15/10/2014
Occlusion plays a part in almost everything we do in dentistry, from the simplest filling to the most complex orthodontics, yet this important aspect of dental health is often ignored.
The principal reasons for this are that:
A) Humans (along with most mammals) adapt surprisingly well, most of the time, to even quite major occlusal discrepancies. It’s important that we do, of course, or our species may not have survived too long. So, most of the time, we dentists can get away with not paying much attention to this area, knowing the patient will adapt to most things we do to them, or so we would like to believe.
B) Occlusal problems can be responsible for a wide range of symptoms and adaptations, many of which may not appear to be directly linked to “the bite”.
C) The connection between this wide range of symptoms and the way teeth contact is rarely made by our patients, and this relationship can sometimes be poorly understood by their dentists too so an opportunity to provide help is often missed.
D) Occlusal problems tend to be mostly chronic in nature, developing and worsening over time, so they may be difficult to diagnose or not brought to the attention of dentists, particularly if patients assume that their symptoms cannot be treated.
It is the wide range of responses to the same stimulus or stressor that can be confusing for dentists and patients alike, but in other fields it is recognised that stresses applied to any system will tend to affect the weakest link first.
Physical stress from a parafunctional habit (e.g. bruxism or clenching) will have a direct effect on
A) the muscles of mastication, head posture and facial expression
B) the temporomandibular and cervical joints
C) the dentition, both natural and prosthetic
D) periodontal structures.
The initial response of biological systems to a stressor is adaptation, but eventually physical stresses may reach a level where the body can no longer adapt and structures will begin to break down. In the case of excessive occlusal forces acting on the tissues (e.g. bruxism) this breakdown causes what we might then refer to as “occlusal disease”, which could be experienced as headaches (when muscles fail to adapt), TMJ clicking or locking (from ligaments that cannot cope), fractured and/or worn teeth (especially when compromised by environmental factors or large restorations) and localised periodontal breakdown (when the periodontal structures are the weakest link in the chain).
The biggest problem for dentists though is to recognise the point at which adaptation switches to breakdown so we can judge when it is appropriate to intervene and when it is safe to warn and observe. Part of this decision making process involves an understanding of the risk factors that may be present for each individual patient.
This is where a simple screening questionnaire can prove an invaluable tool. The SDS Occlusal Screening Questionnaire has been developed over many years in practices around the world and has proven very useful for course delegates. You can download it here: sdsosq
The Occlusal Screening Questionnaire may be used in many ways, but it is primarily intended to be completed by new patients prior to their initial examination. Many of our course delegates have also found it a good practice management exercise to encourage existing patients to fill in the questionnaire whilst at reception prior to routine examination appointments to screen for previously undiagnosed problems. It also has the positive effect of informing patients that we have an interest in their general health and of the potential link between teeth and headaches.
The first five questions all relate to the increased risk of occlusal disease caused by parafunction:
1) Do you clench or grind your teeth during the day?
2) Have you been made aware of clenching or grinding your teeth during the night?
Knowing about an awareness of clenching or bruxism is useful of course, but don’t be too surprised by a negative response here because even when we see the signs of a severe parafunctional habit we will often find that patients are unaware of their noxious habits.
3) Do you often wake up during the night?
4) Are your jaws or teeth tired when you wake in the morning?
5) Do you feel refreshed when you wake in the morning?
Disturbed sleep patterns and tiredness on waking could be related to clenching and bruxing, but these are also the early warning signs of other potentially serious conditions such as obstructive sleep apnoea (OSA) which would require a referral to the patient’s GP.
6) Do you suffer from chronic headaches or neck and shoulder pains?
This question relates to the muscles of mastication and head posture in particular. A positive response here would require further questioning during the examination (e.g. the location and time of day when these pains are experienced) and might indicate an occlusal imbalance that is causing hyperactivity in some of these muscles.
Disorders affecting the temporomandibular joints are covered by the next three questions:
7) Do you now, or have you ever had, pain in your jaw joint or the sides of your face, particularly around the ear?
8) Have your jaws ever clicked or popped when you open your mouth?
9) Have your jaws ever locked open or closed?
It’s important to understand the risk factors inherent in any treatment, but these are particularly important questions, not least from a medico-legal viewpoint as a failure to recognise or record a previous history of internal derangements can be the source of accusations that may be difficult to defend at a later stage.
Finally, we need to ask about any problems in function that patients may have noticed but fail to mention:
10) Do you tend to chew on only one side of your mouth?
11) Have you ever had any dental work (crowns, bridges, fillings etc.) that stopped your teeth biting normally together or felt “in the way”?
These questions might be a good way of opening a discussion with patients about the comfort and efficiency of their teeth, allowing the opportunity for us to discuss options that might help to improve matters.
In summary, using a simple Occlusal Screening Questionnaire like the one discussed here is an essential practice management tool that has many useful functions, but most importantly it helps us to improve the standard of care we offer our patients with minimal effort and cost
British Dental Conference 2014
