THE DENTAL DECISION MAKER June 14 2016, 0 Comments


Every day in your dental office, you tackle a variety of dental challenges that you diagnose and solve for your patients.  Think about the patients you have seen this past week – did you talk to them about periodontal disease, TMJ, broken teeth, root canals, crowns, bridges, dentures, and (maybe) implants?  Of course you did.  These are the most common dental issues that come into the office every day. 

Is that list complete?  What if I were to tell you that this list does not include the most common dental disease that affects a full one third of your patient population?  You never measure it, most of you don’t even see it.  Yet, this dental condition causes countless problems for your patients and often is the main reason for broken teeth, TMJ and orofacial pain, failed dentistry including simple restorations, crowns, bridges, and implants.  

Many of you are probably scratching your heads trying to think of what it could possibly be.  How could you possibly be missing something that occurs in one third of your patients?  The primary reason we don’t think about this disease is because it is so common that we as dental professionals almost accept it as being normal and until now, there has been no way to objectively measure it.  Once we are able to measure this condition, then we can wrap our heads around it, treat it, and then measure it again to make sure our treatment is actually working.  If our treatment is not working, then we can readily adjust the treatment until we reach a satisfactory outcome.


I hope by now you have figured out that we have been describing bruxism.  Bruxism is the underlying condition that affects every single dental treatment that you provide.  It is also the key factor in determining the long term prognosis and success of the dentistry that you work so hard to place in the patient’s mouth. 

Think about this – what moments in your daily dental practice do you dread the most?  It is when a patient comes in with a crown in their hand that you placed 1 week or 1 month ago.  Your stomach really gets upset when there is tooth structure inside the crown and even worse when there is a post sticking out of it. This is the post you literally just placed after the endo was done (either by you or the endodontist).  Of course you know that this represents a few thousand dollar expense for the patient which you are now going to have to address in terms of retreatment, replacement, or refund.  Are you going to discount or pay for the implant the patient may now need? 


Let me share this case presentation about a patient with a situation that happens routinely in every dental office and show you how new technology to measure bruxism can help you eliminate the dreaded scenario mentioned above.  This will dramatically improve the long term prognosis of every dental treatment that you will provide from now on. In addition, bruxism monitoring will help you decide on the best course of treatment for the patient based on evidence based objective data. 

Let’s introduce you to one of my patients, Liz.  She is a 23 year old female who has suffered from TMJ and orofacial pain in her head and neck since she was 19 years old.  Her medical history is clear other than her history of myofascial pain.  She is in otherwise excellent health and is very active.  Her dental history is another story – especially with the left side of her dentition where she had multiple restorations.  When she was about 19 years old, she began breaking some of the restorations and teeth on the left side of her mouth which required treatment.  Tooth #13, the upper second bicuspid, was particularly problematic as it eventually required endodontic therapy.  The tooth was restored with a resin bonded restoration at the time as the patient could not afford a full coverage crown.  This worked well for about a year when the tooth began chipping again.  Liz then changed dentists and had an initial examination and radiographs, you can see the panorex radiograph in figure 1.  The first question any dental professional should have is why does this patient have more restorations on her left side than her right side.  The second question is why do her teeth keep chipping?  Most of us don’t spend more than a minute (if that) thinking about why this is happening, we just deal with the situation as it is presented to us. 

After a consultation, the patient agreed to have a post, core, and crown on tooth no. 13 at what you can imagine was considerable cost.   The crown was seated and the patient was pleased with the result. 


Here comes the dreaded phone call from the patient.  Only 2 months after the crown was placed, Liz comes into the dental office with the crown and post in hand.  Let me ask you this - how do you feel as their treating dentist when you walk into the treatment room this patient is sitting in?  Do you wish you were somewhere else?  We all do. 

Here we are two months after the crown was seated and the tooth is non-restorable requiring an extraction, bone graft, and an implant.  It is a very disappointing visit having to tell the patient this but it is clearly the next step.  Before we send the patient for an implant, should we be thinking about why this happened? Most of us don’t give it a second thought – it must be a material or functional failure.  We tell the patient what the next step is and move on.

It is now a year later and the final implant crown is placed (Emax, Ivoclar Vivadent).  Liz is happy to have a new solid tooth and it looks great too.  She still suffers from TMJ and orofacial pain and a few months after this tooth is placed, Liz is referred to my practice for a TMJ and orofacial pain evaluation. 

Figure 2 shows Liz at her initial examination in our office.  When you are properly trained in orofacial pain therapy, the first thing to do is a complete medical history and then a very good evaluation so you can come up with a diagnosis and treatment plan.  The only addition to her medical history mentioned above is that she has seen her primary care physician and a neurologist for her headaches.  She had tried a variety of medications which did not help manage her pain so right now she is not on anything and has decided to “live with it”. 


Let’s evaluate the patient’s head and neck musculature as approximately 85% of TMJ and orofacial pain comes from muscles.  Before I do a complete head and neck trigger point examination, let’s just take a look at her face.  What do you see?  I’ll tell you what I see – her masseter muscles are way too big which gives her a very square appearance to her face.  Take a closer look and you will see that her masseter muscles are asymmetrical with the left masseter being quite larger than the right masseter.  That is very interesting in the fact I mentioned before – most of her dentistry is on her left side.  There is most certainly a connection.

