Written by Jerry Simon, DDS Tuesday, 28 February 2006 19:00
In Part 1 of this article I discussed dentists’ responsibility to help patients make good decisions about their dental healthcare needs. For the most part, dentistry is a discretionary healthcare purchase in the mind of the consumer. Most dental visits do not involve pain and bleeding or significant disability such as they potentially could with a visit to a primary care physician or a hospital emergency room. Although visits occasionally occur for patients with significant pain from a pulpitis, or swelling and infection from a partly impacted wisdom tooth, most of the time most of our patients are coming in for discretionary (at least in their minds) services, such as restoring a cavity that is as yet asymptomatic, hygiene visits where there is not acute periodontal abscess, or even treatment for the newest dental “disease” that some people facetiously call “old and ugly.” We are not competing with other dentists for our patients’ discretionary dollars, but we are in fact competing with travel agents, retailers in the malls, car dealers, and even life insurance sales people, to name just a few.
Figures 1a to 1c. Occlusal disease: worn, chipped, and cracked teeth.
Since we are not really competing with life-essential goods and services, such as dialysis for patients in kidney failure, we need to take off our “white coat, I-am-the-doctor” mentality and instead learn from people in the industries with which we are really competing, such as retail, automotive, and life insurance, where they have studied communication and sales for many years. The techniques they have perfected are variations of the “try-it-before-you-buy-it” concept, also known as the “puppy dog” sales technique. We discussed examples such as cosmetic imaging and diagnostic wax-up, and even mock-ups in the patient’s mouth in the case of “selling cosmetic dental services” such as whitening and veneers. The problem is that when patients come in with severe occlusion issues such as worn, loose, abfractured teeth and head, neck, and facial pain, we also need to be able to apply this technique, both for a diagnosis and for case acceptance. But this has not been so easily done in the past (Figures 1a to 1c).
The dentist cannot easily say to Mrs. Jones, who he has just barely met, “Hello! Welcome to the practice. Since I have taken all these courses in occlusion at the XYZ institute and can see the wear on your front teeth, I guess that you probably have head, neck, and facial pain due to your bite, and they do not look very nice either, so I suggest that we do a complete rehab on your upper teeth. Just go out to the front, give Kathy a check for $25,000, and we can get started with some models.”
Actually, many dentists do say something similar to the above. Usually, the next sound we hear from patients is that of the office door slamming shut behind them as they disappear down the street and the inactive chart file gets another member. That does not help the patient, and it certainly does not help the dental office...a lose-lose deal if there ever was one.
Figure 2. Full-arch maxillary occlusal splint.
Some of our colleagues have learned that we need a transition between the exam and the rehab for 2 reasons. First, we need to know if the patient’s symptoms (loose teeth, sore teeth, worn teeth, and head, neck, and facial pain) are in fact due to bite issues that the dentist can successfully treat. And we need to give patients a metaphorical “bridge” from where they are now to the interest and desire for the treatment they need in order to achieve the results they would want if they understood their situation. The traditional “bridge” has been the dental bite splint (Figure 2). This is a plastic device that is fabricated to allow the patient temporarily to have the occlusion that the dentist determines is functionally correct, in a reversible fashion so that both the dentist and the patient can evaluate the new occlusion before irreversible procedures are performed. An analogy would be if you are in a restaurant and the table is wobbling. If you are in California and that is happening, you need to diagnose the problem quickly and efficiently. Slipping a matchbook under the table legs lets you determine whether you have a crooked table or are in the middle of an earthquake. Obviously, the remedies for these 2 conditions, earthquake or uneven table legs, are very different.
One problem with the bite splint as an intermediate step is that it takes time and expense to construct one, which requires a commitment from the dentist and the patient before a definitive diagnosis is achieved. Even when an experienced clinician is pretty sure that a set of symptoms is probably due to the patient’s bite, the patient does not experience symptomatic relief until the bite splint has been definitively adjusted over several visits. The doctor and the patient still must make a leap of faith and start treatment that is expensive and extensive without pre-experiencing relief of symptoms.
