Beating bruxism

David Winkler discusses some practical considerations for tackling the destructive effects of unchecked bruxism.

How often does a patient present with specific wants, needs, or expectations? Yet after extensive interviews, intraoral and extraoral examinations, diagnoses, and all treatment plan options presented for informed consent, they respond with: ‘But I don’t grind my teeth!’

Despite all our visual aids – both electronic and hard models – and how obvious the tooth wear is (not to mention the possible problems in the form of TMD symptoms, headaches or back pain), patients still don’t believe that there can be a correlation between the subjective and objective findings and their ‘non-existent’ bruxism.

Silent but deadly

Bruxism and clenching can be ‘silent but deadly’ with minimal apparent attrition and very few or no symptoms until the damage is done and the financial and biological costs to treat them are great. The forces generated in the masticatory system during bruxism can exceed those within the tolerances of already compromised teeth or restorations, leading to further restorative treatment to repair or replace prematurely failed crowns, veneers, inlays and the like. Often, simple to complex restorative treatment is carried out in patients with moderate bruxism symptoms without addressing the problem, with no form of tooth protection post-restorative phase, leaving subsequent remedial repair work necessary – leading to dissatisfaction for the patient and distress for the treating dentist!

Many studies have shown that there can be a correlation between some types of migraine headaches and muscular tension-type headaches, and bruxism and clenching. By examining the patient for muscular dysfunction, dentists can contribute to the physician’s examinations in dealing with patients with these difficult to diagnose/treat problems. In many cases, simple anterior splint therapy, such as the Bitesoft appliance, can provide a cost-effective, non-medicinal and effective treatment modality with no side effects for this group of patients.

Diagnosis and treatment

To help the dentist in diagnosing bruxism, and assisting in putting forward an effective treatment plan, the following questions and observations are appropriate:

  • Is there a pattern, or history of toothgrinding several times weekly?
  • Is there evidence of attrition, flattening, or fractures of teeth or restorations?
  • Is there any tenderness in the muscles in the jaw, or in the temples when clenching, or clicking of the TMJ?
  • Is there any discomfort when eating?

When the answer to these questions is affirmative, splint therapy should be considered both for diagnostic as well as palliative purpose. Many devices have been devised to help dentists in providing this important treatment option. Although many of them theoretically work and relieve the symptoms, the major problem seems to be compliance on behalf of the patient, as most splints tend to be bulky and require quite a long period of adjustment.

Small anterior splints, to just cover the incisors, have been introduced to the profession, and in the case of our patients at Castleview Dental, seem to be better tolerated – sometimes the best therapy is the simplest therapy that a patient will continue to use!

For the past several years, we have been using the laboratory-fabricated Bitesoft appliance, which has an internal surface of a pliable acrylic that slips over the teeth more easily and is more comfortable than the more traditional hard acrylic splints.

Case study one

In the case of this female patient in her 30s, a young medical physician, her chief complaints were the aesthetics of her natural teeth, the attempt to reshape the natural upper right canine with composite restorations to give the illusion of the congenitally missing upper right lateral incisor, and the reshaping of the upper left lateral incisor.

Upon examination, it was discovered that she suffered periodically from mild to moderate headaches with tension in several areas of the masticatory musculature. The amount of wear of her natural teeth was minimal. However, she seemed to clench her teeth fairly often, and especially when stressed – and we can all empathise with the amount of stress when dealing with a waiting room full of patients!

After having thoroughly discussed her various treatment options, it was decided to first bleach her teeth to give her the ‘white’ smile that her boyfriend desired! After 10 days of take-home bleaching, we achieved a baseline shade of B1, which she was content with, and there was a discernible difference with the previous placed composite restorations on UR3 and UL2 (Figures 1-3).

Case 1

She was also interested in closing the gap between the UR4 and UR3. Orthodontic treatment was suggested, which would also have helped to alleviate the discrepancy in the gingival margins, and if we had extruded the UR3, we would be able to have a narrower cervical area to harmonise with the UL2.

However, orthodontics were not appropriate, as she wanted/needed (to appease the boyfriend) instant gratification.

We then removed the composite restorations from the UR3 and UL2 and prepped the remaining UR5, UR4, UR1 and UL1, UL3, UL4 for porcelain veneers. We attempted to keep all the preparations in enamel, although after removal of the composite from the UR3, it was obvious that some of the previous preparation had been in dentine (Figures 4 and 5).

