by Shannon Brinker, CDA CDD and Laura Hansmann Pistoia, DA.

The role of dental restorations used for provisional and indirect restorative procedures has changed dramatically in the past several years. These restorations are no longer regarded as temporary restorations but rather as provisional restorations with distinct functions and purposes. Provisional restorations have become a vital diagnostic and assessment tool to evaluate function, color, shape, contour, occlusion, periodontal response, implant healing, and overall esthetics. An accurate fit and margination is essential to insure and maintain pulpal health.

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By Raj Upadya

There is much more to a healthy mouth than preventing and treating decay and gum disease alone. There are other factors that are critical to long-term predictability of a healthy mouth that will allow you to enjoy a better quality of life and better overall health. The well-trained eyes of a different breed of dentists that completely examine a patient are the key to determining the signs of problems before they become painful symptoms. If you wait to treat a condition until symptoms have developed, you have often missed the opportunity for conservative therapeutic options; thus treatment choices will also become much more costly and involved.

There is a scientifically based rest position for your jaw joint, called centric relation, that has been repeatedly proven to be accurate and stable through not only research, but also through patient experiences, and with trial and error of repeated dentistry. If the joints, muscles and teeth have not been working in harmony with respect to their proper positions you can find extensive damage to the teeth, the joints and muscles. This can lead to dental needs for a patient, sometimes in the absence of symptoms. Masticatory physicians are trained to see and diagnose these conditions when they are signs, before they proceed to becoming debilitating symptoms. This approach may be occasionally viewed by traditional dentists as overtreating, though in reality we are being more conservative in the overall dental life span of the patient. (Figure 1)

Figure 1

OCCLUSAL DISEASE (OD) is a common dental disorder that is usually painless in its nature and involves the development of a traumatic or pathologic bite as a result of an erosive disease process. It (OD) is now considered the highest risk factor for and cause of tooth loss. If teeth have worn through the strong outer enamel layer to the soft core, the bite has become unstable, though you may not even be aware of it. The mouth gets its stability from the back teeth supporting the front teeth, and the front teeth protecting the back teeth, working together in unison from a relaxed jaw relationship. The wear through the enamel into the softer inner tooth creates an unstable stopping position for the teeth so that they are no longer able to function adequately. Lack of enough strong teeth with intact enamel or teeth that have drifted out of their proper position overloads the system as well. Quite often, this does not cause any pain but the effects on the teeth, gum, bone and mouth are very destructive as a whole. At one point, it was thought that it was normal for the teeth to wear out and shift over time. Wear that is confined to the outer layers of enamel and has occurred slowly over time can be, in some cases, considered normal. Wear through the strong outer enamel into the soft internal core, however, is considered pathologic, as it has advanced through the entire protective layers of the tooth. (Figure 2)

Figure 2

Unfortunately, pathologic wear and unstable bites have been routinely misdiagnosed and under-diagnosed by the dental profession. It is often the underlying cause of many problems that we see and, regretfully, is most often left untreated. As a result, a large volume of emergency-based, reactive single tooth general dentistry is performed. This self-perpetuating cycle continues as the work that is subsequently performed then prematurely fails because the underlying cause of destruction has not yet been addressed, once again resulting in overall frustration. Eventually, the front teeth often will break from the excessive forces placed on them. This lack of diagnosis and correction is a huge disservice to our patients because many of the problems that develop were and are preventable. Theories of this alarming increased prevalence of worn and displaced teeth include increased use of processed acidic food and/or drink, clenching and grinding, abrasive toothpaste and pathologic bites. Even though the initial cause is somewhat uncertain, the effect is truly becoming epidemic. (Figure 3)

Figure 3

Criticism of masticatory physicians usually comes from not truly understanding the philosophy. Just ask a masticatory physician who was once also in the dark about how to provide dentistry that doesn’t break down and can last through your lifetime with proper care. Consider a masticatory physician the upper level of competency and predictability in delivering dental care. But most importantly, they care so much about their responsibility to their patients’ care and health that they have often sacrificed greatly. These dentists have gone back to school to advanced dental education institutes to learn how to perform dentistry accurately and with predictability. Just like technology, medicine and all other industries that continually learn more to provide better products and service to enhance consumers quality of life, so has dentistry learned that there is more to dental care than decay, gum disease and making things look pretty. Most of the masticatory physicians themselves were tired of watching dentistry they had performed on patients fail. They did the best they could with what they learned in dental school and they cared for the patients well by trying hard not only to fix problems and make the solutions last but without creating other problems along the way. (Figure 4)

