Managing bruxism is challenging in daily practice. Technical questions must be addressed, including selection of restorative materials and restorative design. In addition, the risk of prosthetic failure goes up. Helping our patients understand this risk frequently begins with helping them accept and own the fact that they are able to generate excessive force.
Easier said than done. The problem is that many of our patients are unaware that they are doing anything beyond normal with their teeth: “My spouse hasn’t ever complained”; “Wouldn’t it hurt?” Helping “resistant” patients accept that they may be grinding their teeth at night can sometimes be frustrating.
This patient presented with a debonded ceramic restoration and was aware that he was going to need some dental treatment. I think, “I’m going to need a full-mouth rehab” were his exact words. For sure, not something we hear everyday. In fact, this patient has several family members that are dentists and had already received several consultations regarding treatment possibilities.
The patient reported daily meditation practice for more than a decade and admitted that he “just couldn’t believe” he could be doing something like clenching or grinding without his conscious awareness.
In order to help both of us better understand what might be happening, I asked the patient's permission to test the idea that he was grinding at night. Adapting a technique described by Drs. Michael Melkers and Jeanine McDonald, I utilized the patient's existing nightguard (See Fig. 1) and a permanent marker (See Fig. 2) to identify and characterize his mandibular movements (See Fig. 3). The clinical steps are outlined below.
This technique is inexpensive and provides tangible, nearly real-time information for patients. Approaching “I don’t grind my teeth” with a sense of curiosity, rather than confrontation, fosters a better patient-doctor relationship and a sense of collaboration moving forward with the case. As this patient began to accept that he does grind his teeth, he was able to ask the next question: What can we do about it?
- Verify fit of existing appliance or fabricate new appliance. Adjust contour as necessary.
- Adjust occluding surface. Create a smooth, flat surface. The goal for this appliance is to identify movements and enhance patient involvement not test out any particular guidance scheme. I was able to achieve this using carbides and rubber wheels.
- Polish. Using pumice and polishing compound on a rag wheel with a lathe.
- Coat the occluding surface with permanent black marker. Usually two coats is sufficient.
- Verify the plan with the patient. Confirm the goals for appliance and set a time for evaluating the appliance. Seven to 14 days is more than sufficient.
Melkers MJ, McDonald JM. Diagnostics: Parafunctional Analysis in Diagnostics and Restorative Dentistry. Inside Dentistry 2007
Darin Dichter, DMD, Spear Resident Faculty