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Special Issues
July/August 2016
Volume 37, Issue 3

Integrative Dental Medicine: Treatment of Occlusion Reflecting Systemic Disorders

Addressing the “triad” of causative factors of wear

Dentists are the “physicians of the masticatory system,” as Peter E. Dawson, DDS, founder of The Dawson Academy (www.thedawsonacademy.com), has described. Indeed, no other healthcare providers can appreciate the critical role of dental occlusion like dental professionals. Dental malocclusion is associated with many signs and symptoms of instability, including sore, loose, worn, and broken teeth; sore muscles; headaches; temporomandibular joint overloading, stress, and strain; and ear and neck symptoms. Astute dentists need a critical eye for changes in dental occlusion that may reflect the presence of associated systemic disorders. This case study, which highlights bruxism, illustrates this point. It emphasizes how the focus of clinical diagnosis and treatment in dentistry is expanding to address known systemic factors that affect both dental and complete health.

Key Takeaways

• Dental attrition (occlusal/incisal wear facets) has been associated with bruxism, which may be related to sleep-disordered breathing, including obstructive sleep apnea. Dental erosion (smooth surface wear and occlusal cupping) may be associated with gastric reflux.

• Collectively, bruxism, obstructive sleep apnea, and gastric reflux may form a “triad” of causative factors of wear.

• Evaluation, diagnosis, and treatment of these systemic concerns and others expand the practice model to a new level described as integrative dental medicine.

About the Author

DeWitt C. Wilkerson, DMD
Senior Faculty Member/Director of Dental Medicine
The Dawson Academy
St. Petersburg, Florida
Adjunct Professor of Graduate Studies
University of Florida College of Dentistry
Gainesville, Florida
Private Practice
St. Petersburg, Florida

Fig 1. The patient presented with “tired eyes,” severe dental attrition, and erosion. Signs of malocclusion, bruxism, and possible serious systemic disorders such as obstructive sleep apnea (OSA) and gastric reflux were also present. He reported sinus problems, snoring, and possible sleep apnea. He indicated low esthetic concern and financial constraints. Testing was indicated.

Figure 1

Fig 2. The patient presented with “tired eyes,” severe dental attrition, and erosion. Signs of malocclusion, bruxism, and possible serious systemic disorders such as obstructive sleep apnea (OSA) and gastric reflux were also present. He reported sinus problems, snoring, and possible sleep apnea. He indicated low esthetic concern and financial constraints. Testing was indicated.

Figure 2

Fig 3. The patient presented with “tired eyes,” severe dental attrition, and erosion. Signs of malocclusion, bruxism, and possible serious systemic disorders such as obstructive sleep apnea (OSA) and gastric reflux were also present. He reported sinus problems, snoring, and possible sleep apnea. He indicated low esthetic concern and financial constraints. Testing was indicated.

Figure 3

Fig 4. A home bruxism sleep monitor (Whipmix) was sent home with the patient to evaluate for nocturnal bruxism and OSA. The result of the test revealed both severe sleep bruxism and a severe apnea hypopnea index (AHI) score of 55 (severe >30). A board-certified sleep physician reviewed the study and diagnosed OSA.

Figure 4

Fig 5. A home bruxism sleep monitor (Whipmix) was sent home with the patient to evaluate for nocturnal bruxism and OSA. The result of the test revealed both severe sleep bruxism and a severe apnea hypopnea index (AHI) score of 55 (severe >30). A board-certified sleep physician reviewed the study and diagnosed OSA.

Figure 5

Fig 6. The patient entered a pilot study, using closely monitored oral appliance therapy rather than the usual prescription for severe cases, the use of a positive airway pressure device. He was fitted with a bruxism/sleep apnea interim oral appliance (BRX-PRO Dual Arch, Whipmix), which was designed to disclude the teeth and anteriorly reposition the mandible approximately 60%. After 1 week, the overnight home study was repeated wearing the appliance. Results showed a dramatic reduction in bruxism and a mild AHI score of 11.

Figure 6

Fig 7. A definitive sleep apnea appliance (DynaFlex® Dorsal, DynaFlex) was subsequently fabricated and titrated. The bruxism activity has since remained minimal and the AHI score below 10. Gastric reflux has been controlled through a combination of maintaining airway patency and a modified diet, as described in Dropping Acid: The Reflux Diet Cookbook & Cure (Jamie Koufman, MD, et al).

Figure 7

Fig 8. The patient’s definitive occlusal therapy included equilibration and composite bonding of the damaged teeth to provide appropriate anterior guidance in centric relation. This image shows the pretreatment condition.

Figure 8

Fig 9. This image depicts posttreatment.

Figure 9

Fig 10. The patient’s improved smile and countenance posttreatment.

Figure 10

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