Bruxism part / specialist in dentistry

BRUXISM
– ITS DIAGNOSIS AND TREATMENT
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

Contents
 Introduction
 Definitions
 History
 Review of literature
 Applied anatomy
 Differences between bruxism and
functional activity

 Prevalance
 Etiology of Bruxism
 Characteristics
 Diagnosis
 Treatment
Summary
Conclusion
References

Prevalance
 Surveys to determine the prevalance of
bruxism in various communities have
been carried over the last 25 years.

Reding , Rubright, Zimmerman23
did one of the earliest
studies using a questionnaire survey among students
 One group- 3-17 years
 2nd
group – 16-36 yrs
 Conclusions of study
 15% of both age groups reported bruxism
 There was association among blood
relations
 No difference between males and females.www.indiandentalacademy.com

A study conducted in Polland
 Conclusions:
 68%- medical students
 51.2% - military students (13-19)
 37.8% - young soldiers(20-23 yrs)
 20.9%- middle aged soldiers(39-43)

 Because of different investigative methodologies,
operational definitions, clinical criteria, and
samples of populations, the reported prevalence of
symptoms related to bruxism varies in both the
adult and the child populations.
 Most individuals demonstrate signs of bruxism that
the practitioner can detect, such as wear facets of
the dentition. Studies involving self-reporting of
clenching of the teeth during the waking hours are
about 20% compared with about 10% for clenching
during the sleeping hours, and grinding of the teeth
during the sleeping hours can range from 6% to
12%

 Other studies demonstrate that bruxism
occurs in up to 90% in the general
population.

 Therefore, determination of the actual
prevalence of bruxism is difficult because
this mandibular parafunctional behavior is
performed at a subconscious level by most
individuals.
 Because of this limitation, more often than
not an individual is dependent on his or her
spouse or other roommate to ascertain by
the sounds that can be generated via the
bruxist forces whether he or she clenches
or grinds the dentition.www.indiandentalacademy.com

 Even though studies indicate that the
incidence of bruxism is highest in the
teens to forties and that this
parafunctional behavior decreases with
age, there is insufficient evidence to
indicate whether individuals with
complete denture prostheses brux.

 With regards to gender distribution, studies
indicate that females report parafunctional
clenching more than males, but clinical
observation demonstrates approximately an
equal distribution.
 One investigation indicated that there is no
gender difference or age difference in the
general population with regards to signs of
bruxism.

Etiology - Why people brux?

 The cause of bruxism is still
controversial.
 Over the years, a great deal of
controversy has surrounded the cause
of bruxism and clenching.

 . Early on, the profession was quite
convinced that bruxism was directly related
to occlusal interferences. - RAMFORD S.P ,
JPD 1961; 11:353-362
1ST
SCHOOL OF THOUGHT

2ND
SHOOL OF THOUGHT
 More recent studies do not support the
concept that occlusal contacts cause
bruxing events.- RUGH, JPD 1984,51,548-553
 There is little question that occlusal
contacts influence function of the
masticatory system, but they are not
likely to contribute to bruxism.

PETER. E. DAWSON (2ND
EDITION,
1989,C.V. MOSBY COMPANY) STATES
THAT
 “ IT HAS BEEN MY CLINICAL
EXPERIENCE THAT THE SIGNS AND
SYMPTOMS OF BRUXING SEEMS TO
DISAPPEAR COMPLETELY WITH
CAREFUL ELIMINATION OF ALL
OCCLUSAL INTERFERENCES”

RAMFORD
 “ SOME KIND OF OCCLUSAL
INTERFERENCE WILL BE FOUND IN
EVERY PATIENT WITH BRUXISM”

EXPLANATION OF 1ST
SCHOOL OF THOUGHT:
When the influence of malocclusion
becomes greater than the
patient‘s physiologic tolerance
parafunctional activity is increased.
If the resultant increase, becomes
greater than the structural tolerance of
any structure, breakdown in that
structure will occur.

