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Why Quality Dentistry Sometimes Fails by Dr. Maryam Motlagh

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Categories: Sleep Medicine; TMJ and Occlusion;
Why Quality Dentistry Sometimes Fails And how to avoid it by respecting function

by Dr. Maryam Motlagh

Dentistry is evolving. Modern dentistry recognizes that long-term oral health and the stability of the dental treatments we provide are closely connected to functions such as breathing and swallowing. Parafunctional habits like bruxism and clenching can be linked to sleep-disordered breathing and overall systemic wellness. It’s well documented that poor breathing and swallowing patterns can impact everything from craniofacial growth to muscle strain, airway resistance, TMJ strain, and malocclusion.1,2

Conditions such as chronic mouth breathing, sleep-related breathing issues, malocclusion, and TMJ symptoms affect a significant portion of the population. Large-scale studies show that more than 30% of adults suffer from TMJ-related conditions. Unfortunately, many of these conditions go untreated, mainly because most of us were not trained in dental school to treat beyond teeth. But the link between oral health and whole health is too strong to ignore, and restoring proper masticatory function is deeply rewarding for both provider and patient. The good news is that many warning signs can be identified early in the dental chair. Since dentists usually see patients more often than primary care providers, we are uniquely positioned to notice signs, initiate conversations, ask about symptoms, and guide patients toward the right care. This perspective helps bridge the long-standing gap between dentistry and medicine and ultimately enhances how we care for patients as a whole.


My path toward functional and physiologic dentistry
Early in my career, my own challenges as a TMJ patient led me to explore a wide range of treatment options. As a cosmetic dentist, I soon realized that many of my patients were showing similar signs and symptoms. I studied concepts such as centric relation, neuromuscular dentistry, and eventually an airway-focused physiologic approach to occlusion.3–5 Over time, I realized that occlusion isn’t a fixed position that can simply be “set.” Instead, it represents a dynamic relationship where the jaw, muscles, teeth, nervous system, and airway work together without strain. As I started considering the balance of the entire stomatognathic system instead of focusing on isolated symptoms, I observed a significant shift in my clinical outcomes. Treatments became more consistent, and patients often reported increased comfort and function.


Why breathing, swallowing, and jaw function are important
With each swallow, the tongue gently rests against the palate. This natural movement supports proper maxillary width and promotes nasal breathing.6 When that balance is disrupted, whether from chronic mouth breathing, allergies, restricted oral tissues, or decreased tongue strength, the effects can go far beyond the mouth. Over time, these changes can impact craniofacial development, airway health, and overall system harmony.

The adaptations that can occur include:
  • Narrow dental arches
  • Retracted lower jaws
  • Reduced airway space7
  • TMJ strain and muscular imbalance
Studies show that up to 86% of people have some level of malocclusion,8 and about 30% of adults experience symptoms related to airway obstruction, TMJ problems, or sleep-related breathing issues.9

Many systemic health issues first show up in the oral cavity. Because of this, dentists are often the first healthcare professionals to notice early warning signs and help guide patients toward appropriate care.


Integrating physiologic dentistry into general practice
Introducing a functional perspective into general dentistry doesn’t always demand complex technology or extensive extra training. Often, it begins with increased awareness, careful observation, and a consistent approach during routine exams.

Ask better questions
One of the easiest ways to begin is by expanding the questions we ask during patient interviews. A few simple questions can reveal important clues about breathing patterns, muscle function, and sleep quality:
  • Do you wake up feeling tired or with headaches?
  • Do you snore or tend to breathe through your mouth at night?
  • Has anyone told you that you clench or grind your teeth while sleeping?
  • Does your child sleep with their mouth open or have dark circles under their eyes?
Questions like these can uncover functional issues that might otherwise go unnoticed during a standard dental exam.

Observe more closely
During every exam, watch for signs of dysfunction such as:
  • Wear facets, abfractions, or failing restorations
  • Scalloped tongue edges or a narrow upper airway
  • Dark circles under the eyes or a small upper jaw
  • TMJ noise or limited range of motion
  • Asymmetrical muscle tension or facial development
These subtle signs can reveal underlying functional instability.

