Caring for a Dental Leaf Gauge 

Lee Ann Brady, DMD 

In the Pankey Essentials courses, we use dental leaf gauges to train dentists in how to feel for the first point of occlusal contact, as a method for occlusal deprogramming, and as a tool for articulating models on an articulator in centric relation. Dental leaf gauges not only assist us in diagnosis and treatment planning but also in enabling our patients to discover the nature of their occlusion as we help them understand how malocclusion can manifest in TMD symptoms, parafunction, tooth damage, and more. 

In our Essentials 1 course, I am sometimes asked how to take care of leaf gauges, so I thought I would share my answer.  

Although they don’t last forever, dental leaf gauges do last a long time and you can autoclave them between uses. When you sterilize them, the leaves become sticky, so I separate them like a hand of cards before putting the gauge in the autoclave bag and separate them again when I take them out of the bag just before going to the mouth. 

Over time, with use, a leaf gauge will start to look a little beat up. I’m looking at one now. The Teflon screw that holds it together has turned color from going through the autoclave. I can see some ink stains from Madame Butterfly silk. It’s at the point where I think it looks too grungy to keep using. Although it might continue functioning for quite some time, I’m going to toss it and use a new one. After all, they are relatively low cost with a high return on investment.  

I’ve never seen a dental leaf gauge break after many trips through the autoclave. I tested cold sterilizing one and discovered the chemistry in the ultrasonic cleaner started to make the leaves brittle and they came out stickier than when autoclaved. So, my preference (and the protocol in my practice) is to bag them and put them through the autoclave. 

Explaining Dentistry in a Way Patients Understand 

Clayton Davis, DMD 

Here are some of the ways I communicate with patients to help them understand dentistry. I hope some of these will be helpful to you in enabling your patients to make good decisions about their treatment.  

Occlusal Disease: In helping patients understand occlusal disease and the destruction it can cause, I have long said to them, “The human masticatory system is designed to chew things up. When it is out of alignment, it will chew itself up.” I tell them, “Your teeth are aging at an accelerated rate. We need to see if we can find a way to slow down the aging process of your teeth.” The idea of slowing down aging is very attractive to patients, and if you relate it to their teeth, they get it.  

Occlusal Equilibration: Typically, I come at this from the standpoint of helping them understand that teeth are sensors for the muscles, and when the brain becomes aware our back teeth are rubbing against each other, it sends the same response to the muscles as when there’s food between our teeth. In other words, the brain tells the muscles it’s time to chew, and this accelerates wear rates on the teeth. Equilibration is really a conservative treatment to reduce force and destruction of the teeth.  

Diseases of the Jaw Joints: Regarding jaw joints and adaptive changes and breakdown, patients understand that joints have cartilage associated with them. Saying there has been cartilage damage in your jaw joint gets the message across simply. 

Treatment Presentation: When patients say, “I know you want to do a crown on that tooth,” I jokingly say, “Oh, don’t do it for me. Do it for yourself.” I never say, “You need to get this work done.” Instead, I say, “I think you are going to want to have this work done.” 

Conservative Treatment: I have always enjoyed John Kois’s saying that no dentistry is better than no dentistry, so when talking about conservative dentistry, I’ll tell patients, “No dentistry is better than no dentistry. We certainly don’t intend to do any dentistry that doesn’t need to be done.” Another way I speak about conservative dentistry is to say, “Conservative dentistry is dentistry that minimizes treatment. In the case of a cracked tooth, a crown is actually more conservative than a filling because it minimizes risk.” 

Moving Forward with Treatment: I love Mary Osborne’s leading question for patients after they’ve been shown their issues and treatment possibilities have been discussed. The question is “Where would you like to go from here?” With amazing regularity, the patients choose a really good starting point for their next steps toward improved health, steps that feel right to them. Always remember, people tend to support that which they help create. 

Dental Insurance: I typically speak of dental insurance as a coupon that can be applied to their dental bills. I’ll say, “Every plan sets limits on how much it pays. The way dental insurance works, it’s as if your employer has provided a coupon to go toward your dental bills.” 

