Bill Dickerson, DDS, founder and CEO of Las Vegas Institute for Advanced Dental Studies (LVI), and Leo J. Malin, DDS, LVI implant director and clinical instructor on implant placement techniques, candidly discuss the science behind neuromuscular dentistry, how it has evolved, its impact on the longevity of aesthetic restorations and dental implants, and the profession’s reluctance to embrace it.
DT: Tell us about the development of the philosophy of neuromuscular occlusion, its inception, and its current status.
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Dr. Dickerson: Neuromuscular dentistry has been around for some 45 years. The father of neuromuscular dentistry is Dr. Bernard Jankelson. Along with the help of his son, Dr. Bob Jankelson, he developed the equipment to help find the optimal position for the mandible.
The science behind neuromuscular dentistry is this: if we relax the muscles, we can find the ideal position for the mandible, and then the bite can be brought to that position. Thanks to the early efforts of Dr. Jankelson, and subsequent efforts of others, we have a way of scientifically measuring that position. We can determine when the muscles are the most comfortable and where the muscles dominate in the stomatognathic system. Then we can either move the teeth orthodontically to that position or we can restore the teeth to that position. In some instances, we can even equilibrate the teeth to that position.
One of the fundamental principles that makes neuromuscular dentistry important in restoring a case with implants (and not just a single-tooth implant) is that it prevents parafunction, certainly the bruxing aspects of parafunction, which is so damaging to an implant case.
Dr. Malin: I agree. In neuromuscular dentistry, we are seeking to maximize the occlusal relationship between the mandible and the maxilla, and then put them in a position where the muscles are at physiologic rest as much as possible. The equipment we use is valuable because it gives us the ability to measure things such as muscle activity. This in turn helps us determine and verify a comfortable position for the patient prior to permanently changing the occlusal position, regardless of how the case is being restored.
In implant dentistry, when we have large cases in which the patients are pretty “beat up” in terms of their occlusal scheme, it wouldn’t make sense to build them back into the same scheme that they had previously destroyed. In order to have a predictable result, you have to have an occlusal goal and a diagnostic protocol in place to change that bite relationship. This is where the neuromuscular side has a lot of authority where others do not. We have the ability to measure specific patient physiologic changes while we alter and improve their occlusal relationship.
Dr. Dickerson: That is an important aspect for everybody to understand. A lot of people will take a worn-down anterior case and restore it aesthetically by putting veneers on it, for example, but those anterior teeth are worn down for a reason: the bruxing or the parafunction has destroyed the teeth. If you just put veneers or crowns on the case, then you are doing nothing to change the situation that has caused the destruction of the natural teeth in the first place. This is one of the reasons cosmetic restorations don’t last. It is essential for a doctor to determine where the relationship between the mandible and the maxilla needs to be to prevent that from happening in the future so that the restorations will last longer.
The other thing that is important for people to understand is the volumes of science behind what we do. People talk about science- or evidence-based dentistry, but no one really looks into it. What we do is not any different than what cardiologists do when they take EKGs of the heart to determine what is going on with the heart, or what neurologists do when they take EEGs to determine brain activity. We measure muscle activity to determine where the ideal position of the bite needs to be. It is scientifically based. Even our determination on the vertical position has a scientific basis. I think many people have the misconception that the machine is an autopilot that takes a bite [measurement]. It isn’t. It is a data-gathering tool. In addition to examining the patient and evaluating the symmetry of the patient, we look at the wear facets on the teeth for data as well. We evaluate all of this data to determine what we need to do to make a patient as comfortable as possible. In most cases the treatment that takes all of this data into account completely eliminates pain.
Dr. Malin: Neuromuscular equipment is an evaluation tool only; the dentist needs to make determinations based on the data derived from the machine and the clinical situation. Of course, the equipment does not substitute totally for clinical experience. The treating dentist needs to select and treat patients on a gradient level of difficulty based on his or her clinical training, knowledge, and experience.
