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Reducing or Eliminating Failed Dentistry

Dental Decision Maker Dentistry Today June 2016

The Dental Decision Maker

Every day in your dental practice, you tackle a va­riety of challenges that you diagnose and solve for your patients. Just think, for a few mo­ments, about the pa­tients you have seen this past week. Did you talk to them about periodontal disease, issues involving their temporomandibular joint (TMJ), broken teeth, root canals, crowns, bridges, den­tures, and implants? Of course you did. These are the most common dental issues that come up in the office routinely. Is that list complete? What if I were to tell you that this list does not include the most common dental disease that affects fully one third of your patient population? You never measure it and most clinicians don’t even see it. Yet, this dental condition causes countless problems for your patients and often is the main reason for broken teeth, TM disorders (TMDs) and/or orofacial pain, and most failed dentistry, including simple resto­rations, crowns, bridges, and implants. Many of you are probably scratching your heads trying to think of what it could possibly be. How could you possibly be missing something that occurs in one third of your patients? The primary reason we don’t think about this disease is that it is so common, the majority of clinicians almost accept it as being normal. Furthermore, until now, there has been no way to objectively measure it. Once we are able to measure this condition, then we can wrap our heads around it, treat it, and then measure it again to make sure our treatment is actually working. If our treatment is not working, then we can readily adjust the treatment until we reach a satisfactory outcome.


I hope by now that you have figured out that I have been describing bruxism. Bruxism is an underlying condition that can affect every single dental treatment that we provide. It is also the key factor in determining the long-term progno­sis and success of the dentistry that we work so diligently to deliver. Think about what moments in your daily practice that you dread the most. Certainly, one of them is when your patient shows up with a crown in his or her hand that you placed a short time ago. Your stomach really gets upset when there is tooth structure inside the crown and, even worse, if there is a post sticking out of it. This is the post-and-core that you had literally placed immediately after the endodontic treatment was done. Of course, you know that this scenario now represents a costly situation that will need to be addressed with retreatment and replacement work at no charge to the patient. Or, are you going to pay for an implant (or at least offer a discount) and new crown that the patient may now need?


Let me share a case presentation about a patient with a situation that happens routinely in every dental office and show you how new technology to measure bruxism can help you eliminate the dreaded scenario mentioned above. This will dramatically improve the long-term prognosis of every dental treatment that you will provide from this point on. In addition, bruxism moni­toring will help you decide on the best course of treatment for the patient based on objective, evidence-based data.

The patient here is a 23-year-old female named Liz. She had been suffering from TMD/orofacial pain in her head and neck since she was 19 years old. Other than her history of myofascial pain, she was always a very active individual in excellent health. Her dental history was found to be another story, especially related to the left side of her denti­tion, where she had multiple restorations placed When she was about 19 years old, she began breaking some of the restorations and teeth on the left side of her mouth, all requiring treatment by her dentist. The upper second bicuspid (tooth No. 13), was particularly problematic as it eventu­ally required endodontic therapy. The tooth was restored with a composite resin restoration at the time as the patient could not afford a full-coverage crown. This worked well for about a year, then the tooth began chipping again. Liz changed dentists and had an initial exami­nation and radiographs done by her new doctor (Figure 1). The first question any dental profes­sional should have had, at this juncture in time, was: Why does this patient have more restorations on her left side than her right side? The second question should have been: Why do her teeth keep chipping? Most of us do not spend more than a minute (if that) thinking about why these things have been happening; we simply deal with the situation as it presents. After a consultation, the patient had agreed to have a post, core, and crown on tooth No. 13 at a considerable cost. The doctor seated the crown and the patient was pleased with the result.

The Dreaded Post-Treatment Phone Call

Only 2 months after the crown was placed, Llz called her dentist’s office to let them know that she would be arriv­ing with the crown and post in her hand. How would you feel as the treating den­tist, as you walk into the treatment room and see your patient with that crown and post sitting on the tray? So, 2 months after the crown was seated by her new dentist, the tooth was nonrestorable, requiring an extrac­tion, bone graft, and an implant. Before sending the patient to an oral surgeon for an implant, should one be think­ing about why this happened? Most of us still don’t give it a second thought, assuming immediately that it must be a material or functional failure. The patient is simply told what the next step is and everyone moves on. (Note: A failure due to the cementation bonding protocol, a lack of adequate ferrule and/or a cementation failure, or occlu­sion problems should all definitely be considered.) Fast-forward one year. The final im­plant crown was placed (IPS e.max [Ivoclar Vivadent]) by the same dentist. Liz was so happy to have a new strong tooth that looked great too. However, she continued to suffer from TMD/ orofacial pain and, a few months after the crown had been delivered, Liz was referred to our practice for a TMD and orofacial pain evaluation. Now She Became Our Patient Figure 2 shows Liz at her initial exami­nation in our office. When properly trained in orofacial pain therapy, the first thing one learns to do is to take a complete medical history and do thor­ough evaluation as an important part of achieving a proper diagnosis and treatment plan. The only addition to her medical history mentioned above is that she had been seeing her primary care physician and a neurologist for headaches. She had tried a variety of medications, which did not help man­age her pain and, at the time of this visit, was not taking any medicines having decided to simply “live with the pain.” What Do You See?

