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View from the Chairside – The Devil is in the Details!

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This is a fairly complicated case that was managed over a lengthy period of time. As is customary of Dr. Paul Belzycki, he chose to show this case because it is loaded with good clinical information and learning pearls. It is fairly lengthy and that’s why we divided the clinical presentation into two parts. However, we sincerely hope that you will enjoy it and benefit from it.  

For those who watch Dr. Belzycki’s work for the first time, Dr. Belzycki is a Toronto general dentist; and he regularly shares four decades of clinical experience with his colleagues. 

During the presentation, we spoke about Dr. Andrew Moncarz’s collaboration in this case and we mentioned his presentation on CDA Oasis.  As promised, here’s the link to that presentation: 

View from the Chairside: An Anatomical Approach to Endodontic Access

Dr. Belzycki’s Thoughts

Yes, the devil is in the details! That is an idiom that refers to the importance of finding the key element that is hidden in a complex problem. That element which may seem simple at first sight and which ends up sucking more time and effort to successfully complete than expected. This has been my everyday experience in Dentistry. I have said it before: “every case has a WEAK LINK.” Failure happens when that element is not identified and/or is mismanaged. Every skilled craftsman, including dentists, must live by the following creed: Measure twice, cut once.

If you want to provide long-lasting restorations, you have to fight for every detail. If there are 10 steps involved, you do nine perfectly and one is not so great, it will come back to haunt you. So, it’s not that it requires a lot of brain power and it’s not that anything is overly difficult. It’s just a lot of simple tasks that need to be executed to an exacting manner to end up with a good restoration.

View Part 1 of the Presentation (33.10″)

View Part 2 of the Presentation (35.32″)

10 Comments

  1. Mark Antosz May 3, 2019

    Dr. Belzycki is clearly a very good technical dentist, but there is a fundamental problem here. These patients he has discussed are all victims of occlusal disease. The teeth fail because there is a problem with the occlusion. The failing restorations are a clue. The tori are a clue. “Lack of TMJ symptoms” is a red herring. First off, many of these patients ARE in pain but they’ve lived with it for so long they think it’s normal. (when you get them stable, it’s fun to see them acknowledge the fact). One has to get beyond the point that “symptoms” are a guide, and look at what’s happening in the mouth. The teeth are failing because it’s an occlusion problem.

    I strongly disagree with the whole approach. When you see a patient with occlusal disease, the LAST thing you should do is major dentistry, orthodontics or whatever. You need to establish a stable centric FIRST, then re-diagnose the malocclusion, and THEN treatment plan the case.

    He shows a patient with a LOT of restorations done over a long term. I would offer that, if the CAUSE of the occlusal disease was addressed in the first place, many of those restorations never would have needed to be done in the first place. I do not look at this kind of case as a success. Rather, I consider these kind of cases a failure of dentistry to understand occlusion.

    I see this time and time again in my practice. Patients with decades of patchwork dentistry – which still ultimately fails because the etiology was never addressed. None of these dentists were “bad”, and no doubt they all felt they could “save” the patient. A recent patient had 10 implants, 13 crowns, some more endo and she presented to me in pain. After decades of dentistry and tens of thousands of dollars of expense. We put her onto a full time splint, deprogrammed the muscles, established a stable centric, and lo and behold she is a big Class II that was posturing into some form of unstable CO. All this dentistry was done on a foundation of sand. That’s just sad.

    The best dentistry in the world will fail if you have not addressed the cause of the occlusal disease.

    The fundamentals of occlusion new. McCollum and Stallard were working on this almost 100 years ago. Charlie Stuart and PK Thomas were heralds who carried the torch forward. A lot of the principles of functional occlusion were established in the 50s and 60s. Bill McHorris was probably the first that recognized that one had to stabilize a patient before the instrumentation and restoration so that you could properly diagnose (and then treat) the malocclusion. Lundeen and Gibb ultimately illustrated that the anteriors needed to be the right length to create nociceptive feedback during function to prevent lateralized chew patterns, which are fundamentally destructive in the long term. But all these principles seem to have been lost somewhere along the way.

    Never in this case presentation was the issue of the occlusion truly addressed. All the photos and radiographs in the world don’t make up for not actually mounting the case to see what was going on. Or establishing a stable centric before launching into a restorative program.

    There is so much more we can offer our patients with a little more knowledge. I urge the readers out there to learn. Spend the money and time and take courses by Spear, or Kois or OBI or whatever. There is a lot of “preventable dentistry” out there if we truly understand occlusion and manage our patients accordingly, rather than patchwork dentistry being repeated until it’s too late.