Dr. Dickerson: It’s no different than a physician listening to a heart with a stethoscope versus one who uses an EKG machine. To practice this style of dentistry, a dentist does not need to have computerized equipment, but the equipment allows us to verify that the position we put the patient in is ideal. Barney Jankelson had a great line: “If you can measure it, it’s a fact. If you can’t, it’s an opinion.” Unfortunately, organized dentistry likes to talk opinion—its opinion of where something needs to be. This is not being done maliciously, but the truth is that they have never studied it and have never opened their minds to what we know to be the truth. And that’s the frustrating part of this. We know this is the right thing to do for the patients, and we know this could help so many people. Yet, dentists are reluctant to change.
|Leo J. Malin, DDS, (left) and Bill Dickerson, DDS, of the Las Vegas Institute for Advanced Dental Studies.|
Dr. Malin: I’ll take that a step further… Many in our profession resist change, especially when the technology is not fully understood. In implant dentistry, for example, I know many dentists that have placed implants for years without looking at the third dimension. However, when you look at the science of why it is important to evaluate the third dimension, it’s impossible to make an argument for not using the information that is available, and yet most doctors still don’t engage in the technology. Neuromuscular dentistry is the same. Doctors may have to admit they don’t know everything (like we all had to) and engage themselves for the benefit of their patients. I think resisting change is a lot of it. It is not always comfortable and easy. There is no resistance from the patients because they see this kind of monitoring equipment used in the medical community all the time. They can see and evaluate what we are doing, and it just makes sense to them.
DT: What do you see for the future of neuromuscular dentistry?
Dr. Dickerson: I believe it will be the standard of care in less than 10 years. It is so powerful and it makes so much sense. There is so much science behind it that it will eventually sweep the industry. Because it is more complicated in some respects, there will always be a group of dentists who will not go in this direction, who will elect to do the piecemeal dentistry. However, enough dentists will, so it will change the public’s perception of dentists from being the “joke” on television to one of the most respected groups of healthcare providers available… who can literally change someone’s life… who can rid a patient of a lifetime of pain… who can eliminate massive doses of pain medication. We’re talking about something so great that no other healthcare professional or medical proprietor has been able to do. I think that is the power that will make neuromuscular dentistry become the standard of care in dentistry. Look, we know it works. Hun-dreds of dentists are having phenomenal success using the predictable techniques we teach.
Dr. Malin: I agree. I think it is so scientifically based. Once you learn about it, you can’t turn your back on it. There is a ton of resistance to it now for whatever reason, but the bottom line is that it is becoming more and more the standard of care because it is the “right thing to do.” Patients will demand both neuromuscular and controlled implant dentistry. It can’t help but succeed; it is past the threshold where people can ignore it. The future is wide open, and dentists ought to get on board at this time because if they don’t, they will be left behind.
DT: In your estimation, how many patients in the average population are experiencing pain who are unaware that it is an occlusion problem?
Dr. Dickerson: We have numbers from a survey of dentists in our Core One course, but before we go into this, I think it is important for people to understand why the majority of the public is not in its correct mandibular position. If you look at any primitive culture, you find large jaws with no malocclusion. The reason Western societies suffer so much from malocclusion is allergies, whether it is to foods with milk at the head of the list or deodorants, perfumes, or other additives to which we are constantly exposed. The vast majority of kids have allergies manifested by runny noses, which cause them to have an airway obstruction. Consequently, they breathe through their mouths. It is the mouth breathing that causes malpositioning of the mandible as the teeth come in during the developmental stage. It all starts as a kid, and if you knew this, you could prevent any kid from becoming a pain patient in childhood or adulthood. The cool thing is that this pain is preventable. We can stop it in childhood, so adults don’t become TMD cases.
As to the numbers, we are finding that 80% of the population probably is not in its correct position; however, that doesn’t mean these people are in pain. I am not in my correct neuromuscular position, but I do not have pain because I can rest my mandible away from where I routinely put my teeth together, or bite. Out of that 80%, my gut feeling would be that probably half of them will have symptoms of TMD, not that they know it is TMD. It’s a headache, a migraine, or jaw, neck, or shoulder pain. Many people who suffer this way assume it is normal because they have lived like this their entire lives, when in fact, it is not normal. According to the American Headache Society, about 28 million Americans endure migraines and 10 million more experience chronic daily headaches, which means they hurt at least 15 days each month. We believe that we could help the vast majority of those people.
DT: How does neuromuscular occlusion affect implant dentistry?
