The Dental Pilgrimage and Teachings on Occlusion of Dr. Henry M. Tanner
Aspects of and Relationships in Dental Occlusion
Dr. Henry M. Tanner with Dr. Ronald G. Presswood
Dr. Henry M. Tanner
All rights retained by Professional Office Procedures
Houston, Texas 77024
Table of Contents
Table of Contents 3
Forward – Dr. Parker E. Mahan 5
Preface – Ron Presswood 7
A. Need - Introduction, Synopsis 11
Forward – Dr. Parker E. Mahan
The Dental Pilgrimage and Teachings on Occlusion of
Dr. Henry M. Tanner with Dr. Ronald G. Presswood
Henry Tanner and Ron Presswood have not written a textbook on scientific principles even though the first few pages discuss Heisenberg’s uncertainty principle and the philosophy of Hume. This book deals with the human mind that science has not mastered. It details the pilgrimage of Dr. Henry M. Tanner through his 59-year career in dentistry. In some parts it is history, in other parts it is discovery and in the part that many dentists will appreciate most it is detailed instruction in esoteric dental technique. It deals with dental diagnosis, doctor and patient comfort and solving dental problems for the patient in their comfort zone. It presents specific ways to take a dental history that makes problem-solving fun!
Dr. Tanner tells how he learned dental occlusion from dental educators and from patients in his chair. He tells about his interaction with Dr. Bob Ricketts as far back as 1959 and how he developed the Tanner appliance. He describes his method of examining occlusal function right down to telling how many thicknesses of Madam Butterfly ribbon to use and how to dry the teeth with Kleenex in a holder. He tells how he talks to the patient when examining their occlusion and how he does and does not manipulate their mandible. He details methods of taking occlusal registrations for mounting casts on an articulator, how he examines muscles, uses vapo-coolant, how he designs and adjusts appliances and even how he repairs them in the mouth.
Dr. Tanner tells how he learned long centric, short protrusive, freedom in centric and the centrum area. He describes six things that cause occlusal problems and how to deal with them. He tells of learning to “let go” in dental practice in order to reduce stress; that even though the fit of the teeth is important, what the patient does with the teeth may be more impostant.
Those that have an interest in dental history and how dental techniques were developed will enjoy reading Dr. Tanners interactions with John Woehler, John A. Anderson, L. D. Pankey, Loren Miller, Steve “Tap-Tap” Brown, Ernie Granger, Rex Ingraham, Nathan Shore, Sigurd Ramfjord and many others that influenced his pilgrimage.
Dr. Tanner describes splint therapy in great detail with specific attention to fine tuning the occlusion in normal and Class II malocclusion patients and even how to repair a broken appliance.
Dr. Tanner ends the book by reminding us that we, as dentists, should examine and treat the whole patient, not just a series of 32 hard, enamel objects that may need restoration or maintenance. He sees the appliance that bears his name not as a means of correcting occlusal malfunction but as a manner of gaining rapport between the dentist and patient and to teach patients how to help themselves.
This book has something for everybody and any dentist who wants to excel in his profession will profit from reading it.
Parker E. Mahan
The Dental Pilgrimage and Teachings on Occlusion of Dr. Henry M. Tanner.
Aspects of and Relationships in Dental Occlusion
Dr. Henry M. Tanner with Dr. Ronald G. Presswood
Scientists and health professionals, particularly dentists, typically like ordered and precise processes. We tend to be list keepers and prefer to follow a detailed path to a predictable result. Which 32 steps result in the proper end for our efforts? Which series of events predictably result in the chosen result or product?
We are trained in reductionistic scientific methods that tell us if we continue to dissect the problem, divide the issue into ever-smaller parts; we will eventually find the answer. ‘Scientific method’ is the center of our knowledge and we believe that it can, and will, tell us all we need to know to win in our pursuit of ideal oral health.
With the advent of the atomic age, the age of quantum mechanics in physics, many new concepts about the certainty of scientific knowledge and process have emerged. With their appearance, a significant discomfort has arisen in some notable scholarly minds.
A few of these areas of disquiet and concern can be summarized in the following illustrations -
Incommensurability thesis - the extent to which science cannot measure and predict accurately. The basis of the concept of chaos of mathematics and science.
in·com·men·su·ra·ble (în´ke-mèn¹ser-e-bel, -sher-) adjective
1. a. Impossible to measure or compare. b. Lacking a common quality on which to make a comparison.
2. In mathematics - having no common measure or number of which all the given lengths or measures are integral multiples.
