We all need something from which to base our actions, and we need to believe that our actions are appropriate for our patients. Occlusion is one of those things.
In the history of our profession, some factions have dismissed occlusion as absolutely unimportant to anything. Others have praised it as the most important absolute truth of the universe. In the quest for understanding, it’s possible, perhaps even probable, that for some, occlusion can become like religion.
I worked diligently to understand fully all of the considerations that explained a philosophy of how teeth should hit each other, and in so doing I isolated my experiences and my learning until that which I studied the most became a faith that I now know and believe. For many, myself included, once we have accepted a belief, there is practically no information that will sway that belief.
We begin to see the truth of that faith in everything that presents itself for consideration, and we live believing in that one appropriate therapy that, if applied correctly, will provide the cure we seek. When that therapy does not produce the desired result, we rarely (if ever) question the therapy itself. That would make me a heretic.
I used to be a believer. My beliefs produced success for me, most of the time. At first I chalked the failures up to my ability (or lack thereof) or to the “noncompliance” of my patient. As I learned more and did more, I had more successes and more failures. I began to look and listen outside of the religion to which I belonged and I noticed that other beliefs seemed to produce results that were also successful, unless they weren’t. My faith was shaken.
In the mid-1980s, I heard a statement about occlusal philosophies that has resonated for me ever since: “Everything works and everything doesn’t.” This observation means that everyone is right when applying a philosophy that works for that patient, but it also means that when the applied therapy does not work, it may not be due to the practitioner’s ineptitude or to the patient’s lack of commitment.
I have observed that some people can have any solution and do incredibly well. I have also observed and experienced that other cases are going to be incredibly difficult to solve no matter what philosophy is applied. Occlusion, it seems, might actually not matter, until it is the most important absolute truth of the universe, something that must be ascertained for each patient I have the privilege to partner with.
This can be a really tough belief to live with until one has accumulated enough time on the planet to develop a tolerance for ambiguity. We all want to have the right answer for a problem we are supposed to be the expert at solving.
Working Past the Delusion
As I have lived with my patients over these past 3 and 3-quarters decades, there have been times when none of my occlusal management has worked no matter how I altered it or how many other ways or things I tried. Some patients destroyed whatever I built. We used to call those patients central-nervous-system bruxers and label them untreatable.
I am learning now that it was probably not the occlusion at all. Turns out, it was most likely related to the patients’ ability to breathe and their airway. Airway, breathing, snoring, apnea, and a bunch of stuff I could not have imagined would be involved in occlusal destruction of teeth have now become an integral part of every diagnosis. Live long enough and everything you know will be wrong, or at least very different.
So what is a confused professional supposed to do? If Aristotle really was right, and happiness is actually what every one of us seeks, I say be happy living in the gray of what we know, what we think we know, and what we want to know.
My recommendation is to develop a protocol for differential diagnosis that looks at all of the possibilities including the airway, apnea, and many other issues that I probably don’t know about yet. Then decide, based on what you know, what part the occlusion plays in what you see.
Get more information when appropriate, and own the occlusion when that is appropriate. Develop a preference for action when an occlusion must be owned and then temper that belief with an understanding that it might not work for this patient. Be ready to change your mind and try something different.
The Perpetual Student
I also highly recommend a commitment to remaining a perpetual student. This will relieve you of the need to already know. Have way more clinical suspicions than diagnoses. You can always change your mind if you have a suspicion, and you can always learn as more information becomes available. That flexibility is more difficult once you make a diagnosis.
Become adept at multiple approaches and utilize them when required. My personal preference is to utilize centric relation as my observational and planning reference when it is available. My next step is to develop a mutually protected occlusion whenever I need to own that occlusion.
By the way, should the occlusion not require my ownership—in other words, it is physiologic and healthy—I am perfectly happy with it, no matter what it is. Once owned, designed, and built, I need to test it for correction or management of the things that caused the need for my ownership in the first place. If it’s not working, I need to try something else.
Everything works, everything doesn’t, and we cannot yet know what we don’t know yet. That is the real absolute truth of the universe.
Dr. DeWood has been practicing restorative dentistry since 1980 and actively involved in teaching dentists since 1992. He currently serves as executive vice president for curriculum and clinical education at Spear Education. In addition to his teaching duties, he maintains a private referral practice on the Spear campus. He has held positions as president of the Seattle Institute; clinical director, director of business systems, and director of marketing and publications at the Pankey Institute; assistant professor at the Arizona School of Oral and Dental Health; associate professor at the University of Tennessee School of Dentistry; and assistant professor at the University of Toledo College of Medicine. He can be reached at firstname.lastname@example.org.