 Each structure of the masticatory system
can tolerate only a certain amount of
increased force created by muscle
hyperactivity. When forces applied to the
structures are increased beyond this
critical level, breakdown of the tissues
begins. This level is known as the
structural tolerance.

Breakdown
Malocclusion
Increase in Physiologic Tolerance
Increase in parafunctional Activity > Structural tolerance

Explanation of 2nd
school of
thought
 Stress is described by Hans Selye as
"the nonspecific response of the body to
any demand made upon it".
Psychologic stress is an intricate part of
our lives. Circumstances or experiences
that create stress are called stressors.

 Stressors can be unpleasant (like loosing
one's job) or pleasant (like leaving for a
vacation).

The body reacts to the stressor by creating certain
demands for readjustment or adaptation.
.
External
shouting
cursing
hitting
throwing objects
internal type
gastric ulcers
colitis
hypertension
various cardiac disorders
asthma
PARAFUNCTIONAL ACTIVITY.
(OFTEN OVER-LOOKED)www.indiandentalacademy.com

 It has been suggested that
parafunctional activity "represents a
regression to or maintenance of the oral
stage of development, in which the
mouth and face are used to vent
the individual's frustrations, stresses,
and anger."

 Much of the emotional state of the body is
derived from the hypothalamus, the reticular
system, and particularly the limbic system.
 These centers influence muscle activity
through the gamma efferent pathways. In
other words, stressors affect the body by
activating the hypothalamus, which must
prepare the body to respond.

The effect of D-amphetamine on
gamma efferent activity in the
acute decerebrate rat.
Bruxism related to leva dopa
therapy
Unusual effect fenfluramine and
Phenothaiazine on bruxism
Other factors

• Alcohol and bruxism

Heriditary

CNS disturbances

Post orthodontic treated
patients

•Discrepancy between CR
and CO
 Pericoronitis and periodontal
pain may trigger bruxism
 Bruxism in children (< 10 yrs
common)- rearly associated
with symptoms. (Self limitting if it is
not associated with masticatory dysfunction <
15years)

Sleep position
 Research speculated that subjects did
more bruxing while sleeping on their
sides compared to sleeping on their
backs.- “Controversy”

Sleep stages
D sleep; Desynchronised
or dreaming sleep, active sleep
S- sleep, synchronised sleep,
quiet sleep,
Orthodox sleep

Diagnosis

Chief complaints:
 Muscle tightness or
fatigue upon waking

Hypersensitivity of teeth
Headache

History taking?
 Question them” do you clench your
teeth during night? ”
 Only 10% of the subjects know that
they brux during night.
 They are told either by their parents,
family members or friends
Most bruxism will not be identified simply by asking questions

Questionnaire?
 Only 20% of the bruxers make sound
during bruxism .
 So cannot be identified in all persons

Drug history
 D-amphetamine
 leva dopa therapy
 fenfluramine
 Phenothaiazine

Habits
 Severe alcoholic
 Severe smoker
 Drug addict

Clinical examination

Intra oral examination
 occlusal wear- shiny occlusal
surfaces
 Antagonist pairs of facets can be
matched and used to diagnose
direction of bruxism
 Hypersensitivity of teeth – dentin
exposure

Flattening of cusp tips

Wear in Incisal edges of
anterior teeth

Why excessive too wear-
mechanism?
 The mechanism of excessive wear
associated with bruxism, according to
Uhlig is based on the loosening and
crushing of enamel prisms between
contacting enamel surfaces,
which provides the grit necessary for
rapid wear of the enamel.

Nadler
 He cautions that attrition of the teeth
can be caused due to various other
factors like excessive or improper tooth
brushing; occupational hazards,
ingestion of hard and gretty foods or
acids like lime juice.

Pulpitis and pulpal death
- severe bruxism cases

Sharpened incisal edges –
produce damage to the lip and
cheek

 If the patient is a complete denture
wearer , the wear may be more severe on
the posterior teeth than the anterior teeth
because the stability of the denture
allows for the greatest pressure in the
posterior regions.

