Bite problems, headaches,and migraines
I do my best to explain the relationship between bite problems and either muscle pain or excessive force on teeth (which can lead to tooth fracture or severe and premature wear on teeth).  I still find that the art of “equilibration (microadjusting the surface of the teeth so they meet in a way that is more comfortable for your jaw muscles) is tough for many of my patients to understand.  People just don’t always seem to see the “value” of the treatment.
The following letter from one of my patients may go further to explain the value of this process than any words I could think up:

“Several years ago I became a patient of Dr. Waterston.  I had avoided dental treatment for about 10 years, and the first dentist I saw for treatment only reinforced my fears.
After I experienced an escalating pain in a tooth with a new filling, a family member referred me to Buzz.;  His staff spent a lot of time on the phone reassuring me about his gentle approach to dental care before I even entered the office.  His care began to change my opinion of dentistry and started me on a path to a renewed sense of trust in my dentist.
I had had years and years of TMJ muscular symptoms, and Buzz suggested that I wear an NTI device at night to stop me from clenching my teeth in my sleep.  This was an amazing discovery to me and greatly improved my symptoms.
Last year, after some dental issues that resulted in my needing surgery, I found myself feeling discouraged when I had pain on the opposite side of my mouth.  I visited an endodontist (ed. note:  root canal specialist), I was told that there was no nerve involvement causing my pain.
Buzz called me personally and asked me to come in.  Anticipating more of the dreaded poking and prodding, I was pleasantly surprised to learn a great deal about bite issues, and I left with the hope that adjusting my bite (an equilibration) might be the answer.
After the first adjustment visit, I experienced a significant decrease in my symptoms prepared me for the fact that it might take several adjustments to complete my muscle “recovery,” and after the third adjustment, I experienced complete relief of my TMJ symptoms for the first time in over 10 years!
I would invest in this procedure again without any hesitation. It has produced a great change in my quality of life by eliminating daily pain and muscle tension.  I am grateful to Dr. Waterston and his staff for keeping up on the latest treatments and technologies to offer the highest quality of care to his patients.”
Amy Peterson

When I do an equilibration, I try to make it clear that this is not a “cheap” procedure.  It takes special training  for a dentist to learn how to do an equilibration properly; very few dentists have that training. That special expertise and the cost in time and money to attain it is reflected in the fee.
What makes a successful equilibration a worthwhile investment is that it can either improve one’s quality of life dramatically and profoundly by reducing or eliminating muscle pain, or it can save a patient many times the cost of  the procedure by reducing or preventing self-inflicted damage to the teeth from grinding and clenching.
Either way, the results can be…….”priceless.”

Recent TMJ course
I think of the pursuit of knowledge  as a ladder to be climbed.  Every so often I’ll take a course and realize how far I’ve climbed up that ladder in 33 years of dental practice and continuing education.  In February, I took a 3 day course on occlusion, the study of problems relating to one’s bite.  I’ve been taking courses in this area for over 25 years, but this course was given by someone who was so knowledgeable and whose knowledge and presentation were so superbly organized, that my knowledge leapt much further up that ladder.  I now have a better understanding of bite-related problems than ever before.
Some personal highlights:
—Many people have GERD (also known as acid reflux) and have no symptoms whatsoever.  The only sign may be erosion of  your teeth from stomach acid literally eating away and dissolving tooth structure.  I talked to my internist and received the recommendation of an excellent GI specialist.  By the time you read this, I will have sat down with him for a “coffee and learning” session.  He’ll be my mentor in this area so I can help identify undiagnosed GERD in my patients BEFORE they get severe damage to  their GI systems.  I’ll tell him what dental materials are available that are most resistant to the effects of acid reflux, such as gold and certain ceramics.
—Since 1991, part of my comprehensive examination process has been to check for what is known as centric relation and compare it to my patients’ actual bites.  Here’s a way to understand centric relation:  imagine that you had a cup with a rounded bottom, and you  dropped a round ball into the cup.  Where would the cup tend to come to rest?—in the bottom of the cup, of course.  Well, your TMJ is the same type of structure turned upside down;  the jaw has a “ball” on either side that wants to nestle up into the top of the “cup” in your TMJ.  Sometimes, your chewing muscles, your bite, or a problem within the joint itself will prevent the ball from seating fully into the cup.  When that happens, the muscles may “brace” your jaw in an  artificial position along the wall of the cup.  The muscles have to become hyperactive to hold the jaw in this unnatural position.  If the muscles tire, you get TMJ muscle tension headaches, which can refer pain to your temples, forehead, behind the eyes, or other location in the head and neck.  If the muscles don’t tire, you get chronic and excessive pressure on your teeth.  This may lead to broken teeth, fractured fillings or cracked porcelain on crowns, loosening of teeth, tender teeth, or severe wear on your teeth.
I now possess far superior knowledge than ever before in diagnosing and treating this type of problem.  For those of you whose muscles were “too tight” for me to accurately check your bite initially, I now have two advanced methods of relaxing the hyperactive muscles to check where your bite would function best.  I am also much better equipped to diagnose and treat situations in which the teeth are severely and prematurely worn.

