Sometimes we suspect a dental patient has tooth wear or damage from attrition. In these cases, we want to help the patient understand what they do with their teeth while sleeping. We also want to see for ourselves the patterns of wear. I recently learned about the Brux Checker® diagnostic material during the 2022 Masters Week at The Pankey Institute.

During Masters Week, Dr. Ricardo Armanetto from Genoa, Italy, showed us this material, which is 0.1 mm in thickness. One side of the material is red, and the other is foil. The material can be placed in your MiniStar®, BioStar®, or Vaquform thermoformer to create a suck-down device that your patient wears over their upper arch overnight. A suggestion is to make two of these devices and ask your patient to wear one for one night and one for a second night.

If the patient is para-functioning during sleep, they will wear the red off the device in the places where their teeth are touching within 0.1 mm of each other. You will see which teeth are touching and grinding.

In thinking about using Brux Checker, the following cases came to mind:

• Brux Checker is designed as a patient education tool. I want to use Brux Checker for patients I think are para-functioning because of signs of wear and attrition—and now I need them to take some ownership of their parafunction. This is an easy, inexpensive way to do that, in addition to the QuickSplints I use in my practice.
• I also want to use Brux Checker with patients I have equilibrated to double-check my equilibration. Sometimes, when the patient is in the dental chair, it is difficult for the patient to find a posterior interference that I failed to clear out. I want to ensure they are not damaging their teeth while para functioning on molars during sleep.
• Similarly, after placing dental restorations, I can use Brux Checker to fine-tune the occlusion after seeing what happens during the night versus in my dental chair.
• In the case of Class IV corners or incisal edge repairs that people want to be replaced in composite and the composite pops off, they may not know that they parafunction and there is a need to fine-tune their occlusion. I don’t know if I can get one of these patients to wear a Brux Checker during the daytime, but it should be easy to get them to wear one of these devices during the night. If the red wears off the foil at the spot where the composite has been used to repair a Class IV corner or incisal edge, there will be no question about the stress they are placing on the repair.

You can see that I’m thinking beyond patient education to using Brux Checker to help me fine-tune someone’s occlusion. I know there are places where people bring their teeth together at night that they can’t show me in the chair.

After practicing dental hygiene for more than twenty years, I went to work in the office of Dr. Doug Roth who was attending courses at The Pankey Institute. He had a copy of Dr. Bob Barkley’s book, Successful Preventive Dental Practices. Reading that book was a revelation for me. Although I never knew Bob Barkley, his work so resonated for me that I had the feeling he had read my thoughts about working with patients.

I had believed for some time that more was possible in dentistry. I had worked with good dentists and felt as though I took good care of my patients in the time I was allowed to spend with them. We were kind, thorough in our exams, and conscientious in treatment recommendations. Sometimes they took our recommendations, and sometimes they did not. I did not think there was much we could do to change that.

As a result of Bob Barkley’s book and the courses Doug was taking at the Pankey Institute, we incorporated a new model for bringing new patients into the office. Instead of moving patients quickly through an exam and treatment recommendations, we invested time and attention to get to know patients in a different way before we recommended significant treatment. I had no idea of the depth of connection we could have with patients, and the impact we could have on their health and well-being!

We spent “engaged” time with patients over a variety of appointments. We came to understand that the clinical tasks we had to accomplish were a small part of caring for patients. We began to see every interaction, with every patient, as an opportunity to get to know them and what was important to them to help them make healthy choices.

Over time we discovered with our patients:

• The status of the dental health
• The challenges of their current conditions
• The implications of these conditions if nothing was done to intervene
• Interventions they and we could do to change the trajectory of disease.
• A possible preferred future of choice
• Considerations involved in various treatment choices.

When we met patients where they were instead of where we thought they “should be” we found that some were ready sooner than others. We stopped giving patients solutions to problems they did not yet own. We came to understand that if we gave patients the time and attention they needed to own their existing conditions they were more curious about what Dr. Barkley called their “Probable Future” and more likely to pursue a “Possible Future.”

Without this spirit of collaboration and intentional patient development, we cannot do our best work.

