more occlusion discussion

By Joseph Gronka posted 09-06-2013 08:27 AM

I believe that if you have been reading this blog/posts, you are getting the idea of the importance of muscle tonicity relative to restorative dentistry. There is more.
Endodontic considerations in malocclusion. 
My philosophy regarding pulpal inflammation and death. Pulps deteriorate to a state of necrosis. At times extremely slowly and then again very rapidly. The rate depends on the manner of the insult. The stages of "death" are subject to interpretation of reaction to temperature changes and pressure. If the pain goes away within seconds of the removal of the noxious stimulus, the pulp is healthy. I then look for cervical erosion, exposed cementum, and/or caries and correct the problem. Finding none of these, the only possible explanation is malocclusion. So, find the offending contact and correct it. If the pain lasts longer, for 30 seconds or more, it is indicative of a hyperemic pulp. This requires further observation and testing and waiting.
Think about the cases where you have to respond to the patient who has a rip roaring toothache. The radiograph is inconclusive, clinical exam shows a tooth in otherwise pristine condition except for some faceting on a cusp or two. Most dentists, under these circumstances, will "diagnose" a cracked tooth syndrome. Perhaps so, but most likely the result of hyperfunctional activity. I tell patients, while tapping gently on the back of their hand, "if I continue to do this for hours, do think that this area might get red?" The answer is always "yes". And that is correct. I then ask "what causes the redness?" Most do not know. So I explain that even that light tapping will cause cell damage if it is continuous over a prolonged period. The redness is caused by the increased blood flow to the area in order to remove breakdown products caused by the trauma to the tissue. The blood vessels near the surface of the skin become larger. So, imagine a tooth under similar stress being caused by a poor relationship with it's antagonist as in the case of malocclusion. You can expect the same result by following the dots. My next observation comes via questioning. Is this tooth sensitive to temperature change Which is worse, hot or cold. Teeth that are very sensitive, ask how intense is the reaction? How long does the feeling last? Then, percus the tooth. Note the reaction as to intensity and duration. Intense pain on percussion, I consider non resolvable and proceed to endo therapy. Any other response to percussion, I rely on reaction to temperature response. Which is worse, hot or cold. If hot, I proceed with endo therapy. If cold, I proceed with occlusal adjustment and wait and see. If the discomfort remains for weeks or appears to be getting worse, I test all over again from the beginning. Something I missed. First, check occlusion. I know I corrected this previously so, if the tooth is once again in need of further correcting, there is, undoubtedly, movement going on. Bad sign, swelling in the ligament space. Now it is an endo-perio problem. I would proceed with devitalization and extirpation and wait and see. No temporary cement is placed. I want the tooth to bleed freely in order to relieve all pressure. Rx suitable antibiotic. If this does not resolve in 48 hours, I recommend removal, no matter what the coronal condition is. I believe damaged periodontal ligaments are susceptible to invasion by multiple types of organisms some of which are not responsive to antibiotics and do not respond favorable to various therapies. I have treated such cases, for very patient people, for months. One case for more than a year, only to have to remove the tooth after all of that time. In my own case 4 years. I believe that chronically inflamed tissue is acidic in nature and the acid condition attracts bacteria from the blood stream. Think of bacterial endocarditis. So, what does this have to do with occlusion ? Think Malocclusion. It can be subtle or a "slap in the face". Whatever the case, it is not present if you do not recognize it. AND LACK of RECOGNITION is no excuse. Excellent dentistry must include the understanding of the gnathic system. I recall the simple observation by a dentist and engineer about the accumulation of bacteria around the ends of wires immersed in a growth medium.  ... and try to connect the dots...................more later..... Perio