We then fitted the eight veneers, which satisfied the patient’s cosmetic needs (although her boyfriend wanted them brighter) for closing the gap between UR4 and UR3 and gave her a better shade match with the previously restored UR3 and UL2 (Figures 6 and 7).

We provided her at the fitting appointment with a Bitesoft anterior appliance to help alleviate her headaches. At her three-month review, she expressed her satisfaction with both the cosmetic results, explained that her headaches were neither as intense or as frequent as before… and she had moved on from her boyfriend!

Case study two

Robert, a pensioner in his late 70s, presented with no subjective dental symptoms other than the psychological problems of having very worn teeth, and the inability to smile. There was tenderness and clicking in the muscles and the TMJ. Most of the wear was in the maxilla. There was a fistula at the apex of the UR2, which he was unaware of. He suffered frequently from tension-type headaches. He wanted therapy to restore his upper teeth to a natural appearing smile and hopefully to alleviate his headaches (Figures 8-10).

Case 2

We discussed his various options and decided to restore his lower posteriors with a single implant and a couple of crowns, and to rebuild the upper dentition with single crowns and a small three-unit bridge to replace the failing UR2. Robert was in provisional restorations for six months in order to assess the effects of the increased vertical dimension with regard to both the headaches and the aesthetics.

After fitting of the final restorative work, Robert was also fitted with a Bitesoft appliance as a precautionary measure, which he continued to wear religiously. The results, two years after fi tting, were satisfactory (Figures 11-14).

Bitesoft has become an invaluable part of our restorative treatment options, as it’s easy for the patient to wear and get accustomed to, and appears to help alleviate many of the symptoms attributed to bruxism and clenching.

Embracing the digital workflow revolution

It is a tough time to work in the dental laboratory industry. The recession has hit us all hard and we face increasing pressure from clients to produce high quality work more quickly and competitively than ever before. However, the outlook isn’t all doom and gloom. Digital technology has begun to revolutionise the industry in recent years and presents a fantastic opportunity for dental laboratories to improve turnaround times and make significant savings in terms of efficiency and material costs.

Taking our own laboratory as an example, at Allport & Vincent we have purposely followed the development of the digital workflow and have embraced it wherever we can. Not only does it solve difficulties in relation to expansion and continued growth, but it also reduces the amount of labour and material-intensive techniques we use in the laboratory.

Essentially, it helps us achieve the ‘impossible’ with quicker turnarounds at lower prices, while also maintaining the same high quality of work.

A flexible option

Of course, the great thing about the digital workflow is that you can select those elements of the process which best suit your requirements. For example, software systems such as 3Shape and 3M ESPE are now available to translate a patient’s intraoral digital impressions into actual printed SLA models. Once you have received the digital file from your client, the printed model can be manufactured using this data, negating the need for a physical impression and eliminating the inaccuracy associated with them.

From there on in, you could opt to continue this case in the traditional way, or, if you wished to proceed further down the digital route, your next step would be to adopt design software. At Allport & Vincent we have chosen Renishaw incise and NobelProcera as systems to design anything from single-unit crowns and partial-implant bridges to full-arch implant bar restorations.

Once you have a finalised design, you are then able to digitally transfer the design direct to your chosen milling machine. There is the flexibility to mill on-site with your own milling equipment (Renishaw incise) or off-site at a dedicated production facility as offered by Nobel Biocare. Work on restorations requiring porcelain or other finishing techniques can then be resumed in the laboratory as necessary. While digital technology is certainly not cheap, it is not as expensive as you may think and a complete digital switchover does not have to take place overnight. Upon analysis of your clients’ demands, you may opt to introduce the appropriate elements piecemeal, as your finances allow. Whether you choose to make the transition slowly, or all in one go, investing in digital technology now will only save you money in the future.

Embrace the change The efficiency and quality made possible by digital workflow are difficult to overstate. In addition to reducing inventory and labour costs, it also reduces lost time associated with rejected impressions and can eliminate numerous chemical-based processes in the laboratory. Furthermore, improved quality in everything from the initial impression received to the overall restoration means we have fewer remakes and returns. This increases our profitability and improves our reputation and relationship with our clients, and thus has an extremely positive impact on our business.

