Be of good cheer! You thought there was a causal relationship between occlusion and headaches and pain? There is!
When I was out of dental school for 7 years, I thought I knew just about everything I needed to know to be a good dentist. However, there were some questions that I could not answer. I, like most recent dental graduates, had a real disdain for occlusion. The subject, to a sophomore dental student, was beyond boring. Besides, at the time, I had no clue as to the importance of centric occlusion (CO) and centric relation (CR).
After graduation, I began to listen to Dr. Peter Dawson and was led to find someone to teach me what did not soak in during dental school. He and other leaders encouraged me to seek out hands-on courses and mentors. You just cannot get it all in the 4 years of dental school or from lectures, videos, and webinars. My hands-on journey began at the L. D. Pankey Institute. It changed my clinical dentistry and me forever, and I must say, for the better! In addition, there are many excellent local study groups and learning centers for a clinician to attend.
CONNECTING THE DOTS
The first step is to recognize the connection between temporomandibular disorders (TMDs) and occlusion. The hardest thing that I had to overcome was all of the confusion surrounding the role that occlusion played with myofascial pain and headaches. So many lecturers and authors were saying to do not do anything irreversible. It’s all in the patient’s head; given some time, the symptoms will go away eventually. Well, they do not.
Misinformed passivity is causing treatment paralysis. Pain-causing occlusal discrepancies are being left uncorrected. Patients continue to suffer from headaches, tooth pain, sensitivity, and other TMDs that are in the sole treatment arena of dentistry. Our patients need our help.
PAY ATTENTION TO THE DETAILS
Beware of the little things. In years past, if the amalgam that we had just placed was high, it would break while we were adjusting it or, sometimes, it would come back later with a very noticeable mirrored wear facet along with a possible complaint of sensitivity. If it were sensitive, the restorations would require an appropriate adjustment and the sensitivity would go away. Composites and porcelain pose a different challenge, because it is often more difficult to find a wear facet or excursive interference on these tooth-colored restorations by simple visual examination. As with all restorations, these must be adjusted carefully and correctly. Then, if the condyle disc assembly is not healthy, proper adjustment can be elusive. This may lead to further unnecessary treatments such as root canal therapy or even extraction of a tooth.
We must pay attention to the health and condition of the TM joints (as they relate to the occlusion) before, during, and after treatment. We have the potential to impact the stomatognathic system negatively or positively with every restoration, extraction, and tooth movement. Yes, humans are very adaptive; however, the system is not as self-correcting/regulating as many would have us believe.
MAKE USE OF AVAILABLE DIAGNOSTIC TOOLS
The diagnostic tools are there via education and equipment. The finest diagnostic tool ever created is you, the clinician. When properly trained, your mind, eyes, hands, and ears can recognize and routinely treat TMD/occlusal-muscle disorders successfully. Use every resource available to increase your ability to see, diagnose, and treat. Begin with the mindset that occlusal discrepancies such as balancing or working interferences and premature tooth contact will cause the condyle disc assembly to be distracted from being properly seated in the glenoid fossae. Uncorrected, this can lead to occlusal muscle disharmony and deformation of the condyle and the disc.
There are many tools and skills that will aid you in your quest for knowledge and skill. The physical examination skills of muscle and joint palpation and bimanual guidance can be mastered. Bimanual guidance is one of the fastest and best ways to find CR-CO slides clinically and can be used to accurately mount study casts. Leaf gauges, anterior deprogrammers that are made directly at the chair (such as the Lucia Jig), lab-fabricated deprogrammers (including the Cranham, Spear, Kois, or Dawson [B-Splint] anterior deprogrammers; or the NTI device [Keller Dental Laboratories] and Great Lakes Anterior Deprogrammer [Great Lakes Orthodontics]), and other prefabricated dental deprogramming splints (such as the Aqualizer Dental Splint) can be used to deprogram the muscles of mastication in order to record CR in order to properly mount study casts. These casts can then be used to fabricate the most accurate occlusal appliance possible.
There are other modern examination tools including joint vibration analysis, T-Scan Occlusal Analysis System (Tekscan), MRI, and CBCT. As you learn to use these modalities and implement them into your examination and diagnosis protocols, your intuitive skills will rise and your treatment success will soar.
