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ePaper created 2014-06-27, 17:04:32 | version 1.30.01
speakers4 Pacific Dental Conference — March 7, 2014 similar. The body is responding to some- thingthatitdoesn’tlike,andwhatwesee is not the disease. We have to respond to what it is that the body doesn’t like in ordertofigureouthowtotreatthesignsor symptomsthatwesee.Oneofthebiggest problemsforusasaprofessionisrecogniz- ing what the real problems are — in other words — diagnosis, rather than just treat- ingsignsandsymptomsastheyappearin themouth. Istheredataontheimpactofocclusal dysfunctiononrestorativesuccess? There is, but what many people don’t always understand is how that impact results in different modes of failure. So when porcelain chips, or when the exter- nal surface of the restoration becomes otherwise compromised, it is obviously very possible that occlusion could be a contributing etiologic component. But there are many other modes of failure — often not directly recognized — that maybecreatingmuscledysfunction,joint problems or even recurrent decay under therestoration. What we have to realize as a profes- sion is that recurring decay under the crownandbridgeoftenisduetoaberrant loading,creatingcementfatigue,whereas decay apical to the margins of a restora- tion is what true caries susceptibility is all about. Many restorations fail because of recurrent decay that is not related to caries susceptibility or even to the preci- sionwithwhichtherestorationwasfabri- cated. It’s due to overloading or problems withocclusion. Ifyouseeocclusalproblems,butthe patienthasnocomplaint,howdoyou explaintheneedfortreatment? Most dentists believe that tooth wear is commensurate with the patient’s age. Well, it turns out that when you look at the data, normal enamel should not wear by more than 11 microns per year, therefore, it should take 100 years to lose amillimetreoftoothstructure.Ifyouhave ahealthyocclusion,youshouldnotreally wearoutyourteeth. When patients present with discom- fort, muscle aches or joint concerns, they arealreadyawarethatthereisaproblem. Butifapatientpresentswithalossoftooth structure progressing much faster than normal,thepatientmaynotbeawareofit. They don’t see or feel the problem. When you tell patients that they have severe wear, especially in areas that they can- not see, they won’t understand what that means. But what if we use specific data instead of general concepts and explain it like this: “It should normally take 100 years to lose a millimitre of your tooth structure. Based on how much structure is missing here, you’ve lost more than three millimitres, which should have takenmorethan300years—orrepresents 300 years of use. I am concerned for you because you are only 56 years old. And I’m concerned with how long your teeth willlast.” Whatwearetryingtodoisgetdentists to recognize how they can conceptual- ize occlusal problems in the mind of the patient. Because unless the wear creates an aesthetic problem, most people are unawareuntiltheycanseeitortheyhave symptomsfromit. Istheentirepresentationondiagnostics, oraretreatmentstrategiescovered? The treatment that is outlined will be based on the three Ps: position, place and pathway. Where do you position the jaw relativetothehead?Howdoyoumakethe teeth fit together properly so they have equal simultaneous contact, which we call place? How do you not interfere with theenvelopeoffunction—orcreateanew envelope,whichwecallpathway? ThosePscanbeaccomplishedbyappli- ances, fibrillation, orthodontics, surgery or full-mouth reconstruction. Depending on the problems that the patient presents with,treatmentmayrequireaspecialist. Cantreatmentforocclusalproblems occursimultaneoustorestorationwork? Thekeyinpracticeistounderstand potential problems with occlusion, even before you begin treatment. And this doesn’t necessarily require a functional analysis. To make it a little more confusing, sometimes what we see doesn’t even reflect that there are occlusal problems. For instance, if a patient presents with wear, you can- not tell by looking at the teeth if the wear represents a previous occlusal problem that doesn’t exist anymore — or a current problem. In the previous situation, even though patients may look as if they have an occlusal prob- lem the risks would be much lower. If the problem is active, you can’t just repair worn teeth and expect success if you haven’t resolved why the teeth are worn down. Again,understandingthemechanical aspects of occlusion that we were taught inschoolisn’tenough.Youneedtounder- standthephysiologicaldynamicrelation- ships that actually create the problems. Right working, left working and protru- sive or linear movements don’t reflect what people actually do with their teeth. Ifthisisallwe’rereallydoingwhenwe’re rebuilding occlusion, it’s not enough to resolvesuchproblemsifyoulaterencoun- terfailurethatyoudidnotexpect. It’s extremely frustrating to manage someone’s occlusion in a way that you believe everything is correct and done appropriately and still have a problem. Why did that happen? Is it that we made a mistake? Is it that we really didn’t do it properly? Or is it that there is something moretotheproblemswearetreatingthat wehaven’tyetlearnedtounderstand? AD OCCLUSION 7 from page 3