Proper occlusion, orthodontic therapy, and the dental hygienist

Proper occlusion is an essential factor in oral health, and dental hygienists are in the perfect position to discuss it with patients.

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I always simply wanted “straight teeth” until I learned first-hand how important it is to have a “good bite” and proper occlusion. As a dental hygienist currently undergoing orthodontic treatment, I find the field of orthodontics very exciting. This is a great time to be in the field of dentistry and to see more adult patients seeking orthodontic treatment. During routine dental hygiene appointments, dental hygienists can alert the patient and dentist to the possible problems they see during periodontal and occlusal assessments. Based on the findings, a dentist may recommend some occlusal therapy including a night guard, splinting, occlusal adjustment, or orthodontic treatment such as braces or Invisalign. As patients want a more cosmetically appealing smile, we must continue to educate them on their occlusal health.

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In simplest terms, the ideal occlusion is when the maxillary teeth slightly overlap mandibular teeth on the facial surfaces, and all teeth in the maxillary arch are in maximum contact with the mandibular arch in a definite pattern.1 Any deviation from the physiologically acceptable relationship of the teeth is called malocclusion. Many factors may cause the dental occlusion to change—for example, tooth extraction. Without replacing the missing tooth, teeth tend to move and tip out of normal occlusion and opposing teeth may “erupt” to fill the void. Another instance is post-orthodontic treatment—even with removable retainers or splinting, teeth drift, sometimes requiring occlusal adjustment. In addition, since teeth are still mobile and are unstable, teeth can “relapse” and shift into malocclusion.

Many dental professionals also see tooth wear presenting with facets and a shiny surface caused by bruxism or clenching habits. It’s important to catch this early, as this places excessive force on the teeth, whether or not they are properly aligned. Teeth can move mesially, and incisal guidance and canine rise can increase (clenching) or decrease (bruxism). Other factors causing tooth movement include traumatic accidents, skeletal growth differences, an abrasive diet, dental carious lesions on the occlusal and proximal surfaces, iatrogenic dentistry, and periodontal disease.2

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The value of occlusal adjustment
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Patients often resist dental treatment if they are not in pain and may reject our orthodontic treatment recommendations—“duration, poor aesthetics, difficulty wearing an appliance, and cost” may be their reasons.3 If patients are not in pain from their occlusion, will they be more receptive if we show them the importance? People are motivated to seek orthodontic treatment because of the negative physical, psychological, and social impacts of malocclusion.4 In a 2011 report by the American Association of Orthodontics, the desire to straighten the teeth and improve the smile were key motivating factors for adults seeking orthodontic treatment.5 Other motives included improving the bite, improving facial appearance, and closing (dental) spacing. Considering the psychological characteristics of self-esteem, body image, and facial body image, the adult orthodontic group was comparable with the general public.5

Occlusal problems rarely cause pain until they reach an advanced stage. Occlusal-related issues that can cause pain include TMJ pain, primary occlusal trauma, advanced periodontal pockets, fractured teeth, and gingival recession that has progressed through the attached gingiva into the gingival mucosa. Patients may experience pain through primary occlusal trauma caused by a high restoration or insertion of a fixed bridge or partial denture placing excessive forces on the abutment teeth. The changes, including pain, a wider periodontal ligament space, and tooth mobility, are reversible if the occlusal trauma is removed. Lacking awareness of orthodontic treatment in patients with occlusal trauma can even lead to loss of tooth structure.6,7 Insubstantial tooth structure can include chipping of teeth in an edge to edge bite and abrasions, which are rounded saucer-shaped notches along the gum line. Abfractions, in cases not otherwise caused by abrasive tooth brushing or toothpaste, can also cause pain in the form of dentin hypersensitivity where the teeth may be experiencing direct occlusal trauma. 8,6When our patients experience even localized dentin hypersensitivity from occlusal related abfractions, in addition to hypersensitivity toothpastes or fluoride varnish treatment, why not recommend orthodontic treatment? Dental hygienists are in the unique position to make this information part of patients' records and discuss various treatment options, as well as the risks of not treating these conditions.4

Occlusal trauma is one of the most under-treated oral conditions. Trauma from occlusion is defined as excessive forces that cause

Occlusal trauma is one of the most under-treated oral conditions.