Heisenberg - Uncertainty principle -
An uncertainty principle announced by German physicist Werner Heisenberg, 26, melds physics and philosophy. He states that certain pairs of variables describing motion-velocity and position, or energy and time cannot be measured simultaneously with absolute accuracy because the measuring process itself interferes with the quantity to be measured, so while quantum mechanics provides valuable information, it is useful only within limits of tolerance since no events can be described with zero tolerance.
Uncertainty Principle, in quantum mechanics, theory stating that it is impossible to specify simultaneously the position and momentum of a particle with precision. The theory further states that a more accurate determination of one quantity will result in a less precise measurement of the other, and that the product of both uncertainties is never less than Planck’s constant. This uncertainty results from the fundamental nature of the particles being observed. Formulated in 1927 by German physicist Werner Heisenberg, the uncertainty principle was of great significance in the development of quantum theory.1
Treatise on Human Nature by David Hume shatters the connection between reason and the empirical world, pioneering modern empiricism. If a rock is dropped, says Hume, it is not reason that tells us the rock will fall, but, rather, custom and experience. Truths, like mathematical axioms, are true by definition, but to believe that any observed effect follows any cause by force of reason is folly.
Hume's philosophical position was that reason and rational judgments are merely habitual associations of distinct sensations or experiences. In a revolutionary step, he rejected the basic idea of causation, maintaining that “reason can never show us the connexion of one object with another, tho’ aided by experience, and the observation of their conjunction in all past instances.” His arguments called into question the fundamental laws of science, which are based on the premise that one event necessarily causes another and predictably always will. According to Hume's philosophy, therefore, knowledge of matters of fact is impossible, although as a practical matter he freely acknowledged that people had to think in terms of cause and effect and had to assume the validity of their perceptions, or they would go mad.
In his book, “Against Method”, Paul Feyerabend discusses the failure of ‘methodological’ process in science. He sees most science as being more like religion. We elect our thesis based upon esthetics. We are attracted to our position because we like it and then we work to prove it. There is nothing wrong with that process except that it is not predictable and can be refuted by another position. 3
And lastly, a quote from Lynn D. Carlisle, DDS –
“Mechanistic science has been responsible for many advances in health care. The tendency has been to venerate the mechanistic or reductionistic method of science. Science is merely a tool to help understand the nature of things and solve problems. The difficulty with veneration is the power and credence given to the subject of our veneration. This veneration leads to a failure to see science’s shortcomings or the over extension of its strengths. A doctor’s focus needs to be on helping people to become healthier. Whatever helps him to do that is important. Science is one of those things, but it is just part of the kaleidoscope of tools that doctors use. Science loses its strength when it is venerated while other ways of helping people are discounted because they are not scientific.”4
These concepts are most easily seen in the human and social sciences that are the most vulnerable to complexity and variability. As we know from repeated experience, there is no sound ground for prediction in these areas of study. Science has not mastered the mind and its complex relation to the cosmos. We do not have the skill to make reductionistic process predict the result of human interaction of any quality and/or nature. Each interaction is sufficient to itself and will not be conditioned, qualified, quantified or reduced to general understanding or reason. We can, however, describe the events of a particular interaction and use them as a guide to the future but not to predict some future outcome.
We, therefore, will not present a scientific argument or process with this book. Such process or argument is flawed, leaving the frailty of scientific process aside, with personal bias and prejudice. The bias and prejudice not only of the author(s) but, also, of the reader. We can prove any point of view with the myriad articles presenting many sides of the various issues while inciting argument from many quarters. Such is not our intent. We wish to share a path of investigation and experience that has supported our dental practices for a combined 80 years - a path that has proved to be effective, rewarding and fun.
We will present an experiential account of a path to success that is usually not predictable, other than being an aid to the client/patient successful interaction. A path based on the myriad options and variables that cannot be seen or defined, only sensed and felt. A path of permission which allows anyone interested and committed to begin to help those many people suffering with head and neck discomfort and pain for which they have found little or no relief.
This book is dedicated and presented to those wishing to be of help and who wish to nurture and support their community of patients and friends.
