Dental Occlusion, What We Can Agree On

Wandering in the world of occlusion in dentistry is a lot like taking a walk with Alice into Wonderland. As we head down the obviously unmarked road, we meet our friend the Cheshire Cat. Mr. Cat, we ask, “Which is the best road to take?” And the Cat asks, “Where do you want to go?” Most dentists say, “We have no idea!” And of course the Cat says, “Then I suggest that you take the road to someplace else.”

In this modern era we treat periodontal disease and restore teeth to perfection with the finest oral care products – composites, veneers, implants, and lasers. We diagnose with intraoral cameras, CAT scans, MRIs, and our ever expanding knowledge of the human system. Surely we should have made some progress regarding the biomechanics of dentistry. But most dentists still agree that the 80/20 rule seems to apply to occlusion:

• 80% of the dentists in practice do not look for, diagnose, or treat bite problems on a regular basis.
• The other 20% who do, seem to spend more time arguing the finer points with each other than they do enrolling the other 80%.

Every dentist has taken a course in physics. We all understand the basics such as force x mass = energy. I do not think that anyone really believes that the laws of physics have been suspended inside the lips. So, how can we continue to ignore oral biomechanics?

What About Other Fields?

In the field of cardiology, there is plenty of disagreement and debate, as well. Many doctors believe that exercise is critical. Many believe that, “we are what we eat”, and so they recommend low fat, or low carbohydrates, or whole wheat, or no wheat. Some are pharmaceutically oriented and recommend cholesterol lowering drugs, while others are surgically oriented and recommend stents or bypass surgery. But here is the crucial difference. At the end of the day, they all agree that the heart matters. As a result the NIH, the regulatory authorities, the insurance companies, the news media, and the public all agree, as well. At the same time, they have created a space for intelligent debate. But here is the amazing part. If you go to a dermatologist and they see that your legs are very swollen, they can start to diagnose what appears to be cardiac failure. An ENT can connect pain in the ear, shoulder, and jaw and suggest an immediate cardiac evaluation. Every doctor does not have to treat heart problems, but they certainly do not ignore them, and frequently assist in the differential diagnosis.

Back To Dentistry

I want to take a moment to point out the current situation by quoting information from several sources considered by most to be the pinnacle resources for medical information.

• National Institutes of Health – “…irreversible treatments that are of little value — and may make the problem worse — include orthodontics to change the bite; restorative dentistry, which uses crown and bridge work to balance the bite; and occlusal adjustment, grinding down teeth to bring the bite into balance.”
  (National Institute of Dental and Craniofacial Research, National Institutes of Health – www.nidr.nih.gov)
• TMJ.org (A web site on TMJ that received 35,000 hits in July) – Quoting the Cochrane Oral Health Group Newsletter, August 2003, Issue 8 they stated,“Another study found ‘no strong evidence of benefit from occlusal adjustment (adjusting the teeth’s biting surfaces) for problems associated with the TM joint.’ Specifically, the review reported there is ‘no evidence from trials to show that (bite) adjustment can prevent or relieve temporomandibular disorders.’ ”
• Insurance – Whether you are submitting to medical or dental insurance you are certain to find that it is often extremely difficult to obtain appropriate coverage for your patients.
• Dental School – In almost every dental school the graduating dental students fail to learn even the most basic joint anatomy or physiology. When I was in dental school we dissected the entire body, excluding only the jaw joint.
• Medical Community – Evidence based medicine is the new emerging standard for medical and dental treatment. The problem is that dentistry is not an “off the shelf” product, like a pill, where every procedure performed by every dentist is the same. Dentistry is a personal service, and there are differences in skill and commitment.

Sometimes, in the field of occlusion and biomechanics we are like a mouse in a trick maze, where you really cannot get there from here. Therefore, allow me to make a bold suggestion. Let’s take a look at where we are now, and then start over. Like when you take a mulligan on a golf course, or a do-over. Go ahead, drop a new ball…no one is looking.

The Evidence – Worn and Broken Teeth

Architects have to go to school to learn how to design structures, and building inspectors are supposed to go and check to be sure that construction contractors follow the rules so that the buildings and bridges do not fall down. But what about dental bridges? Why do we think that it does not matter how teeth hit against each other, given that people can generate forces of as much as 500 pounds per square inch at the molars? Why does the average patient with severely worn or broken teeth think this is normal? Why does the average patient with gum recession and notches in the necks of their teeth think that a soft nylon toothbrush can make geometric cuts in the hardest substance in the human body?

