A recent email from a man in Colorado begins this way:
Dear Dr. Halligan,
I am the victim of an equilibration that, to be generous, didn’t go so well…
The man explained that when he mentioned to his dentist that he suffered from frequent headaches, the dentist told him that equilibration of the bite would resolve that problem. Even though the patient stated that his bite felt fine and that he had no jaw pain, his dentist told him that bite adjustment would be helpful.
So began a series of appointments to adjust the bite and with each adjustment the man’s bite went from feeling fine to not so good and then worse. He states that some of his anterior teeth now hit very hard when he closes and the lower right central incisor is actually loose. He also stated that the left side molars hit harder than any other teeth in the mouth and that the lower left first molar (#19) fractured a few days after one equilibration appointment. Because the tooth split nearly in half, it required extraction.
And now? The man still has the same headache pain he started with, and in addition has jaw pain and the feeling that he can’t get his teeth to meet. He thinks that he may need to see an experienced restorative dentist who can put the bite back the way it used to be. He is intelligent enough to know that this could require extensive dentistry.
In some of my previous posts, such as Equilibration Without a Clue, I wrote about checking occlusion with T-scan after equilibration done elsewhere and seeing less than optimal results. In this case, since I have not actually seen the patient, I can only take him at his word. But what he says rings true.
I doubt if any of the dentists who subscribe to this site would choose to start grinding on teeth as the first step when hearing that a patient has headaches, but a quick look around the internet lets me know that this treatment choice is not uncommon.
My opinion and advice for both dentists and patients is never let equilibration be the first step! Don’t jump into shaving down the teeth.
Can a bite problem cause headaches? You bet it can. Especially posterior interferences with inadequate canine guidance (see Why Do People Have Canines If They Aren’t Dogs?), as well as uneven occlusion. But, there are so many other possibilities among them cervical subluxations, spasms or muscle tension in the posterior cervical muscles, pain in the sternocleidomastoid muscle (the muscles on the side of the neck), true migraine headache, cluster headache, sinus infection, sleep apnea, tension headache, internal derangement of the TMJ. Also possible though less likely are temporal arteritis and trigeminal neuralgia.
More than 40 years ago, one of the best teachers in dentistry at the time, Dr. Pete Dawson, told me that if a patient listed headaches as a chief complaint, he would fabricate a simple anterior deprogrammer with cold cure acrylic at chairside (these looked very much like today’s NTIs), and have the patient wear it for a few nights. If this reduced or eliminated the headaches he would know that there was a good possibility that a bite problem was the root of the headache.
Then and only then would he consider bite adjustment.
He would also perform a TMJ exam including joint imaging.
He taught that a palpation exam of the head and neck was a must.
If a dentist has eliminated many of the other possibilities, he or she can then carefully evaluate the occlusion. Mounted study models are helpful—what are the results when you adjust stone models? How does the alignment look after a trial or mock equilibration?
I recommend T-scan as I believe it is superior to good old fashioned articulation paper, though I understand the profession has been slow to embrace this technology.
The message as I see it for both the dentist and her patients is: don’t do something irreversible until you’ve tested the theory of bite causing the problem with a removable appliance first. An NTI would suffice for this.
A quick note on the NTI. Although many use it as the primary treatment modality, I’ve seen too many patients’ occlusions altered unintentionally with the device. When I use an NTI, I recommend it for short term only—usually no more than 2 weeks or so. There are other designs of anterior deprogrammer that in my experience provide better stability when used long-term.
To review, if a person has frequent headaches, reaching for a high speed handpiece and a polishing diamond should never be the place to start.