Our influence develops throughout a process in which the patient is learning, in touch with their body, and engaged in thinking about the implications of the various aspects of their oral health. Because the conditions we discover today and our patient’s choices will impact their future health, we have a moral obligation to share what our experience tells us is likely to happen (the probable future) if they do nothing or if they choose a stop-gap treatment.

It is also our responsibility to help them see a preferred future that is possible for them when they are ready.

By engaging them in the exam process, creating opportunities for them to experience learning about their health, and welcoming them into collaboration, we enable them to partner with us in shaping their future. We must help them understand the implications of any choice they might make including its limitations, so they are fully informed to make true choices.

We have been trained to be efficient, and most dental clinicians have pride in their efficiency. But by prioritizing being “effective” over being efficient we make better use of our time and theirs. We experience an increase in trust, in our patient’s confidence in their decisions, and a more comprehensive view of treatment. Patients begin to see dentistry as a vehicle to create optimal health, function, and esthetics. Patients are more likely to keep their appointments, follow through on suggestions, and pay for our care with gratitude.

When we invest time in the early stages of our relationships, everything down the road flows more easily.

Many times, patients have some sense about their overall health, but have no idea about what is going on in their mouths. They tell us they’ve never looked in their mouths. Our challenge is to engage them during the exam process in such a way that it raises their curiosity and awareness.

Our goal should be for patients to be so engaged in the exam that they continue to pay attention to their mouths, even when they leave our office. As they are driving home, we would like them to be touching their facial muscles. We would like them to be paying attention to how their teeth come together when they take out a nightguard in the morning. We would like them to notice if there are points of bleeding when they floss. As they go about their lives, we hope they pay more attention to all the things we talked about.

Think of engagement as being like the gears on a bicycle. If the gears on your bicycle are not engaged, the bike will not move forward. You may be inclined to pedal harder, but you are still going nowhere. Similarly, if a patient is not engaged, you might be inclined to give them more information. But you might as well stop talking because you are probably going nowhere.

Engagement has been described by educators as when the student is working at least as hard as the teacher.

We all know what patients look like when they are engaged. They ask questions, they touch their faces, they lean forward, or they point to images on the computer monitor. They give us signals that they are paying attention. On the other hand, when a patient’s eyes glaze over and they blankly nod, it’s a good indication they are not engaged. When you notice that polite smile, stop talking and look for a way to engage them in the process. You might ask them a question. “I know I’ve been giving you a lot of information, and I’m curious, what are your thoughts about what we have discovered so far?”

One of the things I like to do when I begin the exam process is to ask the patient to hold a mirror in case I have some questions for them as we go through the exam. Most patients will take the mirror and put it on their lap. I look for the first opportunity to ask any kind of question that involves the mirror. I might ask them to bring the mirror up to their face and show me in the mirror an area they mentioned as a concern. I might ask them to point to changes made in their mouth by orthodontics and restorations and inquire about how they feel about those changes. Once they do, they are more engaged and understand that what they are telling me has relevance. They begin to see themselves as part of the process with expertise about themselves.

We want to engage as many of the patient’s senses as we can…seeing…hearing…touching… tasting. As I examine the mouth, I might say, “I notice that when I slide the perio prob into this deeper space between the tooth and the gums, there is bleeding. Do you ever see or taste bleeding there?” Their personal involvement in the exam gives rise to questions that are opportunities for them to connect what is going on in their mouth with their self-care behaviors and the choices they will have about seeking treatment from us.

We don’t want our patients to just comply with our recommendations. We want them to be actively engaged in understanding, planning, and working toward improved health. We want them to feel responsible for their choices and to partner with us in improving their health.

Engagement leads patients to take ownership of their health and make healthy choices.

After the next exam or consultation you do with a patient, consider:

• How engaged was the patient?
• How much “work” were they doing relative to how hard you were working?
• What did you do to activate engagement?
• If you could do it all over again, what “one more” question could you have asked the patient?

In dentistry, we’re clear about the connections among the teeth, the muscles, the bone, and the joints—and how all these pieces are related to esthetics. We understand how those pieces fit together. Unfortunately, most patients don’t come to us with that understanding.

Dr. Bob Barkley used to talk about patients not understanding “the web”—the connection of how all the pieces come together.

