Contents Post-Test

Clenching: The Tooth Killer

Clenching is the most destructive force in dentistry. If you treat a patient’s periodontal disease and neglect the patient’s clenching problem, you will have a failure. If you place a crown or a filling and ignore the patient’s bite, you will have a failure. If you construct a denture and ignore the patient’s clenching problem, you will have the patient coming back with sore spots. If you ignore the patient’s clenching problem and perform oral surgery, the patient will be having excessive post operative pain.

This course will help you to identify a clenching problem and give you some solutions. The course will take you through many phases of dentistry and show you how clenching determines the success or failure of the dental or tissue restoration.

Emergencies

When a patient enters the office in pain, the first thing that should come to mind is clenching. Usually the patient’s pain can be attributed to clenching. The abscess tooth usually swells, forcing the tooth to be higher in the mouth. The patient strikes the raised tooth first, driving it down into the socket full of liquid (serous), before the other teeth are met to balance the pressure. The point of pressure continues to the nerve below the tooth, causing pain.

The patient probably has had this abscess for some time with periodic episodes of pain. The tooth may be decayed and the nerve exposed, creating the condition described above. It will actually feel better when the patient clenches his teeth because the pressure pinches the nerve below the tooth. This numbs it a moment. Though, when he releases the pressure, the swelled, injured nerve hurts even more. The patient will bite again to stop the pain, continuing the damage and increasing the pain.

To take the patient out of pain, the occlusal of the infected tooth is reduced and the tooth is opened to drain the abscess. If you only open the tooth, you will not take the patient out of pain. He is still driving the tooth into the serous liquid, creating pressure and pain. The high occlusion needs to be reduced.

There Are Many Ways the Patient Can Create an Abscess

Nerve exposure from decay leading to an abscess is the process we are most familiar with. The initial nerve exposure can be painful, but the patient may tolerate it and allow the pulp chamber to become exposed to the elements of the mouth. The pulp chamber becomes infected. The infection drifts to the apical end of the tooth.

The body cannot do anything to protect itself until the infection emerges from the canal or canals. The body swells the tissues and sends in the army of white blood cells. A battle wages and the serous fluid (pus) develops from the dead white blood cells and bacteria.

The swelled tissue cannot be drained until the serious tissue fluid develops. This can be checked by aspirating the swelled area. However the tooth can be opened and drained. The tooth must be reduced to relieve the pressure on the apical nerve.

Excessive clenching leading to an abscess is less familiar. The patient with a clenching habit can damage one, or several, teeth until the tissue can no longer repair itself. The alveolar bone will breakdown around the tooth increasing the width of the periodontal membrane. The tooth will exhibit mobility ranging from one to four, with four being the greatest mobility. There is nothing wrong with the physical tooth. It is the tissue around the tooth that has become necrotic and infected.

The patient would clench his teeth creating pain and swelling of the tissues around the affected tooth or teeth. The excessive pressure against the periodontal membrane and the periapical tissues causes the tissue to respond by swelling.

The pain created by the pinched nerve at the apical end of the tooth is the body’s way of telling the patient to quit clenching the tooth. The swelling forces cause the tooth to be higher in the mouth than the other teeth, allowing the clenching to continue the damage.

The patient will come in the office with pain in the tooth. The immediate response is the occlusal reduction of the offending tooth to take it out of occlusion. This will relieve the pain by removing the pressure on the tooth. This is not an excessive reduction. It is only enough to bring the other teeth into function and take the stress off the hurting tooth.

If the condition is caught early enough, the occlusal reduction will solve the problem. The tooth will slowly work its way back into occlusion, but hopefully the patient will not be clenching his tooth then. It is surprising to note that the patient is singling out one or two teeth (maxillary and mandibular) as the target for his clenching. This is probably the most common type of clenching.

When the clenching problem is ignored, the nerve and blood supply at the apical end of the tooth is damaged enough to kill the tooth. The tissue in the tooth becomes necrotic for lack of a blood supply. The periodontal membrane breaks down allowing bacteria to enter. The bacteria take advantage of the necrotic tissue. The body responds by swelling and bringing in the army of white blood cells. The war begins, but the body is handicapped because the tooth is still receiving punishment.