Definitions and terms of occlusal function used in the book will follow the convention described by Dr. Major Ash in his review of the literature, “Philosophy of Occlusion: Past and Present”, Dental Clinics of North America, March-April, 1996, pp.233-255. 5
“Controversy in a field usually stimulates research to find answers and to promote clinical excellence. Thus, differing ideas about occlusion relative to centric relation in dental occlusion (added by RGP for clarity), gnathology, TMD, occlusal adjustment, and periodontal therapy have led to a controversial body of literature; however, I think also it has led to better treatment for patients, regardless of whether, for example, the concept of point centric or freedom-in-centric is advocated. No one can (successfully) practice dentistry without some concept of occlusion whether it is applied to one or two teeth or to complete mouth restoration. Although the work of committees to clarify terminology is quite appropriate, common usage, semantics, avoidance of confusion in the literature, and the ideological nature of the bias in science must be carefully considered. At times we learn from history that all ideologies need constant revisions; too often the need leads to changes by fiat rather than by virtue of research on problems that may actually exist in communication.”5
A. Need - Introduction, Synopsis
Intent and goals - (an outline of the coming topics in this chapter, a convention we will follow throughout the book)
1. What to do and how to do it to increase comfort and reduce dysfunction in our patients.
2. Be more comfortable in what to do and how to do it. - “Doctor comfort” in the process.
3. More comfort in approaching and solving problems.
4. Reduce Complexity and Vagueness in diagnosis and treatment.
5. Is this path Complicated or is it Difficult?
What is the nature of the problem we are going to address with the book?
It is a simple book as well as a photo guidebook, an anecdotal book about how to use appliances in occlusal treatments. It will be an informal book. This is a book to show practitioners what to do and how to do it so they will be more comfortable in approaching patients with functional occlusal, temporomandibular disorder (TMD), craniomandibular disorder (CMD), and other head and neck pain issues and problems.
This is a book about discerning the patient’s comfort and increasing their function while increasing the doctor’s comfort. The doctor should feel more comfortable about approaching and solving problems, sorting through problems, solving difficult situations, going through the vagueness of occlusal complaints and allowing themselves and their patients to be more comfortable about the entire process of occlusal generated myofascial pain dysfunction (MPD) complaints and diseases.
We are talking about a book that will allow us to know what to do and when to do it. It will allow our patients to be more comfortable in their relations to themselves, their oral and dental health and to the dental profession; a book that will allow the dentist more comfort in all of these complex relationships.
Are these processes complicated or difficult? We want to uncomplicate something that is inherently difficult because of the tediousness of the operations and the patience required to execute them. We can sort out complicated things and put a sense of structure around them that will simplify the process and allow it to be individually adaptable to each doctor and office.
This can allow more comfort for the practitioner when confronted with these problems. This will give them a path, or direction, on how to think when confronted with these problems -- a decision tree evolved from the experience of years of practice. The entire essence of this book is comfort and quality of life for the patient as well as for those involved and concerned with their treatment and support.
In this process, we attempt to educate the patient into the nature of their complaints, difficulties and problems. More appropriately, we allow the patient to educate us into their perceptions of their problems so that we are more prepared and able to support and help them.
Traditionally, we are trained to be the diagnostician, the weigher of evidence, the giver of health. But, as we grow older, it becomes more evident that the patient is the one that gives the information for interpretation and, actually, with proper guidance and encouragement, the patient can arrive at their own diagnosis and their own treatment plan. The patient has the appropriate information when they are enabled and empowered to do so. When this occurs, the ownership of the problem and the potential success becomes the patient’s responsibility that relieves much concern and pressure for the doctor and staff.
“Will you help me learn where you are? What are your perceived needs? Do your wants relate to your needs?” This is where the complex, difficult, simple and easy issues arise for the doctor, staff and patient. What we are dealing with is a difficult circumstance that does not have to be complex. In fact, it can be simplified. With proper patient education, we can work our way into this system of evaluation and education which allows ownership for the patient of her or his problem, and its solution.
Although we are trained and we want to do something to and for someone to help them feel better, the essential success in approaching MPD issues is an involved and evolving learning experience in which the patient and the doctor discover the path to and through health and comfort. Most of us were not trained this way as professionals. We were educated to be healer professionals, to sort out the issues, point them out to the patient and then be active in dealing with these issues with expectation that the person is going to get better. We now know that in most instances this is not the better path to success.
The path of “patient directed discovery” also leads to emotional comfort for the doctor. As the patient becomes more involved, educated and responsible for their health care and its results, the personal and direct responsibility of the doctor is diminished. This certainly eases the doctor’s anxiety which should allow them to be in a more comfortable relationship with the patient
We intend, with this book, to help the doctor and staff. Those who have need for ‘a process’ or “a path” to feel a little less anxious with the unknown. We want to provide a system of diagnosis (triage tree or flow chart) which can lead them through a process that allows comfort and optimism when approaching the evaluation, diagnosis and treatment of patients with very complex, painful and distracting problems.
