1500 Summer Street, Stamford, CT 06905
(203) 883-4433
1500 Summer Street, Stamford, CT 06905
(203) 883-4433
Occlusal Interference: Dentistry's Great Imposter
Patients in pain are sometimes difficult to diagnose if the pain in not from one of the classic etiologies, such as deep decay leading to pulpitis, periodontal abscess due to a very deep pocket, or inflammation due to an impacted wisdom tooth. One of the more puzzling cases was a woman in her early fifties who presented with severe pain in her lower incisors. She stated that they were broken, painful and needed capping. The teeth were very sensitive to percussion, very temperature sensitive, had very slight mobility but no radiographic evidence of any periapical pathology. The only visible problem was a very odd pattern of wear that could only be due to tooth grinding.
On questioning the patient stated that she had severe pain in the lower incisors for several weeks and had been to her regular dentist several times with no success. She was convinced that she needed to get her lower teeth capped to solve the problem. Fortunately for her, her former dentist could not find the problem and did not think that capping her teeth would provide the solution. He referred her for endodontic evaluation but she was afraid of root canal treatment so she broke the appointment and scheduled an appointment at my office for another evaluation.
Since she had such severe wear on her teeth, a deep bite and spaces between her top front teeth I wondered if her bite could be a factor in the pain and tooth positioning. I asked her if she ever got any headaches or jaw pain. She replied that she had a twenty plus year history of migraines and additionally got severe jaw pain, but was certain that this all had nothing to do with her recent tooth pain. First of all, her headaches were diagnosed by her medical doctor as migraines and have been re-occurring for over twenty years. The tooth pain was recent. When I asked her if she was aware of teeth clenching or grinding, she strongly denied that she ever clenched or ground her teeth, even though the “broken” upper and lower teeth fit together perfectly, indicating that the missing tooth structure was indeed due to wear.
With the accumulating evidence that her bite might be a factor, I switched tactics and began a detailed occlusal examination, noting other patterns of tooth wear that could only be due to tooth clenching and grinding. Then I began to examine her jaw muscles to see if there was a pattern of pain. Her Massater and Temporalis muscles on both sides were very sore to even gentle palpation. Additionally she reported pain down her neck. Finally I palpated where her lateral Ptyergoid muscles which were acutely painful to palpation.
In examining her bite, I found that if I relaxed her jaw muscles and gently manipulated her jaws into a centered jaw position by gently pushing down on her chin and simultaneously lifting up from under the angle of the jaws, as taught by Dawson , I could get her to gently tap together and she only hit on the premolars on the left side. When she continued to maximum closure, it was necessary for her teeth to slide forward and to the left. In addition, when she tried to slide onto her left molars to chew, she hit on the right molars. When she attempted to grind onto the right molars, her left molars interfered. And, when I asked her to come into protrusive position, the worn teeth in the front fit perfectly together, proving that she was grinding her teeth.
As a result of my examination and findings, I determined that the problem was in fact a combination of occlusal muscle pain (sometimes referred to as TMJ pain) and biomechanical dental disease due to tooth clenching and grinding. Unfortunately, the patient completely disagreed with me. She was certain that she had a combination of migraine headaches, unrelated jaw aches and lower teeth that needed capping. She completely denied that she was grinding her teeth and wanted those lower painful teeth fixed “now.”
Even though I had all of the evidence that I needed for a diagnosis, I did not have 100% proof positive that her bite was in fact the cause of her headaches or jaw pain, and she certainly was not convinced that her bite was the problem. The remaining task was to connect the dots between the headaches, jaw aches, painful teeth, and bite issues in a way that proved to both of us that the bite was the cause of both her dental damage and pain.
Dentists have been treating bite problems due to occlusal interference for many years. The gold standard to prove that the bite is the causality has been to interrupt the occlusal interference and see if that would allow the jaw joints to center and see if that would stop the muscle pain. If that worked, then there was proof of a cause and effect relationship between the bite and the pain. Typically this is done by constructing a bite splint to allow the jaw joints to center. Then by observing the pain symptoms of the patient wearing the bite splint, verify that the bite is, or is not, the cause of the pain. The problem was that my patient was not going to spend any more time and money on my theory. She wanted a result now or she would leave to find another dentist to cap her lower front teeth.
A very fast way to center the jaw joints to see if the bite is the source of the pain is the Best-Bite™ Discluder (Manufactured by Best-Bite Inc). It is a system that combines a customizable, one size fits all, anterior discluder and custom liner material to fit on the patient’s teeth that nearly instantly centers the jaw joints and releases any muscle fatigue and spasm. If the head, neck, or facial pain is in fact due to the patients bite, the pain will go away, typically in less than two minutes. If the pain in not occlusal muscle pain, using the Best-Bite Discluder will not relieve the pain, eliminating the bite as the causality of the pain.
