bigger, more substantial things at the foundation of your bite, very often that needs to be addressed first or in combination with your bite correction for it to be stable.

因为再说一次，如果我们只改变表面，但根本原因还在，那可能会让所有结果都白费，你的时间和金钱也可能不持久。

Because again, if we change the surface, but the same root cause is still present, it can undo all of the results, and all of your time and money can be something that doesn't last.

我觉得这里面可以编一首摩根·沃伦的歌了。

I think there's a Morgan Wallen song in there somewhere.

总之，那就是……

Anyway, that is...

算了。

Anyway.

不过，基本上，整个流程就是这样，你知道，从……

But yeah, that's that's generally kind of how the script goes from, you know, the...

当成年人打电话来咨询时，他们需要做核磁共振。

When an adult calls, they need the MRI.

然后，如果是一个儿童患者……

And then also if a child patient is...

如果他们在电话里就提到下巴有咔嗒声或弹响，我们就会开始引入这个想法，就是说，为了看清那个关节，也就是你孩子的生长结构，在生长片上，他可能会建议做核磁共振，这样才能全面评估你孩子的情况，并制定治疗方案。

If they're complaining about clicking and popping of their jaws, even from the phone call, we start to introduce that thought that in order to see that joint, that growth structure for your child to see on the growth picture, this is where he might recommend an MRI to be able to assess fully your child's, you know, what and make a treatment plan.

核磁共振谁来解读？

Who's interpreting the MRI?

是你还是放射科医生？

Is it you or the radiologist?

所以，放射科医生或者任何在医疗机构做的核磁共振，都必须由放射科医生来读片，至少这是标准的医疗规范。

So the radiologist or any MRI that's done at a medical facility does have to be read by a radiologist, or at least that's the standard of care.

所以你总会从当地的读片放射科医生那里得到一份报告。

So you'll always get a reading from the reading radiologist at the place.

现在我要客气地说，很多读这些关节的放射科医生，其实不太仔细看这些关节……

Now I'm going to say this nicely, a lot of radiologists that read these joints don't look at these joints very...

不像你期望的那么频繁。

As often as you would love.

他们可能会更专注于心脏、膝盖、血管或者其他方面，有时候片子落到他们桌上，他们就会说一切正常，或者在正常范围内。

They might spend more focused time on hearts or knees or vasculature or other things, and sometimes it lands on their desk and they will call things normal or within normal limits.

这也是为什么我自己也会读片，对我们牙医来说，了解这些影像上我们看的是什么也很重要。

Now that is why I also read them myself, and it's important for us as dentists to also just have an idea what we're looking at on these things.

很多时候，所谓的正常，就是说椎间盘在12点或1点的位置，保护着这个，内外侧覆盖，但这些其实并不存在。

And a lot of times what will be called normal, meaning, you know, disc at 12:00 or 01:00 position, protecting this, covering medial laterally, that's not there.

在我们做过的两千多例核磁共振中，我一只手就能数过来有多少个正常的关节，不是正常的病人，而是正常的关节。

I can count on one hand how many normal joints, not even normal patients, normal joints, I've seen out of those 2,000 plus MRIs that we've done.

这真的很让人震惊。

Like it is shocking.

当然，这个人群本身就有偏差。

And obviously, this is a skewed population.

这些是咬合有问题的正畸患者，我才会让他们去做核磁共振。

These are orthodontic patients with bad bites for me to even send them for an MRI.

所以我也清楚他们的关节不太可能是正常的，但那些不常看这类影像的放射科医生，却经常会把它们报告为正常。

So I have a good idea that they're not going to have normal joints anyway, but they very often will be called normal to a radiologist that doesn't look at these all the time.

为了提前避免这种情况，我做了一件事：我制定了一份清单，或者说指南，告诉放射科医生在核磁共振的某个位置上，需要评估关节盘的前后位置、内外侧位置，还要看这些咬合位置有没有炎症表现。

Now to preempt that, one thing that I did was I created a whole list or just a guideline of at this position of the MRI, I want you as the radiologist to comment on the anterior posterior position of the disc, the medial lateral position, and also is there any inflammatory look at these bite positions?

于是我去和放射科医生沟通，他说，这很简单，当然可以。

And so I went and talked with the radiologist, he said, that's easy, of course.

然后我还解释了为什么这些很重要。

And then I also had an explanation for why matters.