Finally, when the patient is hurting enough, he stops his clenching. The tissue repairs itself. If the damage stops before the tooth becomes necrotic, the tooth will return to a healthy condition. If the tooth becomes the necrotic, the best the body can do is wall off the offending infection. The alveolar bone will pull back from the tooth. A defensive layer of tissue will line the alveolar bone cavity around the apical end of the tooth to protect it from the bacteria. This will allow the patient to continue using the tooth without pain. The body won the battle, but the war is not over.

Later, when the patient becomes stressed, the tooth is under pressure again. The protective layer of tissue around the apical end of the tooth is breeched and the war starts up. The body brings in the white blood cells. The tissue swells and the tooth hurts from the pressure being applied to the nerve. The pressure causes the alveolar bone to be destroyed, allowing mobility. The pain causes the patient to stop his clenching enough for the body to start its corrective measures, but the alveolar bone does not recover. The periodontal membrane becomes involved creating a wide periodontal cavity around the tooth.

The process repeats itself until the alveolar bone around the tooth pulls away from the offending tooth leaving it in the soft tissue where it will eventually extrude itself from lack of alveolar bone support. When the patient says he extracted his own tooth, he is referring to this condition.

Diagnosis

When you are diagnosing the tooth in trauma, you look for the following:

Physical Exam
  1. The tooth will be sensitive to touch. Using a blue articulating paper, the tooth can be checked for high spots. A light tapping on the blue marks will tell you which tooth is causing the pain. If you tap the opposing tooth and find it is sensitive, you can assume the patient has been clenching his teeth. The blue marks on the offending tooth will tell you where you will need to reduce later.
    It is interesting to note when the patient clenches a side of his mouth. He usually offends only one tooth in the upper arch and one tooth in the lower arch.
  2. Up and down pain is usually a clenching problem. The patient may have an exposure, but the up and down pain is coming from the clenching. Many patients will clench their teeth when they feel pain in their teeth from decay, or an abscess.
  3. The offending tooth will be sensitive to cold air or water.
  4. The tooth should be checked for swelling over the roots and around the gingiva. The classic red ring is the direct result of clenching.
  5. You should look for recent fillings or crowns. Usually when these are left high, they become the offending tooth causing the pain. If the patient is a clencher, a slight rise on any tooth will become a target for pain.
  6. Mobility should be checked by pushing the tooth laterally. If the clenching condition has existed for a period of time, the tooth will have mobility.
  7. Clenching: The Tooth Killer
  8. You should look for wear marks on the teeth. This is especially important for the anterior teeth. A worn tooth indicates the patient has been grinding his teeth. If the maxillary incisors are chipped and the lower incisors have mobility, the patient is a clencher.
X-ray
  1. The periodontal membrane is usually wider around the tooth.
  2. The periapical will show alveolar bone lost ranging from minor to severe depending on the length of time the patient has been clenching his teeth.
  3. The tooth usually shows no decay. This should be the definitive clue. The tooth is in distress, but no decay is present. This has to flash on clenching as the causative factor.
Anecdote

A woman (vice president of a bank) in her late forties came into the office in extreme pain (tears were flowing down her cheeks) in her lower anterior teeth. She had a small mouth with a class two malocclusion. She had bank examiners at the bank and she had to get back, but she could no longer stand the pain in her mouth.

The X-rays revealed a large boney cyst extending from the mesial of tooth number 22 to distal of tooth number 23, including the entire apical portion of the roots. The boney cyst was three millimeters in width and ten millimeters in length.

The tissue on the labial side of the tooth was slightly red, but no swelling was visible. Upon touching the teeth, number 22 and 23, the patient felt extreme pain. There was only slight mobility.

The patient was numbed to take her out of the extreme pain. Normally, when a tooth exhibits a large boney cyst, it is not necessary to numb the patient to open and drain it.

The teeth, numbers 22 and 23, were opened to allow drainage of the bony cyst, but no fluid came out. The teeth were slightly lowered to take them out of occlusion. The patient was placed on antibiotics and sent home. That should have solved the pain problem.

Three days later (Friday afternoon), the patient was back in the office suffering from severe pain in her lower jaw. I could not touch tooth number 24. I thought she was biting on the tooth and attempted to lower it some, when the patient screamed in pain from the cold water.

Her lower jaw was slightly swelled and inflamed, extending down into her neck. I learned she had been placing a hot cloth over her lower jaw to relieve the pain. This allowed the infection to move into her neck.

I attempted to give her a labial injection of anesthetic, but this only caused her more pain from the increased pressure. Something was going on that I was not picking up. The high emotional state of the woman was not allowing me to evaluate her properly.