damage to the periodontium—a contributing factor for periodontal disease, making the occlusal examination an essential part of the periodontal assessment. According to a 2011 statement by the American Academy of Periodontology, “An occlusal examination includes determining the degree of mobility of teeth and dental implants, occlusal patterns and discrepancy, and determination of fremitus.”9 Fremitus is defined as palpable vibrations or movement of a tooth, usually due to excessive contact with another tooth. Current research findings discuss the association between untreated occlusal irregularities and the progression of periodontal disease. Trauma from occlusion does not initiate either gingivitis or periodontitis, but contributes to the disease process previously initiated by bacterial plaque.6 The combination of trauma from occlusion with periodontitis results in more rapid attachment loss and more alveolar bone loss. Thus, effective occlusal treatment can reduce the progression of periodontal disease over time.10 Recent research shows that occlusal trauma is an equal or greater risk factor for the progression of an existing periodontal disease as smoking or poor oral hygiene.4 A few simple checks and patient education can avert many problems associated with occlusal issues. By noting these types of occlusal problems early and encouraging patients to address them and comply with treatment, dental hygienists can help patients avoid costly rehabilitation in the future.5

Because some occlusal changes happen more rapidly than others, dental hygiene recare appointments assessing these changes can avert many dental issues. When occlusion is part of the problem, it is important to address the signs and symptoms as soon as possible with an early diagnosis, proper treatment plan, and correction of malocclusion.6,7 Correcting occlusal discrepancies early could save our patients time and money in the long run. As more patients want orthodontic treatment, I hope to see a decrease in the occlusal related problems that we commonly see.

Katiechiarelli

Katie Chiarelli, RDH, practices dental hygiene full-time in the public health setting for an in-school dental program, as well as a private family-oriented dental office. She has been a dental assistant since 2005 and contributed to ADHA Strive magazine as a dental hygiene student at Burlington County College in Pemberton, NJ. Katie enjoys reading about advancements in dentistry and hopes to contribute by writing valuable articles that can be used as a resource for other dental professionals.

References
1) Wilkins, Esther M. Clinical Practice of the Dental Hygienist. 10th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2009. Print.
2) Gordon J. Christensen, DDS, MSD, PhD. "What Causes Changes in Occlusion?" Dental Economics. N.p., n.d. Web. http://www.dentaleconomics.com/articles/print/volume-103/issue-7/practice/what-causes-changes-in-occlusion.html
3) Jeremy J. Mao, DDS, PhD and Chung H. Kau, DDS, MScD, MBA, PhD, M Orth, FDS, FFD(Ortho), FAMS(Ortho). "Advances in Orthodontic Treatment." (n.d.): n. pag. Web http://acceledent.com/images/uploads/4A-i-Continuing-Education-Peer-Reviewed-Advances-in-Ortho-Treatment1.pdf
4) "Factors Influencing Patient Satisfaction." N.p., Apr.-May 2011. Web. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3059271/
5) Orthodontics, University College London Eastman Dental Institute and Eastman Dental Hospital, University College London Hospitals Foundation Trust, London, United Kingdom. "Assessment of Motivation and Psychological Characteristics of Adult Orthodontic Patients." Pubmed. N.p., Dec.-Jan. 2011. Web. http://www.ncbi.nlm.nih.gov/pubmed/22133960
6) Foundations of periodontics for the dental hygienist By: Gehrig, Jill S., and Donald E. Willmann. Wolters Kluwer Health/Lippincott Williams & Wilkins 2011
7) "Trauma from Occlusion — An Orthodontist’s Perspective." Journal of Indian Society of Periodontology. N.p., Apr. 2010. Web. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110471/
8) Stephen K. Harrel, DDS. "Oral Health Begins with Tooth Alignment." N.p., Apr. 2011. Web. http://www.dimensionsofdentalhygiene.com/2011/04_April/Features/Oral_Health_Begins_with_Tooth_Alignment.aspx
9) Comprehensive Periodontal Therapy: A Statement by the American Academy of Periodontology from the Journal of Periodontology 2011, pp. 943-949. http://www.joponline.org/doi/pdf/10.1902/jop.2011.117001
10) "Occlusion and Hygiene." Dentistry Today. N.p., Oct. 2002. Web. http://www.dentistrytoday.com/hygiene/1193

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