The evolution of a field: A challenge and an opportunity

The last decade has been characterized by major developments in the orofacial pain field: 1. The Recognition of the Orofacial Pain Specialty in the United States, which followed similar pathways in other countires, and the derived PostGrad courses that are flourishing all over Europe and the rest of the world [1]; 2. The progressive recognition of Dental Sleep Medicine as a subject attracting a raising scientific, clinical, and ethical interest [2]; 3. The new definition of bruxism and the derived multidimensional evaluation system (i.e., Standardized Tool for the Assessment of Bruxism) [3].

The evolution of knowledge featuring the fields of orofacial pain, dental sleep medicine, and bruxism represents both a challenge and an opportunity. For dental professionals, who are the first line practitioners involved in the management of individuals with any of the above families of conditions, thinking outside of the usual “magic” box of dentistry, where each procedure seems deemed to a 100% of success rate, is surely an uncomfortable action. On the other hand, the combination of the three topics, all surrounded by a sparkling atmosphere and enthusiasm, represents the biggest opportunity for the dental profession to get definitively out of the muddy waters of gnathology.

Over the years, dentistry has progressively become a profession more focused on the technical than the medical details. For the majority of patients, a real diagnostic pathway is basically unnecessary, since their chief complaint can be addressed and solved with a sequence of procedures that derive almost immediately from the first observation. A caries, a periodontal bleeding, a missing tooth, an imperfect crown, and even poorly aligned teeth are examples of everyday conditions for which our profession can focus more on the technicisms of treatment planning than a medical process of differential diagnosis.

Concurrently, for decades, the study of dental occlusion has been considered the medical gate of dentistry based on claims that an imperfect interarch relationship and mandible position may determine a sequelae of clinical consequences. The sacre graal of centric relation and his derivative concepts, born from the old precepts of gnathology, permeated dentistry. The frontiers of dentistry as a medical profession were shifted onto the idea that dental occlusion influences body posture, and that working on dental occlusion is a ailment for musculoskeletal pains in distant body district. This was a fascinating idea, often backed up with fancy technological devices, something with which dentists can easily fall in love at first sight. Unfortunately, this was never backed up with the most important supporting column that distinguished medicine as a science from the neighbouring pseudosciences: evidence.

Now that evidence has grown in support of the complexity of the diagnostic pathway for orofacial pains, of the role of dentists as a fundamental sentinel for sleep disorders, and of the multifaceted nature of bruxism in the dental office, dental professionals can become pivotal players to access the actual medical gates of dentistry. No more technically-mediated theories about the mechanics of dental occlusion, but medically-driven processes of diagnostic thinking.

As in the case of all the big opportunities, this fascinating evolution also represents a tremendous challenge. Paradigm shifts require time. Shifting the attention away from the good and safe business of dental occlusion will require time, but if dentistry still wants to be considered a medical profession, the time is now for taking on the challenge.

Within this framework, bruxism – yes, that bruxism whose origin was initially linked to the presence of dental interferences (!?!) – is the inevitable entry point. Bruxism, as a spectrum of different muscle activities, is the medical gate of dentistry from multiple access points: 1) bracing is a new kid on the block to explain musculoskeletal orofacial pains; 2) arousal-related masticatory muscle activity is linked to any medical condition that may fragment sleep; 3) an open-minded definition of sleep and awake bruxism has been provided to frame everything. The time is now, and the Standardized Tool for the Assessment of Bruxism is a good starting point! [4].