A second problem is that the bite splint in and of itself does not create a centered bite. It actually provides an opportunity for the mandible to center based on a good starting bite and accurate adjustments of occlusal interferences that prevent the jaw joint from centering. Clearly, this is not the “puppy dog” approach in action. What we need to have is an instant centering bite splint.
Following is a case report in which such a bite splint, the Best-Bite device (Best-Bite), was applied for the benefit of the patient and the clinician.
Figures 3a to 3c. Damage due to clenching and grinding.
A female patient came to the office for a cosmetic consultation to lighten her teeth. She had no idea that she needed restorative dental care, or that her many years of head, neck, and facial pain had anything to do with her bite. Her interview was fairly typical in that her focus was on wanting whiter and straighter teeth. Like most patients she had no idea that her teeth had been wearing excessively over the years. From a professional observation, the biggest deficit in her smile was really that her teeth looked worn, and the chips on the incisal edges as well as internal craze lines that took away the natural luster from her teeth were the real issues that had to be managed. These issues were easy to determine from clinical observation, and were obvious to me due to the wear on the teeth (Figures 3a to 3c).
Patients who grind and/or clench their teeth are likely to have any of 3 possible outcomes. One outcome is they can damage their teeth, like this patient had obviously done. A second outcome is that the intense pressure of clenching and grinding teeth can cause damage in the joint itself from the compression of the condyle against the collagenous disc, which can lead to internal derangement in the joint (Figure 4). The most obvious clinical indication of internal derangement in the joint is joint sounds such as popping or clicking upon opening and closing. This problem is also often determined by observing whether the jaws open and close with a smooth and symmetrical movement, as well as by placing the fingertips over the temporomandibular joint area and feeling for bumpy movement and listening for joint sounds. Amazingly, many patients with internal derangement and joint sounds are completely unaware of these sounds and unnatural jaw joint movements until they are pointed out to them. A description of a more thorough joint evaluation utilizing more specific range-of-movement recordings (Dop-pler auscultation to listen for harder-to-hear crepitus from the joints, and radiographic examination and interpretation including CAT scan and MRI) is important but beyond the scope of this article (Figure 5).
Figure 4. Unhealthy jaw joint.
Figure 5. MRI of an unhealthy jaw joint.
Figure 6. SEMG of patient with muscle contraction pain.
A third outcome is that the patient can have muscle con-traction pain due to the continuous muscle hyperactivity. This can manifest as headaches, neck aches, and jaw aches as primary pain, and pain can be referred to areas of the head, neck, or shoulders, and even trigger secondary migraines (Figure 6). This information is also easy to obtain by taking a simple history, starting with a question such as, “Do you ever get any head, neck, and facial pain?” Remember that patients who are not coming for help with pain issues will often dismiss the question without much thought, so if you see either of the other 2 manifestations of tooth clenching and/or grind-ing, you might have to ask this question more than once to get an accurate answer. In addition, it is important to “objectivize” this subjective symptom by asking the patient to quantify the amount of pain they have at the time of the examination. Often, patients who have more severe head-aches in the 6 to 8 (out of 10) range will report that they feel fine if they only have pain in the range of 3 to 4 on the day of the office visit. If the answer is positive, follow up to determine how often the pain occurs, when it all began, etc.
In this patient’s case, her clinical examination and history revealed a condition where her clenching and grinding had caused significant dental, joint, and head, neck, and facial pain, and the solution to all 3 appeared to be to fix her bite and restore her teeth. The treatment she needed was a long way from the couple of veneers and some bleaching that she envisioned. It was quite obvious to me that if I proposed a major rehabilitation for her occlusion, she would likely not be very receptive to the extent of the treatment procedures and the time and costs required. And of course, I was not completely certain that fixing her bite was going to be the solution to her pain issues.
