As seen in Dentaltown December 2003

Diagnosing the Pain Patient

There is nothing like an unexpected emergency patient in pain to throw a well planned schedule into chaos. The challenge is in the unscheduled nature of acute pain patients. You do not know what the problem is, you don’t know what will be required to solve the problem, how long it will take, and you have not planned for the procedure. And of course people in pain want to be treated now. As a result, dentists committed to their patient’s well being and high quality dental care need to arrive at a diagnosis quickly and provide palliative services efficiently so they can get back to the days schedule.

The most common causes of dental related, head, neck and facial pain include: carious exposure causing pulpitis, a broken tooth cusp, periodontal abscess, peri-coronitis around a wisdom tooth, or hyper occlusion on a recent filling. The problem is that after you have eliminated the usual culprits, diagnosis becomes more difficult and time consuming.

Busy dental practices need a consistent and effective system to triage, diagnose and provide temporary relief for their patients. Consider a typical situation. An unscheduled patient arrives at the office pointing to pain on the side of their face. An x-ray is taken and reviewed in hope of discovering a clear causality such as an abcess or a broken cusp. While there are several old fillings or perhaps a partly impacted wisdom tooth, no direct cause of the patient’s discomfort is revealed. Now what?

It can be very frustrating to the patient and the dentist alike to find a tooth with a deep old restoration or a crown that is sensitive to percussion and or temperature changes and assume that the tooth has dying nerve and requires root canal, only to find that the patient still has the pain following treatment. Then the dentist can be tempted to retreat the root canal or offer an apicoectomy, which might also be unsuccessful in relieving the pain.

A very common source of pain that is overlooked is tooth or jaw muscle pain caused by occlusal interference. The two manifestations of tooth clenching and grinding due to occlusal interference that can result in pain are stress fractures in the teeth that can range from annoyingly sensitive abfractures to extremely painful cracked tooth syndrome, and head, neck, and facial pain from overworked and sore jaw muscles that can simulate a headache, an earache, wisdom tooth type pain, pulpitis or related facial pain. That is why it is very important to include occlusal interference in the differential diagnosis for pain patients.

The diagnosis of pain in the teeth or muscles requires more than a quick “look see”. As a result, this is the diagnosis that is most often missed. The dentist needs a fast, accurate and easy to use methodology to help determine if occlusal interference might be a contributor to the patient’s pain symptoms. Therefore I would like to offer a quick, simple four step process to help determine if the bite is the cause of the patient’s pain.

4 Step Diagnostic Process For Occlusal Interference

Is there a painful tooth with signs of occlusal wear or symptoms of biomechanical dental disease, such as gum recession, cracked, chipped, abfractured, or sore teeth?
Is there is a conflict between the teeth and the jaw joints? Ask the patient to close their teeth until the point of first occlusal contact and stop. Upon closing the rest of the way, note any slide or movement of the teeth to maximal closure.
Palpate the lateral Ptyergoid, temporalis, massater and muscles of the neck and shoulders. Have the patient rate the pain from 1 (no pain) to 10 (very severe pain) noting the level of sensitivity.

These three steps have been the traditional way to evaluate pain from occlusal interference, but stopping here does not create certainly in the mind of the dentist or the patient that the bite is the source of the pain. A comprehensive process requires a fourth step, discluding the posterior teeth to allow the jaw joints to center and release any muscle spasm that might be present causing pain and take the load off any tooth that is in premature occlusal contact. Only by connecting all of the dots will the dentist create the certainty in their own mind, and that of the patient, that will seal the diagnosis and enable the dentist confidently recommend and the patient to confidently proceed with treatment.

Every step in the four process is very important because if the dentist does not connect all of the dots, there is no certainty in their own mind, or that of the patient, that bite treatment will help the pain. Any time spent on treating the bite, as well as fees, might be wasted and leave both the patient and dentist disappointed

This process has been attempted with a variety of methodologies, each of which has their advantages and disadvantages. They range in simplicity from the ubiquitous cotton roll, the medical doctors tongue blade, and the leaf gauge, to the more technically demanding such as the custom anterior deprogrammer as taught by Dr. Peter Dawson, and the highly sophisticated Gothic Arch trays and clutches of the gnathologists.

