It is a standard protocol to recommend a full coverage indirect restoration for patients who present with the symptoms we call “cracked tooth syndrome”. I have personally suffered from multiple cracked teeth, and the pain associated with biting down on these teeth is intense. Despite it’s very short duration, it is also exhausting as you struggle to avoid hitting that tooth while eating, and just when you think you have it figured out, “ZING!”. If you have never experienced the symptoms I am describing you are fortunate, and can’t appreciate how much patients look forward to the resolution and being able to eat normally again. Given this anticipation it is truly frustrating when the pain continues after the cementation of your new crown. We have all experienced how frustrating this is for us as providers as well.
On almost a daily basis I am challenged with trying to diagnose a “cracked” tooth. The easy ones are accompanied by the classic symptoms and respond positively to biting on a Tooth Sleuth or Orange Wood stick. It is all of the others that require diligent thinking and some debate about if treatment is necessary. The American Association of Endodontists have classified five types of cracked teeth: craze line, fractured cusp, cracked tooth, split tooth, and vertical root fracture. Unfortunately this classification doesn’t make things any clearer for me as I am still left with this very broad category called “cracked tooth”.
This winter I hosted an online seminar entitled “Occlusal Diagnosis:Identifying Risk”. The course, divided into three online sessions covered the diagnosis of the joints, muscles and dentition to identify patients with functional risk. The following is a short audio clip from the first session where I discuss the questions I ask during a patient interview around their Temporomandibular joints.
In this video Mary Osborne (www.maryosborne.com) answers a question posed to her by Dr. Mike Melkers. Mike’s question was what he was doing wrong if after an exam and a treatment presentation a patient doesn’t move forward with the recommended treatment.
How many times over the years have I asked this same question of myself? I am glad to have Mary’s answer to share with you. Thanks Mike and Mary for putting this together!
With the increase n the amount of bonding procedures that we do everyday, tissue health has become an even more important conversation. There is nothing more disheartening than removing provisionals to seat the final restorations and looking at red, puffy inflamed gingival tissues. The tissue health is a critical factor to successful bonding and cementation. There are many factors that contribute to the gingival health at the seat appointment. One is the patients oral hygiene. Having myself had splinted provisionals I am clear that very few of my patients are going to use floss threaders. At best we can hope for patients brushing and even then if they are worried about knocking off their temps they will be skiddish about their oral hygiene.
I am old enough that I learned amalgam as the go to operative material. In those days when we encountered deep decay we followed a process of applying calcium hydroxide to the deep areas of the prep and expected good results in the formation of a dentinal bridge and survival of the pulp. When we transitioned to composite products like Dycal(Calcium Hydroxide) and Copalite disappeared. For me it has felt like there has been a void in my ability to pulp cap in the instance of deep decay under a composite. Using glass ionomer or RMGI is probably the most accepted technique. The challenges I have run into are the set time of the materials and the limited bond strengths to dentin. Earlier this year Bisco dental released a new product designed for just this purpose. I have been using it ever since and finally feel like I have a pulp capping product I can use with confidence.
The last step in creating an anatomic appliance is to create the occlusal design prior to polishing the appliance for delivery. Anatomic appliances are designed to capture an actual occlusal scheme that can be created on the patient’s teeth onto an artificial acrylic surface. Alterations from the existing occlusion to the acrylic are designed to eliminate signs and symptoms of occlusal disease and stabilize joints and muscles. The anterior guidance can be designed as either a canine guidance or a group function, and normally mimics the existing interincisal angle or is more shallow. The combination of anterior guidance on the appliance and the angle of the eminence create posterior disclusion.
To complete our series on occlusal appliances I wanted to include this video of doing an intraoral reline. Hard acrylic appliances need to be both passive, meaning they do not exert orthodontic pressure, and retentive such that the patient can not remove it with tongue pressure or when half asleep. Accomplishing this magic combination requires utilizing methyl methacryalte and performing a reline in the mouth that creates a path of insertion. I have yet to find an appliance that works as well without being relined, despite trying many different types. Although the taste of the reline material is unpleasant, the end result is well worth the five minutes of time. I make sure my patients know ahead of time that once set the material has no odor and no flavor.
This past weekend here in Scottsdale I geld a 2.5 day workshop for teams with my dear friends Mary Osborne and Joan Unterschuetz. Over a decade ago I first became aware of the concept of patient centered or relationship based dentistry. Having become disenchanted with the way I was practicing dentistry I was attracted to this model. A fundamental premise is to partner with our patients to help them make healthy choices. Out of this partnership we can find greater trust, appreciation and fulfillment professionally. These rewards come out of our ability to do more of the dentistry we love to do on patients who value and appreciate us and have chosen the care they are receiving.
In previous posts I tried to define a process called oxidative stress, which occurs when our cells are exposed to more oxidizing agents than they can detoxify. Fortifying our cells against this process, and even increasing healing is the premise behind the use of topical anti-oxidants. We have numerous studies that have shown that wound healing is diminished in the presence of oxidzing agents. In addition these studies have shown that the addition of a combination of anti-oxidants topically reverses the cell damage process and even encourages wound healing. From these original studies clinical research was completed. there are a variety of conditions on which the use of topical anti-oxidants has been shown to have a positive effect: