IT WOULD BE NICE TO KNOW March 28 2016, 0 Comments
Let me share with you the tale of a young patient who I first met at an American Academy of Facial Esthetics (AAFE) live patient training course who presented for Botox treatment of her masseters. There is a lot to learn from her story as it is very instructive as to a universal challenge that plaques every single dentist on a daily basis.
This patient came with the complaint “I grind my teeth and my implant is beginning to get loose”. The interesting thing about this patient was that she is only 22 years old and already has a dental implant. After a complete dental, head and neck examination I found that many of her teeth have some restorations but she has a very low caries index. She reports that many of her restorations are a result of teeth that have chipped or broken by themselves and not from “cavities”.
She goes on to explain a very common scenario as to why she has this dental implant. Her tooth suffered a fracture when she was about 19 and was restored with a tooth colored filling. A year later, the tooth and filling broke and was restored. A year later, it broke again and now she needed a root canal, post, core, and full crown. Three months later, the patient woke up one morning with the crown and post out of her mouth. She took this back to be treating dentist who for the first time mentioned that she must have sleep bruxism. As the tooth was non-restorable, a dental implant was now necessary. The dental implant was placed, she waited 6 months, and a crown was fabricated. Now, after spending thousands of dollars, it felt as if the crown was becoming loose, she sought out another opinion.
Just looking at this patient, it was obvious she had significant masseter hypertrophy. Using AAFE protocols that we teach, I had her take a STATDDS home bruxism/sleep monitor test and soon found that her bruxism episodes index (BEI) was well over 8.0 which makes her a very significant destructive bruxer. We treated her masseter muscles with 20 units of botulinum toxin (Xeomin, STATDDS). Two weeks later, she was tested again and had a BEI of only .6 which has resolved her bruxism as long as she maintains this botulinum toxin treatment.
With this new objective data about this patient's bruxism, I could now properly formulate a treatment plan for this patient that will include restorative materials that are very strong and can withstand very high occlusal forces for when the patient regains full contraction of her masseter muscles until she returns for botulinum toxin treatment. In this patient's case based on her BEI numbers, for any restorative treatment necessary I would use a fracture resistant universal nano-hybrid composite resin such as Gaenial Sculpt (GC America) or Reflectys (Itena USA). In her case, I had to drill through the crown to unscrew the abutment. I replaced the implant crown with a full mono zirconia crown (Bruxzir Translucent, Glidewell Lab) cemented with a temporary cement (Dentotemp, Itena). Should any other full crowns become necessary due to her other large restorations failing, I would use either Bruxzir with conventional cementation or Emax (Ivoclar) with full resin bonding cementation. These restorative choices are the result of the objective bruxism data so now I can insure a good long term prognosis.
For this first treating dentist, it would have been nice to know an objective bruxism number to guide them in treating this patient, but it wasn’t available then. With 1 out of 3 patients and now our capability to obtain specific evidence based, objective data on patients that will allow us to properly treatment plan patients, it is no wonder that Dr. Gordon Christensen says, “bruxism monitoring is one of the most important concepts we have today.”
This technology is very cost effective, also tests for sleep disorders, and is easy to administer. This testing can help you finally measure bruxism so you can formulate a treatment plan with an excellent long term prognosis and not guess if the patient has bruxism. The AAFE can teach you how to implement this in your office, get trained today!
Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer and author. Dr. Malcmacher is president of the American Academy of Facial Esthetics (AAFE). You can contact him at 800 952-0521 or email drlouis@FacialEsthetics.org Go to www.FacialEsthetics.org where you can find information about live patient Frontline TMJ/Orofacial Pain, Botox and dermal fillers training, Dental Implant Training, Frontline Bruxism Therapy / Dental Sleep Medicine, Medical Insurance, download his resource list, and sign up for a free monthly e-newsletter.
Disclosure: Dr. Malcmacher is President of the AAFE and is a consultant for STATDDS.