(Monday's)Tuesday's Teeth: the Night Guard

 I'm doing my first Tuesday's Teeth today since I'll be out of town this week, and after meager and easily given up upon attempts to figure out how to schedule this to post tomorrow, I'm just posting it today.
Today's teeth related post will be about my really wonderful patients at one of my offices, whose perfectionist tendencies necessitate the use of a night guard, but whose very analytical nature renders them too skeptical to believe they need it.
In one of my offices I enjoy a population of patients that is almost universally unknown outside of the little community in which our office is nestled... and that is the nearly 100% compliant, best
dental insurance carrying patients, who are willing to get all treatment needed. Almost all of our patients do what we recommend. We say they should get an electric toothbrush - done. Start flossing? (usually) done. They come to their appointments ten minutes early, and I usually have to make them tell me if something is uncomfortable. So to say that I love working in this office is an understatement. However, there is just one thing that I have a hard time conveying: their need for the night guard.

A night guard serves as a splint to protect the dentition from nocturnal bruxism, or clenching and grinding your teeth while you sleep. This is a maladaptive habit, born out of a normal growth and development occurance from childhood. As children, we would clench and grind our teeth, which directs mandibular, or lower jaw growth in a downward and forward direction... so it serves a purpose. As adults, we have achieved this development already, and while we won't see bone growth in this direction, we may see boney projections in the floor of our mouth or palate. These are harmless, and most people never realize they have them. (I should also point out that these projections, or "tori" are consistent with bruxism, evidence hasn't not definitively determined a causal relationship.)
 In this community of truly Type A people, it is extremely common for me to see signs of nocturnal bruxism, in other words, clenching and grinding unconsciously to deflect stress. Generally these signs are in the form of extreme wear on their dentition. Often the cusps of their posterior teeth are flattened, and front teeth appear shorter or fractured. Sometimes patients will chip front teeth, or shear entire cusps off of posterior teeth as a result.

There is wear through the external tissue layer of the tooth, the enamel, which is an otherwise protective layer that is not innervated, thus we can eat or drink cold things, brush our teeth, and chew without discomfort. When this layer is eroded, our teeth become sensitive to otherwise innocuous stimuli. What may even be worse, is the damage bruxism has on our temperomandibular joint, causing excess wear on the articular disc, which can cause clicking, popping, and pain in front of your ear when you chew, yawn, or talk. Furthermore, it is common to experience muscle pain in the masticatory muscles, or jaw opening and closing muscles, as a result of the slow sustained contraction exerted during bruxism.
Often our patients come in with sensitive teeth in areas that jump around. One week it was the lower left, another week it was the upper right. They may feel sensitive in their muscles in the morning after waking if they are nighttime bruxers, or at the end of the day if they clench while at work.
All of that being said, it is extremely difficult for me to convince most patients that their symptoms are a result of bruxism, and they need a night guard.  I think one of the first reasons is cost. Night guards are usually around $500 at the very least, and they are not covered by insurance. Also, most people haven't heard of night guards before, or bruxism, and its hard to fathom that they don't just need a filling, which is covered by insurance, in order to fix the problem. Second, as I mentioned before, these patients have gotten pretty far in their life as a result of their constant questioning and need for extensive, irrefutable evidence before coming to a conclusion. This means they often see the aforementioned signs as insufficient evidence of bruxism.
I explain to the patient what I see, and how common these findings are in this population. I explain my recommendation for the night guard, and then... I tell them how much it costs, and they're skeptical. So then we're at the part of the appointment where I feel like a car salesmen, and I don't like that.   I honestly do feel bad that it is so expensive, but the fact of the matter is, its fabricated by a good lab, and they're expensive to make. If they balk at the cost, I encourage them to try an over the counter night guard, which is significantly less expensive, usually around $25, but I know its a waste of that money because the quality is such that it makes nighttime use of the thing pretty unpleasant. So am I doing my patients a disservice by immediately recommending the OTC night guard? Should I emphasize their need for the prescription night guard even more? Its tricky when it becomes about money, when they're sitting in the chair that I perform treatment in. It starts to blur the line between business and health. Unfortunately, this is just the way it is. I don't have a private office where I discuss the treatment plan, and yes, perhaps that would be the most ideal and something I will do in my own office, but in a big group practice that just isn't practical. If the patient has a big treatment plan and wants to work out how to maximize their insurance benefits, they talk to our office manager or billing manager privately in their offices, and that works out pretty well... this is just the one area that's tough.  In any event, if you have any questions about bruxism or think you might benefit from a night guard I'd be happy to answer any questions for you in the comment section.
Have a great Monday, (and Tuesday) everyone!

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