TMD, tooth pain, unbearable night guard, painful chewing, all in one patient: Oh my.

Dr. Halligan
Dr. Halligan

I wrote myself a note, perhaps after a couple of beers: Map and understand the worldview of the culture you wish to change.

Ok, what is the worldview of the culture I wish to change? The worldview of dentistry is narrow and needs to be deeper and wider. There is much dentistry to be done if only the dentist would expand her view. This would benefit all our patients as well as us as professionals.

If your work is a commodity, a response to an obvious need, a fractured lower molar for example, then your view is not very deep. Even if you succeed, you’re just like every other dentist and can be crowded out by others who compete on price, location, convenience, and ad copy.

My exam is focused on the overall function of the system and takes a fair amount of time.

Shall I pretend that I know how you do your new patient exam, Doctor? No; but I’d be willing to wager. Recline the dental chair, ask the patient to open, look at existing restorations (hoping you see a defective one that you can diagnose for replacement), check for obvious carious lesions with an explorer, spot check periodontal pocket depths or perhaps even do careful six point probe scores, note obvious recession. Maybe an oral cancer screening. Done. Takes about five minutes.

Anita, a new patient, came in recently. First step in my office is a new patient interview in a consult room, i.e. outside of the clinical area. Yes, it’s time for me to ask questions and for the patient to talk, but I’m also observing. We are knee to knee, eye to eye across a table from each other. Anita is well-dressed, casually elegant in her attire, but even from four feet away her crowded lower anterior teeth are obvious. She could have benefitted from orthodontics. How important is that? I’ll have to observe further during my exam.

I notice an area of redness and slight swelling on her lower lip on the right side. Does she inadvertently catch her lip with her right canines? It looks that way.

Anita tells me that she has a night guard that “doesn’t feel right,” but she’s afraid to sleep without it because if she does she has pain in an upper left molar—a anchor, she tells me for a bridge on that side.

She says she recently broke the last tooth on the upper left and that it was extracted. She’s afraid she could break the bridge abutment next, so she keeps wearing the night guard even though it feels wrong.

Anita’s dentist suspects a TMJ problem and has referred her to me for joint x-rays and exam.

Even before seating Anita in the exam room, I have my suspicions. Why do people break posterior teeth? Why lip biting in the canine area on one side?

But I start by measuring range of motion. She opens 50 mm with no pain, no deviation or deflection and no apparent joint noise. Ok, at my age I’m losing my hearing, and so I will use a computerized device to check for unusual vibrations. So far though, and in only seconds, I suspect that Anita does not have a joint problem at all. Unhealthy joints generally leave clues, and hers look innocent.

Joint imaging is done next. Anita has normal condyles. There is no flattening or beaking of the condyles, and they are both well-centered within the glenoid fossae.

Yes, today’s thinking is that when a person is closed in MIP the condyles should be slightly anterior to center, with the condyle disc assembly braced against the slope of the eminence. Still, I’ll accept centered in the fossa as normal.

So, Anita does not have a TMJ problem. Her dentist will be disappointed.

I use T-scan to check occlusion. Could I use articulation paper and shim stock? Sure. But T-scan gives me a detailed view of the patient’s occlusion and does so in seconds. Here is Anita in MIP (or C.O.)—habitual closed position. What’s going on? Heavy biting pressure on the right side.

I notice that #14, a bridge abutment, is barely contacting even though Anita states that it is painful if she does not wear her night guard.

Next, here’s T-scan of Anita’s night guard. She is correct when she says the bite feels wrong on the guard. But notice that it is simply a duplicate of her already improper occlusion, just at a greater vertical. This is a very common finding with night guards—just a duplication of an already screwed up occlusion. At least she feels that it is protecting the bridge abutment on the left side.

But why does #14 become painful if she doesn’t wear the night guard? A look at what happens when she grinds her teeth on the left makes this very clear: #14 is by far the hardest tooth hitting. The 2nd molar on the right side also contacts in left lateral excursion, i.e. there are working and balancing side interferences.

The left second molar is missing, a recent casualty perhaps to these same extreme working side interferences. If #15 was contacting as hard in left lateral excursion as #14 does now, I’d say it’s no surprise that it fractured beyond repair.

Tooth #14 is a full coverage crown and bridge abutment. Could Anita conceivably fracture it at the gingival crest and cause the loss of both #13 and #14? Yes; that is a risk. Certainly the occlusion needs to be corrected.

What about her function on the right side? Remember my early observation? The four lower incisors are tipped lingually and the right lower canine is tipped facially. As a result there is no canine function. When she chews on the right side, there is hard contact on the right first molar and second premolar. Likely results? Tooth pain, jaw muscle pain, and possibly even cusp fracture of one or more teeth.

When I wrote a report to Anita’s dentist, I included T-scan print-outs and comments. All of Anita’s TMD-like symptoms are related to occlusion. If, as an adult, she does not want to consider orthodontics, then at least adjusting occlusion to balance right and left contacts should be helpful. Restoring canines and eliminating posterior interferences would be a tremendous help.

Meanwhile I’d say Anita is stuck between the proverbial rock and a hard place: she hates the night guard, and with good reason; without it she risks losing #14 and with it the bridge on the upper left.

In addition, that seemingly small problem of the lower right canine being tipped out toward the lip—and therefore not in function with the upper canine—is the cause of a multitude of problems. Those problems are hard to solve and it is unfortunate that they have gone unnoticed by various dentists for years.

Back to my original point: The culture I wish to change, perhaps even disrupt, is dentistry’s tooth focus. Yes, a mirror and explorer look at each individual tooth is appropriate, but I believe that is secondary to a look at the overall picture.

A local orthodontist recently complained to me, “You know, all the dentists I know just look at their patients with mouths wide open. I wish they’d take a look at how they close!”

Yes. That would be a good start.

One of the giants of dentistry, Dr. Pete Dawson, has preached for decades the Concept of Complete Dentistry. My observation is that, as a profession, we haven’t heard that message yet. When you examine patients, take the time for a careful look, not tooth by tooth, but overall: how is the system working? Could you start with that? Why, or why not?


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