Presenting Optimal Care: If I want to present optimal care to a patient who is ready to hear it, I ask permission by saying, “Mrs. Jones, if I were the patient and a doctor did not tell me what optimal treatment would be for my problems because the doctor was concerned that I couldn’t afford it or that I would not want it, I would think, ‘How dare you make that judgment for me. You tell me what optimal care would be, and I’ll decide for myself if I want it.’ So, with that in mind, Mrs. Jones, would it be okay with you if I presented you with the optimal solutions for your problems?” 

One of the most important things I aim to do is create clear expectations for my dental patients. Over the years I have intentionally tried to shift my language from discussing “treatment” to “management” when talking with patients who have dental risk factors that will persist throughout life. Perhaps, the following short discussion will empower you to do the same.

By being intentional about this, we can:

• Reduce patient frustration,
• Avoid patients thinking we have failed them,
• Boost their confidence that we are working together to address their oral health problems, and
• Inspire them to try management therapies and return to therapies that helped in the past when there are flare-ups.

When I describe something as a treatment versus describe something as a management therapy, I inform my patients about the difference and explain why management therapy may or will never eliminate the underlying cause of their oral health issue — but by continuing to manage their issue therapeutically throughout life, they will hopefully reduce discomfort and disease.

I make a clear distinction that treatment fixes a problem, and in their case, the problem may not be fixable, although it can be managed. For example, I focus on this when the patient is truly at high risk for periodontitis. This is a patient who has suffered from bone loss and has a body that is highly reactive to the bacteria in the inflammatory disease known as periodontitis. I also focus on this when the patient has significant TMD issues.

When I tell a patient, that we are going to treat something, the use of the word “treat” sets the expectation that the problem will be eliminated. That is very different from a management strategy that helps to reduce the symptoms and/or the continued degradation of their oral health. When we tell patients we are going to do scaling and root planning and we’re going to “treat” their periodontitis, it can be really challenging for them when we recommend that they do additional periodontal therapies.

When we think about periodontal risk, functional risk, and caries risk, the reality is that risk is a bell curve. There are some people whose risk factors are easy to manage, and some people whose risk factors are very challenging to manage. We need to help patients understand that when they have certain risks, certain disorders, there really is no treatment. What we do have is a lot of therapeutic modalities that can help manage the damage, manage the symptoms. Sometimes these modalities are so effective that it appears the disorder has gone away.

We need to recognize and the patient needs to know that the disorder really has not gone away and can surface again. With clear expectations, our patients (and we) do not have to experience disappointment and frustration. Instead, we can have supportive, empathetic conversations, and move ahead with restarting therapies and trying new ones.

Both periodontal disease and TMD are inflammatory disorders.

We have lots of dental patients who are suffering from the effects of inflammation, and one of the things we can do is help them look at inflammation not from just a local perspective but also from a systemic perspective. Our goal is to help them reduce inflammation where it occurs in the mouth and, also, throughout their bodies in general.

In addition to the first line dental treatments, we can work with our patients at higher risk to manage their general inflammatory response by advocating and discussing dietary changes. I have had great success with some patients by giving them nutritional guidelines.

I know some of you are “rolling your eyes” when you read this because you have had little impact on dietary changes. But we can throw it out there, and some of our patients will latch on to that information and try hard between their dental appointments to make a visible difference when we next see them. These are patients who want to be proactive, and this is something over which they can take control, much like the percentage of patients who accept fluoride varnish and implement the Sonicare devices we recommend.

We don’t need to hold ourselves out there as nutrition experts. We can explain that periodontal disease and TMD are inflammatory processes and one of the things we are learning today is that the foods we eat can increase or decrease inflammation in general. We can suggest this is something they could become curious about, do some internet research, and use the anti-inflammatory foods information they find to affect positive changes in their total health and the oral health issues we are observing.

I tell patients there are great books on anti-inflammatory diet guides and anti-inflammatory cookbooks on Amazon. Dr. Joel Fuhrman and the Forks Over Knives publications are two I mention. If you delve into reading on this topic yourself, you will find you can easily converse about the impact this reading has had on your own diet and the health of other patients.

Be as general in the information you provide or as specific as you are comfortable, but by starting this conversation with patients, you are doing your best to help them.

