Defining Our Role As Dentists By: Gregory Tarantola, DDS

What an incredible time to be a dentist! The opportunities we have to help our patients enjoy dental comfort, good function, health and esthetics are countless. The number and quality of materials, techniques and procedures available to accomplish this are mind-boggling. We can bond to tooth structure with stability and longevity. We are able to restore with composites and porcelains virtually undetectable from natural tooth structure. Bone and soft tissue can be replaced where it has been lost, or placed where it was not present in the first place. For those patients who have been unfortunate enough to lose all or part of their natural secondary dentition we are able to provide a stable, oftentimes non-removable tertiary dentition. These technical accomplishments are incredible, but the most remarkable thing is how all this has the ability to change our patient’s lives. We can help them smile without embarrassment, chew with confidence and become healthier.

In our excitement to provide quality treatment for our patients, we have to remember not to shortcut basic, fundamental principles. I am talking about:

• complete masticatory-system-based examinations with thoughtful cause-effect diagnoses;
• reflective, patient-appropriate blueprints, treatment plans and sequences; and
• addressing the details and subtleties of occlusion.

All of this includes involving our patients and listening with empathy and responsiveness.

As Clinical Director of the Pankey Institute from 1991 to 2002, I was privileged to meet 3,000+ dentists as they progressed through the continuum courses. Although I am now practicing full-time and making home study courses (available at www.TarantolaDentalLearning.com), I am able to stay in contact with these dentists through lecturing. The wonderful opportunities to interact with dentists all over have allowed me to make a couple of interesting observations. One, as the complexity of a case increases, so does the tendency for dentists to shortcut fundamental principles! Two, as a practice becomes busier and busier, the tendency to shortcut fundamentals increases! Shortcutting fundamentals certainly is not done with any bad intentions, I think it is simply time management, so many things to think about and address and not enough time to do them.

To illustrate these points consider the following case. The patient in figure 1 comes to you after suffering for years with a variety of problems: headaches, TMJ pain, TMJ noise that worsened through the years, and tooth pain. Her history shows her suffering was often treated symptomatically with pain medication. Her chronic pain got to the point she became depressed and further attempts for treatment had a tendency to put the source of pain in a psychological category.

She already has quite a bit of nice dentistry done, so where do you start? Perform a complete, masticatory system evaluation to pinpoint the condition of important structures and the source of her pain and problems. That includes TMJ palpation, auscultation, range of motion tests and vertical compression tests as well as palpation and provocation tests of the masticatory muscles, dental exam and dental pulp testing (by either you or your endodontist) and a complete periodontal exam. Also, complete a careful occlusal analysis of how the teeth interdigitate when the condyles are completely in the fossa and during excursive movements both in the functional and parafunctional range of motion.

It is interesting to consider the stepwise sequence of how this occurs and how it is orchestrated for each patient. When the patient arrives, first is the pre-clinical interview to meet and better understand her and her concerns. A lot of information is already gathered at the first phone call and from the referral source. This determines how we actually begin the exam. In this patient’s case it was tooth and TMJ pain so we started there. Then we cycle through the rest of the exam: TMJs, muscles, teeth, perio, esthetics and occlusion always “connecting” each part of the exam to her concern and major problem. Make every effort to involve the patient, get her talking, asking questions and describing what she is feeling. Put simply; make it interesting to the patient and not just boring data collection. The better the patient understands her present condition, the better she can understand what the possibilities are. This is especially helpful when it comes to the occlusal exam and how “if all the teeth don’t contact equally, like a door closing in a door frame, it can be a cause of....”

A “casual” observation of her occlusion in figure 1 might lead one to believe her occlusion is not a big contributing factor. Her maximum intercuspation looks reasonable, and the relationship of her anterior teeth looks acceptable. One might conclude she has a reasonably good anterior guidance; however, a more detailed analysis reveals otherwise.

