Anterior Bite Plane Appliance

Part 5 - Patient care instructions

Instructors:

Lee Ann Brady, DMD

Lee Ann Brady, DMD

Dr. Lee Ann Brady is currently the VP of Clinical Education at The Spear Institute and was the former Clinical Director of the Pankey Institute.

Dr. Brady reviews the patient care instructions for an anterior bite plane appliance

So the next thing to do is really just to trim this up for Katie. One of the things I want you to see if where the green dots are relative to the lingual of this composite. I'm going to smooth a little bit of this composite off for her. But I'm not going make that much thinner because I'm not sure how far back or lingually her mandibular teeth will move if her condyle is seat. And I don't want her to fall off of that appliance. So I'm going to leave some of that until we have an adjustment appointment. But I am going to thin it for her so that it doesn't feel quite as bulky down at the edge of the Biocryl. Now for polishing this. I'm actually going to move to my polishing points that are on my Brasseler appliance kit and I'm going to just start out with the dark blue. It's the coarsest of the polishing point. And this again is one of the reason I love doing this out of regular composite is they polish up just beautifully. And then now go to the lighter blue. So it's just slightly more fine. And then the last step is this sort of a beige or light yellow polishing tip to really put sort of a high fine shine on this. Now one of the things is you want to be making sure that you're using this in a hand piece that's going at slow speed. The shanks of this polishing points will bend or torque really simply if you go too quickly. Right now I'm using an air driven hand piece. So I'm having to control the speed with my foot. If you have an electric you just want to dial them down. So now that I've gone through my polishing tips that were on my kit, the last piece of this would be I'll take it into the lab and I will use flour of pumice on a wet lathe wheel and then I'll use some kind of polishing paste so Kenda blue or the Ivoclar polishing paste to really put a high shine polis on it and then it's simply a matter of just sending Katie home. So what kind of instructions am I going to give Katie with her anterior bite plane appliance? I'm going to make sure that she knows that the maximum amount she can wear it is 6 to 8 hours every 24. What I preferably like her to do is sleep in it. One of the things I let all of my patients know is that first three nights or so it's an adjustment period. First of all, they typically salivate like crazy if they've never wore an appliance before. Something about our brains thinks anything in our mouth should be able to be dissolved. But then our bodies kind of give up after the third night. The other thing is depending upon her sleep patterns. I find some of my patients sleep like a baby with the bites splint in. So if they've been bruxing and clenching and working their jaws out all night long having the appliance in can really help them sleep better and feel more rested. On the other hand some of my patients are the kind that any change a new pillow, a new sheet, an window open at night will disrupt their sleep patterns cause they're very light sleepers. So I let my patients know that I do expect it will have impact on their sleep for the first couple of night but hard for me to know whether that would be an improvement or that would take them a few nights to get used to it before they feel like they're sleeping well again. What I want my patients to do is brush and floss their teeth then put the appliance in the evening. When they get up in the morning brush and floss their teeth and now they're going to clean the appliance by simply brushing it inside and out with whatever residual toothpaste that's left on their toothbrush. Rinsing it and we give them a retainer case and we ask them to store it dry. So it should not be soaked in anything. If you soak it in Listerine or something with a color it will not only absorb that color but it also leach that material back out. I just recently saw a patient that had been soaking her appliance in hydrogen peroxide thinking it was going to clean it. And low and behold she had very beautifully bleached teeth but only where the appliance touch her teeth because the acrylic was absorbing it and leaching it back out almost like bleaching trays. So you really don't want your patient soaking their appliances in anything. They really need a thorough cleaning. Every once in a while they use denture cleaner to do the cleaning cycle and follow the directions and we have our patient brings their appliances with them every six months when they have their teeth clean and we clean them professionally in the ultrasonic. The other thing I coach all of my patient about is that the common reason I replace appliances is either the person takes it out and sets it in a paper towel or a Kleenex and there's someone else doesn't realize it's there and it cleans up and it ends up in a trash or pets have an affinity for these appliances. And so dogs and cats will find them and then will take them off and then chew them up and then we're stuck with making another one. So really if it's not in your mouth it needs to be in the retainer case were my instructions for my patients. With an anterior bite plane appliance, their first appointment after delivery will be 2-3 weeks following the delivery. We don't need to follow it for adjustments. As I said that's why I leave that platform a little wide in the posterior or lingual aspect so that their muscles can relax, their condyles can seat. They don't fall off of the platform and they don't pick up any posterior tooth