What is it about occlusion that gets dentists so worked up? Occlusion is a subject in which many dentists have not had any kind of advanced training since they left dental school. Many dentists have invested thousands of dollars in advanced training based on one occlusal philosophy that then becomes the basis of all their treatment delivered to patients. I completely understand the challenge—once a huge investment of time and money has been made, it may make it difficult to have a broader view of what occlusion’s real role is in dentistry. Truthfully, it is even ridiculous to suggest that there is one occlusal philosophy that fits all patients. I know how much some would love to believe that, but it’s simply not true.
In this short article, I would like to offer my opinion and perspective on occlusion based upon nearly 40 years of treating patients, especially patients with temporomandibular joint (TMJ) and orofacial pain, as well as the thousands of dental professionals trained in the American Academy of Facial Esthetics (AAFE) who have integrated treatment philosophies and techniques related to facial aesthetics, orofacial pain, bruxism, and sleep dentistry into their practices. In terms of occlusal philosophies, the AAFE education remains neutral, considering itself to be the “Switzerland of occlusion.” What that means is, in our live-patient training courses, we don’t care what occlusal philosophy you believe in, have been trained in, or choose for your patients. Everything that we teach in our courses are the minimally invasive and nonsurgical techniques that are performed before any irreversible occlusal changes are made, making it much easier for you to implement the occlusal treatment plans you believe are best for your patient.
DOES OCCLUSION MATTER?
Let’s identify where occlusion is important and where it is irrelevant. I am a restorative dentist and, certainly, dental occlusion is very important. Where the occlusion controversy really rages is in the areas of malocclusion, TMJ syndrome, TMJ position, and orofacial pain. In my opinion, I will unequivocally state that every occlusal philosophy has something to offer in these arenas of diagnosis and care. However, there is no one philosophy that is the end-all and be-all when it comes to the role of occlusion in TMJ and orofacial pain and, in fact, occlusion is often irrelevant to the patients who have these conditions.
Let’s take a look at what is taught at the 2-year orofacial pain residencies that exist at approximately 8 US dental schools. What do they teach when it comes to occlusal philosophy and the role that occlusion plays in the treatment of TMJ and orofacial pain? I think the answer might surprise you.
I’ll frame it this way: I know dentists who have gone through the full 2-year orofacial pain residency and, in that entire time, they never once picked up a high-speed handpiece to adjust anyone’s occlusion for the treatment of headaches, migraines, or TMJ/orofacial pain. These residencies also spend an incredible amount of time looking at evidence-based studies and, as you may well imagine at this point, occlusion does not factor in significantly (if at all) in the treatment of TMJ and orofacial pain as a starting point.
STARTING POINTS
The most common question that I receive when discussing these matters at AAFE TMJ/orofacial pain trigger point live-patient training courses is, “If we don’t start with the occlusion, then where should we begin with a TMJ patient?” The way to start with every patient is by taking a thorough medical and dental history. In addition, one must learn how to do a proper examination of the head and neck areas, which includes but is not limited to a cranial nerve examination and a full muscle trigger point examination. Why a muscle examination? I have sat through many orofacial pain lectures given by some of the foremost authorities, and they all begin with the same evidence that up to 85% of TMJ and orofacial pain comes from the patient’s musculature, not from the joints or from the occlusion.
If this is what is taught in the orofacial pain residencies and is the standard of care, why would any dental professional begin with bruxism appliances or irreversible changes to the occlusion in trying to treat headaches and TMJ/orofacial pain? One of the best things about treating the muscles first is that since this treatment is minimally invasive and nonsurgical, it does no irreversible harm to the patient. There is no downside as only 2 possible scenarios can take place—either the trigger point muscle therapy works for the patient and that relieves the pain, or it is not successful and now serves as a diagnostic differentiator in letting the clinician know that the muscles are not the primary source of the patient’s TMJ and orofacial pain. In either scenario, the patient has gained in knowing what the ultimate treatment plan should and will really be.
WHY TEST?
One of the biggest frustrations in the past for even trying to study and treat occlusion is to quantify dental occlusion in some way and to be able to reliably measure it. This is now possible with home bruxism monitoring, which will also measure for sleep disorders. This is a key area that I have instituted into the AAFE educational process and into my own practice, allowing one to quantitatively measure bruxism and integrate dental sleep medicine into the treatment of bruxism and TMJ/orofacial pain. These are all co-morbid conditions that must be identified before any kind of therapy begins, especially if one wants to use any kind of dental appliance. With what we know today about sleep medicine and the importance of the patient’s airway, no dental appliance should ever be made for a patient without knowing his or her Bruxism Episodes Index (BEI) and Apnea-Hypopnea Index (AHI), which measures the airway.
