The image on the left is of a 28-year-old patient I saw for a routine exam. She was unaware that she had any wear on her teeth and also didn’t realize that she might be engaging in some parafunctional activity.

She has wear facets on her molars that are suggestive of what we call “CR” bruxing or bruxing from a retruded position. The patient pulls the jaw posteriorly until the back teeth contact and then squeezes into a more forward position. Frequently, the earliest signs are wear facets on the distal marginal ridges or inclines of lower second molars.

Intervention at this point might be an occlusal guard and perhaps an equilibration.

Interestingly, the image on the right is her mother, essentially showing what can happen over a 28-year period without any intervention. The mother has always done what her dentists suggested and even though she knows she grinds her teeth no one has ever suggested that there might be a way to minimize the damage now and in the future.

The result was loss of #18 secondary to a root fracture; wear into the dentin and a crack into the fossa of #31 and fractured porcelain on the crown on #19.

 

It is entirely possible that much of this dentistry could have been avoided with early intervention if her dentists had recognized the consequences of no treatment and simply had the discussion with her.

I understand that there are many patients who might not want to do anything; however, if they understand the risks of no treatment and the long-term benefits of treatment, they WILL say yes.




occlusion



Comments

Commenter's Profile Image Carlo Poggio
January 25th, 2014
Interesting considerations, it reminds me of discussions about Angelina Jolie mastectomy. How can we state that something is necessary? Always hard. However maybe breast cancer has different consequences than a molar fracture. Maybe.
Commenter's Profile Image Steven Leach
January 25th, 2014
Great article Steve,we are all guilty of "watching" a potential problem when we pop in to check a hygiene patient in the midst of a hectic day.Thanks for the reminder to slow down and to notice signs of brewing problems,Sincerely,Steve
Commenter's Profile Image Arnie Mirza
January 25th, 2014
Does this condition happen even with enough occlusal reduction? Thank you Steve
Commenter's Profile Image Gary Login
January 25th, 2014
Hi Dr Ratcliff Thank you for your article. Can you or any faculty at the Spear Institute identify a randomized controlled study that shows a cause and effect relationship between occlusal forces and tooth wear? I include the review article below that reports there is no controlled study that shows a relationship between occlusal principles and clinical outcomes (60 years and 10,000 articles searched). Occlusion for fixed prosthodontics: A historical perspective of the gnathological influence Paul H. Pokorny, et al. (J Prosthet Dent 2008;99:299-313) This issue has become increasingly important in debates among my dental colleagues treating sleep apnea with occlusal appliances. I look forward to your response. Gary Login, DMD.
Commenter's Profile Image Steve Ratcliff
January 28th, 2014
Arnie, yes, it happens in spite of adequate reduction when occlusal forces exceed the flexural and compressive strength of porcelain. Gary, I know the Porkorny article, thanks for the citation. No, I am not aware of the a double blind, RCT that correlates occlusal principles to long term clinical outcomes. However, there are hundreds of studies that taken collectively point us in a direction that indicate that occlusal wear is a disease, that bruxism is strongly correlated to sleep disorders, that shear stress over long periods of time causes occlusal breakdown. My point here is that even if the only treatment was an occlusal guard, and had the second patient worn it regular, it is highly likely her mouth would look different today. If occlusal therapy, including equilibration was part of a long term strategy to manage her occlusal force, it most certainly would have to be monitored. Definitive occlusal therapy doesn't mean that nothing will ever change in the mouth again, it simply means that steps have been taken to manage force in the face of evidence that forces are causing breakdown and they are being mitigated to some degree. Steve
Commenter's Profile Image Panks
January 1st, 2015
What would you do in equilibration? Do you have any article that I could refer to? Would equilibration change or complete prevent the future bruxism and wear? Panks
Commenter's Profile Image Steve Ratcliff
January 2nd, 2015
Hi Panks We have a complete course on equilibration in our digital suite that includes the steps of equilibration, indications and expectations of outcomes. Equilibration in itself will seldom stop the patient from bruxing, however, when they do brux or clench, having a well organized occlusion can slow down the process of wear and damage to the teeth. Steve
Commenter's Profile Image Glenn Chiarello
March 24th, 2015
i have spoken to my clients who present with these same findings until i am on the verge of feeling like they see me with 2 heads. the fact that the previous dentist did not mention anything plays a role to why clients just dont get it and are reluctant to proceed. a case comes to mind from just last week. it has been 3 years since i advised her about the same situation that Steve has shown here. every time that she comes for hygiene she complains about transient temp sensitivity and headaches. i say the same old things and she leaves the same old way-thinking about it. Last week though she finally agreed to an occlusal analysis but " not the night guard". thank you Steve, you dropped it into my lap. i have printed the article and when she comes in i will give it to her. its funny how things appear to be so logical and easy when someone else shows you the way.
Commenter's Profile Image fabrizio R.
June 9th, 2015
if not possocontrollare his mind and his quality of life with all that entails, my only option is to reduce the wear of his teeth within the limits of our principals