I conduct a cranial nerve, ear, TMJ and dental examination which is within normal limits.  There is one area of concern on her dental examination.  Her left bitewing radiograph in figure 3 shows some osseous cupping around the implant she had placed a year and a half before.  The periapical radiograph in figure 4 suggests deficient trabeculation of the bone on the mesial of the implant.  Indeed, the tooth is slightly loose which we will address later.  I checked the occlusion which seemed to be fine with no centric, lateral or protrusive interferences. 

The trigger point muscle examination revealed trigger points in both trapezius, superficial masseter and deep masseter muscles which cause repeatable moderate to severe radiating pain to the corners of her jaws, both TMJ (left one was worst), front of her head, and behind her eyes.  She says this is exactly the pain she feels chronically which then turns into headaches which occur daily. 


There is one more very important piece of diagnostic information that we need to know before we treat this patient.  We need to quantify the patient’s bruxism so that we can know exactly what we are dealing with and then be able to treat this patient and measure again to measure treatment efficacy.  We also need to know if the patient has any sleep disorders that may be contributing to her bruxism. The patient was given a STATDDS home bruxism/sleep monitor (figure 5) to take a home bruxism/sleep test so we can see what her Bruxism Episodes Index (BEI)and Apnea/Hypopnea Index (AHI) numbers are.

Quick introduction to these numbers – the BEI is the number of bruxism episodes the patient has per hour of sleep.  A number above 2.5 suggests significant bruxism which has to be addressed.  If the BEI is above 5, this is very destructive bruxism that can easily break and chip teeth and any dentistry the patient has in their mouth.  If the AHI is above 5, then the patient has obstructive sleep apnea which needs a medical diagnosis by a physician and possibly an oral appliance in conjunction with the physician.  These numbers are so important as they will guide our treatment decision as well as let us know if our treatment is working with post testing.

Figure 6 shows the initial STATDDS bruxism/sleep test with a BEI of 6.8 and an AHI of 3.6.  What does this mean?  Liz has no obstructive sleep apnea but does have very destructive bruxism which is an evidence based number for this patient.   Now that I have the right diagnostic information, I am ready to begin treatment. 


Trigger point injections with botulinum toxin (Xeomin, STATDDS) were performed in the affected muscles mentioned above. Xeomin is an alternative to Botox (Allergan) which is equally effective and much less expensive.  10 units of Xeomin were used in each one of the affected muscles except for the left masseter which received an additional 5 Xeomin units due to its larger size.  Xeomin was also delivered into the frontalis, lateral orbicularis oculi, procerus and corrugator muscles bilaterally. 

An amazing thing happened at the treatment appointment – the headache Liz had that day started going away immediately.  The intermittent radiating pain started to resolve.  By the end of the appointment, about 80% of her daily pain was gone.  It takes 2-10 days for the botulinum toxin to take full effect, and indeed, a week later, all of her pain was gone for the first time in years. 

How do we know if our treatment is really effective?  Liz took a posttest with the STATDDS monitor.  Figure 7 shows her post test results which now show a BEI of 2.0 which is now insignificant.  Figure 9 shows the full face photo of Liz in which you can clearly see improved facial esthetics with a more heart shaped face and normal sized masseters.  Figure 8 shows the before and after comparison in a very happy patient.  The patient was given a Custom H/S Bite Splint (Glidewell Labs) to protect her teeth when she feels the bruxism coming back as the botulinum toxin wears off.  Now, what about the upper left bicuspid implant?  If it continues to fail, it will be replaced with a Hahn implant because of its initial stability and a Bruxzir Translucent Crown (Glidewell) for its strength. 


Here is the one question that I have for every single dentist reading this article – wouldn’t it have been nice to know this patient’s bruxism episodes index (BEI) before the endo was done a few years ago?  Look how much this young patient has gone through with dentistry she may not have needed had her bruxism been measured and controlled.  Before you do any restorative case and certainly one that includes crown and bridge, dental implants, or porcelain veneers, you should test your patient for their BEI number so you know exactly how much the patient is bruxing and treat it before you put in a single restoration.  This will make your dentistry last longer or even better, will help the patient preserve their own teeth.  This is exactly why my dear friend and mentor, Dr. Gordon Christensen says, “Bruxism monitoring is one of the most important concepts today!”


Training is the key in the areas that we call the AAFE Circle of Treatment (figure 10) which includes facial esthetics, facial pain, bruxism and dental sleep medicine as evidenced in this case.  Simply put, you can make your patients look great, feel great, and sleep great!  Successful restorative, esthetics, TMJ/orofacial pain therapeutics and bruxism treatment can now successfully and predictably be treated with botulinum toxin (Botox, Xeomin) and cost effective qualitative objective bruxism testing.  This will guide your treatment decision making giving your patients better therapeutic and esthetic outcomes than ever before.  It is time for you to join the over 9000 AAFE members who already use these concepts in their practices. 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   Go to where you can find information about live patient Botox and Dermal Filler Training, Frontline TMJ/Orofacial Pain Trigger Point Therapy, Dental Implant Training, Frontline Dental Sleep Medicine, Bruxism Therapy and Medical Insurance, download his resource list, and sign up for a free monthly e-newsletter.


Disclosure: Dr. Louis Malcmacher is a consultant for STATDDS.