Stepping back a moment, I noticed she had large wear areas on teeth numbers eight and nine. I remembered the stress at the bank, but I was puzzled how a person with a class two malocclusion could possibly clench her front teeth. It takes a great effort to accomplish this.

I questioned the patient, but she denied doing this. I even had her bring her lower jaw forward to attempt this. Her jaw was in such pain, she could barely move it forward. Yet the symptoms were all there.

I took another X-ray. It revealed tooth number 24 had a thick periodontal membrane. This was new and it would explain the cold sensitivity earlier. The patient was not striking teeth numbers 22 and 23, because I had taken them out of bite. Now she was placing all the force of her clenching on tooth number 24.

She was clenching her anterior teeth. Everything fit the diagnosis. Now, I had to convince the patient, her husband, my office manager and my assistants. No one else believed it could be something so simple causing all of this pain and destruction of her teeth.

Against much opposition, I took the impression for the bite appliance. The patient’s tears rolled when I placed the cold impression material against her lower anterior teeth, but I managed to obtain a workable impression.

The laboratory we usually send our cases to had left for the weekend. All I had was thin tray material used for bleaching. I put three of them together and made the bite appliance. I cut out the labial section over the anterior teeth. This took the pressure off the teeth, numbers 22 through 27. The lingual portion of the bite appliance was left to keep it together.

The bite appliance was inserted. The patient could not touch her lower anterior teeth. The patient left the office in tears. Her husband was upset. The office staff continued to think I was the worst dentist alive to allow a patient to leave the office in this condition.

Later in the evening I called the patient to learn she was sleeping. It was the first time she had slept in days. I called the next day. This time I talked to her. The intense pain was gone. She was only experiencing the soreness in her jaw. I told her, “It was the clenching after all.” Her response: “You think!”

Analysis

In hindsight I should have diagnosed the clenching problem on the first appointment, but the obvious infection below teeth numbers 22 and 23 said the teeth needed to be opened and drained. The obvious pain the patient was experiencing was countered with two submandibular injections of anesthetic. It masked the symptoms. This led me to believe we had solved the immediate problem of pain for the patient.

On the second appointment, no anesthetic was given. This forced me to look for other symptoms and led to the clenching diagnosis.

Types of Clenching

1. Centric Clenching

The patient bites hard into the upper teeth. There is no other movement except the driving vertical force. This will leave the teeth hypersensitive to cold, painful to touch and create swelling in the periodontal membrane and gingiva. If it is not corrected, the teeth will become extremely painful. The patient will not be able to close his mouth without pain. The teeth taking the punishment may eventually lose their blood supply and become necrotic. This will lead to alveolar bone lost, mobility and abscesses. A bite appliance (night guard) will give immediate relief to the patient experiencing pain.

2. Lateral Movement

The patient grinds his teeth very hard back and forth. There is very little movement in the grinding process, but pressure is applied buccally and lingually.

Usually, only one or two teeth take the punishment, but I have seen it affect all of the posterior teeth. Buccal-lingually pressure will extract teeth. If this grinding is allowed to continue, the teeth will become mobile and eventually lose all of their alveolar bone support. The first symptom of this is the swelling and inflammation of the tissues around the teeth involved. The scaling and curettage treatment will have little effect on the inflamed tissues. It is a clenching problem.

3. Circular Movement

The patient grinds his teeth in a circular motion. This type of clenching is very loud. The patient will tell you he grinds his teeth at night. Usually the alveolar bone is very strong in these patients, but the destruction to the teeth is severe. All of the teeth are involved to some degree.

The amount of excessive wear on the teeth will depend on the age of the patient and the degree of pressure being applied. The occlusal surfaces of the teeth are usually flat. If the patient continues in this habit, he will grind though the enamel and dentin exposing the pulp chamber. You will be able to see the pulp chamber on the surface of the teeth.

Age does not seem to be a factor. Many children come into the office with very flat and worn teeth. The fact they will be losing their primary teeth shortly is their only saving grace, but the habit will continue into their adult years.

The teeth need to be crowned while there is still room to place the occlusal. If there is not room, the teeth can be root canalled, or the vertical dimension can be increased with full mouth rehabilitation. The techniques for correcting this condition can be found in the crown and bridge CE courses. It is good to note that the new crowns need to retain the flat occlusal or the patient will be in pain.