The cotton roll between the teeth is the seemingly easiest method. However, this method is not directive in that the patient can grind down on the cotton in any jaw position without centering the jaw joints. In addition, it is not stable and cannot be repositioned in the mouth in the same relationship repeatedly. The leaf gauge developed by Dr. Long or the medical doctors tongue blade can be somewhat directive but it has no inherent stability or simple reproducibility. It requires the doctor or the assistant to hold the leaf gauge in an accurate position each time it is placed into the mouth. In addition, neither of these methods create a stable bite or allows the patient to have anything to take home as temporary relief. In addition, they are of no practical use in the dental laboratory procedures of mounting diagnostic casts.
The more technically advanced procedures such as Gothic Arch tracings and Gnathological clutches are certainly accurate, reproducible, and can be used with laboratory procedures. But they are cumbersome to deal with, cannot be quickly removed and replaced from the patient’s teeth to demonstrate the effect of centering the jaw joints on the patient’s pain, and not a part of the armamentarium of the average dentist. They are definitely not something that the patient can take home with them to use as a rescue device.
Custom anterior deprogrammers, such as the type taught by Dr. Dawson, are excellent in that they are highly effective and can be used in the treatment process as well as worn as a rescue device at home by the patient, although they do not have a safety retention strap built in so there is potential risk of dropping or aspirating the device. When they are completed, they are both permissive in that they allow free movement of the teeth and condyles, and they are directive in that they assist the condyles to center. They can be made of temporary bridge acrylic resin or with the newer laboratory composite materials such as triad. However, since they are custom made, the dentist first has to get the jaw joints into a centered jaw position and incorporate that position into the device. Then the dentist has to create the guiding planes and surfaces on the device so as to allow the free movement of the teeth to permit the condyles to center. The process is technically demanding and time consuming, requiring up to 45 minutes to complete. And if it does not relieve the pain, that time has been wasted.
The newest method to center the jaw joints and release any muscle spasm is the Best-Bite ™ Discluder. This is a prefabricated, one size fits all device, that is custom molded to the patients teeth is less than 30 seconds with an absolute minimum of training. It is permissive in that it does not force the jaws into any predetermined position, but it is directive in that it is self leveling and designed to assist the condyles to center in the jaw sockets. The patented 8 degree incisal table of the Discluder, acting as a fulcrum and guide, and the muscles, acting as the force, prohibit occlusal interference and gently assist the condyles to seat upward into a centered position. The preformed design and safety retention leash makes it an ideal rescue device for the patient to outside the dental practice during the treatment process.

Once the condyles are centered, the muscles no longer need to brace the condyles in an unstable position and the jaw muscle fatigue, strain and spasm is released, and the corresponding muscle pain quickly stops. The pain relief experienced is then used to set both the doctor’s and patient’s expectations as to the results that can be expected from bite treatment, as well as to manage acute pain during the treatment process. Additionally the centered and pain free jaw position should be used to help develop the long term treatment including bite splints and occlusal equilibration.

Custom Fitting the Discluder in Seconds

Place the Best-Bite™ Discluder on the upper central incisors sitting squarely on the teeth so that the flat surface on the bottom is parallel to the incisal edges and the retention leash is centered.
Immediately after seating the bite former on the top front teeth, the doctor should gently guide the jaw up and back by pushing down on the chin and up from under the angle of the mandible. Instruct the patient to aim to tap on their back teeth with a gentle force. Do not force the jaw in any way as that will increase the intensity of the patient’s muscle spasms, prohibiting centering the jaw joints.
Continue tapping gently until the custom liner material sets and the pain is relieved, or three to four minutes.
If there is pain relief, ask the patient to rate their pain between 1 and 10 and note the change from the prior rating. Use the pain relief provided by the Discluder as a means of setting treatment outcome expectations for the patient.

Summary Emergency pain patients can be an interruption to an otherwise well planned schedule. If they do not have an obvious problem, the dentist should consider the possibility that their problem is either biomechanical dental disease, or head, neck and facial pain that is due to occlusal interference. There are many ways to assist the dentist in the diagnosis of this very common dysfunction that causes pain and dental damage for over 40 million people. Is it essential that every dentist have these types of techniques and devices in their armamentarium to ensure successful diagnosis and treatment.

About the Author: Dr. Jerry Simon has been an active dental practitioner in Stamford, CT for over 30 years with a focus on bite dysfunctions. He is also the author of the book Stop Headaches Now: Take the Bite Out of Headaches and inventor of the Best-Bite Discluder.