interferences. If I'm going to be seeing them cause I wanted to get bite records for centric relations we schedule to do that at the time of the next appointment. And what I ask the patient to do is sleep in their appliance that night. Make their appointment for first thing in the morning. Wear the appliance into the office and I'll actually take the appliance out as I'm doing the bite records. So that their muscles don't have any chance to reprogram because they've been in intercuspal position before I do those bite records. If we're doing it for therapeutic reasons as well we're going to see them first and just reevaluate. Go back and repeat parts of the muscle exam or their joint exam. See how we're doing on those assessment numbers. See if it's actually getting us where we thought it needed to be. I said earlier in the piece if the patient gets better that's valuable information. It confirms my differential or my clinical diagnosis. If there's no change I need to ask myself the question was my differential wrong, do we miss something? Is the appliance not having the intending effect? If they get worst that's valuable information that lets me go back and look at my clinical suspicion and rethink it. One of the traps that I find dentist get into is that when we make an appliance and the patient doesn't get better as we intended we believe it has something to do with how we adjust to the appliance. On certain types of appliances yes they have to be followed and adjusted in. But if we're not seeing the intended outcomes base on what we know scientifically about how an appliance work I would encourage you to go back and ask yourself the question. What else could it be diagnostically/? What else did I miss? And not simply think if I just adjust it more exquisitely then the patient will suddenly get better and their symptoms will go away. The other instructions I always give my patients is that if they have any problem wearing it, if they develop any new symptoms, any discomfort that they need to call the office immediately. And there's one last piece. Let's talk about two things that sometimes patient can find kind of disconcerting. One is patient may actually experience that their popping or clicking their joint noise will get louder when they're wearing an appliance because of the fact that we're loading the joint it make the noise seem louder or more apparent. It is not actually worsening their condition. And I always make sure the patient knows. This is actually telling us the appliance is working. It's doing what it needs to do and we're going to maybe try to shower their guidance a little bit if necessary to alleviate some of that noise. But you want to let them know ahead of time that that's possible. They may notice the joint noise more than they did before. The next thing that we want to make sure our patient know is that when they wake up in the morning their bite may feel different. Most of our patients probably upward of 80% have a difference between how their teeth together in centric relation and what they know to be their intercuspal position. When the muscles are relaxed they're going to be able to find that first point of contact that centric relation bite first thing in the morning. I actually engage in my patient in finding that. So I actually ask them when you take your appliance out in the morning one of the things I want you to do is just slowly bring your teeth together and just make a mental note of where your teeth touch. It's probably going to feel different than your normal bite. And that's good. It tells us the appliance is working. By the time you're done brushing your teeth and eating breakfast you should be able to bite your teeth together and feel like you have your bite back. If you start to notice that it's taking longer and longer in the morning prior to being able to find your bite, I want you to stop wearing the appliance, call our office and we'll have you come in immediately so we can check. That still means the appliance is working but you and I need to talk about how we're going to manage that and whether or not continue the appliance therapy is going in the right direction. So it is possible a small percentage of our patients especially ones who have a very large AP component to their slide between center relation and intercuspal position. Their muscles can deprogram so effectively that they forget how to find their intercuspal position again. Again that's what the appliance is design to do. But unless we've talked with the patient about how we're then going to move forward and get all their teeth to touch again we want to know if that's going to happen. It's a very small percentage probably less than a percent or two. In the 15 years I've been making appliance I've only had it ever happened once and I know one or other two dentists who had it happened. But I always give my patients that heads up and that way they can know. If they can't find intercuspal position by breakfast, they need to stop wearing the appliance and they need to come back in. So that really concludes our segment on fabricating an anterior bite plane appliance. I hope that this has help you walk through knowing how you can make this in your office so that you can do it. You can train a dental assistant to do this in your office. It's very useful tool and this together with our other segments as an overview of appliances and joint muscle diagnosis should really help you be able to make a difference for your patients who have symptoms, have signs or you would like to do restorative dentistry and you'd like to understand more about what's going on with their temporal mandibular system. So thanks for joining us and thanks for being part of HDiQ.