Friday, January 16, 2015
One of the hardest parts of dentistry is in the diagnosis. By diagnosis I do not mean just deciding what you would like to do to a tooth. I mean the critically important step of determining why that tooth needs something.
For example, simply replacing a filling that broke may address a patient’s problem in the short term. But it may be most important to look at the etiology of the fracture in the first place in order to provide a long-term solution to the actual cause of the problem. Is the patient grinding his or her teeth causing the filling to fail or is there an issue with occlusal forces on that tooth. The reason looking for a complete diagnosis of the entire clinical situation is so important is because doing this will ensure the true success of your restoration. If you don’t understand what was going on to cause the problem in the first place, it very likely is going to happen again.
At my practice we recently had a new patient come in requesting a second opinion. He was told he needed a night guard because it looked like he was grinding his teeth. When asked about symptoms associated with bruxism such as pain in masseter muscles, jaw joint or teeth, he reported he has never had any issues. He also mentioned he was not wearing his night guard because it only contacted on his front teeth and actually caused pain when he was wearing it.
We took a look at his teeth, and I would agree that we saw a loss of enamel on the occlusal surfaces. However, it did not have the same appearance as someone who grinds their teeth. Rather than chipping and sharp edges, the teeth had smooth and rounded edges. Even the front teeth showed thinning enamel and divots from the opposing teeth.
The deep pits with smooth sides are easy to see.
Erosion on the anterior teeth was equally deep with the same smooth sides.
I sat him up in the chair and asked if he ever had trouble with heartburn or reflux. He said he had experienced problems with that for as long as he could remember. The issue here was not a matter of attrition from bruxism, but erosion from stomach acids.
So what was our recommendation? We potentially could have adjusted his night guard or made him a new one. However, no amount of functional occlusal protection would have stopped the issue he is experiencing. Instead, our recommendation was to see his primary care physician, diagnose the source of his reflux, and get that under control. In this case, understanding the etiology of his issue made all the difference in the world.
Have an interesting case from your office? Let us know or drop a comment below!