Discovering Undiagnosed Pain Patients in a General Dental Practice – The Four Pillars of Occlusion

by James E. Carlson, DDS

Emotionally, physically, and spiritually all humans live in varying states of ease or “dis-ease”. The physical condition of humans is due, in part, to the head, neck, and face, which includes the stomatognathic system. Traditionally, from a dentist’s view, this has been thought of as ease or dis-ease of the teeth and gums. However, an important segment of the stomatognathic system has been often overlooked by many dentists: neuromusculature of the head, neck, and face, and the temporomandibular (TM) joints, both of which are part of the occlusion.

Examining and diagnosing a patient’s state of “occlusal ease” or “occlusal dis-ease” have not been usual and customary services provided by most general dentists. This has resulted in vast numbers of patients seeking and receiving dental care, while still living with undiagnosed occlusal disease. Symptoms of occlusal disease are characterized mainly by head, neck, and face pain emanating from muscles, pain and dysfunction in the TM joints, and many times by broken down teeth. While dentists can see the patient’s broken down teeth, they do not often “see” the muscles of the head, neck, and face and the disc-condyle complex of the TM joints.

Why aren’t general dentists routinely examining the muscles and TM joints? Historically the focus of dentistry has been on teeth. Avoiding and/or preventing tooth loss as a result of dental decay or periodontal disease is the major objective of dentistry. The muscles and TM joints are many times ignored because most patients are only seeking care for tooth and gum related problems. They are not aware that occlusal disease exists. Also, most dentists have not been trained to recognize occlusal disease. They just have not paid much attention to it.

Dentists are now faced with the practical challenges of how to fit temporomandibular dysfunction (TMD) pain patients into their practice, and how to get paid for it. The insurance “morass” around TMD reimbursement affects both the dentist and the patients. Reimbursement policies and procedures from insurance companies for TMD therapy are unlike those from standard dental insurance companies. In many cases dealing with TMD insurance claims is a real hassle for the doctor’s staff. Dentists may be working for insurance programs that do not pay for the examination, diagnosis, or treatment of occlusal disease.

It must make good economic sense for dentists to invest their time and resources into learning about occlusal disease, and then implement a new syntax of care into their “tooth oriented practices”. Patients whose occlusal disease is properly treated, and whose pain “miraculously” goes away, will not only be your loyal patients for life, but will refer their friends to your practice, in an ever-expanding circle of satisfied patients.

Ignorance, embarrassment, not wanting the responsibility, reimbursement red tape, or some other reason should not keep general dentists from learning about, diagnosing, and treating occlusal disease.


Much of what we have been taught about occlusion is inadequate. Occlusion may be more than you think it is. Interdigitation of teeth is not occlusion, it’s only part of it. Occlusion can be viewed as a dynamic functional system designed for mastication, speaking, singing, and so on. It includes bones (skull, maxilla, mandible, and cervical vertebrae), muscles, nerves, and temporomandibular joints, as well as the interdigitation and spatial alignment of the teeth. The teeth are only a part of the whole.

The dilemma we have is that we cannot always see the whole because most of the parts are “hidden” under the skin. Nonetheless they are there, and they affect the patient and the outcome of our dental treatment.

The stability of our finished dental cases depends on four primary elements, which I have termed the Four Pillars of Occlusion. They are:

1. The condition and alignment of the teeth;

2. The temporomandibular joints;

3. The muscles and nerves of the stomatognathic system; and

4. The bones of the head and neck, starting with the maxillae and mandible, and including the rest of the skull and cervical vertebrae. We must decide whether we restore these Four Pillars of Occlusion to their previous condition or to a new, more stable ideal condition. We must expand our paradigm and look beyond the teeth and see the interrelationships of all the elements to create a far better treatment outcome for our patients than what we have done in the past.


Before we can discuss occlusal dis-ease we must first look at occlusal ease. Ease can be defined as: “A normal condition of physiological function of an organism or part.” Disease is defined as: “An abnormal condition of an organism or part, especially as a consequence of infection, inherent weakness, or environmental stress, that impairs normal physiological function.” In order to identify a dis-ease, the clinician must first recognize what ease looks like. Ideally, the clinician should be trained to recognize disease by knowing the characteristics of normal physiology and anatomy.