As professionals, we have concentrated on technical excellence our entire life. It is very difficult to release the security blanket of ‘process’, excellence and technique and stand in the moment of uncertainty with the patient. As we meet new and unknown patients, in this moment of uncertainty, ignorance and pain, it is easier to recruit them into the learning process. It is more comforting and beneficial for them to be involved in the discovery process. They do not have to go it alone -- a solitary, frustrating and frightening experience is replaced with a team of support and nurture.
In this system of patient directed discovery, they can begin the process any place they choose. While taking the time to allow the patient to process through the issues, we can evolve the information necessary to allow us to make a provisional diagnosis, provisional treatment plans and to get involved in a technical phase that is to our comfort. This phase is conducted with the comfort of the patient as the main objective and with their active participation. As time goes on, there is more involvement, comfort, caring, sharing and maturation of the relationship of doctor to patient and patient to doctor. As this relationship evolves, the confidence of the patient in the process and the office expands. The patients that have been manipulated and felt abused in non-caring, fact-finding treatment in other experiences will find a healing quality in the interventive nature of this process and care.
This, then, allows the real issues to surface, allowing us to be prepared to ask the appropriate questions to increase the learning cycle for both doctor and patient - care giver and receiver. This facilitates the entire treatment process.
This process involves eye-to-eye, interpersonal communication dynamics. It does not depend on questionnaires, information forms or some prescription of examination. It allows for an initial visit in which unstructured dialogue develops; a visit that is more comfortable and inspiring to everyone. The things that we want most to do for the patient are really inappropriate until the patient asks for them in various ways. Such as, “This is something I want to do.” “This is something I understand I need and I want to do it.” “This is something that I believe will help me.” “Will you please do these things for me in as much as I can’t do them for myself?”
We like, and use, the concept of “MPD” in these early diagnostic visits and conversations because it is something physical. It is not psychological. It is something that we can feel and touch. It is also something with which we can see early and positive results with proper management. It keeps the relationship in the more “known” realm in the early phases. Later, we can ‘discover’ the emotional, psychological and spiritual aspects to the problem. This, MPD, is a physical medium for us to relate in and through. It takes the problem out of their head and puts it into their physical body. This, then, gives us the time to develop the sharing and, ultimately, caring relationship from which we can evaluate and involve ourselves in the treatment of the more complex aspects of the problem with excellent dental technique.
The use of an occlusal appliance gives us time to learn about ourselves, the patient and some of the real dynamics in the functional aspects of their complaints. In this process, we can almost always describe how dysfunction and dysfunctional aspects to their dental health participate in the MPD issues.
Experience has shown that as we grow in wisdom and experience in dental practice, the acceptance of self is important in our relationship to the patient and the technology we use in assisting them. The ability to support them to a better dental IQ so they can accept and handle appropriate care grows with age.
Certainly, the trials of learning our way into the profession are a growth and maturation experience that allows this comfort and freedom to develop and evolve in good strong relationships with the patient. Hopefully, that will be reflected in the system of this book. The dynamics of personal growth are such that although it looks self-centered, the reality is that the most direct path to service of others requires that we, as individuals, grow first.
If you don’t really know yourself and if you are confused in complex treatment issues with the patient, then why not allow the patient to become involved and ‘lead’ you through the initial phases of care so that the comfort goes up for everyone?
“It is not what you have that makes you sick (occlusal dynamics), it is what you do with what you have that makes you sick; that creates the problems.” It is the patient’s habits that create the issues in most MPD diseases. After we have been through the technical minutia to allow the patient education -- emotional and physical education of the true experience -- then the patient can become more aware of this “do” complex and how behavior influences wellness.
This text evolved from a series of videotaped interviews (about 90 hours) with Dr. Tanner in 1988 to a written text in 1992. The text has been edited to maintain relevancy as new research and knowledge is brought to the subject of dental occlusal function. This text frequently has the word “centrum” in body of the text in the discussion of a given subject.
The concept of “centrum” function was, for me, a unique “Tannerism” and describes almost all of the function we believe to be in the best health interests of the patient. While many believe that my discussion of “Posterior Guided Occlusion” is antithetical to all of dental occlusal philosophy, this is really not the case.
Dr. Tanner asked that the posterior teeth contact in full dynamic function without the contact of an anterior tooth until an excursive move was made. This functional pattern of tooth contact allows a full and coordinated contracture of the major muscles of closure which we believe is the healthiest state of musculo-skeletal function.
Using the anterior teeth to reduce muscle effort on closure and dis-coordinate muscle function in excursive movements is, in our philosophy, unhealthy.
As you read through this text, these thoughts continually appear. They are Dr. Tanner’s thoughts which we have been privileged to study and expand.
22 October 2009