THE SPLINT AS A DIAGNOSTIC TOOL
The diagnostic and treatment modalities are here, and experienced teachers and mentors are available. Splints are a diagnostic tool, not definitive treatment. A splint is, by far, the best tool in the clinician’s hands to diagnose and treat the pain caused by occlusal muscle disorders. They also prove to patients that their pain can be alleviated with properly executed occlusal adjustment. In certain cases, other patient-specific treatment protocols designed to improve the occlusion may be required, such as orthodontics and/or restorative dentistry. Whenever possible, full-mouth equilibration of the natural dentition is the most common and least invasive definitive treatment.
No matter what form of splint (lower or upper) or anterior deprogrammer is used, the goal is to eliminate or reduce the TMD symptoms. Then, the patient’s occlusion needs to be changed to one that reproduces the positive effects of the splint. The use of a splint or deprogrammer is simply a method to ensure that the condyle disc assembly is seated in the most favorable position and that a repeatable center of rotation can be obtained and used for any procedure.
Note that not all patients with occlusal muscle pain need a splint. In many patients, if the condyle disc assembly is healthy and well positioned, maximal comfort with an accurately performed occlusal equilibration can be achieved. If you cannot determine a repeatable center of rotation and the condyle disc assembly needs time to be rehabilitated, splint therapy should be the first line of treatment.
Here often is the weak point in the overall the clinical protocol. On many occasions, not enough time is being devoted to the delivery of the appliance. Dental splints must be adjusted very accurately. In my practice, we schedule 3 hours for the delivery of a lower, nondirectional, and passive splint. (And no, I am not slow.) The splint is adjusted every 15 minutes (or so), allowing the muscles of mastication to seat the condyle disc assembly. I continue adjusting the appliance until it is determined that the mandibular migration has stopped and the patient is dismissed. The splint is worn nonstop, even during eating. It is only removed from the mouth during tooth brushing and to clean the splint. If occlusal interferences during maximum intercuspation are damaging the TM joint assembly, and if the appliance is not worn during loading during mastication, the interference will disrupt the healing process. The splint is adjusted as needed during the next 3 months. I have found that 90 days is a good time period to wait for the tissues to heal.
DO UNTO OTHERS…
It has been said that, if you believe in and prescribe a treatment, you should feel comfortable in having it done on yourself. I ended up choosing to do just that! I was told throughout my teens and twenties that I was grinding my teeth and should try to stop it. I began looking for answers. My journey and search for knowledge lasted 10 years. I had headaches and could not even chew gum comfortably. My right joint was painful and clicking. By the time I reached the age of 40, my teeth had been worn so badly from bruxing that a full-mouth restorative rehabilitation was needed. If someone had intervened earlier, I could have been spared the need to do 25 crowns. (Hmm, an ounce of prevention is worth of pound of cure!) My mentor, Dr. Guy Haddix, delivered a mandibular repositioning appliance (a modified Tanner appliance). I wore it all the time, even when I ate. Once I was stable and comfortable, he then restored my mouth using the tenants of the Pankey-Mann-Schuyler technique. I have been comfortable for 23 years, needing only one occlusal adjustment to remain so. Since I was treated, I can chew gum until it practically turns into dust…without pain.
CLOSING COMMENTS
I am so grateful to all of the dentists who are teaching the relationship between proper occlusion and the comfort and health of the stomatognathic system. I am a beneficiary of that passion and knowledge and am dedicated to passing it on, in turn, to my colleagues and patients.
So what would be my parting advice? Do not try to do everything all on your own. It is a process! First, do the simpler stuff and then find a mentor to whom you can refer the really difficult cases when it is best for the patient. You will learn along on your journey. Above all, know that you too can make a difference.
Dr. Jesek earned his dental degree from Loyola University Dental School (1979) and has maintained a private general practice in Decatur, Ill, with a strong emphasis on restorative dentistry and conservative temporomandibular disorder (TMD) treatment. He is an executive board member of the American Equilibration Society and has served as a teaching assistant for the TM joint dissection course at the L. D. Pankey Institute. His articles have been published in Dentistry Today, Dental Economics, the Pankeygram, and the American Equilibration Society’s Contact. He is the founder of Jesek Seminars, offering lectures and hands-on training focusing on TMD splint therapy, occlusal equilibration, CAD/CAM restorations, 2-D, and 3-D imaging as well as practice management. He has presented for the Chicago Dental Society, the AGD, the American Equilibration Society, the ADA, the American Academy of Pain Management and the American Academy of Craniofacial Pain. He can be reached at wjesek@aol.com or via the website jesek.com.
Disclosure: Dr. Jesek lectures for Planmeca as a key opinion leader and is the owner and founder of Jesek Seminars.