Just as with a delicate spider web, if you touch any one aspect of it, you change everything. Bob Barkley would say to his patients, “I know you are concerned about that one tooth. That’s your job to be concerned about that one tooth. My job is figure out and to help you understand how what’s happening with that one tooth is related to everything else that is going on in your mouth.”

The exam is a process by which we can do exactly that. We can help our patients understand the connections in their mouths. The exam is also an opportunity to encourage our patients to have confidence in us. Confidence building starts with the new patient exam and continues in subsequent interactions. The more thorough the examination we do, the more in touch we are with what is really happening in our patients’ mouths and the more confident patients will feel about our ability to help them.

Our thoroughness and knowledge aren’t the only aspects of the exam that develop patients’ confidence in us. The gentler we are in our touch and the more careful to include the patient or others in the room during exams are important. These aspects of the exam communicate our character and the way we tend to approach our work. Patients anticipate our care and approach will be similarly open and comfortable during future consultations and procedures.

People don’t take risks when they don’t feel confident. Unfortunately, many patients do not have confidence in making decisions for themselves when they sit in a dental chair. They think of significant dentistry as a risk. For best long-term results and positive relationships, we always want the patient to feel as strong and confident about their choices as they can.

Repeated comfortable interactions are needed for them to develop their confidence. Every time we find something good in their mouth, every time we point out health such as healthy gum tissue or a beautiful restoration, and areas not needing restoration, we are reinforcing healthy choices they made in the past. This can be a confidence booster to help them move forward in making next choices.

The examination process is an opportunity for the clinician to:

• Understand what the patient is experiencing emotionally and physically,
• Provide sensory learning experiences (see Art of the Examination: Part 1),
• Help the patient draw connections for deeper understanding of their health
• Explore options for what the patient might choose to do.

The examination is an opportunity for the patient to develop understanding of:

• The clinician’s ability to help them.
• The current condition of their teeth and other oral structures.
• The impact on them of what they are learning.
• The choices they can make to improve their health.

Every examination is a next opportunity to develop our patients’ confidence in us and in their ability to make healthy choices for themselves.

All dental schools teach a system for doing a clinical examination. The goal is typically to gather as much information about current clinical conditions as possible, as efficiently as possible. It is an important aspect of patient care. The science of the exam is useful, but it misses the art of the examination. In my experience, it is often a missed opportunity

In dentistry, we are always trying to figure out the best way to influence our patients to make healthy choices for themselves. When I left Hygiene school, I thought it would be simple to influence patients. I thought that if I did a good examination, a good diagnosis, and then made a good presentation, patients would go ahead and do the treatment.

What I experienced when I was in practice was different. Over time, multiple conversations, and multiple interactions—in their own time and in their own way, patients would move forward with treatment. Sometimes it seemed random, but what I’ve come to understand now is that every interaction was an opportunity to influence the patient.

Every single interaction, with every single patient, by every single member of the dental team is an opportunity to influence.

I think most of us have learned over the years to be skillful at providing information. We know how to “Teach and Tell” what we are finding and recommending. But there is an aspect of that process that has to do with experience. What we have not always paid attention to is how we can go beyond information to create learning experiences for our patients.

When I see a baby touching grass, I imagine that the experience of learning about grass through the senses is entirely different than learning by being told about grass. Creating opportunities for people to interact physically with their own bodies is an opportunity we have in a number of different situations. We can do this during a consultation, but we really have this opportunity during an examination.

If we place priority on effectiveness over efficiency, we will do our exams with the intention of creating physical-sensory experiences, which can be as simple as having them touch their muscles as they touch their teeth together, sliding their jaw forward and side to side, finding a relaxed jaw position, tapping their teeth together, clenching, feeling fremitus with their tongue or finger, feeling the difficulty of flossing between tightly packed teeth, and taking us on a tour of their mouth in a mirror while telling us about their concerns. It’s natural to say, “Tell me more about that. Show me where.”

Consider the new patient exam as the initiation of an experiential learning process to influence our patients to make healthy choices.