Figure 4

The Complete Exam starts far before the patient even enters the dental office - it is a process. The well-trained office:

1. Conducts a telephone interview learning about patient expectations of the dentist, past dental experiences and explains the individuality given to each patient and the practice philosophy and care that they provide.

2. Sends a welcome packet to learn about the patient so that they can prepare for the first visit by customizing their approach to the patient’s needs and concerns. It also allows the practice to share their philosophies and set the proper expectations for the experience and the type of practice that one is entering.

3. The day of the appointment, time is spent with the Doctor clarifying the information provided and learning in more detail about patient needs and health goals. A review of the medical history, dental history and any concerns about dental health and past dental experiences.

4. Together the Doctor and patient care assistant spend anywhere from 1 to 2 hours performing a thorough comprehensive diagnostic exam. Typically recommendations for treatment are not discussed at this exam. The exam is for information gathering to study the findings and work out a plan for getting the patient’s mouth maintainably healthy for the rest of their life. This initial exam is not a quick periodic check by the doctor in the hygiene column — it is an involved diagnostic process that involves the patient’s input and opinions.

The exam should include a diagnosis of the entire Masticatory System not just teeth or symptoms. The System includes the joints the muscle, the supporting structures and the effect they have on the health of the teeth. The working harmony of all of these parts defines health.

5. A discussion with the patient at the end of the exam to review initial findings and what needs to be done to determine recommendations to get you healthy. This could include:

Diagnostic Records

• X-Rays - Examining for decay, infections, lesions, bone height
• Models of your teeth – To study the jaw, muscle and teeth relationship
• Photographs – As important as radiographs. Used to study detailed relationships of the teeth, and help in esthetic diagnosis as well
• Panoramic X-Ray - To study further unseen problems (Figure 5)

Figure 6

6. A complete study and diagnostic work up by the Doctor analyzing all the information gathered at the exam and the records taken. Often a Doctor will completely work the case out on a before and after set of models determining a plan to achieve health and ensuring the long-term results instead of practicing and playing guesswork in the patient’s mouth.

7. The second appointment will be the time for the patient and Dentist to review the information he has prepared and determine the best plan of action to get healthy. These doctors want the patient to understand the problems and make sure they agree with the solutions. They welcome all the questions, concerns and want to understand the patient’s circumstances. Most of the time a comprehensive approach to dental health can be spread out over several years. It is the role of the Dentist to determine with the patient the areas that are in need of immediate attention and the areas that can be deferred or are elective. Not everything is necessarily urgent.

8. A dentists who will maximize any insurance benefits you may have but will not allow the insurance companies to have control over what is necessary to get you healthy. These dentist believe the decision should be between you and your dentists once you both have a clear understanding of what is necessary to get healthy and what insurance restrictions may prevent that.

9. A discussion with you about the time and cost involved in obtaining a healthy mouth. The treatment plan can only be successfully executed as a partnership, therefore your circumstances and budget will be taken into consideration as you and the Doctor plan for your health. Once you both are ready to move forward, a special arrangement of payment will be made for the time, care, skill, knowledge and judgement of the Doctor to make your investment predictable.

Important questions to ask patients:

Have you experienced:

1. Teeth that are sensitive to cold?
2. Teeth that have shifted in any way?
3. Teeth that feel chipped, jagged or rough?
4. Teeth that appear worn or are shorter than you remember?
5. That you have clicking or popping of your jaw joints?
6. That you suffer more often from headaches?
7. That you clench or grind your teeth?
8. That you have sore, tired jaw muscles?