All restorative materials have wear properties. We need to understand both how they wear and survive in the oral environment and how they impact opposing natural teeth.  

The wear of enamel is the basis for comparison.

Despite what we sometimes see clinically, enamel is highly resistant to wear (attrition and abrasion), with average annual wear rates of 30-40 microns. The range is from as low as 15 microns to as high as 100+ microns, and there is variability depending on the tooth position in the arch.  

Unlike enamel, which basically all has the same structure and properties, composites come in many different formulas. The chemical and physical properties of the material have a direct impact on its wear resistance and impact on other teeth. Some examples of this include: 

• Size, shape, and hardness of filler particles 
• Quality of the bond between filler particles and polymer matrix 
• Polymerization dynamics of the polymer 

These same properties affect the other physical and handling properties of the material and have to be balanced to create a composite that works clinically.  

Creating improvements in the physical properties of composites has eliminated the high degree of wear in non-contact areas we witnessed years ago. The loss of restorative material gave the appearance of fillings losing their shape and contour. Today our primary concern is in areas of direct occlusal contact.  

One approach might be to avoid using composite that has direct occlusal contact.

I would say this is not only not practical but not necessary. We have a variety of materials available today, with a range of handling and physical properties, and wear rates that are between 30-200 microns a year.  

We need to choose a composite based on things like wear versus polish–ability, anterior versus posterior, and the properties of the particular material we are using. In addition, we can manage the occlusion to maximize the success of the natural teeth as well as the composite. 

When we nose breathe, our tongue is elevated against the anterior portion of the palate and held there with gentle pressure. This position mechanically pulls the base of the tongue forward increasing the size of the airway. At the same time, the gentle pressure and movement of the tongue to this position helps to strengthen the tongue and keep it strong. A strong tongue is less likely to collapse backwards and obstruct the airway, so nose breathing is important for airway.

There is also great research today that breathing through your nose promotes better health. It creates higher levels of oxygenation of the blood, it cleans and humidifies the air for better lung health. Studies also show that mouth breathing suppresses the immune system and can have other adverse health effects. To this end, one of the current trends is to work with patients to train them to nose breath, including using a mouth taping technique.

A simpler way that may be effective is to use behavior modification and have people actively work on nose breathing. Many of the step tracking devices today can be set to vibrate every 15 minutes, to remind the person to move. I use this to remind people who parafunction to check if their teeth are touching, and for mouth breathers so they can check-in and nose breath instead.

You are accustomed to consulting with patients about the association of TMD with craniofacial pain, but the link to sleep disorders should now be on your radar. Your patients want to know that you can help them sort out whether their frequently occurring headaches are the result of TMD, obstructive sleep apnea (OSA), a combination of the two, and/or other comorbidities.

Because research evidence suggests up to 50% of individuals suffering from morning headaches have OSA, every dentist likely has some sufferers they can detect, educate, diagnose, and refer or treat. If you are not already an expert in Dental Sleep Medicine, The Pankey Institute’s immersive Dental Sleep Medicine course is one of the best in the country.

A preclinical interview that includes questions about headaches will get you started with a co-discovery diagnosis for OSA related headaches and set you and your patient on the path for the most appropriate diagnostic testing and treatment.

Early in my career, I became frustrated with splint therapy. In the clinical area it was working. In theory, it made sense to me that I should be able to take the appliance back through well-articulated CR casts and ultimately to my patient’s mouth.

Turned out, patients treated with splints were not beating down my door for definitive dentistry. Like Mick Jagger, I Couldn’t Get No Satisfaction. A decade later, I have experienced something magical happening and am singing a new Rolling Stones song in my head, Time is On My Side. (Yes it is!)

Time and Splint Therapy

Perhaps I was not waiting on my patients or more than likely they were waiting on me. I have hundreds of splints on unrestored patients that visit me a couple of times a year. They bring along the plastic to have it ultrasonically cleaned, sometimes tweaked, sometimes repaired.

There was a time when I believed the transition to treatment was a given once the appliance was well-adjusted on a patient willing to trust me with their investment in therapy. (I mean geez, that happens every time for the folks who taught me how to make one, right?) The presentation of the next phase was a conversation that probably sounded a whole lot like a sales pitch and generally fell flat on its face.