A question needs to be answered. Why do people who grind their teeth in a circular motion make the alveolar bone stronger, while people who clench their teeth in the other movements lose alveolar bone support?

The circular motion equilibrates the teeth, allowing all of the teeth to receive equal pressure. There are no bumps. The teeth become very flat, allowing the vertical forces to remain. There is no point of extreme pressure. The circular forces tend to strengthen the alveolar bone. It is probably due to the stimulation from the grinding.

4. Protrusion Clenching

The patient grinds his teeth by bringing his lower jaw forward to grind on his upper teeth. The physical evidence of this is the wear area on the anterior teeth and the mobility of the mandibular incisors. If you bring the lower jaw forward, the edges of the mandibular incisors will match up perfectly with the maxillary incisors. If the condition is allowed to continue, the maxillary incisors will become chipped and mandibular incisors will become mobile. Usually, teeth eight and nine, and 24 and 25 exhibit labial gingiva inflammation. The anecdote described above is an extreme case of protrusion grinding.

5. Spot Clenching

This is when the patient picks one spot and clenches very hard. He will shift his jaw around to find the one spot (tooth) to vent his emotions. It is usually not in the centric or the functional movements of the teeth. The one tooth will take all the vertical pressure from the mandible resulting in swelling, inflammation and pain. It is usually the tip of a cuspid or bicuspid in the anterior and the cusp of the second or third molars in the posterior region. If the posterior teeth become involved, it can affect the Temporal Mandibular Joint and create tremendous pain.

Anecdote

A patient came into the office with her left jaw swelled and inflamed. She was in a great deal of pain. She could barely open her mouth to talk. She had been to several doctors, one being an ear-nose-and-throat specialist. None of them had been able to help her.

Thinking it might be an infection in the third molar area, she came to me. After a difficult X-ray, it revealed her third molar on the left side was missing. The second molar was fully erupted and had no decay, but the tissue around the tooth was swelled and inflamed.

I told her she had a bite problem and offered to make her a bite appliance to relieve the pain. She did not believe it could be that simple. She argued with me saying she did not clench her teeth. I made the appliance and relieved the posterior area of the second molar. I convinced her to wear the appliance overnight. She came in the next morning. The appliance was bitten in half. She became a believer.

Sequence of Clenching

1. First Stage

A patient will experience sensitivity to cold water or air. The tooth offended is being traumatized by the heavy pressure being applied. When the tooth is tapped, the patient will experience pain. This is usually the result of leaving a filling or crown too high. The patient now strikes the high spot on the crown or filling first before the other teeth touch, making the tooth extremely sensitive.

Treatment

Use blue indicating paper to mark the high spot. Using a football shape diamond, you reduce the high spot. The remaining rough spot is polished with a white stone and prophy cup.

It is interesting to note: The spot to be reduced is extremely sensitive to cold air or water, but once the tip is removed, the tooth can be worked on without the patient experiencing the sharp sensitivity

2. Second Stage

Gingivitis (red ring) occurs around the offending tooth. When you see the red inflammation around a tooth or crown, your mind should click on clenching. The tooth continues to hurt when cold water or air touches it. The opposing teeth will begin to hurt and the patient will experience up and down pain.

Treatment

Blue indicating paper will mark the high spot. Using a football shape diamond, you reduce the high spot. The remaining rough spot is polished with a white stone and prophy cup.

3. Third Stage

Periodontitis develops from pressure being applied to the tooth over an extended period of time. The tooth moves from the heavy pressure. The alveolar bone breaks down around the tooth, but the continued pressure does not allow the alveolar bone to repair itself. The X-ray will show the periodontal alveolar bone absorption. Vertical alveolar bone loss indicates the condition is current. Horizontal bone loss is older alveolar bone absorption. When the pressure is not being applied to the teeth for a period of time, the vertical alveolar bone will level out, trying to heal itself.

When the periodontal tissue around the tooth is swelled and inflamed, it causes the tooth to be pushed toward the occlusal. This places the tooth higher than the other teeth causing the tooth to take more punishment from the clenching. Unless this is corrected early, the tooth becomes abscessed from the continued punishment.

Treatment

If the periodontitis is caught early, a simple reduction of the occlusal will relieve the pain and allow the tooth to recover. Then, a full mouth scaling and curettage to remove the necrotic tissue and other necessary aggressive action is done to bring the tissue back to a healthy condition.

4. Fourth Stage

Necrotic tissue develops around the periapical and in the periodontal membrane. The broken down tissue allows bacteria to enter, creating an abscess. The tooth becomes very painful to the touch. The X-ray will show a wide periodontal alveolar bone loss. The gingiva around the tooth becomes inflamed and swells.

Treatment

If the periodontal membrane is still intact, root canal therapy and occlusal adjustments may allow the tooth to remain. If a periapical abscess has developed and the cystic sac is present, the tooth will need an apicoectomy to remain.

If the periodontal membrane is involved with the apio cystic sac (wide periodontal membrane), the tooth cannot remain in the mouth. The body is rejecting the tooth at that point.

Anecdote

A patient came into my office for his six-month check up. During the examination, I discovered swelling and inflammation around his teeth. The condition was more pronounced around teeth numbers eight and nine. Gingivitis immediately came to mind. Then I noticed a film of white cotton dripping from his teeth and mucosa. The patient had a yeast infection. I question the patient further. He had been rinsing his mouth out with a bactericidal oral rinse once a day, killing the bacteria.

There were no bacteria in his mouth to create the swelled and inflamed gingiva tissue. The condition was not caused by bacteria. It was a bite problem. The swelling and inflammation was coming from his clenching.

Laser Surgery

This is a relatively new technique to treat the periodontitis condition. The mouth is divided into four quadrants, upper left, lower left, upper right, lower right. Doing one side at a time, the laser drops down into the periodontal membrane all the way to the alveolar bone. The laser circles the tooth leaving a sterile ring of clot blood behind. The teeth are taken out of occlusion to allow the tissues to heal and regenerate the alveolar bone. Three months later, the other two quadrants are done. The point to be noted here is the fact the teeth are taken out of bite. This allows the tissue around the teeth to heal and regenerate the alveolar bone.

Periodontal Disease Resulting from Clenching

1. First Stage

When the patient is centric clenching, he is involving the entire mouth. The sequence of events is very similar to the single tooth clenching except the symptoms will involve the entire mouth. The patient will experience vertical pain going up to the eyes and forehead. Sometimes this pain is described as a migraine headache. The pain can continue up and over the head and into the shoulders of the patient.

The temporal mandibular Joints will become swelled if the condition is allowed to continue. When the mandible smashes into the socket continually, it causes the tissues in the TMJ to become stressed and break down. Swelling and pain are the results.

Treatment

A bite appliance (night guard) is the immediate treatment. This will open the TMJ and take the pressure off the tissues. It will also give the teeth something soft to bite on relieving the stress on the periodontal membranes of the teeth.

If the teeth exhibit extensive calculus deposits, a good scaling and curettage will remove the debris, but it will not relieve the problem.

2. Second Stage

The gingiva around the teeth becomes swelled and inflamed. The up and down pain will come and go depending on the patient’s emotional stress. This could go on for years with periods of excessive pain and periods with no pain.

Treatment

A bite appliance is the first line of defense. It should be worn when the patient is in pain and removed when he is not in pain. The appliance is not a cure. It is a temporary measure to take the patient out of pain.

3. Third Stage

Gingivitis begins to take roots in the broken down tissues. Swelling and the up and down pain are the result of the pressure being applied to the teeth. The teeth are tender to the cold air and water.

Treatment

A scaling and curettage can be preformed and a periodontal rinse with periodex is helpful to control the soft tissue against the bacteria loading up the periodontal pockets. A bite appliance is placed to ease the pressure on the teeth. The teeth are equilibrated to even the pressure from the clenching.

4. Fourth Stage

Periodontitis can be the direct result of clenching. When the centric clenching is allowed to continue, the teeth will begin losing the alveolar bone around the roots. If the X-rays show vertical bone loss, you know the teeth are in active clenching. If the X-rays show horizontal bone loss, you know the patient did clench his teeth at one time. The periodontal pockets begin to form as the alveolar bone is lost around the teeth.

Calculus and debris can begin to collect in the open pockets, bringing in the bacteria and infection along with them. The tissues around the teeth will go through periods of inflammation and swelling. It can be severe pressure creating pain, or it can be a lighter pressure and extend over a longer period of time.

If the condition is allowed to continue, the periodontal membranes become necrotic. Teeth become mobile as the periodontal membrane widens. The pulp chambers and apical portions of the most stressed teeth become necrotic. Infection sets in. The teeth will eventually be forced out of the alveolar bone and extruded from the soft tissue.