Utilize existing tools
Digital impressions, available in most dental practices, are a valuable tool for identifying issues and communicating with patients. Radiographs and digital occlusal scans can reveal important clues such as uneven tooth contacts, occlusal discrepancies, bone adaptation, or potential airway limitations.10 More advanced technologies such as CBCT imaging, electromyography (EMG), and computerized jaw-tracking systems can provide additional objective information on abnormal muscle activity and mandibular movement. That said, meaningful clinical insights don’t always require sophisticated equipment. Consistent observation, documentation, clinical photographs, digital scan comparisons, detailed notes, and symptom tracking can go a long way in helping clinicians track functional changes over time.

Collaborate across disciplines
No single provider can manage every aspect of these conditions on their own. Building referral partnerships with professionals such as ENT specialists, sleep physicians, physical therapists, chiropractors, and myofunctional therapists enables patients to access more comprehensive care. Effective collaboration not only enhances treatment results but also emphasizes the significant role dentistry can play in overall health and prevention. One of the simplest ways for me to work with colleagues on multifaceted cases has been a secure case-collaboration platform that allows us to share patient information and exchange ideas.


Treatment approaches: Conservative and evidence-based
Once a functional issue has been identified, several conservative and well-supported treatment approaches may be considered:
  • Orthopedic or anatomical orthotics to eliminate a pathological occlusion, relax the muscles or guide the mandible into a more balanced physiologic position.12,14
  • Myofunctional therapy to improve tongue posture, breathing patterns, and swallowing habits.13 Imagine the long-term impact of correct tongue posture on orthodontic retention.
  • Selective equilibration or restorative adjustments aimed at reducing nociceptive input, lowering muscular hyperactivity, and helping the jaw function in a more balanced position.11
  • Management of sleep-disordered breathing, which can help address the related parafunctional habits such as clenching and grinding. A protrusive wear pattern on the anterior teeth may result from mandibular advancement during sleep to open the upper airway.
Each of these options serves a different purpose depending on the patient’s diagnosis. Ultimately, the goal is not to depend on a single device or protocol, but to base treatment choices on a careful, individualized assessment of each patient’s functional needs.


Clinical vignette: Stabilization before definitive treatment
A patient presented with noticeable facial asymmetry, a posterior crossbite, and a canted smile (Fig. 1), along with persistent TMJ discomfort. She had previously been advised that orthognathic surgery would be required to correct what was believed to be a skeletal imbalance.
Why Quality Dentistry Sometimes Fails
Fig. 1: Unilateral left-side posterior crossbite creating facial asymmetry and obvious head-neck malalignment.

During the clinical evaluation, however, the occlusion revealed a significant distortion in the maxillo-mandibular relationship. It became clear that the problem extended beyond tooth position alone. Her symptoms appeared to reflect a broader functional imbalance within the stomatognathic system rather than simply a structural issue.

Instead of rushing into irreversible procedures, the initial aim was to assess the patient’s physiological occlusion and mandibular position. ULF-TENS therapy, cleared by the FDA for relaxation of the masticatory muscles, was used to achieve neuromuscular relaxation, immediately followed by a neuromuscular bite (MyoBite) registration to document the optimal cranio-mandibular relationship. As shown in Fig. 2, after muscle relaxation, the mandible decompressed more on the left side (the compression side), pressure on the left joint and ear was relieved, and the dental midline aligned naturally without any jaw manipulation by the provider.
Why Quality Dentistry Sometimes Fails
Fig. 2: Aberrant occlusion (left) and neuromuscular bite registration in place (right).

Based on data from CBCT, EMGs, and computerized jaw tracking, a physiologic orthotic device (Myoaligner), FDA-cleared for TMJ disorders and migraines, was introduced as the first phase of treatment to support the mandible in a physiologically friendly muscle position day and night (Fig. 3).
Why Quality Dentistry Sometimes Fails
Fig. 3: Three-month follow-up after physiologic orthotic therapy. A) Pathologic bite, B) Neuromuscular bite registration, C) Physiologic bite with orthotic in place, D) Removable orthotic.