Things you don’t feel CAN HURT YOU!
I have a profound appreciation  for the workings of the human body;  the way we can often sense problems when they’re just starting.  However, 35 years of experience have taught me that  certain serious dental problems can develop and progress without any awareness on our part. Just as most people can’t “feel” that their blood pressure is high,  sometimes “silent” dental damage can be considerable, even irreparable.
This is the first in a series of articles on “silent” dental problems.  The more you know, the more likely you are to avoid these problems.

1)Worn and broken teeth
It is normal for your teeth to gradually wear down.  Normal wear is about 15 microns a year (that’s about one thousandth of an inch in two years!).  In the photo below, you’ll see abnormal tooth wear.  Since the back teeth were missing, all the force of this person’s bite was directed to the front teeth, almost destroying them.

How much pain do you think this person was in when the teeth were so severely worn?  Actually, there was no pain whatsoever.  The front teeth were wearing quickly to the point where some of them literally snapped off, but the entire process was painless.

At every comprehensive examination I do (that’s the exam we do on our new patients), I evaluate the bite and I check for excessive wear.  At  six month checkups I’ll also check for wear.  If I see that your wear is age-inappropriate or excessive, I may recommend a detailed evaluation of your bite so that I can rebuild the teeth successfully and predictably.
I’ve spend the last year increasing my education in this area.  18 hours of continuing education and 8 DVDs later, I have more knowledge than ever before on how to correct bite-related problems.

How would you know if you have a bite-related wear problem?  Telltale signs might be having teeth or fillings break;  developing sharp edges on your front teeth and noticeable shortening of your front teeth.  Will you feel pain?  Probably not, unless a tooth wears down so severely that the nerve is exposed.

Wear is not the only thing that can destroy tooth structure quickly.  Acid erosion is emerging as a very serious dental problem in recent years.  I’m talking about bulimia, gastric reflux, excessive soda drinking (especially Mountain Dew;  soda, even diet soda, has a very acidic pH, and Mountain Dew more closely approaches the pH of battery acid than any other soda), or excessive eating or sucking on citrus fruits.
In the photo below and to the right, this excessive erosion of back teeth was noted on a college-aged young man. Tooth enamel is the hardest substance in your body—harder than bone—and this young man managed to destroy the tooth enamel on his back teeth in just a few years.  The underlying tooth structure is seven times less resistant to wear or acid damage, so you can see how the tips of the teeth have been worn flat and have deep indentations where the enamel has been worn through:

Compare this with a photo of normal wear in a person in her mid-‘30s.  The enamel cusps are rounded and hardly worn:

At your next checkup, ask us if we see signs of abnormal tooth wear in your mouth.  We’d be happy to double-check and suggest appropriate preventive or corrective treatment.