Treatment

Nonsurgical

A scaling and curettage will remove the debris from the pockets. A periodex rinse will remove a major portion of the bacteria. Antibiotic plugs can be placed in the deep pockets to prevent the bacteria from growing.

The patient can be given a bite appliance if the condition has become acute. Maxillary and mandibular trays can be given to the patient for the peroxyl gel home treatments. Refer to the course on periodontics for details of this treatment.

Surgical

A surgical reverse bevel procedure can be done to remove the vertical bone and reduce the alveolar bone pockets.

A gingivectomy can be done to remove all the tissue pockets, but it will leave roots of the teeth showing. This can be corrected with splinted crowns (bridge) Splint the teeth with splinted crowns to give the teeth more support.

Dentures

You would think a patient with a clenching problem would stop clenching once he lost all of his teeth from the problem, but this is not the case. When you have a denture patient coming back continuously with sore spots, you can attribute the problem to clenching. He will always have sore spots until he stops his clenching.

Treatment
  1. You can use a soft liner in his denture. Sometimes this helps, but I find this usually creates more problems. Adjusting a soft liner can be difficult.
  2. The teeth should be flat plane, especially if the patient is a circular clencher. Any high spot will cause the patient problems. Cusp teeth are asking for problems.
  3. Special attention needs to be given to the vertical dimension. If the vertical dimension is too low, the TMJ becomes the target for the clenching.
  4. The bite has to be equal on both sides of the mouth. Only the anteriors need to be slightly out of occlusion to keep the denture from tipping forward.
  5. Any sharp ridge or portion of the denture that the patient strikes first will become the target for a sore spot. The denture may need to be relined, even if it has been recently made. All of the tissue beneath the denture needs to be struck equally to spread the pressure of the clenching.

Oral Surgery

Most post operative pain is attributed to clenching of the teeth adjacent to the extraction site. When the patient is numbed for the extraction, he does not realize he is clenching his teeth. When the numbness wears off, he is in extreme pain. Instead of loading the patient up with pain medication, he can be instructed to place something between his teeth on the opposite side of the extraction site.

You cannot extract a tooth that is under extreme pressure from clenching with local anesthetic without hurting the patient. If the patient has a tooth with the classic symptoms of clenching, it is not wise to attempt an extraction. It is better to take the tooth out of occlusion even it requires several millimeters to accomplish it, place the patient on antibiotics and see him another day when the swelling is down.

Even if you manage to extract the tooth in this condition, the patient will still experience pain from the increased swelling of the tissues. The extraction disrupts the patient’s own defenses allowing the bacteria to take control.

Crown and Bridge

Most laboratories make the restorations with the bite in centric. They are not given lateral or protrusion. When the laboratory impression is limited to one quadrant in centric, there is no way to pick up the other functions well. This cannot be ignored if the patient is a clencher and likes to run his teeth through the functions.

When you see inflammation and swelling (red rings) around your crowns or abutments, it is probably a clenching problem. The crowns, or abutments, need to be adjusted by reducing the occlusal slightly and equilibrate the crowns or abutments with the rest of the mouth. A clencher needs perfect occlusion.

You cut the preparation, take the impression and place your temporary. The patient is brought back a week later for the delivery. You find the tooth has shifted mesially. You should immediately think of clenching. The clenching pressure moves the teeth until the equilibration is found.

The temporary needs to be perfect with a clencher. A bite left too high will move the tooth. If a contact is weak, the tooth will move that direction.

Fillings

Amalgam or composite fillings need to be in correct occlusion. A clencher will pick up a high spot immediately. It will be like biting on a nail for those who clench. If the problem is caught early, the high spot can be reduced and the patient will recover quickly. If the problem is allowed to persist, the patient may continue clenching, affecting the other teeth. “I did not have a problem with my teeth until you did the filling.” Patients do not admit they are causing the problem.

Symptoms of a Bite Problem

Treatment
Bite Appliance

This appliance will give the patient in pain immediate relief by placing a soft surface over the teeth and preventing the patient from striking the sensitive tooth or teeth. The appliance does not stop the habit of gritting, but it does give the patient’s jaw vertical support and relief. Usually, the patient should wear the appliance at night and during the day when his teeth hurt.