To define occlusion, dentists need physiological and anatomical benchmarks for the muscles, teeth, bones, and TM joints. These occlusal benchmarks are necessary both for the dentist and the patient. Patients want to know the state of their “occlusal health” compared to what is considered optimal. Also, how can dentists make the diagnosis and determine the optimum treatment plan if they do not know what “normal” or “optimal” occlusion looks like? If dentists choose to treat occlusal disease, the goal should be to help the patient return the muscles, teeth, bones, and TM joints to a state of ease.


The following is a partial list of benchmarks used to help the dentist examine, diagnose, and treat occlusal disease.

Healthy muscles are pain-free and should not exhibit pain or trigger point referral patterns when palpated with moderate pressure.

Healthy temporomandibular joints are quiet during the mandibular open/close cycle and should not make “popping”, “clicking”, or “grating” noises and/or emanate vibrations.

The mandible should open and close straight, without deviation or deflection.

The mandible should have an interincisal distance of 45 to 55mm at maximum opening.

The plane of occlusion should be level and parallel to the horizontal reference plane of the skull.

The plane of occlusion should be at right angles to the sum of the forces of occlusion, which are created by paired muscles of mastication on each side of the face.

The plane of occlusion should have an ideal curve of Wilson and curve of Spee unique to that patient.

The posterior teeth should interdigitate with cusp tip to fossa occlusion.

The anterior teeth should have an optimum overbite/overjet relationship unique to that patient.

All the posterior teeth should exhibit centric stops.

The interdigitation of the teeth at an optimal mandibular position should support a physiologic neuromuscular position and physiologic position of the disc-condyle complex in the temporomandibular joints for which the nervous energy supplied to the muscles is at a minimum.


To treat occlusal disease, clinicians must first examine and diagnose the patient. That may not be as easy as it sounds. Some patients of all ages have occlusal disease, but most often it goes undetected. This is especially true in adolescents and teenagers. They may be victims of occlusal disease exhibited as sinus pain, earaches, headaches, migraines, neck and facial pain, but do not know that the pain is related to their occlusion and may be diagnosed and treated by their dentist.

Neither the child nor the parents sees a connection between the pain and a dentist. Some of the pains are passed off as normal “growing pains” and the child needlessly suffers because of ignorance on the part of the parent and dentist. This, in part, is a fault of dentistry because dentists are rarely taught to look for pain in children except those arising from te
eth and gums.

Blame should not be put on the parents. It is the responsibility of the dentist to educate parents and make them aware of the possibility that some of the pain in their children may be from muscles of the head, neck and face and the TM joints.

Adults are also prone to dismiss sinus pain, headaches, neck pain from dental origins as part of normal living. Many, but not all, seem to cope with the pain by taking over-the-counter pain medication. No matter what the age, it is not normal to have pain in the head, neck, face, and temporomandibular joints. Early detection of TM joint dysfunction and myofascial pain from the head, neck, and face should be part of the general dentist’s services. This requires a new paradigm of occlusal examination and diagnosis. Times have changed, and progress has been made in the area of occlusal examination, diagnosis, and treatment techniques.

New and better methods and instrumentation are available to help examine, diagnose, and treat patients with occlusal disease than have been available in the past. With this awareness comes responsibility. No other health care provider is responsible or trained to examine, diagnose, or treat occlusal disease. Patients have the pain. The general dentist should be trained to find the cause and treat it, not mask the cause and treat the symptoms.

It does not take much time to screen patients for occlusal disease. Palpating a few key muscles, examining the teeth for attrition, wear facets, and abfractions, palpating the TM joints for pain and swelling, listening for noises, and feeling for joint vibrations are just a few procedures for screening patients for occlusal disease. If there are positive signs of occlusal disease from the screening, the patient can be appointed for an occlusal examination of the teeth, muscles, TM joints, and bony structures of the head neck and face.

To begin the journey of learning to examine, diagnose, and subsequently treat these pains and dysfunctions dentists need to have a basic understanding of anatomy and physiology of the muscles, TM joints, bones of the skull, and alignment of the teeth. That means taking postgraduate courses on occlusion. Learn how to recognize what is not ideal, make the diagnosis, and inform the patient of what you see. If they choose to be treated, either learn how to take care of them or refer to someone who can.

Dr. Carlson has spoken worldwide to audiences on the subject of occlusion. He is the author of Physiologic Occlusion and Occlusal Diagnosis.

Oral Health welcomes this original article.