Yoga, stand up paddle boarding, nutrition, your investments, the tires on your car. All of those things, just to name a few, require balance for success.
We've all been to that restaurant and sat in the chair with one leg shorter than the others. The chair drives you crazy, rocking back and forth, until you wedge a napkin under the leg to get it stable.
Dentistry is no different; balance is crucial for long-term success. When we begin to look at balance, we need to look beyond a single tooth. We need to appreciate that teeth are a part of a system. The system mainly includes joints, muscles and teeth. This is the F, or Function, in EFSB, which is taught in Facially Generated Treatment Planning at Spear.
Listed below are five “real world” scenarios to be aware of which could indicate that a patient's system may be out of balance. Each section is worthy of its own Spear Digest article, but here's an overview, just to scratch the surface.
How many patients have you seen that continually break teeth? Some patients break multiple teeth within a short time frame. Often, these fractures are caused by cuspal interferences when the mandible is moving side to side or forward. Assess how many crowns a patient already has and ask him or her why the crowns were placed. Gather information from his or her past crown history to gain a respect for the system you are about to put the next crown into. Every time we do a crown on a single fractured tooth, we are placing our new crown right back into the system that broke it in the first place. Set a number in your mind of how many teeth a patient needs to break before we are comfortable discussing balance.
Have you ever had a patient ask you to “just smooth” a chip in one of their front teeth? If the patient doesn’t know how that chip got there (fork, chewing finger nails, fishing line), our suspicions should lead towards an imbalance of the system. Check their mandibular movements in all directions. Assess how level their incisal planes match up. Look for the sharp spot in the opposing arch that notched the tooth, as they often match up like a puzzle piece.
We all know that there can be various sources of pain in dentistry. Imbalance of the system can be one such source. The great variations of pain are beyond the scope of this article, but for simplicity’s sake, we again look at the system of joints, muscles, and teeth to evaluate balance.
For a single tooth under excessive stress, this can present as anything from mild cold sensitivity to a full-blown toothache that needs a root canal. Have you ever had a patient with a crown that “never felt right?” Then the patients gets a root canal and still doesn’t feel better. It could be a crack, or it could be a balance issue. Pain due to imbalance can extend beyond a single tooth and manifest in the TM Joint and/or in many of the muscles surrounding the teeth and face. Does the patient have headaches? A sore jaw in the morning? Any pain directly around the ear? A patient who presents with pain needs to be evaluated from the systematic approach of joints, muscles and teeth.
Often, patients recognize when they have a mobile tooth. The real challenge is catching mobility before it becomes noticeable to the patient. Here are some tips for doing so:
- Evaluate the stress on loose teeth.
- Check for fremitus.
- Have the patient place his or her finger on a premolar or incisor that has recession or wear, see if the tooth moves.
- Check mobile teeth to see if those teeth are single-handedly carrying the load in excursions.
- Evaluate periodontal status and bone support in the mobile tooth area and compare it to what you see throughout the mouth. A localized area of mobility with otherwise normal periodontal health can be an indicator of imbalance.
Like pain, tooth wear can be multifactorial. After a thorough history and clinical exam, we should be able to sort out tooth wear caused by extrinsic forces (acid erosion) compared to tooth wear caused by tooth-to-tooth contact (attrition). Cases of attrition are often present in the unbalanced environment where a patient is naturally balancing themselves. The question here is, what is the long-term consequence? Clinically, this can show anywhere from one canine with a flat incisal edge to an entire arch of teeth with completely flattened cusp tips. The worn area of one tooth or arch will have an equal and opposite pattern of wear in the other tooth or arch.
The idea is to look beyond a single tooth and appreciate the system of joints, muscles and teeth. What impact, if any, does the imbalance have on the patient for the short term and the long term? How long will your dentistry last in the current environment?
The great thing about gaining a respect for balance is every dentist can implement what is learned on every patient. Begin to gather information as to what kind of system that single tooth is in. How balanced is the environment? How destructive is the environment?
As dentists, we will all treat imbalance differently depending on our knowledge, skill and comfort level. Treatment could include observation, tooth adjustment, diagnostic casts, splint therapy, equilibration and so on. However, every dentist can provide better treatment by simply having a respect for how a balanced system can benefit a patient. Dentistry is much more predictable and fun when we can place good dentistry in a good and balanced environment.
(Click this link to read more dentistry articles by Dr. Brent Bush.)
Brent Bush, D.D.S., Spear Visiting Faculty