She reported her bite has never really felt “even”. When her maxillary to mandibular tooth to tooth relationships were observed with the condyles in the fossa, another story is told. Her joint position was not in centric relation or even adapted centric posture.¹ Her TMJs could not comfortably accept vertical loading either with bimanual manipulation² or with her own muscular contraction. However, as she rotated closed with this joint position, there were distinct interferences in the right molar area she could identify and occlusal analysis could pinpoint. When she contracted her muscles at this position, there was a distinct shift of her mandible into maximum intercuspation. A Tekscan analysis (Fig. 2) confirms interferences in the right molar area. The Tekscan also calculates net vector of force as seen by the red and white flag. The net vector is to the right, 71% right and 29% left, and this information can be used during the diagnosis and reflection on cause-effect to other signs and symptoms.

Figure 3 begins to tell a bit more about her occlusion. There is an excessive Curve of Spee at the second molars. An excessive Curve of Spee can result in balancing interferences. The wear facets on the incisal edges of the upper and lower anterior teeth tell another story. The angulation of wear facets of upper and lower incisal edges appear to match up suggesting that the patient moves the mandible to these excursive positions with enough force and duration to cause the wearing of enamel. In an extreme left lateral excursive movement into a parafunctional position (Fig. 4) a balancing interference between teeth #s 2 and 31 can be observed. In this position, note the anterior teeth are not contacting. Imagine the stress and strain this can put onto the various components of the masticatory system with this occlusal condition. Studies have shown that maximal bite force at night while sleeping can exceed maximal force that can be exerted while awake.³

One can only wonder if while sleeping this patient can exert enough force to actually cause the mandible to flex to the degree that the anterior teeth actually contact. A close-up photo of the teeth in this position, figure 5, shows wear facets that match up suggesting that these surfaces do actually contact and with enough force to cause wear. If these surfaces were unworn, convex surfaces, one would observe more of a point-to-point contact.

Figures 6 and 7 explain this phenomenon of jaw mechanics in terms of simple physics. The masticatory system is a Class 3 lever meaning that the “force” (masticatory muscles) is between the “fulcrum” (the TMJs) and the “resistance” (the teeth). Figure 8 is a simple example of a Class 3 lever. Mechanical advantage can be calculated by dividing the distance between the fulcrum and energy source by the distance between the fulcrum and the resistance. In a good occlusal scheme with NO posterior interferences, the distance between the fulcrum and resistance is a bigger number resulting in a lesser mechanical advantage. If there ARE posterior interferences, either posterior interferences to the arc of closure and/or excursive interferences, the distance between the fulcrum and resistance (those interferences) is a lesser number. Since you are dividing by a smaller number, the mechanical advantage is greater. A greater mechanical advantage means you can do more work. But in the case of the masticatory system, it is more destructive work, that is, greater force to the teeth and fulcrum. The benefit of engineering a good occlusion is a mechanical DISadvantage resulting in less destructive forces.

So let’s see how this might apply to this patient in particular and the signs and symptoms present. The upper right second molar is sensitive to cold and biting pressure (Fig. 9). Observe the widened periodontal ligament space. Makes an interesting case for the role of occlusion and the increased mechanical advantage. The upper right first molar was necrotic with heavy suppuration as reported by the endodontist. This tooth obviously had a history of decay and/or other problems, since it has a crown, so the pulp has had its share of trauma. You can’t help but wonder how the occlusion may have played in the history of this tooth too.

Look at figure 10 and reflect on these forces as it relates to TMJs and muscles. The range of motion was within normal limits, but with pain in both TMJs and muscles. Lateral and posterior aspects of TMJs were painful to palpation suggesting inflammation in these structures. Coarse crepitation observed in excursions but not rotation (Dx: Piper 3B) suggesting lateral pole breakdown. Both TMJs were tender upon light vertical compression again suggesting TMJ inflammation. The medial pterygoids were tender to palpation testing as was the area of the lateral pterygoids. Tension was reported in front of the TMJs during lateral pterygoid provocation again suggesting inflammation in this muscle.