Dr. Malin: Everything is about occlusion in dentistry. That is all we are really trained to do. If you are replacing a single tooth, for example, you are building back to centric occlusion. The only neuromuscular philosophy involved is whether you can coronoplasty the case correctly, and if you can get rid of the class I, II, and III interferences. If you can, you are basically dictated by that patient’s habitual bite. If you are going to add something to the occlusion, you want to be sure you are not adding more interferences. Understanding coronoplasty is important in implant dentistry.
Dr. Dickerson: If you are doing just one tooth, and the patient has signs of occlusal disharmony, putting that implant in is not going to change the things that are causing the occlusal disharmony. Even though you are only doing a single-tooth implant, you will still run the risk of that implant having a higher failure rate if you do not move the jaw position to the neuromuscular position to get rid of the occlusal disharmony first.
Dr. Malin: Sometimes treatment is dictated by one tooth because that is all that the patient is interested in; so you do the best you can to restore that one tooth. The first question I ask myself and the patient is, “How did you lose it?” If they have many signs and symptoms of malocclusion, the implant market today will recommend that we place an implant in there and load it today. We should not do things like that. We should evaluate the patient’s current occlusal patterns first, and then restore that single tooth at the appropriate time.
When doing the larger cases, which involve changes from habitual occlusion, the neuromuscular orthotic is always the first step. It is critical to establish stability in the occlusion prior to any implant surgery. Once we have established the relationship between the maxilla and the mandible, then we can determine where the teeth belong. The placement of implants should always be dictated by the proposed final restoration positions, not just the bone available. In other words, if we know where the teeth belong, then we know where to put the implants to support those restorations. Once we know that, CT technology and treatment planning software allow us to fully evaluate our patients prior to surgery. This technology allows us to place implants in our “virtual” patient using our dictated occlusal position prior to actually performing surgery. Any compromise to our plan is then fully discovered prior to surgery, and adjustments can be made. This evaluation guarantees our success. Using this protocol, the teeth dictate the ideal implant position needed to provide the patient with the most ideal functional and aesthetic result possible.
In other implant courses across the country, you won’t hear about occlusion because it is too controversial. This makes no sense to me. As a restorative dentist, you have to know about occlusion and should make some occlusal decisions before you ever touch the patient. That is what is wrong with a lot of implant dentistry today—most implant cases are boned-based. The implant is placed based on bone availability with little consideration given to how the mandible will relate to the maxilla in the final occlusal scheme. The end game or final occlusal position is often wrongly established after surgery instead of beforehand. Therefore, there can be significant compromise in the final result.
The point is, if you are going to treat extensive implant patients, you have to evaluate your philosophy of occlusion and make sure patients are where they should be before you start placing implants. If you don’t do that, you are compromising the case.
Dr. Dickerson: The cool thing about what we do is that we will know, before we ever put a handpiece to a patient’s tooth, whether we can help get rid of the patient’s pain. And that is through orthotic therapy. By testing the bite out first, finding and creating a removable or fixed orthotic to go in and move the patient to that position, we will know whether we can eliminate the pain. If we do, we can restore the patient in that position. If we don’t, we work to see if we can find the right position before restorative work is started. If we cannot help the patient, we assume it is not an occlusally related problem or it is beyond the experience of the treating clinician.
Dr. Malin: I agree. In implant dentistry, the restorative dentist will have total responsibility for restoring the case, so he or she ought to have total control of that case, including surgery. If one can figure out where the tooth belongs and establish that relationship in plastic, all that is reversible. Once you surgically start placing the implant or prepping that tooth though, it is no longer reversible.
In many ways, neuromuscular dentistry is much more conservative than some of the other philosophies because you have evaluated the case completely before you start it. I think that is why we have the long-term success with these cases.
The point we are trying to make is that the neuromuscular philosophy at LVI is simply a diagnostic philosophy. It’s built into an occlusal scheme. In the implant courses we’re doing the same thing. I think we were one of the first ones to say that we need to look at the patient in a 3-dimensional view. We started looking at tomography and teaching that diagnostic protocol to our doctors, and now we are teaching the CT technology because that has replaced tomographic x-rays. I think that we were about 5 years ahead of everybody else because now, when you go to these implant presentations, that’s what everyone is talking about, and 5 years ago some of the people that are supporting it now were strongly opposed to this technology! Neuromuscular dentistry is the same way. You can oppose it until you understand it, and then, it’s hard to look the other way!