比如，如果患者在关节窝完全就位时，也就是常说的CR位，关节盘已经脱位了，那么……

For instance, if the patient is off the disc at fully seated condylar position, you know, commonly alluded to as CR, then...

而且如果有关节炎症，作为牙医或正畸医生，我不一定想把咬合建在那个位置上，因为那个位置没有保护。

And if they have inflammation, me as a dentist or an orthodontist, I don't want to necessarily build that bite to that position because that is not protected.

反过来，如果稍微往前一点或者位于关节窝中央的位置能让患者回到关节盘下方，那可能是我更愿意把咬合建在那里的位置，前提是能保持稳定。

If on the other hand, a slightly forward position or centered in the in the fossa is where that patient gets back underneath the disc, that is likely a better position for me to build the bite to if it's possible to keep that stable.

所以，你看……

So, again, see...

总之，我就不深入讲CR关系了。

Anyway, I won't get into, you know, CR relationship.

别别别，讲吧。

Oh no, do.

你面对的听众大多是修复科牙医，这很关键。

You're listening to an audience largely comprised of restorative dentists, so this is critical.

我明白。

I get it.

不，其实我也是修复科的。

No, well, I mean that's me too.

作为正畸医生，我接触到的每个病人的牙齿，我都会做全口重建，而且都是用天然牙。

As an orthodontist, I do a full mouth rehab on every patient I touch their teeth, and it's with natural teeth.

所以回到我做MRI之前，我采用的是传统正畸方法，每个病例我都会在完全就位的位置上架，放到铰链式咬合架上，每个病人都这样处理。

So it is back to me prior to MRIs, I practiced broth style orthodontics, I would mount every case in fully seated position, put them on the pendant articulators, that was me, every single patient got it.

最终，那还是关节就位的位置，我尽量让每个病人都达到那个位置。

And ultimately, again, that's a seated joint position and I tried to treat everybody to that position.

然后我观察到的是，回到MRI，如果病人关节就位时，关节盘不在位，而是偏后，他们可能不会喜欢那个位置，原因有两个。

And what I saw was some, know, and back to the MRI, if that patient when you seat their joint is off the disc and behind it, they're not going to love that position for maybe two reasons.

第一，就位位置如果关节盘不在位，可能会压迫后面的组织，引起不适。

One is that seated position again off the disc possibly compressing tissues behind and causing discomfort.

这种情况很可能发生，或者经常发生。

It can happen very likely or very often it happens.

另一个，好吧，如果关节盘不在，无法起到垫片作用，不能抵抗关节向后压缩，那下颌骨会怎样？

The other, alright, let's compress that joint further than, you know, if the disc is not there to gasket that joint and doesn't resist it compressing back, what also happens to your mandible?

下颌骨会向后移，对吧？

Your mandible goes back, right?

所以，从气道的角度来看，患者可能也不喜欢那个位置，他们可能更喜欢待在别的位置。

So okay, from an airway standpoint, patients might not like that either, and they might like living in a different spot.

那这对我们决定在哪里建立咬合重要吗？

So is that important to where we decide to build the bite?

我觉得非常重要，绝对重要。

I think so, absolutely.

为了关节基础的稳定和良好，我们需要知道我们面对的是什么情况。

For stability of the joint foundation to be good, we need to know what we're working with there.

回到小孩子，如果核磁共振显示他们完全就位时不在关节盘上，但如果他们稍微向前一点，能到关节盘下面，那么我们在研究上看到的，以及我在病人身上一次又一次看到的，就是髁突的生长可以重新建立。

Back to younger kids, if the MRI shows that they're off the disc and fully seated, but if they get underneath the disc in a slightly forward position, then what we see on research and I see it time and time again on the patients I see is that now you can reestablish growth of the condyle.

把这一切联系起来，这些走进我们正畸诊所的二类错颌患者，我们会想，这个孩子会长吗？还是不会？

And bringing this all back full circle, these patients that walk into our orthodontic office with class twos and we are like, is this kid gonna grow or are they not?

核磁共振会告诉我们答案。

The MRI is gonna tell us.

所以最终，如果关节盘能完全复位，研究再次表明，而且我也说过，我一次又一次看到，髁突可以生长，下颌可以向前生长，功能矫治器对这类患者是有效的。

And so ultimately, they get reduction of that disc over the top and a complete reduction, what is shown in research again and also, like I said, I see it time and time again, that condyle can grow, the mandible can grow forward, and a functional will work for that patient.