Table 1 - The Complete Examination

• Patient Chief Concern/ Desires
• Medical/ Dental History
• Soft Tissue Exam/Oral Cancer Screening
• Periodontal Charting/Assessment
• TMJ Evaluation:
• Doppler Auscultation (5MHz Ultrasound)
• Joint Vibration Analysis (JVA)
• Piper Classification
• CR Load testing
• Muscle of Mastication Palpation Results
• Dental Exam Findings: Caries, Faulty Restorations, Abcesses, etc.
• Occlusal/Functional Findings
• Esthetic Assessment

Table 2 – Signs of Stability and Instability

Signs of Stability:

1. Even tooth contacts in CR
2. Anterior guidance that immediately discludes the posterior teeth in all mandibluar movements
3. Stable TMJs
4. Teeth that are in harmony with the neutral zone and envelope of function.
5. No pain/sensitivity

Signs of Instability: 

1. Excessive tooth wear into dentin
2. Unwanted tooth migration
3. Broken/fractured teeth
4. Excessive mobility
5. CR-MI discrepancy
6. Tooth hypersensitivity

Oral Cancer Exam
The areas of your cheeks, tongue and the floor of your mouth.

IDEAL: 

No Lesions, growths or discoloration. Dentists diagnose a large percentage of oral cancer annually allowing it to be caught early. Masticatory physicians have trained their hygienists to exam for oral cancer at each hygiene visit.

Diagnostic Measures

• Visual and physical inspection by the Doctor and Hygienist
• Tissue fluorescence with VelScope or

Joint Health Exam
The joint that positions your jaw in opening and closing.

IDEAL: 

The joint position in its socket with the disc, fluids and ligaments all in proper form. Health defined by no popping, clicking, grating noise, pain to the touch or pressure of joint loading or deviation in opening and closing.

Diagnostic Measurements

• Screening History of Joint Health
• Blood Flow Evaluation
• Ear Symptom History
• Ligament Health
• Disk Health
• Jaw Range of Motion Exam
• Noise Detection Exam

Muscle Health Exam
The Muscles that open and close your jaw

IDEAL:

All muscles working in harmony by turning on and shutting off at the proper time and place while the putting the joint in the proper position and contacting the teeth all at the same time with equal force and intensity.

• Muscle Health defined by no pain or tenderness to the touch of the muscles.
• Diagnostic Measurements
• Physical touch or palpation of Head Muscles
• Touch of Neck Muscles
• Open and Closing Patterns
• Touch of Facial Muscles
• Touch of Cheek Muscles

Biting System Health Exam
The relationship of your teeth to the current joint and muscle position.

IDEAL:

For proper muscle and jaw position, when chewing food your teeth should all contact at the same time with equally intensity. Your back teeth should separate and your front teeth should contact guiding your lower jaw in left to right and front to back motions. This ideal relationship of your jaw, muscles and teeth are critical in the distribution of the 600 pounds of force from the muscles when chewing and talking.

Note: There are cases where the ideal described is not achieved and a patient may have adapted to the position of jaw, muscles and teeth relationship. The concerns then becomes is the adaptation destructive to the teeth and the joints.

Diagnostic Measurements

• Upper and Lower Jaw Relationship
• Equal Force Tooth Contact Exam – Points of contact defined
• Chewing and Talking Movements Tooth Contact
• Chewing and Talking form with tongue, cheek, and lips
• Unconscious Habit Movement Exam (i.e. bruxing, clenching, grinding)

Gum, Bone and Root Health
The supporting structures that hold your teeth in place.

IDEAL:

The attachment of your gums to your teeth should be tight enough to clean between that space with a toothbrush and the bone around the tooth should be at a height that keeps the teeth tight in their place. Otherwise bacteria can live and cause infections, eat away at bone then loosening teeth. The roots should be attached to the teeth. Health defined as a 3 millimeter space between tooth and gum, no bleeding, no puss, gums pink in color, no root or bone exposed, roots attached to teeth.

Diagnostic Measurements

• Measurement of Gum attachment to teeth
• Recording of bleeding points
• Root Height Exam
• Gum Levels to teeth
• Bone Support – X-rays

Teeth Health Exam
The signs and symptoms of the conditions of the joints, muscle, biting contacts, gums, root and bone are viewed on the teeth. These symptoms can be painful or non-painful depending on the damage. Much like Diabetes, High blood pressure or Clotted arteries.