The appliance should be of soft material. The hard acrylic bite appliances do little to help the patient clenching. It does hold the mouth open giving relief to the muscles and aids in keeping the teeth from moving. Soft appliances allow the patient to close his mouth and protect his teeth. The mere fact the mouth is open gives a great deal of relief.

The appliance can be made in the office or sent to the laboratory. If the office already makes trays for beaching, then the bite appliance can be made by using heavier material.

When the anterior teeth are involved in the clenching problem, the anterior teeth need to be cut out of the appliance. The lingual portion must remain, but the labial and the incisal can be removed from the appliance. This will keep the incisal of the mandibular anterior teeth out of occlusion.

Equilibration

When the patient is experiencing pain, swelling, or inflammation on one side of the mouth, the bite is off. This can be the result of the recent fillings or crowns and/or the movement of the teeth (third molar eruptions). What we try to do in equilibration is to remove the high areas of the bite registration until the teeth occlude evenly in all functions.

Starting with the centric occlusion, the bite is brought into function. Blue articulating paper is used to mark the high spots on the teeth or crowns. Always use two pieces of blue articulating paper (one on each side of the mouth). The patient will then give you centric occlusion.

You should grind on the cusp of the teeth (maxillary or mandibular teeth) when possible. The high spots are removed with a flame-shape (football) diamond.

When the high spots are removed, the blue articulating paper will show up on all the molar and bicuspid teeth. This should not be overdone. You do not want flat plane teeth to accommodate a tooth several millimeters out of function.

The blue articulating paper will show heavier marks where the teeth hit first. These are the teeth you remove the high spots on. This is not a heavy reduction. A light touch with the flame-shape diamond bur will be enough. When all of the marks show equal pressure and all of the posterior teeth are hitting that are in range (excluding the large open spaces), the occlusal portion is completed.

The anterior teeth need to be included in the equilibration. If they come in contact when the posterior teeth move into centric occlusion, the equilibration must include them. It is always a debate as to where the reduction should take place on the anterior teeth. It is either on the lingual side of the maxillary anterior teeth, or on the incisal of the mandibular anterior teeth. I would say do the reduction where it will be less destructive to the natural teeth.

This will depend upon whether the anterior teeth are in a severe over bite, slight overlap, or they are hitting end to end. Deep over bite and end to end alignment require reduction on the mandibular incisors. The slight overlap teeth can be reduced on either the incisor of the mandibular teeth or the maxillary lingual anterior teeth.

Next, the teeth are taken into function by moving them laterally. Laboratories often forget the lateral movements when then construct our crowns, or bridges. They must deal with quadrant impressions and bites that we give them. They are lucky to achieve the correct occlusion.

The blue articulating paper is used to mark the spots when the teeth move into right and left lateral function. If a blue mark strikes the lingual side of the buccal cusp and nothing else, it needs to be relieved until the other teeth come into function. The teeth need to slip through function evenly when the jaw moves from side to side.

Protrusion is important for some patients. When the patient is striking his anterior teeth, you will see chipping marks on the maxillary incisal teeth and find the mandibular anterior teeth to be mobile. The teeth can be reduced slightly to distribute pressure to the other anterior teeth. There is no-good solution to incisal gritting of the anterior teeth short of an appliance.

When the equilibration is completed with the diamond bur, the white stone should be used to smooth all the surfaces touched by the diamond bur. It may be necessary to use a polishing wheel on the crowns.

Hypnosis

This is an excellent method of removing the need to clench, or at the very least transfer the emotion to another location. The patient can rub his fingers together instead of clenching his teeth. When he becomes tense, his fingers go into action. The technique of setting up an induction and placing this suggestion is one of the CE courses offered by HomeStead Schools.

Psychological Applications

It is very difficult to convince the patient he has a clenching problem. It does not matter how severe the pain is, the patient will argue with you, insisting he does not clench his teeth. The pain is real enough, but he does not notice himself clenching his teeth. It is a subconscious habit his mind is not aware of. The patient will never cure himself of the problem until he believes he has a problem and he will not respond well to treatment. I am yet to meet the patient who will say, “Yes, I have a clenching problem.”

Clenching is the expression of an emotional problem. The emotional problem can be expressed in less destructive ways. Rubbing ones fingers together is a way to express emotion. It seems in today’s high stress world, people are clenching their teeth more. The bank lady had been clenching her teeth for some time, but the symptoms did not become severe until the bank examiners arrived at her bank.