    Unfortunately, this comment probably won’t get published. Which is sad in and of itself.

    Reply
    1. The above comment expressed with near religious fervor, contains unsubstantiated suppositions, does not constructively add to the conversation, and is irrelevant to the clinical treatment.
      Dr. Paul Belzycki, DDS

    2. Cliff Leachman May 9, 2019

      Kois, Spear, Neuroromuscular goggly gook, can’t do dentistry without it, haha….
      Paul you rule, love seeing all that amalgam, must make their eyes water.

      1. Dr. Paul Belzycki, DDS May 10, 2019

        Dear Cliff, you wouldn’t believe what I saw today at the convention. An American presenter who practises sleep dentistry claims that the true culprit is obstructive airway disease. This causes the condyles to be malpositioned resulting in bruxism which results in poor cranial spinal position which results in osteoarthritis throughout the body and “blow out of the knees.” He showed a video where the insertion of an occlusal appliance instantly corrected posture, gate and balance of an elderly female. It was reminiscent of a tele-evangelist faith healing moment.

  2. Dr Mark Antosz May 9, 2019

    Wow. What an astute comment. I’ve been in the game for 40 years too, pal. But there is none so blind as he who will not see. But I can’t say I’m surprised.

    Reply
    1. Dr. Paul Belzycki, DDS May 11, 2019

      This is the second comment espousing “occlusal disease” that we received to this series of clinical posts.

      The first was in response to the post “Bad Decisions Make Great Stories”. The argument there was that initial treatment failure was due to “occlusal disease” leading to parafunction and breakdown of the dentition/restorations. The argument then prophesized the imminent failure of my treatment due to the continuous presence of the “occlusal disease” I failed to manage. Note this argument was confidently made without the respondent ever examining the patient firsthand.

      It is my understanding their definition of “occlusal disease” is that parafunction and pain will result if the condyles are not in an “idealized position”, coupled with an “idealized vertical dimension”, coupled with an “idealized occlusal scheme”.

      The theme of the current comment represents a problematic viewpoint due to the lack of evidence that surrounds it. From its overarching concept that “occlusal disease` is the primary cause of failure of all dental treatment to the respondent’s detailed statement that a “properly managed occlusion will prolong a restoration with defective margins“.

      My reply is not aimed at debating the respondent himself, simply because “a man convinced against his will, is of the same opinion still”. My reply is aimed at young clinicians to help them develop much needed skepticism and critical thinking. For that matter, this addresses all clinicians.

      You will notice that I italicized the phrases “occlusal disease” because the jury is still out on the evidence underpinning this concept; and therefore, it remains vague to this day.

      As a practicing dentist, I rely on a network of trusted university academics who live and breathe oral health research and know the evidence inside out. On this topic, their response to my question whether occlusal disease is recognized or classified as an oral disease, was NO. Assuredly, there are various classifications of joint/facial pain, attrition, bruxism, abfraction and cracked teeth as a result of prolonged and intense parafunction, but there is no “Occlusal Disease” where the condylar/fossa relation is an evident causal factor. In the absence of evidence, the concept of occlusal disease remains the creation of priests of occlusion based on unsubstantiated assumptions.

      Arguments on occlusion take me back to the early 80’s when I attended a week long seminar at the Pankey Institute. There, I stood before the high priests of occlusion, who argued for what constitutes a True Centric Relation. I unearthed no gems there as the same arguments made then are still hotly debated today, again due to none other than: lack of evidence.

      Ironically, the same camp who argues for the existence of occlusal disease recognizes the shortcomings of the research to prove their own arguments. In an article published in the Journal of Oral Biology and Craniofacial Research (2013), Mohd et al. clearly state the following:

      “ The issue of relationship between dental occlusion, body posture and temporomandibular disorders (TMDs) is a controversial topic in dentistry. In particular, claims for treating TMD according to pathophysiological concepts to correct purported occluso-postural abnormalities seem to be based on doubtful theories. The invasive nature of such treatments requires that these concepts have to be proven with evidence-based data which account properly for the physiology of such relationships.“ (p.146)

      I recently attended a two-day CE session by Dr. Michael Fling, a faculty member from the Pankey Institute, who argued that uppermost-anteriormost-braced against the eminence was the most ideal condylar position. Others have argued for uppermost-rearmost. Others for uppermost-midfossa. One can lose friends and make enemies based on one’s choice. As proof of this near-religious fervor, I offer the respondent’s reference to me as “pal”.