Many, if not most, patients exhibit nocturnal bruxism for one simple reason: when they fall asleep, they have obstructive sleep apnea (OSA) which closes off their airway, and the brain sends signals to the masseter and temporalis muscles to begin moving the jaw forward to open up the airway. The patient comes into the dental office with jaws hurting and exhibiting teeth wear due to this aggressive activity, which can happen dozens of times every night. Many dental practitioners tell patients they have a malocclusion that is causing this, but we now know that most nocturnal bruxism is caused by the patients’ efforts to breathe!
DEATH BY OCCLUSAL THERAPY
You can see why the AAFE has instituted home bruxism and sleep testing into all of its courses that cover facial aesthetics, orofacial pain, implant dentistry, and aesthetic dentistry. It is crucial to know if the patient exhibits bruxism before you start any dental therapy and even more important to the patient’s health if that bruxism is tied to a sleep disorder. Making the wrong appliance for patients with airway issues can increase their bruxism, sleep disorder, and TMJ and orofacial pain, exacerbating a serious and dangerous medical disorder. This has significantly opened up our eyes as to specific evidence-based data on the patient being treated, becoming a huge advantage in proper diagnosis and treatment planning as well as measuring treatment efficacy; something that we have never been able to do before in dental treatment. For more information, please see the following related Dentistry Today articles: “The Dental Decision Maker: Reducing or Eliminating Failed Dentistry” (June 2016), “Ensuring Restorative Success with Bruxism Testing” (July 2015), and “Why Are You Prescribing Bruxism Appliances?” (September 2014).
I can personally attest that, after nearly 40 years in dentistry, I have never had a patient die from malocclusion, bruxism, or orofacial pain. Patients do exhibit high morbidity with sleep disorders, especially OSA. I am particularly proud of the many AAFE dentists who are presently testing patients for bruxism and related OSA and are uncovering thousands of previously undiagnosed OSA patients. These dentists are now able to deliver much better dental treatment while helping facilitate patients’ treatment for these sleep disorders, literally saving their lives.
Sleep disordered breathing affects approximately 40 million patients in the United States;1 90% are undiagnosed, and most of these patients have bruxism and TMJ disorders. According to a recent JADA study,2 one out of 6 patients in your practice has some form of TMJ and orofacial pain, so this is a big part of your practice right now that you may not be treating reliably, if at all.
STOP BEING JUST A “TOOTH MECHANIC”
It is time for all dental professionals to stop looking at the occlusion first and start using a medical diagnostic protocol with quantitative testing for treatment planning and treatment efficacy. In short, it is time for dentists to stop being “teeth mechanics” by looking at the occlusion first and to start being “real doctors,” treating these patients like the dedicated professionals who we really are. Learn how to treat TMJ and orofacial pain cases from the outside in (muscles first, teeth later) rather than from the inside out. Get trained today!
References
- Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328:1230-1235.
- Horst OV, Cunha-Cruz J, Zhou L, et al. Prevalence of pain in the orofacial regions in patients visiting general dentists in the Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry research network. J Am Dent Assoc. 2015;146:721-728.e3.
Dr. Malcmacher maintains a general and facial aesthetic private practice in Cleveland and is president of the American Academy of Facial Esthetics (facialesthetics.org), which presents more than 200 courses a year on Botox and dermal fillers for dental aesthetics as well as frontline TMJ, headaches, facial pain therapy, bruxism therapy, dental sleep medicine, and dental implant training. He is an evaluator emeritus for Clinicians Report, a Master of the AGD, a Fellow of the International Academy of Dental Facial Esthetics and the World Clinical Laser Institute, a visiting lecturer at a number of universities, a contributing editor for Dentistry Today, and a spokesperson for the AGD. He has served as a consultant to the Council on Dental Practice of the ADA. A monthly columnist and contributing editor for Dental Economics, Dental Tribune, and the Common Sense Dentistry Newsletter, he has been one of Dentistry Today’s Leaders in Continuing Education since 2000. He works closely with dental manufacturers as a consultant and clinical researcher in developing new products and techniques. He is an internationally known lecturer and author, having addressed many major dental meetings and local dental societies throughout the United States, Canada, Europe, and the Middle East. His educational organizations have presented nearly 20,000 hours of continuing education worldwide, and he has published thousands of articles in dental journals during the last 35 years. He can be reached at (800) 952-0521 or via email at drlouis@facialesthetics.org.
Disclosure: Dr. Louis Malcmacher is the president of the American Academy of Facial Esthetics and a paid consultant for STATDDS.
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