This is the case in which many dentists find themselves with their patients. There are several dangers here. First, the dentist might be wrong, and although the dental damage might be due to the bite, the joint sounds will not go away from bite treatment, and the headaches might in fact be due to something other than the bite. If the dentist begins a course of treatment without a test run and thorough diagnosis, everyone could be disappointed, even if the patient does accept the recommended treatment.
The more likely consequence of proposing treatment like this to uneducated and therefore unmotivated patients is that the patients will “need to think about it” or “talk to their spouse,” and they will disappear into the “dead file” that in virtually every dental office is actually much bigger than the file of active patients. When that happens, the patients lose by not getting the treatment they really do need, the dentists lose by not providing the care that they are trained to render as well as earn the resulting income from such care, and the profession loses, as another patient leaves the office with the feeling that he or she was being “sold a bunch of work that was not really needed.”
PUPPY DOG TECHNIQUE REVISITED
Figure 7. Best-Bite fitted to patient’s teeth.
Figure 8. SEMG of patient after Best-Bite.
Figures 9a and 9b. Case mounted in centered jaw position.
Let’s go back to the car dealers or the pet shops and see what they would have done. They would have created a simple, inexpensive, no-risk “try-it-before-you-buy-it” experience for their customers. That is what the dentist can do as well by utilizing a chairside, prefabricated bite splint that can be customized so that patients can “demo” a centered jaw position and see if it does feel more comfortable than their off-centered bite. The device I use in the office is the Best-Bite device that I developed for this purpose. All you do is fill it with the PVS liner material that comes with the kit, and in literally 15 seconds it is out of the box and into the mouth. The PVS material sets in less than another minute, and because the patient gently taps the teeth as it is setting, the arc of closure of the jaw automatically sets the angle of the occluding surface perpendicular to the arc of closure of the jaw joint. In just minutes the jaws are freed of the influence of the tooth surfaces and allowed to center (Figure 7).
Once the jaws are centered, this stops the muscle bracing that was required to manage the conflict between the centered position of the jaw joints and the position that the jaw was forced into based on the position of maximum intercuspation of the teeth. Any pain that was due to the muscles melts away in minutes (Figure 8). Using this procedure, I immediately know for sure that the bite is a factor in the pain, or it is not. And equally important, so does the patient. Since the entire procedure takes less than 10 minutes, is reversible, and involves no lab fees, this fulfills every part of the puppy dog technique...except the bark.
In this patient’s case the pain did in fact go away, and she became convinced that her bite really was an important consideration in her dental, joint, and head, neck, and facial pain situation, and she enthusiastically accepted the treatment she needed. The intraoral device was able to center her jaw joint and permit a stabilized bite record of her centered jaw joints. Then a face-bow record was obtained for a more accurate mounting of the diagnostic casts (Figures 9a and 9b). Her teeth were subsequently equilibrated into this centered jaw position so that her new MIP (maximum intercuspation position, in which the maximum number of teeth touch) was coincident with her centered jaw position, and she was given anterior and canine guidance.
Figures 10a to 10e. Cosmetic and functionally correct restoration.
The cosmetic result was obtained by restoring her anterior teeth (Nos. 7 to 9) with feldspathic porcelain three-quarter crowns, and her posterior teeth were restored with a bridge of high noble PFM on the left side, using abutments 10, 11, and 15 to support the pontics for 12, 13, and 14. The right side was restored with PFM high noble crowns with butt porcelain margins, since those teeth were al-ready previously crowned.
The final result (Figures 10a to 10e) shows that we achieved an excellent functional as well as aesthetic result because of a combination of first managing the communication aspect of the care, and then executing the clinical dentistry. As one of our “practice management” teachers said years ago, “Nothing happens until the patient says “yes!”
Dr. Simon has been an active dental practitioner in Stamford, Conn, for more than 30 years, with a focus on bite dysfunctions. The author of the book Stop Headaches Now: Take the Bite Out of Headaches, he can be reached at best-bite.com or (888) 865-7335.
Disclosure: Dr. Simon is the inventor of the Best-Bite Discluder.
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