这确实能起到推动作用，或者说，你知道的，就是引导下颌骨向前生长。

It will work in driving or, you know, just modifying growth of the mandible in the forward direction.

如果那个患者没有处于稍微向前的位置，或者卡在关节盘后面，那对生长来说就不是个好情况。

If that patient is not underneath the disc in that slightly forward position or is stuck behind it, again, that's not a good scenario for growth.

最终，如果你强行把下颌往前推，让髁状突顶着关节隆起，中间又没有关节盘，那就会加速退化，髁状突会加速变短，越来越多的髁状突会萎缩，下颌也会复发。

And ultimately, you could cause way more harm by putting that mandible forward, loading that condyle against the eminence without a disc between, you're gonna see accelerated degeneration, accelerated shortening of the condyle, more and more condyles melting down and relapsing mandibles.

所以，还是那句话，就是……

So again, it's just...

我，我，我觉得我们……

I I I think that we...

如果我们能克服对核磁共振的恐惧心理，它真的能帮我们更好地处理日常工作。

If we can get over the mental hurdle of the MRI being something that will scare people away, it's gonna help us in what we do every day.

而且有很多方法可以让它更高效。

And there's ways to make it more efficient.

哦，这里面的内容可真不少。

Oh, there's a lot to unpack here.

你有没有想过，修复科医生在给患者做修复时，如果让髁突完全就位，也就是所谓的正中关系位，他们是不是也应该考虑做这些核磁共振呢？这听起来既可行又合理，而且可能是个非常好的主意。

Do you ever think it's conceivable and feasible and perhaps a very good idea that restorative dentists that are restoring patients in fully seated condylar position, also known as centric relation, should perhaps be considering taking taking these MRIs.

是的。

Yes.

我确实这么认为。

I do.

而且我知道，每次我做讲座的时候都会强调这一点，但是……

And I know this, you know, I kind of bring this home whenever I do lectures, but one...

我最后通常会讲到的病人是我妈妈。

The last patient I usually talk about is my mom.

我妈妈她……

And my mom had...

在伊利诺伊州中部的一个农场长大。

Grew up on a farm in Central Illinois.

我以前不知道，她年轻的时候被马踢过脸。

I didn't know this about her, but was kicked in the face by a horse whenever she was younger.

她年轻的时候下巴老是咔咔响，后来慢慢就不响了，也不疼了。

Jaw clicked and popped all while she was younger, and then eventually it didn't, and she wasn't in pain.

所以她觉得，嘿，没什么大不了的。

So she's like, hey, no big deal.

所以基本上直到三年前，我从来没听说过这件事，也完全不知道。

So never heard about it, never knew anything about this until three years ago, basically.

我妈左边有颗牙需要拔掉，而左边正好是她被踢的那一侧……

My mom had to have a tooth taken out on her left side, which is the side she was kicked on...

被马踢的那一侧。

Kicked by the horse.

还有15号牙，那是她咬合最后面的支撑点，看起来像有个小小的根尖病变，医生就说，不如把15号也拔了，然后做个种植，种两颗。

And also tooth number 15, which was her furthest posterior stop of her bite, appeared to have what looked like a little endo lesion and they were just like, why don't we just take out fifteen too and just maybe do a, you know, implant, two implants.

做个上颌窦提升什么的。

Let's do sinus lift, you know, whatever.

我们要重建这个咬合。

We're gonna reconstruct this bite.

所以我……

So I...

我之所以参与进来，唯一的原因是我妈妈当时正好路过阿尔伯克基。

The only reason I even got involved was my mom was running or coming through Albuquerque.

他们开车经过，她说，嘿。

They were driving through, and she's like, hey.

要不要做个CBCT？

Wanna take a CBCT.

我能在你办公室做吗？

Can I just do it at your office?

我说，好啊。

And I was like, yeah.

为什么不呢？

Why not?

那就做吧。

Let's just do it.

所以我做了完整的CBCT，全容积的，就想着，嘿。

So I took full CBCT, full volume just because I was like, hey.

咱们就……

Let's...

为什么不顺便检查一下这些东西呢？

Why not just check this stuff?

果然，她的左侧髁突很小。

And sure enough, her left condyle's tiny.

髁突和关节窝之间基本没有间隙。

No space between the the...

基本上髁突和关节窝之间没有空间。

Basically no space between the condyle and fossa.