      In addition, in a systematic review of 22 other systematic reviews, titled Interventions for Temporomandibular Joint Disorder: An Overview of Systematic Reviews, the Canadian Agency for Drugs and Technologies in Health (CADTH) looked into the optimal interventions for the treatment of TMD in children and adults in terms of clinical effectiveness and safety. They concluded the following:

      “ Due to the low quality of included literature, the limited evidence regarding TMJ clicking and adverse events, and the heterogeneity of SRs [systematic reviews] included in this report, firm conclusions regarding the optimal interventions for TMD cannot be made […] the volume of literature obtained was large and heterogeneous, making solid conclusions based on the current literature challenging.”

      In other words, there’s no substantive high-quality research or data to make assertive conclusions one way or the other.

      At this point, I could say with a clear conscience, I rest my case! But I won’t.

      I state repeatedly in this series of posts that I rely on my past clinical experience and I rely heavily on photographic evidence not to boast but to demonstrate that I stress, really stress over the details of every case I treat (hence the title of my recent post, The Devil is in the Details). However, the factor that causes me the least amount of stress is occlusion. If a sufficient number of teeth are present, I build to that centric occlusion (maximum intercuspation) as this is a repeatable position that can be shared between the patient, myself and the lab. If landmarks are lacking, I will build to something vaguely repeatable and that happens to be “centric relation”. Note vaguely repeatable. The TMJ is a visco-elastic biological complex which means a precise condylar/fossa relationship is illusory. The amount of fluid in the joint differs from morning to evening. I would not be surprised if these differences arise even during the course of a long dental appointment. Commonsense tells me I have little control over this. Therefore, I aim for restorations with solid flat occlusal stops that provide freedom for the patient to move in function, or for that matter, in parafunction without awareness. Both Dr. Fling and I are hopeful that a patient’s powers of accommodation, both physiological and psychological, contribute to the success of our restorations as we are keenly aware of the tolerance of error.

      Philosophically, “Seek no more precision in a system than it may admit to.”

      I never bring a case to completion in the presence of symptoms. Any symptoms!

      I attended another lecture this year at Mount Sinai Hospital, where another clinician/ academician stated similar conclusions. So, between me, a solo GP, a Pankey Institute lecturer, and an academician, we three agree on the following:

      1. We have seen dentitions where no two opposing teeth come together properly and yet the patients remain asymptomatic for life.
      2. We have seen and treated patients with various types of joint/facial symptoms and their occlusions and radiographic TMJ images appear as textbook features.
      3. Bruxism/parafunction cannot be cured, only managed. Dr. Fling offered himself as a prime example. He certainly knows better, but claims he cannot control the urge to brux nor bite his nails. I would argue that if anyone, Dr. Fling could be “cured from occlusal disease“, as he has access to treatment from the Pankey ‘experts’ who may posit that a mechanical cure exists.

      This leads me to conclude that factors unrelated to occlusal articulation and joint anatomy may be at play. Put another way, how the teeth come together is not a predictable causal factor in joint pain or bruxing or TMD.

      The proposition that a singular concept, Occlusal Disease, is the occult cause of all that fails in dentistry demonstrates the adage “If all you have is a hammer, then every problem is a nail”. Alternatively, “If all you see are nails…get the hammer”. Let the reader choose which is most appropriate.

      Having said this, would I insert a restoration not harmonious with a repeatable asymptomatic occlusion or some concept of centric position? Of course not. That is just Good Dentistry. It’s a no-brainer goal that does not require a guru.

      Have I alleviated symptoms by grinding down balancing-side interferences? Yes, and I certainly looked like a genius.

      Have I repeated this on a second patient and not succeeded in alleviating symptoms? Yes, and I looked not so genius.

      Do I employ occlusal splints? Yes. But I explain to the patient that their individual results will vary. It has been my experience that TMJ problems are sporadic and typically self-limiting. Folks have gotten better with merely suggesting relaxation, self-awareness, soft diet, use of moist heat, and NSAIDS. Let us see what Mother Nature can do for us with a commonsense, low cost, non-invasive approach.

      Patients that are provided with an appliance are informed that if it works, I will take all the credit. If it doesn’t, I will accept no blame. We really do not know why occlusal splints work when they do. We have guesses and here is mine. Somewhere in the deep recesses of a patient’s mind, the presence of a block of plastic in the mouth somehow modulates neuromuscular activity. I am certain this is a huge over-simplification and the cerebral pathways are complex and vary extensively between individuals. I will state that the effect is partially placebo! I am sure this may be the case in some folks and this too is honestly explained to the patients I treat. Perhaps it is merely the laying-on of hands. The rendering of diligent and compassionate care may itself reduce heightened stress and anxiety that is part of pain appreciation.