Over a short period, noticeable clinical improvements began to appear. Facial symmetry improved, TMD symptoms resolved, the patient’s head and neck posture appeared more balanced, and mandibular movements became smoother and less restricted. These observations indicated that once neuromuscular stability was reestablished, much of the compensatory strain affecting the joints and surrounding muscles had decreased.

With that stability established, the patient was then able to proceed with orthodontic treatment to correct the crossbite and enhance the overall relationship between the arches. Keeping joint and muscular balance during this phase helped guide the transition toward a more stable physiologic occlusion. Follow-up imaging and clinical assessment showed improvements not only in tooth alignment but also in airway space and overall craniofacial harmony.


The bigger picture: Whole-health dentistry
Physiologic dentistry is not defined by a specific appliance or technique. Instead, it embodies a philosophy focused on restoring balance throughout the stomatognathic system. This approach recognizes the close relationship between oral structures, muscle function, and airway health, and how these factors influence overall well-being and dental health.

By incorporating functional screening into routine exams, working collaboratively with other healthcare providers, and focusing on physiologic balance, dentists can expand the scope of comprehensive care. This approach can also help prevent downstream complications such as fractured teeth, restorative failures, or persistent discomfort that may result from untreated occlusal instability.

Ultimately, our role as dental professionals goes beyond just treating teeth and gums. When we focus on both function and structure, we can help patients achieve better outcomes and enhance the long-term success of our treatments.

References
1. Abelson A, et al. The role of the stomatognathic system in systemic health. J Dent Med. 2021;15(2):45–52.
2. Simmons M. Craniofacial morphology and airway function: A review. Sleep Breath. 2020;24:123–132.
3. Dawson P. Functional Occlusion: From TMJ to Smile Design. Elsevier; 2006.
4. Jankelson R. Neuromuscular aspects of occlusion. Dent Clin North Am. 1969;13(3):627–642.
5. Singh G, et al. Airway-centered dentistry and facial growth. Cranio. 2018;36(4):256–264.
6. Moss ML, Salentijn L. The primary role of functional matrices in orofacial growth. Am J Orthod. 1969;55:566–577.
7. Guilleminault C, et al. Mouth breathing and its impact on health. J Pediatr Otorhinolaryngol. 2016;90:1–7.
8. Proffit WR. Contemporary Orthodontics. 6th ed. Elsevier; 2019.
9. Peck S. Epidemiology of malocclusion and TMJ dysfunction. Orthod Rev. 2017;5(2):89–96.
10. Kerstein RB. Digital occlusal analysis in clinical practice. Compend Contin Educ Dent. 2019;40(2):80–86.
11. Okeson JP. Management of Temporomandibular Disorders and Occlusion. 8th ed. Elsevier; 2020.
12. Cooper BC, International College of Cranio-Mandibular Orthopedics (ICCMO). Temporomandibular disorders: A position paper of the International College of Cranio-Mandibular Orthopedics (ICCMO). Cranio. 2011;29(3):237–244. doi:10.1179/crn.2011.034. PMID:22586834
13. Guimarães KC, et al. Effects of oropharyngeal exercises on obstructive sleep apnea. Am J Respir Crit Care Med. 2009;179:962–966.
14. Motlagh M. Myoaligner: An Innovative Approach to Occlusion, TMD, and Airway Treatment—A Case Study. Adv Dent Tech. 2024;3(1):1–12.

Author Bio
Dr. Maryam Motlagh Maryam Motlagh, DMD, MICCMO, is a dentist, educator, and inventor whose expertise combines occlusion, airway, and systemic health. Her recent peer-reviewed article in the Journal of Advanced Dental Technology & Techniques (2024) discusses managing complex malocclusion and TMJ issues using noninvasive techniques. As CEO of MyoHealth Technologies and inventor of Myoaligner, Motlagh aims to support general dentists through education, innovation, and collaboration, promoting functional, whole-health dentistry with the ultimate goal of making treatment more accessible to patients by empowering dentists.
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