她的下颌骨真的很不对称，我其实也注意到了一点，但当时没太在意。

Her mandible really asymmetric, and I I noticed that a little bit, but I wasn't really looking.

你知道吗？

You know?

你不会那样看你的父母的。

You don't, like, look at your parents that way.

不知道。

Don't know.

反正，至少小时候不会。

Anyway, at least not growing up.

但是……

But...

所以，总之，我……

So anyway, I...

我就想，哎呀，糟了。

I'm just like, uh-oh.

然后我就……

So I then...

之后，我就想，嘿，发生了什么？

After that, I was like, hey, what happened?

然后她跟我讲了那匹马的故事之类的，我就让她做了核磁共振。

And she told me the story about the the horse, things like that, and I ordered the MRI.

结果核磁共振显示她左边的椎间盘往前突出得很厉害，根本就没法复位。

Well, the MRI showed that her left disc was way forward, like, nowhere close to reducing at all.

所以现在这意味着……

So what that means now...

而且她也不疼。

And and she's not in pain.

幸运的是，她不疼。

Luckily, she's not in pain.

所以她已经适应了。

So she's adapted.

但现在的问题是，唯一能防止她那个关节承受更多压力的，就是第15颗牙碰到下面的牙。

So what's happening though is the only thing keeping her from putting more force on that joint is tooth number 15 touching the lower tooth.

那就是个止动点，对吧？

That is the stop, right?

所以，后面有个咬合止点，确实能防止她尽可能压缩关节盘后组织或关节内的组织。

So by having an occlusal stop back there, it does keep her from compressing as much as she possibly could on that retrodiscal tissue or the tissues in the joint.

如果拔掉五十号牙，会发生什么？

What's going to happen if you take out fifty?

她会直接陷进去，可能一下子就把一个无症状的人变成有症状的，对吧，或者导致组织破坏，或者就像引爆一个潜伏在表面的大火山。

She's going to sink right into that thing, possibly take someone who is asymptomatic into symptomatic in a heartbeat, right, or cause breakdown or just erupt a huge dormant volcano that's lining the surface.

所以从我的角度看，我就说，嘿，咱们回到修复治疗的决定上来。

And so from my standpoint, I was just like, hey, let's go back to restorative decisions.

别拔那颗牙。

Don't take that tooth out.

咱们……

Let's...

如果真要做什么，尽量保住它。

If anything, try and save it.

咱们做根管治疗。

Let's do the endo root canal.

最终，正是这一点让她维持住了现状。

And ultimately, that is the one thing that is keeping her there.

我们尽量在重建其他部分的同时，保留她咬合中的这一部分。

Let's try and maintain that as part of her bite while we rebuild the other parts of things.

所以现在，她……

And so right now, she...

这……

This...

所以我根据核磁共振的结果，给她做了一个保护性的咬合板，用来减轻关节的负担。

So I made her also just a little protective splint that was guided by the MRI to unload things.

她一直没有出现任何症状。

She hasn't had any symptoms.

她一直在逐步重建咬合的不同部分，但我认为，通过做影像检查，我们真的避免了一场可能非常严重的连锁反应。

She's been rebuilding different parts of her bite along the way, but I think we really saved a big, you know, possibly catastrophic tailspin from happening by doing the imaging.

所以我认为，从修复决策到甚至……

So I do think from restorative decisions to even...

你要拔牙吗？

Are you gonna take out a tooth?

你要给第二磨牙备牙做牙冠吗？到时候同样的问题还会发生。

Are you gonna prep that second molar for a crown when the same thing will happen?

比如说，你要给第二磨牙做修复，需要备牙，而那个病人可能靠关节盘维持着，但因为牙齿结构还在，所以还能减压。

Let's just say that you've got second molar restorations where you gotta do a prep, and that patient is maybe living, you know, off the disc but is able to decompress because the tooth structure is holding.

但一旦你拿掉了那个牙齿结构，突然之间，你就会想，我的咬合空间去哪了？

But now you take away that tooth structure and all of a sudden that's the patient that you're like, where'd my occlusal clearance go?

他们直接就回去了。

They just went right on back.

很典型，对吧？

Classic, right?

所以我们当时怎么想的？以前我们管这叫CRCO移位。

So what did we think, you know, we called that a CRCO shift back in the day.

我觉得现在应该叫它“不再受关节盘保护”的移位，或者对某些病人来说，是“盘在”和“盘不在”的移位。

I think it's a not protected by the disc anymore shift or disc on, disc off in some of these patients.