Take a closer look at the condyles in figure 11. These radiographs suggest condylar and eminence remodeling. Patient does not recall any history of trauma. As you ponder these radiographs, think again about the possible role of occlusion. Initial occlusal analysis with T-scan showed hyper occlusion on the right and therefore increased force on the right side. Functional and parafunctional occlusal analysis revealed excessive balancing and crossover interference on the right side increasing the mechanical advantage on the right side, as described earlier. Isn’t it interesting the right condyle appears to have more flattening and remodeling than the left side? Is this positive proof that this occlusion caused these changes? No, but it certainly suggests the possibility. An article by Franco Mongini addresses forces at the occlusal interface and the effect on the TMJs.⁴

Now that a masticatory system examination is done; which includes the clinical assessment, photographs, radiographs and articulated diagnostic casts, and a cause-effect diagnosis made; a treatment plan and sequence can be developed. Bite splint therapy, which introduces all the components of a physiologic occlusion is initiated to control and redirect occlusal forces (Fig. 12) with the following goals:

1. Decrease/elimination of signs and symptoms due to muscle relaxation and healing/remodeling/adaptation of TMJ structures.
2. Stability of the bite on the splint over time suggesting stability of TMJ structures. This is an advantage of a full-arch splint as opposed to an anterior bite stop. As the patient is seen after insertion of the splint, one will most likely see changes in the occlusal marks on the splint. This is expected as the muscles relax and TMJ structures remodel and adapt. As long as we see changes in the occlusion on the splint, something in the masticatory system is still changing. The splint is further assessed and readjusted over time. When stability of these occlusal marks can be observed over a period of time, say two to three months, that would suggest the components of the system have stabilized.

The consultation regarding the plan and sequence is typically done at a follow-up visit, not at the initial appointment. Rather than a “presentation” it is more a consultation, conversation type of thing––like with a friend at the kitchen table. The focus is always on the patient. Start by reviewing the patient’s photos, such as on a computer monitor, give them a laser pointer and invite the patient to stop and ask questions any time she wants. Why do all this at a subsequent appointment? There is a lot of data to “process” and put together in an understandable, meaningful, appropriate form for the patient and it takes time. To try to rush and do this at the initial visit, I feel, is not fair to the dentist or patient. It is amazing what is “seen’ when there is quiet time to think and reflect. Abraham Lincoln said it is indispensable to develop a habit of observation and reflection––exactly what examination and diagnosis is. After 22 years of practice, this “thinking time” is very beneficial. The patient understands, through our conversations, that this thinking time is essential, and is generally very appreciative that this time is offered. Giving the patients time and alleviating decision-making pressure differentiates our office in a positive way. Patients complaining about having to “wait” for a treatment explanation and consultation are generally not a problem if you and your team help the patients understand this time is for them and is in their best interest.

What if there are objections to your treatment plan? Questions and objections are encouraged, as it suggests patients are “thinking”. Try to understand what is behind the objection and encourage discussion. If patients are not interested in an optimal plan, don’t write them off. There is usually a way to time treatment so a compromise is not necessary, but is treatment extended over a period of time best for the patient. (Of course, you can’t ignore decay, infection, periodontal disease, etc.) We, as the leader of the practice, can help guide the patient to remember the big picture and what optimal treatment will mean in the long run. With a complete exam and especially a diagnostic wax-up, you usually can figure out a way to sequence treatment and still get a good result. You have to have the vision (diagnostic blueprint wax-up) first. It is not uncommon to have patients on a phased sequence. But again, work off a “master plan” and don’t just float from crisis to crisis. The fun challenge is figuring out how to stretch it out, if necessary. It is very gratifying for both the dentist and the patient to find a way to make optimal care possible.

The dental team needs to see the treatment planning is really about helping the patient achieve optimal dental health, and that the patient’s best interest is first and foremost. The administrative assistant should be comfortable at talking to and understanding a new patient on the phone and helping the patient see the benefit of a complete exam. If most patients are well referred (by other patients, specialists, etc.) it is not a big problem. Occasionally an appointment for a shorter exam may be appropriate, but it typically leads to a complete exam, or the patient may just decide you don’t offer what they want. If there is an urgency, that certainly is looked at and addressed first and then have them back for a complete exam. Sometimes their concern, like the case patient, is so involved it necessitates a complete exam. I feel it is best not to begin any definitive treatment such as esthetic, restorative, or occlusal therapy without a complete exam. Also, help the patients discover, especially if they don’t have what they consider to be problems, that a complete exam is a great investment in their long-term health because it becomes an important baseline for future comparisons. Some clinical observation may not be “ideal” but it may not be a problem, such as a small amount of wear. But if a baseline is established and a comparison done in a year or two, that wear may have advanced, and a rationale for intervention may be in order.