The new patient exam is not “the one” opportunity we will have to influence patients. We’ll have many more opportunities, but it sets the tone for every conversation you will have with your patients about their health, about the conditions present in their mouth, about the implications of what is going on in their mouth, and some of the choices they might be able to make.

Job one is to engage the patient in discovering just how intriguing their mouth is and why the health of its various components matter for long-term comfort, function, beauty, and overall health.

I know we are all familiar with the devastating effects cancer therapy can have on our patient’s oral health. We think of chemo and radiation and know this can increase the risk of caries and root resorption. A very common cancer therapy called Androgen Deprivation Therapy can have a significant impact on periodontal risk.

This therapy is an injectable medication given to a significant number of men who have been diagnosed with prostate cancer. It is a commonly chosen therapy because, on the medical side, it is one of the medications with the lowest impact on the patient’s life and ability to more forward with other medical procedures.

Now that it is common among our older male dental patients, I’ve been reading about it. It turns out that this therapy does significantly increase the periodontal risk of bone loss.

When they study males receiving chemotherapy for prostate cancer, 80%+ of the patients on Androgen Deprivation Therapy develop periodontal bone loss. Less than 10% of the males receiving different chemotherapies develop periodontal bone loss.

This is interesting because we think of periodontal disease as being driven by our immune system and that some patients are hyperresponsive to the bacteria in their mouths. In this case, the origin of periodontal risk appears to be different but there is no argument that the risk is there.

Knowing our patients’ medical histories is important yet again! When you do your med-history reviews with your patients, ask them if they are receiving cancer therapy and review the drugs they are on.

As soon as we know a patient is on Androgen Deprivation therapy, we need to start the preventative high-recall, high-maintenance process. Take them to three-month recalls instead of six-month recalls. Apply chlorhexidine varnish and start home hygiene protocols–brushing with baking soda…hydrogen peroxide…all the things we normally advise for our patients when we know they are at high periodontal risk.

Start this as soon as possible even though the patient is presenting with a healthy mouth. The risk percentile is in the 80s, so we can expect to see loss of mucogingival attachment, deepening pocket development, and bone loss.

When restoring peg laterals and laterals that are undersized, great goals are to optimize the final aesthetics and not have to do any tooth preparation prior to adding restorative material. In this blog, I’d like to discuss where we should have the orthodontist optimally position the laterals prior to restoration.

True Peg Laterals

In the case of a true peg lateral, I think of the tooth like I would an implant abutment. In my mind’s eye, I visualize the tooth as a fixture with an abutment on it.

When I talk with the orthodontist, I communicate that I want a minimum of 1 mm and a maximum of 1.5 mm of space between the mesial on the lateral incisor and the distal on the central incisor.

If there is excess space, it is going to be on the distal. We always hide excess space or insufficient space on the distal side of an upper anterior tooth. We always want to perfect the effect on the mesial so we achieve a perfect emergence profile.

And then I communicate that I want the labial of that peg lateral to be positioned about 1 mm to the lingual of where the final facial of the tooth position will be so that I can add material–composite or ceramic, without having to prep the tooth. This position is going to ideally position the free gingival margin of the tooth exactly where I want it based on the free gingival margin of the canine and central incisor. The CEJ is going to be placed exactly where I want the CEJ.

Undersized Lateral Incisors

Often, we have lateral incisors that are not true peg laterals. They’re just undersized lateral incisors. In this case, we must do a thought process about how much restorative material will be added and calibrate how much forward dimension will be added to the tooth. If I’m going to have .5 mm of material on the labial, then I will have the orthodontist position the tooth .5 mm lingually.

If the emergence profile is perfect, then the orthodontist should make it touch the central and all the added material will go on the distal. If not, then a little material will be added to the mesial and to the distal.

Often, for me, the process is thinking, “Where do I want to add restorative material and how much material do I want to add?” Then, I think about where to position the tooth in the space so I will not need to remove any of the tooth structure.

It can often be difficult to make an accurate endodontic diagnosis when patients present with tooth pain. We want to be able to get clear results from diagnostic testing so we can feel confident in our treatment recommendations.

One of the things I know to be true for my office and for many of our offices is the challenge of getting clear endodontic diagnostic information. One of the things that can cloud our diagnosis is the effect of over-the-counter medications.