Let’s evaluate this patient’s head and neck musculature, since approximately 85% of TMD and orofacial pain comes from muscle disharmony. Before doing a complete head and neck trigger point examination, I looked closely at her face. What do you see in Figure 2? Let me share what I observed. Her masseter muscles were enlarged, giving a very square appearance to her face. Take a closer look and you will see that her masseter muscles are asymmetrical,with the left masseter being quite a bit larger than the right masseter. That is very interesting, since most of her den­tistry had been done on her left side. In this case (as routinely performed in our practice), cranial nerve, ear, TMT, and dental examinations were done, and all findings were found to be within normal limits. There was one area of concern from her dental exami­nation: her left bite-wing radiograph (Figure 3) was showing some osse­ous cupping around the implant that had been placed 1.5 years before. The periapical radiograph (Figure 4) dem­onstrated a deficiency in the trabecu­lation of the bone on the mesial of the implant. Indeed, the tooth was slightly loose (we will address this issue later). I then checked the occlusion; it seemed to be fine with no centric, lateral, or pro­trusive interferences. The trigger point muscle examina­tion revealed trigger points in the tra­pezius, superficial masseter, and deep masseter muscles. This caused repeat­able moderate to severe radiating pain to the corners of her jaws, both TMT s 0eft one was worse), front of her head, and behind her eyes. She said that this was exactly the chronic pain that she felt, which would then turn into head­aches that occurred on a daily basis. Knowing the Numbers: BEi and AHi There was one more very important piece of diagnostic information that we needed to know before treating a patient like Liz. We needed to quantify (measure) her bruxism so that we could know exactly what we were facing in order to be able to treat her. We then needed to repeat the measurement after prescribed treatment to quantify treatment efficacy. We also needed to know if the patient had any sleep disor­ders that might have been contributing to bruxism. So, she was given a home Bruxism and Sleep Monitor (Figure 5) with instructions for use. This bruxism/sleep test provides valu­able information about the patient, the Bruxism Episodes Index (BEI) and Apnea/Hypopnea Index (AHI). The BEi is the number of bruxism episodes a patient has per hour of sleep. A number higher than 2.5 suggests significant bruxism that should be addressed. A BEi higher than 5 is indic­ative of very destructive bruxism that can easily break and chip teeth and/ or any dental restorations. If the AHi is higher than 5, then the patient has obstructive sleep apnea (OSA), need­ing a medical diagnosis by a physician, and possibly an oral appliance and/or any prescribed care recommended by the physician. These numbers are very important in guiding our treatment decisions and, through post-testing, will let us know if our treatment pro­tocol is working. For Liz, the initial brux­ism/sleep test resulted in a BEi of 6.8 and an AHi of 3.6 (Figure 6). These test results indicated that she did not have OSA; however, the BEi (at 6.8) indicated that she did have destructive bruxism. Now, armed with the right diagnostic information, my team and I were ready to begin treatment.

Trigger Points

Trigger point injections with botuli­num toxin (incobotulinumtoxinA) (Xeomin® were performed in the affected muscles mentioned previously. Xeomin® is an alternative to Botox® (Allergan); equally effective, but much less expensive. Ten units of Xeomin® were used in each one of the affected muscles, except for the left mas­seter; this muscle received an additional 5 Xeomin® units due to its larger size. Xeomin® was also delivered into the fron­talis, lateral orbicularis oculi, procerus, and corrugator muscles bilaterally. An amazing thing happened at this treatment appointment-the head­ache Liz had that day started to go away immediately, and in addition, the intermittent radiating started to resolve. By the end of the appoint­ment, about 80% of her pain was gone. It takes from 2 to ro days for botulinum toxin to take full effect and, indeed, one week later, all of her pain was gone for the first time in years. How did we know if our treatment for Liz was really effective? She was given a post-test using the monitor. Figure 7 shows her post-test results demonstrating a BEi of 2.0 (an insignificant score). In Figure 8, the postoperative full-face photo of Liz shows the clearly improved facial aes­thetics with a more heart-shaped face and normal-sized masseters. Figure 9 shows another before-and-after com­parison. Liz was given a Custom HIS Bite Splint (Glidewell Laboratories) to protect her teeth from any bruxism that might recur as the botulinum toxin wore off. Now, what about the upper left bicuspid implant? If it were to fail in the future, in my practice it would be replaced with an implant (such as a Hahn implant, due to its excellent initial stability) and a high-strength all ceramic crown (such as BruxZir Trans­lucent [Glidewell Laboratories)).

Wouldn’t It Be Nice to Know?

single dentist reading this article: wouldn’t it have been nice to know this patient’s BEi before the endodontic treatment had been done a few years ago? Think about how much this young patient went through, including dentistry that she might have been able to avoid, had her brux­ ism been measured and controlled Before doing any restorative case (especially ones that include crown and bridge, dental implants, or porcelain veneers), the clinician should test the patient for his or her BEi number to know exactly how much the patient is bruxing so treatment can be rendered, if necessary. This will make any dentistry delivered last longer, and it will also help the patient preserve his or her own natural teeth. My friend and mentor, Dr. Gordon Christensen, says, “Bruxism monitoring is one of the most important concepts today!”


Training is the key in the areas that we call the American Academy of Facial Esthetics (AAFE) Circle of Treatment (Figure 10). Training and proficiency in diagnosis and treatment planning, and clinical treatment protocols in facial aesthetics, facial pain, bruxism, and dental sleep medicine, should be attained. You too can make your patients look great, feel great, and sleep great!

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