Occlusal Interferences Are Like Tables

If you went into a restaurant and they seated you at a table near the swinging door to the kitchen, and every time the waiter opened the door it hit your table and knocked over your water glass, what would you do? Would you send the waiter for biofeedback training so they would learn to gain better control over their muscles, so they would push the door more gently? Maybe cut down the number of menu items or the number of tables so the waiters feel less stressed? What about several years of psychotherapy so that the waiters could learn to understand that the hostility they feel really relates to their relationship with their mother, and then they might develop more constructive ways to deal with their anger besides slamming the door open? Wouldn’t it be easier to just move the table? And is that really any different than removing the interfering contact on the tooth?

Jaw Joints Are Joints Too

What about problems in the jaw joints? Orthopedic physicians have to learn the anatomy of the knees, elbows, and wrist joints. There are even subspecialties of orthopedic doctors who focus on the hand or leg. Why aren’t dentists required to study the jaw joint? If you complained to your MD that your knees hurt or they made funny clicking or rubbing sounds, they are likely to take an MRI and look for damage in the joint. So, why is it that when the average patient comes to the dentist with pain in their jaw, or clicking or rubbing sounds, they are told that it is stress, to relax or take anti- inflammatory drugs and muscle relaxants without any testing, imaging, or diagnosis?

Muscle Pain

If the average couch potato goes out and runs a 5K race, are they shocked that they are sore the next day? If you carry a bunch of heavy bags in from the store, is it a surprise that your arms hurt until you put the bags down, but then the pain immediately goes away? So, why does the average patient not consider that their jaw muscles, which wrap around their entire head, might be hurting from over work when they have a headache? There are several thousand dentists who have treated millions of patients who have extensive histories of head, neck, or facial pain being relieved after bite treatment of various types. There are also dozens of EMG studies that support the evidence that changing the bite lowers muscle activity. (See Becker, I., Tarantola, G., Zambrano, J., Spitzer, S., Oquendo, D.: Effect of a prefabricated anterior bite stop on electromyographic activity of masticatory muscles. J Prosthet Dent 1999 Jul;82(1):22-6).

NASID Complications

Evidence is clear that long term use of NSAIDs causes serious health problems. These drugs were prescription items when they first came out, but for years they have been available in smaller “OTC” size doses. Do we really believe that the consumer is not going to assume that if one pill is good, 2 or 3 must be better? Were they intended to be taken unsupervised day after day, and year after year? Does the average consumer know that in 1997, according to the National Center for Health Statistics 16,685 deaths in the U.S. were related to AIDS, and 16,500 deaths were related to NSAID toxicity? Can we continue to believe that drugs prescribed without a diagnosis is “conservative”, yet fixing patients’ bites is not conservative treatment? The last time I looked, it was easier to replace enamel than a kidney or liver.

We Must Communicate Agreement and Practice Our Specialty

We need to start over again, and see what we can agree upon. I believe that as a starting point we really do have several areas of agreement. Like the cardiologists we must find fundamental tenants which we can agree upon, and clearly communicate them to the rest of the dental community, medical doctors, regulatory authorities, insurance companies, news media, and patients. I will now propose 7 such tenets:

1. Excessive force in the oral cavity will not be tolerated without long term consequences for most patients.
2. A joint that is injured or unstable is likely to suffer additional damage without intervention.
3. Long term drugs that only mask symptoms are not “conservative” treatment.
4. It is not a battle of CR vs. neuromuscular dentistry. Every dentist should be concerned with the muscles, and the nervous system, and every school of occlusal thought addresses this in their own way.
5. Quality research done by qualified professionals is essential.
6. Continuing education is the gateway to improved quality of care.
7. Careful communication and definition of terms will improve understanding.

Surely, there are many other areas where we can find and communicate agreement, and in the process find other colleagues to share, learn, and growth with. Just like our medical colleagues, we need to unite and agree that the bite matters! We can continue to disagree as to the best ways to treat it, because that is within our professional realm, but in the public realm we need to communicate unity, professionalism, and strength.

Remember Nero, Who Fiddled While Rome Was Burning?

I am here to tell you that the barbarians are at the gate. We are losing a fundamental basis of our profession. We who want to be physicians of the mouth must remember that we are in the realm of physical medicine, like our orthopedic and surgical colleagues. We are not pill pushers, we have to act and intervene. We can no longer pretend that dentists who treat bite problems are special and the rest of the world can be left behind, and dentists who ignore bite problems cannot continue to pretend that this is an area that can be ignored without serious consequences. The patients are not getting the care they need. The profession is not carrying out its mandate to help the patients who trust us with their care.

We must seek to find commonality and ways to draw our colleagues in, rather than circle our wagons in an exclusionary defense. As dentists we are either part of the solution, or part of the problem. Which will you choose?