One of the most critical components of the examination is evaluating for “at risk” occlusal conditions. These risks can take even the most seemingly simple operative dentistry into the rabbit hole and have the patient blaming everything they are now experiencing on the dentist. Hope you've never been there, I have and it is NOT a happy place.

Upper teeth with red and blue areas of at-risk occlusion.
Lower teeth with red and blue areas of at-risk occlusion  at-risk occlusion.

This patient presented with sensitive teeth on the lower left and had two occlusal composites placed. The dentist told the patient that he was surprised they were sensitive as they did not seem to be very decayed despite the brown stains in the grooves. The sensitivity did not go away, it was in fact exacerbated by the trauma to the first and second molars. The patient feels worse and is becoming a little concerned with the decision to have you treat the teeth.

Pulp test these teeth now and you are virtually assured that they will appear totally fired up – no doubt the nerves are or are becoming pathologic. It's idiopathic! ... and it's not a fun ride for the dentist or the patient. Some of these end up with the endodontist and some even with the implant surgeon. Occlusion was the initiator and the continuing aggravator.

Whether your patient is in your chair for an emergency exam before an emeregency procedure, an initial examination or a comprehensive evaluation, looking closely at the occlusion can tip you to where the white rabbit is hiding to pull into the hole where the Queen of Hearts waits to lop off your head.

Always check for first point of contact with the leaf gauge and look at the functional occlusion. The images show what is happening on this occlusion, but you don't need to mark every occlusion to SEE what's happening. Talk about what you see BEFORE doing even simple procedures – if you are wrong regarding what might happen no one will be happier than you. If you are right, well, we're never happy when patients are uncomfortable but sometimes the lesson that comes with discomfort are more deeply understood, and you look like a genius.

Read more dentistry articles by Dr. Gary DeWood.

Gary DeWood, D.D.S., M.S., Spear Faculty and Contributing Author


Commenter's Profile Image Mark Olson
March 12th, 2013
Is that Madame Butterfly marking ribbon?
Commenter's Profile Image Gary DeWood
March 12th, 2013
Madame Butterfly Silk - the typewriter ribbon of marking paper.
Commenter's Profile Image Will Kelly
March 12th, 2013
Somehow the Madame Butterfly question flowed so well into the Lewis Carroll analogies that I started thinking I was listening to Jefferson Airplane! Thanks for the article Gary. The "marked" occlusal pics have become standard operating procedure after splint therapy. I then have been showing a B&A of an equillibrated patient. It is becoming a no-brainer. Thanks--Will
Commenter's Profile Image Gary DeWood
March 12th, 2013
Thanks Will!
Commenter's Profile Image Glen Doyon
March 19th, 2013
Nice teaser article. Occlusion and it's importance is so misunderstood and underappreciated. I hope you continue to write as many articles on this subject as you can possibly publish anywhere. I can't begin to tell you how often I am referred a patient for endodontic therapy where occlusion was simply ignored or not understood and was clearly the culprit. Frank's occlusion course (at least the one I took) should be mandatory for dental school graduation.
Commenter's Profile Image Denny Barker
March 20th, 2013
Hi Gary Great job, as usual. Keep them coming. Great to see you and Cheryl in Chicago. Denny
Commenter's Profile Image Brad Shern
March 20th, 2013
Gary! Nice article! Love the analogies and topic. I have been there with some of my CEREC restorations and with some small adjustments the cold/heat and tenderness disappear. I echo the others sentiments that more and more should be written on this - so we can revisit it - repetition learning. I'm mentoring the Occlusion course at the end of May and looking forward to the refresher. All the best, Brad
Commenter's Profile Image Sharon Goodwin
March 20th, 2013
Gary thank you for showing these interesting pictures. I am diagnosing from these pictures that the patient has heavy working and non-working contacts on the first and secone molars? Did they have any muscle or TMj signs or symptoms? Thanks for sharing this with us!!
Commenter's Profile Image Gary DeWood
March 21st, 2013
The patient had tender masseters (2 on a scale of 0-10) but no other signs or symptoms other than what you see. I have seen this is many patients - teeth sensitive, no muscle findings and no joint findings. The key is to notice the functional interaction and then intervene to see if symptoms change. In this case I made an appliance for nighttime wear and the muscle tenderness was gone, as was the dental sensitivity.
Commenter's Profile Image Kevin Huff
April 5th, 2013
An added thought on the molar sensitivity..... I find the Travell flipchart that I bought from Great Lakes Orthodontics is a great chairside tool for educating these patients because masseter trigger points often cause molar sensitivity via referral. Great case, Gary!