If the patient is having fillings
Fractured restorationswww.indiandentalacademy.com

Fractured tooth

 Increased mobility of the teeth is often
associated with bruxism and is especially
significant when found in teeth with very little
or no evidence of periodontal disease.

Periodontium
 Karolyi was the first person to associate
bruxism with periodontal lesion.
 It is hypothesized that constant force of
bruxism exceed the pressures of
normal mastication leading to
periodontal breakdown

 However some others say that bruxism
itself cannot initiate the periodontal
lesion. However the phenomenon can
aggravate the periodontal status.

Resorption of alveolar bone

Extra oral examination

Increased Tonus and
Hypertrophy of Masticatory
Muscles
 Patients with bruxism often develop
unilateral or bilateral hypertrophy of the
masticatory muscles, especially the
masseter muscles.

Soreness of Masticatory
Muscles
 Sometimes the masticatory muscles are
tender to palpation in patients with
bruxism. The tender spots are most
common alongthe anterior, lower
borders of the masseter and the
medial pterygoid muscles but may also
be found in the temporal region.

Radiographic findings

 The roentgenographic findings for
bruxism are not specific, but a funnel-
shaped widening of the periodontal
space toward the alveolar crest and
around the apex is suggestive of
bruxism.

A prolonged silent period and sustained high
EMG activity between contraction patterns are
also suggestive of bruxism.

Tmj examination
 Bruxism is considered one of the major
factor in the etiology of tmj disturbances
 ( clicking, crepitus, locking of jaw,
restriction of mandibular movements,
subluxation etc;)

Confirming diagnosis of
nocturnal bruxism- HOW?

Provocation test
 Ask patient to move mandible in lateral
and protrusive positions until facets
matched.
 Patient asked to clench until symptoms
are noted
 Symptoms during this test and
symptoms told by patient will be same

2. One week 5mg diazepam
given at bed time temporarily
rduces bruxism

3. Portable electromyogram
 Provides tone
throgh an earphone
to alert the patient to
bruxism.
 With this patient
himself will come to
know that he is
bruxing

4. Diagnostic splint – night
guard
 If symptoms are relieved – confirmation
of bruxism

Treatment

four objectives in the Treatment of bruxism are to
(1) reduce psychic-tension.
(2) Treat the signs & symptoms.
(3) Minimize occlusal irritations &
(4) Break neuromuscular habit patterns.

REDUCE PSYCHIC
TENSIONS
 The dentist must listen to the patients
story. The patient will feel better
because the dentist shows concern,
patients & empathy. This, itself, is
therapeutic in relieving anxiety.

 Education of the patient is important.
You must hint at the possible causes of
bruxism and point out that it is a normal
occurrence in most individuals from
time to time.

 Tranquilizing agents
 Hypnosis
 Educate the patient about the restful
uninterrupted sleep

Treating signs and symptoms
 Ask pt to sleep on the back
 Sleeping sideways
Displaces the mandible
Also cause streching and discomfort to joint and muscles

 Wet ice pack- 10 to 15 min 4 times daily
 Soft diet
 Muscle relaxants and analgesics

MINIMISE OCCLUSAL IRRITATION .

 An occlusal splint or "night guard" is a useful
device for dissipating the powerful &
potentially damaging effects of bruxism.
 By covering the occlusal surfaces of the
maxillary & mandibular teeth with a hard
acrylic resin splint,
 Occlusal interferences are minimized or
eliminated in all excursions of the mandible &
in centric relation.

 After several weeks the muscles of
mastication are usual more relaxed &
less symptomatic. Permanent
stabilization of the occlusion can then
be accomplished by occlusal
adjustments.

 The effect of bruxism is easy to
eliminate if the flat anterior guidance
can be maintained.

Break neuro muscular habit
patterns

 cotton pellets & occlusal splints are
actually devices to assist in relearning
neuromuscular patterns of mandibular
function as well as a method of
minimizing occlusal irritations.