Time is on our side. I’ve grown to realize the virtue of patience and listening. Specifically, I listen for compliments, appreciation of the appliance, and sometimes simply a statement of dependency on the plastic. Sometimes this takes years. This is the time to ask, “Would you like to discuss dentistry that can make your teeth feel this way?” Sometimes they outright ask me.

Time is on our side. Appliance therapy is a seed. Our caring attention is a well-nurtured garden. Patients will bloom when they are ready.

My experience with splint therapy was like most dentist’s prior to developing the skills taught at Pankey. In fact, my appliance was not really therapy at all. Perhaps just a shot in the dark “helmet” that protected teeth against collisions with very little intention.

Throughout the years there have been many facets of my experience I value greatly in guiding patients to health using plastic:

Splint Therapy and Appliance Design

Appliance design is a provisional analog (that is, a practice replacement) for any changes we make to the teeth and ultimately the stomatognathic system. The splint is a great diagnostic tool that is capable of healing, but it’s also an iconic part of the behavioral interaction between the provider and the patient.

Aside from physically being an orthotic analog, the splint is a training tool, maybe even the greatest reversible “do-no-harm” in our profession. Case by case, each patient experiences changes and familiarizes themselves with my touch and caring.

Month by month and year by year dentists educate themselves and develop an understanding of bite relationships by using therapy. This happens case by case too, much like waxing cars and painting fences for Mr. Miyagi. As the experiences compile, sometimes our questions do as well. Sometimes we turn to our mentors for answers, much like the Karate Kid.

For the learning dentist, different parts come together when bringing splint therapy from the classroom to the operatory. There is the initial understanding of the “why” that can be conceptualized in theory, but not realized in practice until the “how” of the technical piece arrives through experiential understanding.

Each provider comes into their own by developing skills to have patients relate needs and eventually invite them confidently to enter appliance therapy.

There’s more to come in Part 2! What challenges have you faced in splint therapy techniques to ease patient discomfort? 

How Studying and Treating TMD Transformed One Dentist’s Practice for the Better

When Dr. Michelle Lee embarked on her dental career, she felt like there was a missing piece in how she approached dentistry. Discovering the power of TMD ultimately made her work more fulfilling and effective.

Dr. Lee relates her journey of achieving professional balance while attending the Pankey Institute, how treating TMD has transformed her practice, and why she believes career fulfillment is crucial to success.

Dr. Michelle Lee on the Power of TMD and Pankey Learning

Very quickly in my dental career after purchasing my dental practice, I knew I needed to expand my dental learning. I was seeing changes and problems within my patient’s dental health where I didn’t know WHY? Though I could easily tell the patient what we needed to do to fix their problem, I couldn’t necessarily explain the reasoning behind it: why a tooth broke, why wear occurred on one tooth but not the others, why the patient was having pain in their face, why pain was in a tooth for no apparent reason.

Not having these answers wasn’t good enough. I knew I needed to know the WHY. I believed if I figured this out I could partner with my patients and help them before problems like failing restorative dentistry, TMD issues, and myofascial pain started to arise. I decided to go down to the Pankey Institute within the same year I purchased my dental practice.

Dr. L.D. Pankey said, “A tooth never walked in the door.”

Attending the Pankey Institute changed my life both professionally and personally. I received a top notch dental education on comprehensive dentistry that included concepts like occlusion and TMD. The learning was presented from a technical, behavioral, and financial perspective. The Pankey Institute also guided me in creating my own personal and professional philosophy to achieve a work-life balance.

I am passionate about learning how the temporomandibular joint, muscles, and dentistry work together. Treating TMD allows me to deliver truly comprehensive dentistry to my patients. It’s like lifting up the hood of a car and examining the engine.

Learning about the TMD joint and the orofacial muscles helped me see dentistry from a new perspective. I am better able to delivery dentistry that is both protective and preventative. I have created a whole new culture within my practice because I show my patients WHY. This has made my work extremely rewarding.

What continuing education has had the most significant impact on your professional life? Please leave your thoughts in the comments!