What is your problem? Dr LD Pankey began all his interviews and examinations with this question. He knew that no one knows better than the patient why they have come.
When it comes to exceeding the expectations of new patients, it’s all about having the right information. What is their problem? Is that the real problem? What do they see as the solution to that problem? Why have they come to see me? Why have they come now? What is their understanding of their present condition? What is their understanding of the path necessary to achieve the solution they seek?
A comprehensive evaluation is designed to allow us (the patient and I) to explore questions like these, often prompting discovery far beyond the typical dental exam. Comprehensive evaluation implies a broader scope than initial examination. The goal of finding and fixing damage caused by decay, periodontal disease or occlusal forces is refocused to evaluating and celebrating health, and to maintaining teeth in maximum comfort, function, health and aesthetics throughout life.
It is refocused towards the future, towards what might be done now to ensure continued health or to restore health where it is found to be lacking. The biggest difficulty encountered in this paradigm shift rests in expectations. If the patient sees this new relationship as focused on fixing damage and you see it as assisting in the maintenance and restoration of health, it follows that you won’t ask the same questions and therefore will not seek the same answers.
For a number of years following my decision to practise comprehensively, I gathered bags of information about new patients. I became very good at finding and collecting data, a lot of data. I educated my new patients in terms of what I had found, and I recommended appropriate solutions to their problems. I waited for them to excitedly request the best dentistry I could offer. I’m still waiting. If it were only about information and knowing what’s in their best interest, then everyone would request; no, everyone would demand the best dentistry I could offer.
Here in the States, we kindly remind those who buy and use cigarettes that ‘The Surgeon General has determined that smoking is dangerous to your health.’ While visiting London this past holiday season, I saw a warning label on a package of cigarettes reading: ‘Smoking cigarettes causes a slow and painful death!’ I must assume that no one in the UK smokes given this level of ‘education’.
I must also assume that the large groups of smokers I observed there were foreign visitors whose inability to read English meant they failed to benefit from this education and therefore continued to suffer in their ignorance. If a slow and painful death doesn’t get their attention, I’m wondering how tooth wear is going to stir them into action. I must find a way to create interest, to create experience, to create a question.
Education experts tell us that we learn 10% of what we read, 20% of what we hear, and 30% of what we see. They also have shown that we learn 90% of what we teach! You and I spend our time in the 90% zone, observing the very clear connections between bite and stability, wear and breakdown, predictable aesthetics and functional occlusion.
We wonder why patients don’t get it, but they barely have a chance if education has a 30% limit. Fortunately, the same research illustrated that we learn 80% of what we experience. If we could harness experience for the patient’s benefit, we might see a change in understanding, in appreciation, and in the questions that are asked. One of the best tools at my disposal to create experience is the bite splint.
Bite splint applications
If you think ‘bite splint patient’ and immediately see muscle and joint pain, calls after-hours for medication, schedule clogging and dependent patients who are not really getting better, I’m certain you don’t enjoy (or use) bite splints. For many years dentistry has considered the bite splint solely as treatment for a group of disorders involving pain, a use that has benefited countless patients. Using the bite splint as an experience for the patient requires seeing it in a very different light. It requires using it as a tool that illustrates for the patient what is, and what could be.
At the Pankey Institute, we classify bite splints by diagnosis. Using history, muscle examination, range of motion, joint loading, joint sounds, imaging and functional and static occlusal observations, the skilled clinician is able to develop a diagnosis and create expectations.
The design of the splint – what it looks like and which arch it goes on – are independent of the diagnosis and will vary according to the clinician’s preferences and the patient’s desires. I use six different bite splints: the NG splint, the CRV splint, the OMD splint, the LID splint, the MID splint and the CRV4U splint, named according to the diagnostic criteria above. I have different expectations of each of these splints, a different endpoint.
The night guard
The simplest use of a bite splint is as a night guard (NG). The NG splint protects the patient from him/herself or adds protection to completed restorative and/or aesthetic treatment. Once fabricated, relined to a precision fit and perfected occlusally, I expect to see this splint only occasionally over the next three to six years, usually at hygiene visits. Because the muscles, joints, and occlusion are stable, this splint rarely requires adjustment. The expected endpoint is the splint wearing out. I discuss ongoing replacement every three to six years, and patients are usually rewarded by much longer service.