What about the fee for this exam? Consider an all-inclusive fee that includes radiographs, photos, casts, plus thinking time and the consult next appointment. A fee for one-and-a-half hours of time may be fair, although it may not cover all your time. Consider it an investment, and an important one at that, in helping the patient choose the value and benefit of optimal care.

Insurance may be a concern for some patients. It generally breaks down to pretty typical procedures: complete exam; FMX; panoramic; diagnostic casts; occlusal analysis, mounted case; diagnostic photos, etc. Insurance coverage may typically pay some of the fee. If patients really see the value, the time spent on their behalf, the benefit to them and how it fits with their concern; insurance coverage becomes less an issue. We all will find a way to pay for the things we value. If the insurance doesn’t pay well, the patient is more aggravated with the insurance company rather than with the dentist.

Now, back to our patient. Once we begin splint therapy, in addition to accomplishing these technical things, we also have a patient who becomes pain-free for the first time in 20 years! She smiles as she has not done in years, has hope and is incredibly appreciative someone has taken the time to listen––not jump to the conclusion it was just “psychological”. We have a real relationship with the patient and she can now focus on the esthetic treatment of her teeth that she has wanted for years, but was afraid to pursue because of her pain.

Once these goals are accomplished, a definitive restorative/occlusal treatment plan will be developed. The bite splint is simply a reversible method of designing a good occlusion to allow the masticatory system to improve. The complete masticatory system exam will be completed again to confirm the status of its components. Two sets of new centric articulated diagnostic casts will be made, one an archival set to refer back to and the second to complete a trial equilibration/diagnostic wax-up to fully visualize the form and function anticipated in the finished case.

This patient is still in bite-splint therapy. She is out of pain, but more time is needed for stability of occlusion which is a good test of masticatory system stability. The overall plan (which was already discussed with her) is lower anterior veneers and a full upper reconstruction for functional (occlusion) reasons, structural reasons (a lot of old composites and wear) and esthetic reasons (her desire and displeasure with the esthetics of her old upper crowns, now that she is pain free).

We cannot underestimate our primary responsibility as our patients’ dentist: examination and diagnosis. We need to carefully listen for symptoms a patient reports, but also carefully investigate and look for subtle “signs” of problems or breakdown. Signs are typically evident before symptoms. Also, look for contributing factors for these signs and symptoms of which occlusion may be a significant etiology. This requires more than just a casual observation of the occlusion, but a detailed investigation with articulated diagnostic casts. Once the details are observed, we need to think and ponder the potential cause-effect relationships. Only then can we design an appropriate treatment plan. I don’t see how this can be done with a quick five-minute exam. Our patients deserve no less and our profession needs to give no less. I also believe all the wonderful dentistry we are able to do today will be more appropriately planned and very likely will have exceptional stability and longevity.

Dr. Tarantola is former Clinical Director of the Department of Education at The Pankey Institute for Advanced Dental Education in Key Biscayne, Fla. In January of 2002, he opened his full time restorative practice on Brickell Avenue in Miami, Florida. He continues as a Visiting Faculty Member at The Pankey Institute. Practicing comprehensive dentistry in a relationship-based setting is the message he is committed to teaching to dentists everywhere. You can reach Dr. Tarantola at www.TarantolaDentalLearning.com. There you can also see his Learning CDs and sign up for a free monthly e-newsletter.

Bibliography

1. Dawson PE. New definition for relating occlusion to varying conditions of the temporomandibular joint. J Prosthet Dent. 1995 Dec;74(6):619-27
2. Dawson PE. 1974. Evaluation, diagnosis and treatment of occlusal problems. The Mosby Co. pgs 54-61
3. Nishigawa K, Bando E, Nakano M. Quantitative study of bite force during sleep associated bruxism. J Oral Rehabil. 2001 May;28(5):485-91
4. Mongini F. Condylar remodeling after occlusal therapy. J Prosthet Dent. 1980 May;43(5):568-77.