      The CADTH report cited early claims that occlusal adjustments did not significantly reduce symptoms when compared to placebo, reassurance, or no treatment. This finding confirms my clinical observations that often TMJ/TMD symptoms are transitory and self-limiting. Therefore, one can erroneously ascribe success to the last therapy that was undertaken before the acute event spontaneously resolved.

      Here is my message to young and seasoned clinicians. Gurus are in the business of being gurus. And they are good at it as their lectures are typically well attended. Obviously, knowledge in occlusal management is vitally important, as is everything else we do in Dentistry. But, be warned as considered skepticism is required to integrate efficacious knowledge. One needs to carefully consider their guiding sources before providing irreversible treatment to “reposition” condyles, provide orthodontics, and/or grind away enamel in the name of “occlusal disease“.

      It was stated to me that ” there is none so blind as he who will not see”

      I wish to discuss the following philosophical truism.

      We are all familiar with “you gotta see it to believe it”, i.e. Seeing is Believing. It does not quite work that way. Psychologists and philosophers argue that Believing is Seeing. One first forms a Worldview based on parental nurturing, formal education, morals, customs, and religion. It forms our personal Reality of how the world works. This also affects how one comes to Knowledge. Rarely, do we self-examine how our own unique Worldview developed; we take for granted that our view of Reality is the correct one. Humans are pattern-seeking/pattern-recognizing entities. By our nature, we ascribe causality to events linked spatio-temporally, even though those events are unrelated. Put simply, we can err and “see” cause and effect when there is none. An a priori Worldview affects how we come to Knowledge; and hence, what one considers truth, is infused with bias. Science is Modernity’s method to reduce bias in spite of it being a human endeavour. Thus, we conduct systematic reviews of systematic reviews.

      There are those convinced of “occlusal disease” and who see it everywhere.

      I remain skeptical. Because in my ethos, I follow the words of Hippocrates…”Above all, do no harm”.

      Dr. Paul Belzycki, DDS

  3. Yogi C Yogeswaran May 10, 2019

    I don’t know if correcting occlusion alone will prevent decay and fallout after.Paul’s approach of treatment is methodical to address problems in day to day dentistry.

    Reply
    1. Dr. Paul Belzycki, DDS May 13, 2019

      Dear Yogi. Thank you for your comment. In addressing this case, it remains my opinion that with an absence of TMJ/TMD symptoms, there were no occlusal issues to alter other than how to best secure the teeth in a harsh environment.

      And, yes an occlusal appliance was delivered on completion of the case to help dissipate the destructive forces generated by bruxism. I was remiss in not stating this

      But, I remain skeptical of claims that it is repeatably possible to eliminate bruxism, or “romance the condyles” to some idyllic position, or “recapture” chronically displaced discs with a block of plastic, irrespective of its design or designer. It is my understanding that the peer-reviewed literature substantiates my skepticism.

      Dr. Paul Belzycki, DDS

  4. tony mancuso May 14, 2019

    Hi Paul,
    I was interested in your reason for splinting crowns of posterior RCT’ed treated teeth —-is it your 35+ yrs experience that you feel this is best or do you base this on some published literature? Just curious.
    Excellent work!
    Tony

    Reply
    1. Paul Belzycki May 15, 2019

      Tony,

      As I have claimed on several past posts, whenever possible I will place splinted crowns. I routinely employ Full Metal or PFM crowns for strength and durability; and hence splinting is an option. I routinely splint crowns on multiple implants as well. The motivating concept is strength in numbers. This is vitally important with endo treated teeth anywhere in the mouth. It is hoped that forces of occlusion are dissipated and shared among several teeth/implants. As my perio colleague Jon Adam has claimed, I tend to over-engineer.

      In addition, splinting crowns negates the opening of contacts. Over a long career, I have observed that this does occur. Patients with heavy parafunction tend to move teeth and these are the very patients that require crowns. So, I feel I gain strength and security and loose nothing.

      I know of no formal studies that support this viewpoint. But I was advised by an old engineering professor that my clinical experience should “stand for more” than research carried out on a lab bench.

      As demonstrated, there is an extra step to try-in metal and solder-index to assure accuracy of fit and embrasure design and the fee is adjusted for this.

      All in all, I and patient sleep better a night. Perhaps that is the best reason.

      Dr. Paul Belzycki, DDS

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