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.

I was at the Ontario Dental Society meeting giving a presentation on occlusion, and I was asked one of the most common questions I receive when discussing anterior-only appliances: “What about tooth movement, either eruption or intrusion? Isn’t that a risk with these devices?” The answer is, yes there are risks, as with everything we do. Let’s consider the risks and how we can minimize and avoid them.

There are many types of anterior-only appliances, temporary and long term. Popular temporary anterior bite splint appliances are QuickSplint® and the Best-Bite™ Discluder from WhipMix®. NTI-tss Plus™ from NDX® National Dentex Labs is designed as a permanent anterior only and then there are the Kois Deprogrammer, Spear style deprogrammer, Lucia jigs, regular deprogrammers, Dawson B-Splints and so on. They are designed so that when the patient bites in MIP, they only touch on the front. When the patient goes into any excursive position (right, left, forward or back), they can only touch in the anterior—plastic to plastic or teeth to plastic.

We love anterior-only appliances because of their efficiency and effectiveness in eliminating posterior contact and allowing TMJ muscles to optimally relax. But we do worry about tooth movement, so how do we evaluate the risk and how do we minimize it?

There are a couple of pieces to this puzzle. We know that super eruption of the back teeth may occur if the appliance is worn more than ten hours a day, consistently over many days, even weeks, in a row. This means the risk is minimal with nighttime wear only for eight hours a night. Since we do not want patients to wear these types of appliances 24 hours a day, a patient in acute pain might be best helped with an anterior-only appliance for nighttime and a different type of appliance for daytime.

There is also a risk of lower tooth intrusion. There are two ways to deal with that. One is to make sure they have contact from canine to canine to distribute forces. Another is to make the upper anterior discluder against an appliance on the bottom that is called “a slider.” This is essentially a thicker version of an Essix retainer on the bottom to distribute the forces. I have made these appliances for many years and have not observed a problem in my own practice. I had one patient with significant deprogramming who could only touch on her first point of contact, but that was not due to tooth movement. It was because of total elimination of her masticatory muscle memory.

If you are concerned about tooth movement, I recommend making the upper discluder on a full arch Essix and then put the patient in a full arch lower Essix (lower slider) that will distribute the forces. That will prevent the problem of super eruption and should significantly minimize potential for intrusion, even though you only have midpoint contact. This is a great way to moderate the risks of tooth movement for patients who are going to wear an anterior-only appliance long term.

I would like to add, that any time you put a patient on appliance therapy, you need to see them for post-op appointments. You need to verify the appliance is working—that their signs and symptoms are going away or minimizing. And, you need to check their occlusion and mandibular position. So, I always plan multiple follow up appointments and include those in the appliance therapy fee. Even when the patient and I think everything is going great and they are wearing their appliance only at night long term, I ask them to bring their appliance to every Hygiene appointment for professional cleaning. This reminds us to ask how things are going with their appliance and gives me the opportunity to check their occlusion and make sure there are no negative consequences of the therapy. I also tell my patients to call if they notice any change in their bite. “We need to have you come in and check that right away.”