The laboratory industry has always been thought of as a ‘cottage industry’, and in many respects it is. However in the last few years, with the digital revolution, laboratories are now moving into a far more sophisticated world. In order to remain competitive and keep up with those dentists who are pushing the boundaries on the clinical side, the onus is on us as dental laboratories to keep up with the latest developments. We cannot afford to sit back and wait for change to be pushed upon us – rather we should embrace the change, and use it to help our businesses grow.

Growing your business with same-day support

Same day

Over the past few years we have seen massive growth in the number of dentists enquiring about our support services for treatments such as All-on-4. This has been led by the surge in demand for same-day treatments that provide an efficient and effective solution for patients with missing teeth.

Thankfully, at Allport & Vincent we have been able to meet this growth in demand as we have invested heavily in both technology and training to help us deliver on-site support across a range of implant systems. We even invested in a ‘mini-lab’ that our prosthodontics expert can take with him on the day of surgery, so that he can create anything from a new set of full dentures to a temporary acrylic beam.

Benefits

Though it is fair to say same-day support is by no means an ‘easy’ option when it comes to the services we offer, it can be highly profitable for all parties involved. One of the biggest benefits we have noted at Allport & Vincent is that it gives the patient huge levels of satisfaction. This has a ripple effect onto all other members of the team, from the dentist to the technician and the nursing staff. From our own experience, we have discovered that this further strengthens the dentist-technician bond and even generates additional work from the same client, because of the mutual trust and respect which has been created between us.

Lessons learnt

If there is one thing we have learnt from offering support for the likes of All-on-4, it is that pre-planning is definitely key. This includes both planning for the case itself and the checking off of equipment and materials that we take with us. Though we all hope surgery will go smoothly, as the saying goes ‘failing to plan is planning to fail’. We aim to be prepared for every eventuality if we can and of course, it is also important that the dentist is likewise prepared for the treatment ahead. From our perspective, we do encourage clinicians to use guided-surgery techniques, as this helps to eliminate any uncertainties and also means that we can prepare most of the main restoration before the day of surgery.

Another lesson is to be sure that the technician you send is comfortable working under pressure. They should also have the flexibility to adapt to any changes on the day of surgery. At Allport & Vincent, we employ Grahame McCaslin who is head ofour specialist product division. Grahame has over 30 years of prosthetics experience and not only responds well to pressure but has the ability to evolve and adapt individual protocols each time he works on a case. As a laboratory, this is essential as you need to identify the positives and negatives from a day of surgery, in order to draw on those experiences to improve your efficiency and the quality of the final result.

Same-day solutions

As we have seen, there have been a number of different factors driving the demand for same-day full-arch rehabilitation treatments. One of the main factors here has been the fact that patients, in a world with ever-increasing time pressures, demand quick and efficient solutions to their problems – they want their new smile immediately.

Similarly, many dentists have identified that marketing these treatments is a lucrative income stream.

As technicians then, we are in an excellent position to take advantage of this growing market in dentistry. If we can offer effective, highly-focused on-site support, then we too can reap the benefits of this innovative new treatment concept.

Trade shows: a survival guide

Trade shows are an important part of the dental industry and can be an excellent way for laboratories to network with dentists, develop existing relationships and make new contacts. However, these events can be very expensive to attend. A stand in itself is not cheap, and once you factor in costs such as staffing, hotels and travel, this bill can often stretch into many thousands of pounds.

So, to help you get the most out of your investment, here are my top 10 tips to make a success of your trade stand:

1. Never go alone

Running a stand is a full-time job.

However, you do need to take breaks and every minute your stand is left unattended you are losing business. Even if you work on your own, there is always someone you can take along, even a family friend who can at least engage customers in conversation and keep them on the stand until you are back.

2. Dress appropriately

Exhibition halls often get very hot or very cold, so it’s important you are prepared for all eventualities. Also, you will be standing for long periods of time, so make sure you wear comfortable shoes. You might want to think about hiring or taking along a chair if you know that standing for long periods of time will be difficult for you.

3. Get there in good time

This may seem obvious, but arriving early gives you plenty of time to familiarise yourself with the show, the facilities available and where you are in relation to them. It can also be useful to look at other exhibitors’ stands before the doors open.

4. Check your checklist

If you are saying ‘what checklist?’ then you’re making your first basic error. Don’t forget essentials such as: a record book / enquiry sheet, an invoicing book, notepads and pens, sticky tape, extension cables, and a small first aid kit just in case. In general, larger shows will have a checklist you can use and will offer support such as furniture and lighting for hire.