My patient was losing patience with me at that point, but I convinced her to stick with me for just a few more minutes and immediately placed the Best-Bite discluder on her front teeth. In literally thirty seconds she started to feel different. You could see her surprised look as twenty years of head and jaw pain literally melted away. She started with a pain level of 9 out of 10 and in just a few minutes, she reported that the pain in her head was under 2 out of 10 and her jaw pain completely went away. Even the pain in lower front teeth was relieved.
When I removed the discluder and asked her to clench down, the tightness and pain in her head and jaws started to return. When I replaced the discluder and asked her to tap her teeth again, the tightness and pain immediately began to go away. Much to her amazement, she had to agree that her bite had to be at least part of the problem. Based on this result, the patient was convinced that her bite was indeed a part of the pain so she allowed me to continue her bite work up and we agreed to put off capping the lower front painful teeth for at least a few visits.
The next step was to obtain diagnostic models and mount them on an articulator for further study. We obtained a facebow record with a Denar Slidematic facebow and mounted the upper cast. To obtain an accurate centric relation record, we used Best-Bite to re-center the jaw joints to a pain free position, verified as taught by Dr. Peter Dawson of the Dawson Center for Advanced Education. Once she was again in a pain free position, we used a dab of polyvinyl adhesive on the under side of the Best-Bite device to help retain a small amount of the bite registration material (Blue Mouse Fast Set Material by Parkell Dental and again had the patient close into the verified CR position. Once the incisor position was captured, we immediately used the same material between her posterior teeth for a posterior index on both sides. Now the posterior indexes plus the Best-Bite discluder we used to mount the opposing model on the articulator. The articulator selected was the Denar Combi manufactured by WaterPik.
Once the models were mounted in CR position, we designed a long term, full coverage maxillary bite splint to support and stabilize the bite as well as keep that patient’s teeth and the jaw muscles comfortable for a period of three months. The splint was a hard acrylic processed splint. It was designed to be permissive in that it did not have any posterior contacts, other than in CR. In addition, it provided canine guidance and protrusive disclusion of the anterior teeth. The bite splint was inserted and after several adjustments the bite remained stable and the teeth continued to be comfortable.
Based on this period of stability, the mandibular models were remounted with new CR bite records and the occlusal relationships were analyzed to determine if the patients current bite relationship could be equilibrated to achieve a bite that was coincident with the CR jaw position that we established was comfortable and stable. After a trial equilibration confirmed that it was possible, she agreed to a course of treatment that would involve occlusal equilibration to eliminate the occlusal interferences to a centered jaw joint. We equilibrated the patient’s teeth over several visits to this CR position. After just one visit, she noticed a significant reduction in the headaches and jaw aches and improvement on the lower front teeth, even though she was no longer wearing the bite splint. This immediate improvement gave her the confidence to finish the occlusal equilibration. The result was a complete reduction in the head and jaw aches with a marked reduction in the pain in the lower incisors.
Since she trusted my judgment, she shared that she hated her smile and that the spaces between her teeth had been worsening over the years. She realized that her tooth grinding and clenching was contributing to the movement of her front teeth. Now she figured that I would finally cap those bottom front teeth.
She was still not correct. After obtaining a periodontal consultation, we determined that there were pockets around the upper front teeth that needed to be treated and that in the process, we could raise the gum line and simultaneously shorten the incisal length of the upper front teeth and allow me to place porcelain veneers to close the diastema, keep the teeth in proper proportion, and maintain the new bite we had created for our not so skeptical patient.
During the several weeks required for completing the equilibration, the dental laboratory created a diagnostic wax up of the upper teeth that had the incisal edges where I determined they would give us the correct functional and cosmetic result. Based on this fixed position, we worked backwards to create a length that would allow us to achieve an ideal, golden proportion relationship of the length to width of the central incisors and then set up the length of the other incisors to match. We fabricated a stent so that the periodontist had an intra oral reference point for the surgical procedure. The periodontist performed an apical repositioned full thickness flap that simultaneously eliminated the periodontal pockets but maintained the incisal papilla in the correct position and resulted in the proper length of the anterior teeth.
When the healing was complete, the teeth were prepared for modified porcelain veneers that covered the entire incisal edge and wrapped completely interproximally to close the diastemas. Transitional restorations were inserted that would mimic the eventual porcelain restorations and the patient was given the opportunity to preview the restorations and verify that the functional aspects, including the phonetics, were acceptable as well as to verify that the appearance was acceptable. The occlusal relationship was maintained throughout the restorative process. After it was determined that the transitional restorations met all of the objectives of the case, alginate impressions were taken and the models of the transitional restorations, bite records and the final impressions were sent to the laboratory for fabrication of the final porcelain restorations. Feldspathic porcelain was selected because of the ability to create internal colors and ideal contours with no metal that could compromise the cosmetic results.
The final results show a pretty smile and a patient who is free of pain. By the way, we never had to cap those lower incisors because the pain that was due to excessive occlusal forces just went away.
Summary
Pain that is due to occlusal interference can manifest itself as headaches, jaw aches or tooth aches or a combination of all of them. The solution is to first diagnose the problem. If the pain is due to occlusal interference, relieving the bite problem will be the solution to the patient’s pain.