As I began to consider subjects for my first editorial, as a new associate editor for CRANIO, I knew that it had to be timely and germane to this highly respected publication and its readership. I was taking the place of Dr. Wes Shankland and those were big shoes to fill. I wanted to discuss a topic that I felt required serious attention by all involved with the treatment of TMD, but had heretofore been largely overlooked. As I searched the recesses of my mind, a topic that is close to me finally presented itself. My story begins a couple of summers ago. The American Academy of Craniofacial Pain decided to implement a beginning doctors program as part of its summer international symposium. The powers that be, under the guidance of Dr. Charles Holt, decided that one of the topics that needed attention was basic principles of occlusion. Yours truly was asked to present this two hour lecture. I suppose that this was decided because of my background as a member of the board and an instructor for the Seminars for Occlusal Studies organization, later named the Society for Occlusal Studies. This organization was one of the premier groups that offered training on occlusal principles, both through lecture and hands on workshops, as well as guidance on implementing them into practice. Beginning in the 60s and through the 80s, this organization heralded instructors with well recognized names such as Niles Guichet, Jack Haden and Peter Neff among others. As I considered the development of this lecture, I took stock of what I believe now, regarding principles of occlusion, as compared to then; what has changed with time? I came to realize that other than the axiom that centric relation was the only and an inviolatable condylar position, everything else was pretty much the same. I still used occlusal instrumentation. I still equilibrated the occlusion (as a finishing therapeutic procedure, which now, with all of our sophistication, we call coronoplasty). I still used axial loading. I still used anterior guidance and I still eliminated posterior working and balancing contacts in lateral movements (now referred to, again due to our sophistication, ipsilateral and contralateral posterior contacts). I had plenty of the teaching material and what I did not, I knew I could develop.
I sat about my task with enthusiasm, but as I immersed myself in the project I began to feel uneasy. I remember thinking: it couldn't possibly be stage fright. After all, I had presented many programs ranging from one hour to 3-day workshops. I had stood at the podium literally hundreds of times. In fact, I enjoyed being in front of an audience. (That probably comes from being a theater major in my early college days . . . really!) What in the world could it be? Nonetheless, I brushed this uneasy feeling aside and forged on. But no matter how I tried, I could not lose the feeling until finally, Eureka! I knew what it was: I was actually fearful that the class was going to laugh me off of the stage. Why? Because I knew that the assembled audience of skilled doctors would look at me and say, “He might as well be lecturing on how to do an occlusal cavity preparation on a bicuspid. This is basic. Why am I wasting my time?” Despite those misgivings, however, it was too late to back out. I finished the presentation, put it in the can (or in my case, the slide carrousels), and waited for my day of reckoning. When my Day of Judgment finally arrived, I was, of course, the last speaker, giving me the whole day to work myself into a nervous frenzy. As I set up my slides my palms began to sweat. I think I may have even had heart palpitations. The normal introductions were made and the presentation began. At first I did not want to make eye contact with the class, but as I started discussing condylar position, I saw that the doctors were not twiddling their pens. They were not doodling on their note pads and best of all, they were not asleep. As I delved into concepts of axial loading, cusp fossa relationship, and proper cusp placement, there was actually a glint of interest in the assembly. As I got to the relationship of condylar paths of motion and its relationship to occlusal morphology, there was a uniform class interest on the screens. As we continued through occlusal instrumentation, such as the face bow, pantograph, articulator and instruments to compare interocclusal records, interest remained high. And as I finally arrived at various clinical cases that demonstrated the proper use of the aforementioned principles (i.e. how to develop proper anterior guidance using lingual veneers not facial veneers), interest peaked. I discussed how to properly fabricate a permanent removable occlusal overlay appliance, with proper occlusion, to maintain mandibular position after repositioning therapy (Hey! This has something to do with TMD). But it was not until I displayed a full mouth fixed reconstruction as a phase II finishing procedure that I actually noticed expressions of wide-eyed surprise. “What is that strange looking silver die stone? It is a metal?” I was showing them a remount. “I propose that if you do a remount of your case you can detail the final occlusal position on the lab bench instead of trying to do all that post insertion adjustment (after placing twenty eight units) directly in the mouth, reducing stress on the patient and doctor.” And so the presentation ended and I survived. After the presentation, I was approached by no less than six participants all eager to discuss various parts of the presentation. Two of the doctors told me they had graduate degrees in prosthodontics and had never heard about the majority of this stuff. As I walked back to my room, I reflected on what had happened. How could a doctor manage temporomandibular disorders, manage the craniomandibular articulation, alter mandibular position, and interact with the neuromuscular system of the gnathostomatic complex without a knowledge of occlusion? Well, apparently that is happening. My experience, over thirty-three plus years of practice, has demonstrated that it is often far easier to get plastic into the mouth than to get it out. Without knowledge of occlusal principles, it is all but impossible—at least properly. I assumed this was fundamental. It certainly was for me. But when I entered this arena in 1972, occlusion was king, but then again that is pretty much all we had. From the time of my entry into the SOS programs, I had attended other programs and read textbooks from authorities with names like Dawson, Shore, Celenza, Lucia, Jankelson, Ramfjord, Ash, Frumker, and Arnold. You see, I am just old enough to have been around when the giants were teaching (Dr. Dawson continues to present programs on a regular basis). After that, I evolved into knowledge of internal derangements taught to me by Farrar and Haden. I had my understanding of the biomechanics of the TMJ and pain management increased by Bell. I learned of postural influences from Gelb and Rocabado and learned of myofacial disorders from Travell and Simons. I implemented the use of physical medicine modalities, trigger point injections, prolotherapy, neuromuscular therapy, and learned the concepts of neuropathic pain, craniosacral therapy, acupuncture, pharmocologic management, etc., etc., etc. But even after all of that, occlusion was still fundamental. After all, I am a dentist. I cannot manage my discipline without this knowledge. Occlusion is, after all, why this TMD discipline has been relegated to dentistry. We dentists are the only practitioners who can develop and manage this part of the temporomandibular articulation. Some have tried to tell us that the teeth are inconsequential to the discipline. Well, my patients just want four things: to be pain free, and have teeth that feel good, look good, and work right. With all of our sophisticated evolvement over the past forty years, with all of the good things we can accomplish for our patients, my question is: “Have we thrown out the baby with the wash water?” You decide. Or maybe, instead of being laughed off the stage, you will just laugh off this editorial. I may be, to paraphrase Al Fonder, “a physician of the oral cavity,” but I am fundamentally a dentist and very proud of that.
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