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I was invited by Dr. Sushil Koirala, Founder and Coordinator – MiCD Global Academy, Chief- Editor of MiCD Clinical Journal, as one of many globally renowned clinicians, academicians and researchers to answer 15 exclusive interview question for their clinical e-journal sharing my experience, clinical and research findings on the subjective of “TMDs – Confusion & Consensus: Expert’s Advice“. The following is the twelveth of 15 responses to their questions.
12. We have witnessed that there are growing number TMDs education and treatment centers in the global market that demonstrate and use irreversible and invasive dental treatment such as, occlusal equilibration, disclusion time reduction (DTR), change of vertical height, and condyle re-positioning using overlays, crowns (full mouth reconstruction) and orthodontic procedures for the TMD management. What are your views and suggestions to our readers on this growing trend of expensive, invasive and irreversible dental treatment in the management of TMD in dentistry?
I repeat: Occlusion is the foundation for advanced dentistry. Conservative and reversable therapies are standards by which our Occlusion Connections (OC) GNM teachings advocate. Stabilizing the masticatory system is a basic and fundamental principle that every dental professional should acknowledge as well as implement into his or her dental practice regardless of what treatment methods are rendered. Stabilization does not mean to cut and prepare more tooth structure while teeth are in “temporaries” or provisional restorations trying to find that physiologic jaw position before finalizing one’s restorative dentistry. I am a firm believer that the stabilization process begins before one decides to cut enamel and dentin and placing provisional restorations for new crowns or bridges. Stabilization does not mean to continue guessing which high spots to grind or guessing one’s mandibular position using occlusal equilibration techniques in a supine position. Stabilization does not assume that just because a patient may have an even balanced bite/occlusion when tapping their teeth together that everything is acceptable and comfortable. Note: Just because a restorative or orthodontically minded dentist can create and even bite/occlusion, does not mean the patient’s mandible and jaw joints are stable and in a correct physiologically functioning position. Full arch splints whether maxillary or mandibular or anterior discluding appliances does not necessarily mean the TM joints and muscles are brought to a physiologically stable position or relationship. Stable means to be pain free (comfortable), free of abnormal muscle tensions (strains) and jaw joint dysfunctions (grating, clicks and pops) that displace the mandible to a strained opening and closing path of closure. Think six-dimensionally!
Doing full mouth rehabilitation to an altered jaw position on patients may have good intentions, but can have devastating consequences to patients who have unrecognized joint derangements or underlying masticatory problems. When the treating dentists does not first align, test and prove the new established jaw relationship so the masticatory system is free of pain and muscle tenderness (establishing homeostasis), regret, unhappiness and blame after seating the restorations can be avoided.
Homeostasis (physiologic stability) is a key and important bio-physiologic concept that is difficult to understand for most dentists today since they do not objectively measure muscle conditions prior to rendering occlusal treatment. Without objectively measuring and recording muscle health (resting modes and functional modes), jaw joint functional health and considering mandibular posture in the six-dimensional domains, it is difficult to grasp the details of what it requires to establish “stable” occlusion. Hyper EMG muscle activity or super low EMG muscle activity are indicative of instability effecting the occlusion. Dentist will experience occlusal challenges and frustrations at follow-up adjustment visits when the condyles/discs that present with dysfunction and/or muscle strains are ignored.
How many follow-up occlusal adjustments are necessary to satisfy a complaining patient’s headaches, neckaches, facial pain or tooth sensitivity problems after the new restorations have been placed? Does the clinician need to grind teeth or restorations down to accommodate the existing bite to make the occlusion even? Or should the dentist consider adding up a little vertical height in the posterior regions of the bite when they finally realized the clicking/popping joints are compressed in superior and posteriorly in the glenoid fossa? Or do the dentists just ignore and refer the case to another office?
When the clinician begins to discern, detect and begin to recognize the numerous musculoskeletal occlusal intra oral and extra oral signs and symptoms of their patient’s, their diagnostic awareness and treatment planning will evolve toward a more conservative and less hurried perspective. I have learned never to assume the patient is going to relax their muscles to a proper vertical or antero-posterior position when their underlying muscles are straining, skewing and twisting the mandibular-cranial relationship. These unrecognized muscle strains and compressed joint problems lead dentists to clinical occlusal frustrations with the many occlusal follow up adjustment visits. Why? Because the patient was not pain free and comfortable first (stable).
One of the often used phrases my good mentor and teacher, Dr. Robert Jankelson, use to tell many of his students was, “Keep the hand-piece in the holster”. Dentistry should be 90% thinking and 10% doing. But in today’s world of dentistry, we observe just the opposite. Why? Because the type of training and philosophies we have received from dental schools and post graduate continuing education and the strong marketing of products by dental manufactures to influence the way dentist think to do their dentistry.
- As diagnosticians and good investigators of the stomatognathic system we must first consider the complete dynamic postural masticatory system, to assess in what manner does the mandible/TM Joints relate to the maxilla/cranium physiologically – Vertical, Sagittal, Frontal, Pitch, Yaw, Roll.
- Secondly, relax the masticatory muscles (break up the proprioceptive engrams) to establish a base line (homeostasis/foundation) to properly relate the upper and lower arches accurately. Reduce the muscle tensions between the mandible and cranium that skew, strain and torque the teeth, supporting periodontium and temporomandibular joints toward a pathologic occlusal position.
- Thirdly, decompress the temporomandibular joints. Remove any disc displacement issues by supporting the temporomandibular joints and muscles with a removable lower orthosis in order for the lower jaw is able to function along a proper myo-trajectory free of any afferent and efferent noxious stimuli that would limit entry and exit to a physiologic terminal contact position prior to any restorative or orthodontic treatment!
I believe a patient who presents with occlusal signs and symptoms, pain, masticatory dysfunctions and joint derangement should begin a Phase One: Diagnostic stabilization process first. Phase Two, is usually required following Phase One “Diagnostic Orthotic Therapy” for the final solution. The orthotic device is used for both diagnosis as well as therapy. At the end of the successful completion of Phase One stabilization therapy, a consultation appointment would be set up for the patient to discuss the various treatment options and procedures for Phase Two (Treatment Phase): 1) Crown and/ or bridge restorations, 2) Orthodontia, 3) Combination of crown and/ or bridge restorations and orthodontia and or 4) A semi-permanent orthotic. Any treatment requiring full arch restorative crown treatment must be properly managed to the six-dimensional stable position during bite transferring protocols from the operatory to the lab and back to the patients mouth in a specific and detailed manner to prevent clinical mishaps. Any follow up occlusal adjustments must be done in a sitting up position (not laying down, supine position) when micro-occlusal adjustments are implemented to meet the needs of the patient’s central nervous system (CNS).
A patient is stable when they are pain free and off all medications for at least 3 months. Three months begins when the patient is pain free – no tender muscles are exhibited on palpation.
Clayton A. Chan, D.D.S. – Founder/Director
Telephone: (702) 271-2950
Leader in Gneuromuscular Dentistry