5. Stand display

Everyone has their own ideas of what works best, but I strongly suggest you mock up your stand back at the laboratory before you go, so you discover any issues before you arrive at the show! If you intend to use a computer, make sure you have thought about your electricity supply and an internet connection. Also remember to include a ‘recess’ where you can keep coats and other clutter out of the way. Fresh flowers can always make a pleasant difference to a bare tabletop or shelf.

6. Make friends with neighbours

It is always useful to make friends with the people on neighbouring stands. Make sure you help them as much as they help you – if they are not your direct competition then they may even be able to send extra business your way or even keep an eye on your stand if you have had to attend alone!

7. Don’t pounce, but don’t sit back

Finding the right balance is difficult, but you don’t want to be too pushy or too laid back. Make sure you smile and make eye contact with passers-by. Open with a good neutral question that requires more than just a yes or no response. The worst thing you can do is say, ‘Can I help you?’ Much better to ask, ‘Are you in search of anything particular today?’

8. Qualify your visitors

Exhibitions attract a lot of auxiliary staff. Before you waste time engaging too much, qualify whether a visitor is someone who can make a decision, and a decision in your field. Don’t be shy to ask!

9. Keep notes

Most professional exhibitions are about finding well-qualified prospects. Make notes and follow your goals. Find people interested in the products you want to push at the trade show and make sure you have contact details to follow-up.

10. Prepare for the follow-up

This is the most important part of any show. Don’t just ring people up the next day – go through the notes you have made (point 9) and make sure you are well-read and ready to present a good confident pitch on the topics they are interested in.

Full support

Many readers will be familiar with the All-on-four treatment concept. This protocol, developed by Paulo Malo of Portugal, is rapidly becoming one of the most popular techniques for treating edentulous patients. Not only is the same-day, immediate solution absolutely life-changing for patients, but dentists also benefit from offering a high-value implant treatment that is completed in a relatively short period of time.

If you are thinking about offering same-day full-arch rehabilitations in practice, it is important that you do not offer this treatment lightly. Even highly experienced implant dentists would find it useful to seek mentorship for their first few cases to ensure that the process runs as smoothly as possible. This is especially relevant if you are not using guided surgery techniques.

Factors you should consider when choosing a laboratory include:

  • How much experience does the laboratory have?
  • Which systems is the laboratory familiar with?
  • Does the laboratory frequently provide same-day support?
  • Does the laboratory support guided and/or non-guided techniques?

Consider this

You should also pay careful consideration to the laboratory you choose to work with for such complex cases. Not all laboratories are necessarily set up to offer same-day full-arch rehabilitation support. Similarly, not all technicians are able to work under the intense pressure that same-day support cases create. Thankfully Allport & Vincent is fortunate enough to employ Grahame McCaslin, a highly-skilled and experienced technician, who heads up its specialist product division. Grahame is calm under pressure and he has the ability to evolve his protocols on a case-by-case basis, constantly improving efficiency and the quality of the results he produces.

Clearly, working with a good and reliable laboratory is vital for any dentist, but for same-day support the connection you have with your technician will most certainly be under the spotlight. After all, the technician will be in the more unusual position of managing both the expectations of the dentist and the patient. They should be prepared to resolve any unexpected problems that may arise on the day under the scrutiny of, most likely, several uncompromising parties.

Prove it

From experience, we have seen many examples of laboratories who, over the years, have tried to offer same-day support and have either failed or had limited success. Reasons for this may be down to a lack of investment in technician training or insufficient planning. To avoid falling foul of this situation, it is advisable to request case examples of your laboratory’s completed work and evidence of a proven track record of success in this field. This evidence may be offered by way of testimonials from other implant dentists or contact details for other clients for whom they have carried out similar cases.

Familiar

We must not overlook the importance of the implant company for these cases. There are many different manufacturers out there and the best will provide you with training, mentorship and ongoing support. Ensure that your laboratory is fully familiar with the system you use and that your implant company representative can be relied upon to provide you with all the additional support you need.

Over the last few years, treatment protocols such as All-on-four have become an exciting area for growth in dentistry. From the laboratory’s perspective, we are certainly finding that more dentists are now offering it as an option for their edentulous patients. However, while the benefits for all parties are clear to see, it is essential that you work with a team who you are confident can provide you with outstanding same-day support.