In this monthly feature, Dr. Gordon Christensen addresses the most frequently asked questions from Dental Economics® readers. If you would like to submit a question to Dr. Christensen, please send an e-mail to [email protected].
Question...
I have been using NTI splints for the last few years, and have had success treating bruxism, clenching, and TMD. However, some of my colleagues have questioned my use of the simple NTI concept. They say conventional occlusal splints, which include all teeth in the splint, should be used instead of the NTI concept. When should conventional occlusal splints be used, and when should the NTI or other similar splints be used?
Answer from Dr. Christensen ...
The NTI-TSS (Nociceptive Trigeminal Inhibition Tension Suppression System) has been popular for several years. It has been my experience, after hearing comments of dentists on the lecture circuit and from our controlled research findings, that the concept of placing a small, discluding piece of resin in the anterior of the mouth - which disallows any other tooth contact- has been successful when compared to conventional occlusal splints. Which one is best is a moot point. Each works well. However, I will offer an opinion on when one or the other concept appears more appropriate.
If a person comes to your office with a painful TMD while you are busy with other patients, you cannot avoid providing immediate treatment for the patient in pain. Making a conventional occlusal splint usually requires a significant period of time. Conversely, making an NTI splint can be accomplished by a staff person relatively quickly. It has been our experience that, in most cases, pain relief comes within a few minutes of seating the splint for a patient with TMD pain.
There are many times when a patient does not want to wear a full-coverage occlusal splint or cannot wear one without gagging. In such cases, the smaller, less objectionable NTI is a good choice. When it is anticipated that a patient will not be compliant in wearing a full-arch splint, the smaller NTI is a better choice. There are many practitioners who use only the NTI splints for bruxism, clenching, and TMD patients. They have had success. On the other hand, practitioners have been successful using only full-arch maxillary or mandibular splints for these conditions.
I use both concepts, and find both to be acceptable. But I somewhat favor the full-arch splint for long-term use for bruxing and clenching patients. Occasionally, patients can be given one splint of each type to satisfy occlusal problems. This allows them to wear the one that feels best at any given time.
Recently, we produced the following videos on occlusal subjects: V3104 “Occlusal Splints - Predictable and Frequent Use,” V3106 “Simple TMD Therapy for Your Practice,” V3105 “Uncomplicated Occlusal Equilibration,” and C500A “Occlusal Disease Therapy Simplified (NTI-TSS).” You will find these videos helpful in answering most of your questions about treating occlusal challenges. For more information, contact Practical Clinical Courses at (800) 223-6569, or visit our Web site at www.pccdental.com.
Question ...
When restoring the posterior teeth of a patient who bruxes or clenches, what is the best material to use for crowns?
Answer from Dr. Christensen ...
The best material is gold alloy; however, it is out of style with most people unless they are educated about its use. I find that patients who will accept gold-alloy restorations are those who have had previous experience with them, or have dentists who know the longevity of this type of restoration.
In a recent poll of members and guests attending a discussion about restoring their dentition at an American Academy of Restorative Dentistry meeting, the following preferences were expressed:
❶Gold alloy was the preference for lower-first and second molars and upper-second molars.
❷Tooth-colored restorations were favored for the remainder of the posterior teeth for an acceptable esthetic appearance Porcelain-fused-to-metal was the preference for restorations on the remaining teeth.
Now let’s discuss those people who will not accept gold-alloy restorations in spite of their bruxing or clenching habits.
Bruxers have worn off their anterior guidance and canine rise, both of which are present in most young adults. If these patients will not accept gold alloy on the posterior teeth, they can be restored with porcelain-fused-to-metal crowns, or some types of all-ceramic crowns, if they will agree to the following requirement: They must wear a resin occlusal splint, preferably a full-arch one, every night and in the daytime during times of stress.
Clenchers do not wear off incisal guidance and canine rise, but they do severely wear the centric occlusion contacting surfaces, thus collapsing their vertical dimension of occlusion. When restoring these patients with porcelain-fused-to-metal restorations, they also should be required to wear an occlusal splint at night and during times of stress.
I have rehabilitated many patients who brux or clench, and have found that if they will wear their occlusal splint as directed, the porcelain-fused-to-metal crowns and fixed prostheses serve them well for many years.
The newer zirconium-oxide-based, all-ceramic restorations, such as DENTSPLY Cercon® and 3M™ ESPE™ Lava™, should have the same occlusal splint protection as porcelain-fused-to-metal crowns. Although more clinical research is needed, these restorations - at this time - are looking good. It appears they will be the first real competition for porcelain-fused-to-metal crowns and fixed prostheses.
In summary, gold alloy is the best restoration type for posterior teeth of bruxers and clenchers. After treatment, I suggest making an occlusal splint to be worn during sleep and times of stress to protect the gold alloy from being prematurely worn. If patients will not accept gold-alloy restorations, occlusal splints are needed at night and during times of stress to protect the all-ceramic or porcelain-fused-to-metal restorations.
Dr. Christensen is a practicing prosthodontist in Provo, Utah. He is the founder and director of Practical Clinical Courses, an international continuing-education organization for dental professionals initiated in 1981. Dr. Christensen is a co-founder (with his wife, Rella) and senior consultant of Clinical Research Associates which, since 1976, has conducted research in all areas of dentistry and publishes its findings to the dental profession in the well-known “CRA Newsletter.” He is an adjunct professor at Brigham Young University and the University of Utah. Dr. Christensen has educational videos and hands-on courses on the above topics available through Practical Clinical Courses. Call (800) 223-6569 or (801) 226-6569.
