I dare you to talk about occlusion

Nov. 1, 2001
The knowledge gained in occlusal concepts supports true comprehensive care and a total oral wellness plan.

The knowledge gained in occlusal concepts supports true comprehensive care and a total oral wellness plan.

Business etiquette dictates — as well as the tradition for professional "small talk" — that the topics of discussion to be avoided are religion, politics, and sex. Well, I would like to start my own "list" of dental topics to avoid.

I personally never shy away from a good debate, and I seldom follow my own advice — kind of a "do what I say, not what I do" philosophy. So you can decide for yourselves whether or not to bring up the topics of my list in a dental conversation.

Hygiene autonomy would be at the top of the list. I would avoid this topic in a crowd consisting of 90 percent or more dentists, especially if you are the only hygienist present who can distinguish the difference between autonomy and independent practice. So, unless you are ready to handle the heated discussions, the knife-like stares from across the ballroom, and/or the labels of "team wrecker" and "hygiene Nazi" by ignorant, closed-minded professionals, I would carefully pick the time and place for a discussion about self-regulation.

The second addition to my list of "controversial" topics can be mentioned by dental hygienists for the sole purpose of diverting attention away from themselves (especially if you did not take my advice and proceeded to talk about item #1 above with a group of dentists). The topic is occlusion!

Massive controversy and egos lurk in almost every dental conversation about occlusion, all clamoring about which occlusal theory is absolutely the only way to position the jaw joints when restoring the mouth. To simplify, the two main camps are 1) the gnathological dentists and the centric relation principles of occlusion and 2) the neuromuscular dentists and myocentric principles of occlusion. The following are three basic starting positions for how the jaw can be restored:

Centric occlusion (CO) — A habitual/acquired occlusion or tooth-to-tooth relationship that is developed by the patient. This common position is maintained until dental therapy.

Centric relation (CR) — A jaw/joint position in the most superior position, regardless of tooth position or vertical dimension. It is achieved through mechanical or bilateral manipulation, which allows the skilled dentist to verify the repeatability of the position with needlepoint accuracy.

Myocentric (NM) — A stable jaw/joint position which the upper and lower teeth intercuspate and are synchronized bilaterally/symmetrically with the elevator muscles. This position is achieved by electrical stimulation (TENS) of relaxed masticatory muscles to move the mandible on a trajectory, which originates at a muscularly rested mandibular position (Cooper, B.C., 1999). This position is reproducible and is found by bimanual manipulation or mechanical intervention.

Hygienists are starting to understand that esthetic hygiene is not just about "cosmetics" but also about providing comprehensive dentistry. We also serve clients almost as a "practice within a practice."

A hygienist's scope of services does not involve diagnosing malocclusions or implementing restorative treatment plans based on CR, CO, or the NM concepts. But a hygienist should understand the following:

  • The multiple factors, signs, and symptoms associated with occlusion and TMD.
  • How, if undetected and untreated, poor occlusion can negatively effect the longevity of any restorative material used in rehabilitation and esthetic dentistry.
  • How correcting occlusal discrepancies can help decrease the progression of, and assist in the management of, periodontal disease.

To begin training themselves in the clinical signs and symptoms and developing a working knowledge of occlusion, hygienists and other team members should start with their employer. Asking him or her what position they favor when rebuilding the dentition will provide the opportunity to discuss and develop together hygiene protocols, skills, and rationale that supports doctor/hygiene communication during clinical examinations.

For the past 15 years, I have clinically worked with, and have had my dentistry completed, under the philosophy of CR. The following are some starting points for discussion between a CR doctor and a hygienist:

  • The temporomandibular joint
  • The role of muscles
  • Vertical dimension
  • The neutral zone
  • Centric relation
  • Long centric
  • The envelope of function
  • Anterior guidance
  • The occlusal plane
  • Occlusal contacts, signs, and symptoms.

Another place to gain information and other perspectives on this topic is to attend a wide range of continuing education programs. With the goal of "seek first to understand ... then to be understood" (Steven Covey), I attended the Myotronics 30th anniversary seminar last August in Seattle. I sat amazed while listening to all of the speakers at the meeting. I had registered as a hygienist (first hygienist to do so, I think), and I found each speaker, program participant, and manufacturer's representative extremely friendly and willing to spend their time throughout the weekend to share their information and perspective on TMD.

Here are some areas for discussion between a NM doctor and a hygienist:

  • Neuromuscular diagnosis
  • Bio-instrumentation [computerized mandibular scanning (CMS), electromyography (EMG), transcutaneous electro-neural stimulation (TENS), sonography (SONO)]
  • Scan interpretation and techniques
  • The relationship of posture, muscle balance, signs, and symptoms

I freely admit that I am continuing to study occlusion and how it merges with hygiene services. But I recognize that dental hygienists are the team members with the most consistent access to the client base. The hygienist is the ideal person for re-enrolling clients of record for comprehensive examinations. This coordination makes hygienists' knowledge of functional reasons for dentistry imperative.

The knowledge gained in occlusal concepts supports true comprehensive care and a total oral wellness plan. When hygienists gain an awareness of occlusion and supporting muscles, it will help break the string of prediagnosing for the "Crown of the Year Club." A lack of awareness during treatment planning supports random crown recommendations or amalgam placement. These hunt-and-discover protocols can lead to destructive consequences, such as fractured restorations, increased occlusal pathology, and/or periodontal breakdown.

Learning about the various occlusal theories, the appropriate prediagnostic evaluations, clinical signs and symptoms, and establishing hygiene protocols for implementation lead to an involvement of the entire team. It can set the practice apart from others in the delivery of comprehensive care.

Kristine A. Hodsdon, RDH, BS, presents seminars nationally about esthetic hygiene. She also has developed Pre-D Systems, a pre-diagnostic computerized clinical checklist for oral health professionals. She can be contacted through www.pre-d.com.