Massed practice therapy
 The patient is forced to bite as hard
as possible for a minute & then relax
for a minute. This biting is repeated
5 times during each of six sessions
scattered throughout the day. After 2
weeks the bruxist behaviour is
extinguished.

 The treatment of bruxism is
directed at eliminating the cause or
the effects of the problems. It
appears that regardless of the
cause the most effective treatment
is perfection of the occlusion.
 This can be accomplished in two
ways.
 Directly: By equilibration, occlusal
restorations, orthodontics.
 Indirectly: By occlusal splints.www.indiandentalacademy.com

DIRECT CCCLUSAL
CORRECTION:
 Before alteration of an occlusion is
accomplished directly, a careful analysis
should be made on mounted diagnostic
casts. If it can be determined that the
corrections can be made with selective
grinding without mutilation of enamel
surfaces, equilibration is most often the
method of choice.

 If restoration of posterior teeth will be
needed for other reasons,
equilibration procedures can be used to
correct the occlusion directly even If
some enamel penetration is necessary.

 Whenever possible equilibration should
result in multiple equal intensity stops in
centric relation with immediate
disclusion by the anterior guidance in all
excursion.

INDIRECT CCCLUSAL
CORRECTION

Many types of biteplates, biteplanes and occlusal splints
have been recommended for the treatment of bruxism
since
Karolyi introduced the vulcanite occlusal splints. Success
of
treatment using a biteplane often depends on the design of the
biteplane, the disturbance being treated, and the relation of the
biteplane to other forms of therapy.
The use of the term stabilization to refers to
biteplanes that cover all the teeth
(maxillary or mandibular ) and thus splint the teeth together. A
biteplane should provide stable jaw position defined as
even,
bilateral and anterior - posterior contacts between the teeth and
the biteplane in centric relation, swallowing centric, and tap
centric.

 Biteplates are all very easy to make, with a
heat-cure or cold-cure acrylic on a maxillary
cast. The plate is fitted directly into the
mouth and adjusted, and self-curing acrylic
is added to the palatal plateau area if
needed to make even contact with the
mandibular incisors. The bite should be
raised only enough to provide freedom of
contact between the posterior teeth.
Following adjustment, the biting pressure
should be even on the mandibular anterior
teeth against the palatal acrylic.

 These biteplates eliminate occlusal
interferences in centric, and balancing
interferences in lateral excursions.
Protrusive interference is usually not
eliminated by any of these biteplates,
but this interference is often of less
significance than centric and balancing
interferences. The esthetic result may be
fairly good, and the biteplate is well accepted
by the patient.

Soft acrylic splints
These splints may feel
comfortable to patients with a clenching habit
at the time of
insertion, because the soft acrylic provides an
even pressure on the
teeth when biting.
But there is a tendency for patients to "play"
with these appliances by biting on the
resilient surface.
Furthermore, such surfaces cannot be finished so
accurately.- so soft splint act as trigger areas

Principles Of Stabilization Bite
Splint Therapy

Material selection
 The material selected for the appliance heat-
cured acrylic also plays an important role in
control of bruxism. The material should
provide sufficient density to maintain
stable occlusal contact relationships
without contributing to further dental
attrition. The material should, in effect,
wear faster than tooth structure while not
contributing to parafunctional clenching as
some soft materials may tend to do.

Criteria Of An Acceptable
Appliance

1. Retention and Stability
 The appliance should be easy for the patient
to insert ad remove with no discomfort, and
the appliance should not "rock" or dislodge
with unilateral finger pressure (performed
by the clinician) or upon lateral
"bruxing" positions of the patient's
mandible.
 A splint that lacks stability and rocks or
wiggles with movements of the mandible may
subject the teeth to uncontrolled stresses.
The instability may result in
uncontrolled tooth movement or many
contribute to a patient's parafunctional
activity www.indiandentalacademy.com

2.Occlusal Contacts
 A primary goal of the maxillary stabilization
splint is to provide a stable occlusion, free of
deflective contacts that may tend to position
the mandible. To accomplish this goal, the
occlusal surface of the splint must remain
relatively flat and smooth and must follow the
curvature; of the curve of occlusion.
 Aggressive episodes of bruxism or Improper
adjustment of the

 A 'freedom in centric' contact of at least
0.5 mm should be provided from centric
relation through free closure and
laterally for all opposing mandibular
teeth.