To get accurate endodontic information, the patient must not take pain medication or anti-inflammatory medication in the 8 to 10 hours before you are doing your diagnosis. So, we need to ask patients if they have taken any Tylenol, Advil, or Aleve. We also need to think of patients who are taking nonsteroidal anti-inflammatories on a general basis. These are patients who are not taking them for the tooth but on a routine basis for other reasons such as arthritis.

If I am going to refer the patient to an endodontist and they are going to continue the diagnostic process, I want to coach the patient to not take any pain medication or anti-inflammatory medication for about 8 hours before that appointment. Otherwise, they may not be able to provide the accurate information needed for an accurate diagnosis and most appropriate treatment.

This is something I have passed on to the team members who answer the phone and schedule appointments in my practice. When someone calls to schedule an appointment to diagnose their discomfort, we tell them to do us a favor and not take any more pain medication or anti-inflammatory medication before we see them. Ideally, any of these drugs will be out of the patient’s system before the patient arrives.

Note that your patients who suffer from chronic inflammatory pain conditions such as bursitis, arthritis, and fibromyalgia are often prescribed anti-inflammatory medications that are long-lasting, for example, Celebrex and Meloxicam. These drugs are taken every 24 hours, so their effects last longer and pose a greater risk of clouding a pulpal diagnosis.

If the color of a prepared tooth darkens between the time you prepare it and the restoration is seated, the aesthetics of the final restoration can be impaired. This frustrating situation can be eliminated by knowing the causes of discoloration and what to do when planning treatment and prepping the tooth.

There are two processes that cause prepared teeth to discolor to a darker shade:

1. Pulpal necrosis
2. Chemical interaction between liquid vasoconstrictors and bacteria in the dentin tubules

Note that both processes can continue to further darken dentin weeks to months after you have seated the restoration. For more predictable aesthetic results, I learned some time ago to do the following.

Assess pulpal vitality first.

I am highly cautious when planning significant restorative treatment such as crown and bridge. Before prepping teeth, I review CBCT radiographs to make sure there are no pulpal health issues that need to be treated first. Like most dentists, I do not have CBCT imaging in my own practice, but I do have access to CBCT imaging via a collaborative relationship with a nearby specialist.

Use retraction paste instead of liquid vasoconstrictors for hemostasis.

Because the chemistry in liquid-viscosity vasoconstrictors can interact with bacteria in the dentin tubules to darken the dentin, I use retraction paste when I need hemostasis.

For me, these two seemingly simple steps are important ones when seeking optimal aesthetic results.

About a year ago, in my office, we reviewed our protocol for managing and treating patients with traumatized teeth. We reviewed the literature to learn how we could improve how we help our adult patients who have avulsed or mobile teeth following a traumatic event.

Antibiotics? Yes

One of the new things we read and thought about was whether to put the patient on antibiotics. We added this to our protocol—the patient goes on antibiotics for seven days after learning what antibiotics the patient can take, i.e., will not likely cause an allergic reaction.

Splinting? Yes

The literature now recommends splinting the traumatized teeth for two weeks and then removing the split after two weeks. Although there has been a conversation over the years about whether to splint or not to splint and if splinting has anything to do with the teeth ankylosing or resorption, the current recommendation is to splint but for just two weeks.

Improved Counseling of Our Patients? Yes

We learned that three common sense items needed to be reviewed with our patients, because it is easy to retraumatize teeth, and patients easily forget to be attentive to personal “gentleness.”

• We added to our protocol list counseling the patient to go on a soft diet that does not require biting down for three to four days, then longer if they sense the tooth roots are still mobile.
• Similarly, we added counseling the patient to do gentle mouth cleaning. They should brush traumatized teeth very, very gently so as not to re-traumatize or move them.
• We also added to our list making sure patients understand the importance of follow-up visits and radiography to track the health of the traumatized teeth.

Following the Health of the Teeth

We use periapical or CBT radiography to follow the teeth at one month after the initial trauma and again after two months, four months, and six months. If there appears to be healthy pulp and attachment of the teeth to the bone and connective tissue at six months, we can extend the time between making new images.