The centric relation verification splint
The next splint in my armamentarium is the centric relation verification (CRV) splint. It does what its name suggests. Often, even with muscles and joints that show no signs or symptoms of instability, the discerning clinician is keenly aware that centric relation is neither clearly observable nor recordable. Mounting and working up a case in a position other than CR is essentially a guess, a guess I am not comfortable making when predictability is high on my list (predictability is always high on my list). The expected endpoint is stable posterior contacts of equal intensity on the splint that do not change between appointments. I expect this endpoint to occur within two to six weeks.
The occluso muscle disco-ordination splint
The OMD splint is used in cases where joints are stable but muscles, and almost always the occlusion, show signs and symptoms of instability. These signs and symptoms indicate that I can’t be confident in an occlusal relationship at which to articulate casts for the purpose of planning appropriate restorative treatment. The expected endpoint is: no muscles tender to palpation, normal range of motion, joints that can be fully loaded and stable posterior contacts of equal intensity on the splint that do not change between appointments. I expect this endpoint to occur within two to 12 weeks.
The lateral internal derangement splint
The fourth splint I use is an LID splint. It is used with the patient who shows instability or suspected instability in one or both joints that is occurring on the lateral portion of the condyle. In almost every case, instability in muscles and occlusion is part of the observed condition. Translational joint sounds are the diagnostic differentiation for use of this splint. The expected endpoint is: no muscles tender to palpation, normal range of motion, joints that can be fully loaded, and stable posterior contacts of equal intensity on the splint that do not change between appointments. There may be a change or elimination of joint sounds, but this is not a criterion of the endpoint. I expect this endpoint to occur in six to 16 weeks depending on the degree of inflammation present at the comprehensive evaluation.
The medial internal derangement splint
The MID splint, like the LID, implies joint instability. In this case, the area of concern includes the medial portion of the condyle. Most of these patients present with pain, restricted movement and limited function. They are usually on a long journey through treatment, adaptation and recurrence, and often bring a long history of different doctors and treatment philosophies. They respond variably depending on the point at which your relationship begins. If the patient comes to you late in the adaptive process, you look (and feel) like a hero. If you meet early in the process, nothing you recommend may help. You may see obvious occlusal instability and be tempted to treat it. Use caution. Occlusal instability may have been an initiating factor, but correcting it may not impact the present condition of the patient. Pain can become the disease. Because these patients have extreme difficulty functioning normally, they may create psychological crutches to help them deal with it. With these patients, the MID splint is part of a much broader treatment plan that is constantly being evaluated and redirected. It is not in the scope of most restorative and aesthetic practices to routinely treat patients presenting with these problems. The expected endpoint here is improved comfort and function, and may be a moving target.
The CRV4U splint
The final splint I use is the CRV4U splint. Like the CRV, it is designed to verify centric relation, but not because I couldn’t observe or record it. The CRV4U splint is aimed at allowing the patient to experience the feel of solid, stable and smooth occlusion. It also lets the patient experience the feeling when their teeth do not exhibit those characteristics. I noticed that every patient with whom I had completed the use of a bite splint responded very differently to equilibration. When simultaneous contacts in the centric relation arc of closure were accomplished, they nodded and told me that was it. They had been there. I use this splint routinely with restorative and aesthetic cases when changes to the occlusion are part of the plan. The endpoint is reached when the patient feels the difference between the splint and their teeth so clearly that they ask a question about it.
The diagnostic criteria used to classify the splint do not determine the design. At the Pankey Institute, we teach two designs; the universal appliance (see Figure 1) and the Tanner appliance (Figure 2). Other designs used by excellent clinicians also may fulfil all the requirements of bite splint therapy. The expectations, the course of therapy, the time spent and the endpoint will be dependent on the diagnostic type, and thus the type determines the fee.
Splints that are used only or primarily to create an experience take less investment, with more complex diagnoses requiring more resources from all parties. The value of the bite splint far surpasses the superior predictability it provides. The real value is the increased understanding of what is and could be. This understanding leads to questions and solutions the patient is ready to hear.
I decided many years ago that I would never complete any treatment with a patient until she or he asked me to do it, including treatment for occlusal problems patients rarely ask about. The game was getting them to ask for solutions to the occlusal issues that I knew were important to achieving an aesthetic and predictable result. The bite splint is without a doubt the finest tool I can use in playing that game. The best part is it’s a game we both win.
Gary DeWood DDS MS is clinical director at the Pankey Institute for advanced dental education.