3. Excursive Guidance
 The maxillary stabilization bite plane
splint generally designed with canine
guidance to separate the posterior teeth
during lateral and protrusive eccentric
excursions.
 The guidance are adjusted to provide a
gradual distribution for eccentric forces. The
guidance are adjusted to provide a gradual
separation of about 2 mm for the posterior
teeth

4. Splint Form
 The splint should follow the normal
anatomic contours of trie teeth and hard
tissues that the appliance will cover.

Fabrication of splint.
 The best occlusal biteplane splint
is designed on casts mounted on an
adjustable articulator.

Step1
 The maxillary cast is mounted on
the articulator using a facebow.

Step 2
The mandibular cist is mounted in one of three
ways:
(I) in centric relation using a centric relation check
bite;
(2) in centric occlusion with the casts positioned in
intercuspal position with a centric occlusion check
bite; or
(3) in open vertical dimension check bite in the
presence of a lateral slide in centric, absence of
condylar translation of one condyle on jaw opening

Because of pain and dysfunction, a centric
relation check bite may not be possible, and the
casts may have to be mounted In centric
occlusion.

Step 3- setting the articulator
 After the casts have been mounted, it is necessary to
set the condylar guidance and the incisal guide table.
 The condylar guidance inclination should be set at
parallel with the plane of occlusion.
 The incisal guide table is set at an angle that barelv
avoids contact of the incisors and the cuspids

 a long centric pin and an offset pin are
useful to develop freedom in splint
centric.

 The vertical dimension should be raised
to allow avoidance of contacts on the
balancing sides and to allow about 1
mm of clearance for the thickness of the
splint.

Adjunctive Therapy

Psychotherapy
 A number of patients with bruxism have
deep-seated emotional or psychic
disturbances. Psychotherapy aimed at
lowering the patient's emotional or
psychic tension has been suggested
and is occasionally successful.

Hypnosis
 Hvponosis has been recommended as
a means to break the habit ol bruxism.
In most instances, of the post-hypnotic
suggestion is overpowered rapidly
and the patient resumes bruxism
without a serious psychic reaction.

Relaxing Exercises and
Physiotherapy
 relaxing exercises, of both a general
and a local nature, may serve to
decrease muscle tension and bruxism
 Exercises, massage, heat, and other
forms of physiotherapy provide relief for
bruxism.

Biofeedback
 Biofeedback or external psycho
physiological feedback, is a concept of
bruxism treatment in which muscle
activity signals are fed back to the
patient for the purpose of
behavioral modification.- reduction in
muscle hyperactivity

Drug therapy
 Tranquilizers

Summary

Conclusion

References
 At wood Douglas : Some clinictil
factors relntcd to rate of resorption
ot'residual ridgw IPD 1962, 12, 3: 441-
450.
 2. Brecker Charles: Conservative
otvlusal rehabilitation. JPD 1059, 9, 6:
1001-UM p.

 Carranza Fermin A and Nowman
Michael G: Clinical periodontology
1996. 8th edition.
 4. Colquitt Tom : The sleep-wear
syndrome. JPD 1987, 57, 1 : 33-

 Carranza Fermin A and Nowman
Michael G: Clinical periodontology
1996. 8th edition.
 4. Colquitt Tom : The sleep-wear
syndrome. JPD 1987, 57, 1 : 33-41.

 Freese Arthur: degenerative joint
disease of the
temperomandibular joint. Jpd 1957. 7,
5: 663-73.
 Glaros Alan ;Rao Stephen: effects of
bruxism a review of literature IPP 1977,
38. 2: 14-156.

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Bruxism part / specialist in dentistry

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