WIIFM if my dentist is a “bite detective?”
WIIFM is short for,  “What’s in it for me?”  The occlusion course I took in February wasn’t an academic exer-cise;  the purpose was to allow me to become a better “bite detective” so I could  help my patients.  Here’s how the information I learned can help you:

The way your teeth fit together (occlude) when you bite down can determine the health of your jaw joint (TMJ), muscles, and teeth.
When teeth occlude improperly the joints can be damaged, the muscles can hurt, and the teeth can loosen, wear down prematurely, or break.  If an imperfect occlusion can be improved,  the force created by the muscles can be lessened and redistributed more favorably (i.e., with decreased likelihood of damage to the joints, teeth, and restorations).
An unstable, imbalanced bite is a ticking time bomb.  Your jaw muscles have been brilliantly designed to work in coordination with each other.  If the muscles start “firing” in a way that is uncoordinated, something in the system has to break down.
You may not know you have a bite problem unless your jaw muscles are in pain.  Even then, you may not associate that pain with a dental cause;  jaw muscles can “refer” pain to your forehead, temples, under your jaw, behind your eyes, or to your ears and TMJ (which is located just in front of your ears).
If your teeth wear flat or break you may have no pain, but something is still wrong with the bite system.
When you are awake there is a “self-protect” mechanism that limits how much muscular force you can place on your teeth,  like a “speed limit” for your muscles.  This self-protect feature does not function when you are unconscious (i.e., asleep), so your jaw muscles can clench far past their daytime speed limit. 
One of your muscles helps your jaw seat into the cup-like TMJ.  Your back teeth may hit in a way that prevents the “ball-end” of your lower jaw from seating fully into the “cup” of the TMJ.  Then, this muscle tenses up to brace your jaw forward into this not-fully-seated position.  This can cause pain in your ear, TMJ, or behind the eye sockets.  Subtly reshaping your back teeth, a process known as equilibration, can allow your jaw to seat fully in the TMJ cup, reducing or eliminating pain and muscle bracing.
How do you know if equilibration can safely be done on you?  In some cases I can tell just by checking your bite.  In more complicated situations, I can take models of your teeth.  These study casts can be mounted on a TMJ simulator called an articulator.  Your bite can be studied in detail and a trial equilibration can be done on the models before I ever touch your teeth.
This makes the entire diagnostic and treatment process more predictable.

When teeth wear down
I touched upon the problems of worn teeth last month.  What I forgot to mention is this:  as teeth wear down, your appearance can change dramatically for the worse.  Severe tooth wear almost always causes severe aesthetic problems.  You can’t just “build up” the teeth;  you have to restore an aesthetic appearance at the same time.  This is one reason why rebuilding severely worn teeth is such a complex problem.

Are you a bruxer?
When you are awake and conscious, your body has a marvelous system that limits the force you can place upon your teeth.  The problem is that we have to go through a daily cycle of unconsciousness;  we need to sleep.
During sleep, you can apply nine times the force on your teeth that you can when you’re awake.   Also, your jaw’s range of motion at night is 30% greater than when you’re awake, so you can cause much more damage to your teeth if you grind your teeth uncontrollably at night.
This uncontrolled grinding and clenching is called bruxism.  Sometimes, this habit is actually a central nervous problem brought on by brain injury (car accidents or other severe trauma).   Bruxers can cause almost unbelievable damage to their teeth.  This problem can sometimes be controlled, but often is a lifetime issue despite the best treatment.
Bruxers who have severely worn or broken teeth can have their teeth rebuilt to better co-exist with this habit, but they are at a high risk for breaking the porcelain off the rebuilt teeth and must always wear some sort of device to protect their teeth at night;  either an NTI or a full nightguard.  Bruxism is now medically  classified as a neurologic disorder.

One of the reasons I now do a comprehensive examination on all my adult patients every five years is that, today, I can diagnose and treat tooth wear problems that I couldn’t diagnose even 5 years ago.  This is not the type of thing that’s taught in dental school;  in fact, at my 19 hour course on “Treating the Worn Dentition” in September, one could look around the room and see one dentist after another mouthing the words, “Oh!—-that finally makes sense to me.”   Frank Spear is the best dental speaker I’ve ever heard, and I’m grateful to him for sharing his knowledge so freely.

Night bruxism and TMJ
Note: bruxism is uncontrolled teeth grinding
More recently-learned facts about night bruxism:
—Sleep bruxers have gastric reflux (GERD) episodes with a pH of 4.0 (acidic enough to remove the minerals from the teeth the acid touches) an average of 3.6 times per hour all night long.  3.6 times 8 hours is 29 episodes per night.  The combination of your teeth being weakened by repeated acid baths and severe grinding forces is lethal to teeth.  This is why science is trying to come up with drug treatments for nighttime bruxism.