• Tooth By Tooth Health
• Looseness
• Cracks
• Fractures
• Shifting of teeth
• Missing Teeth
• Erupting Teeth
• Strength of teeth and existing dentistry performed
• Worn teeth
• Contour/Shape
• Seals of existing restorations
• Color
• Notches in enamel at gumline

 Conclusion

There is a pot of gold at the end of the rainbow… a complete exam leads to a complete diagnosis, which does translate to profitability for the practice, and the most ethical care that the patient can receive… Without doing the exam, you cannot make the diagnosis, so you won’t be able to present or produce the treatment.

by Dr. Dory Stutman

We all in our careers have faced situations in which a patient walks into the office with a problem that appears to have no practical solution. The main roadblock might be do to many reasons including poor prognosis, poor health, fearor financial concerns. We would deem these cases untreatable and tell the patient its something that they have to live with.

One day into my office walked this woman who expressed to me some valid concerns regarding an existing maxillary roundhouse fixed bridge. The history revealed a thirty plus year old bridge from tooth 2-15. She has had recent repairs with composite to cover root exposures from severe recession. She has been functioning on this bridge trouble free for many years. Her main concern is very poor esthetics do to long teeth, black triangles, and ugly exposed black margins.

She has been to several consultations and was told replacing the bridge was impossible. Her only options were either extensive bone grafting with some type of implant restoration or a full upper denture. Being an active woman she was set against a denture and finances ruled out implants. She was now “going to have to live with it”.

She was now in my chair and we had to devise something practical so she could feel better about her smile. Funny thing because the prior day I read about Amaris Gingiva composite in a trade journal and felt that it might be the solution. Options were discussed with the patient and it was felt that there is nothing to lose by trying.

The patient was scheduled to try it out on the worst tooth first to evaluate the outcome. The following is a description of the treatment sequence.

Figure 1

Showing recent composite repair to cover recession and metal margin

Figure 2

Initial composite removal, and beveling back and roughening of crown margin. The undermining tooth surface beneath crown margin in order to create a space large enough to fill with flowable composite and seal it.

Figure 3

Flowing the white opaquer up and under the open metal margin, on the root surface and on top of the metal margin to block the dark metal color.

Figure 4

Application of pink composite over the root surface to restore tissue color. To root surface. Note gingival area eventually to be blended in to the root surface smoothly for tissue health. Once we determined success on the worst tooth it was then decided to proceed with the others.

Figure 5

Initial roughening of pontics and undersurfacees.

Figure 6

Application of bonding agents.

Figure 7

Flowing of composite into all undersurface irregularities.

Figure 8

1-Use of cellophane pulled under pontics to form a matrix against tissue. 2-Composite was then packed under pressure in to all the nooks and crannies. 3-The cellophane was then pulled downwards over the teeth when the composite was still soft. This was to pack the composite tightly into the pontic undersurfaces. All was then light cured.

Figure 9

The composite was then trimmed to resemble root surfaces in preparation for the new gingiva.

Figure 10

Amaris gingiva was then placed onto the surface and contoured.

Figure 11

Final contouring to allow for smooth transitions and cleansing.

Figure 12

Exagerated High Smile.

Figure 13

T he dreaded single central restoration is often a challenge for the dental team to communicate the shade correctly to the laboratory on the first go around. For the dental laboratory, it is the most common reason for a remake. It is not unheard of for some practices to charge 2 to 3 times what a normal restoration would cost, simply because of the time and effort put into getting the restoration shaded correctly, as it could entail a re-shade at the lab, and or remake of that restoration. Color perception is subjective by nature and many variables can affect how the final shade is chosen. Some dentists will send the patient to the lab for a custom shade. Read more

A picture is worth a thousand words is a proverb that refers to the idea that complex stories can be described with just a single still image, or that an image may be more influential than a substantial amount of text. When we take photography in our practice, we don’t have to say anything. It is so much easier to show the patient what we are talking about and they are able to visualize the key points as to the treatment plan.

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