Journal club presentation

Presentation by Dr. Sai Kumar Chandrasekar

guided by Dr. Anam

BRUXISM: A LITERATURE REVIEW

J Indian Prosthodont Soc (July-Sept 2010) 10(3):141148

CONTENTS
Introduction

Etiology
Diagnosis Management occlusal splints

biofeedback pharmacological
Conclusion References

INTRODUCTION
The term parafunction was introduced by Drum. Parafunctional activities are non functional

oromandibular or lingual activities that includes jaw clenching, bruxism, grinding, tooth tapping, cheek biting, lip biting, object biting etc. that can occur alone or in combination and are different from functional activities like chewing, speaking and swallowing.

 The term la bruxomanie was first introduced by

Marie Pietkiewicz in 1907 .

GPT-8 defines bruxism as parafunctional grinding

of teeth or an oral habit consisting of involuntary rhythmic or spasmodic non functional gnashing, grinding or clenching of teeth in other than chewing movements of the mandible which may lead to occlusal trauma.

Classification:
Awake Bruxism (AB) or Diurnal Bruxism (DB).

Sleep Bruxism (SB).

SB is an oromandibular behavior that is defined

as a stereotyped movement disorder occurring during sleep and characterized by tooth grinding and/or clenching. Prevalance:

ETIOLOGY
1.

Central or Pathophysiological Factors- arousal response, It is hypothesized that the direct

and indirect pathways of the basal ganglion, a group of five subcortical nuclei that are involved in the coordination of movements is disturbed in bruxer.
Psychosocial Factors 3. Peripheral Factors
2.

DIAGNOSIS
1. Questionnaire for detecting bruxer-(symptoms) Has anyone heard you grinding your teeth at night? Is your jaw ever fatigue or sore on awakening in the morning? Are you teeth or gums ever sore on awakening in the morning? Do you ever experience temporal headache on awakening in the morning? Are you ever aware of grinding your teeth during the day? Are you ever aware of clenching your teeth during

 2. Clinical Findings/Evaluation Clinical Examination-Report of tooth grinding or

tapping sounds . Presence of tooth wear seen within normal range of jaw movements or at eccentric position. Presence of masseter muscle hypertrophy on voluntary contraction. Complain of masticatory muscles discomfort, fatigue or stiffness in the morning (occasionally, headache in temporal muscle region). Tooth or teeth hypersensitive to cold air or liquid. Clicking or locking of temporomandibular joint. Tongue on cheek indentation.

 3. Tooth Wear-

First, the extent of incisal or occlusal wear for a single tooth was evaluated by the following fourpoint scale: 0: no wear or negligible wear of enamel; 1: obvious wear of enamel or wear through the enamel to the dentine in single spots; 2: wear of the dentine up to one-third of the crown height; 3: wear of the dentine up to more than one-third of the crown height; excessive wear of tooth restorative materialor dental material in the crown and bridgework, more than one-third of the crown height.

 Then, the individual (personal) tooth-wear index

(IA) was calculated from the scores of incisal or occlusal wear for each tooth of that individual. IA = 10 * G1 + 30 * G2 + 100 * G3/G0 + G1 + G2 + G3

 4. Bruxism activity can be evaluated using the

intra-oral appliance and is classified into two groups: (i) observation of wear facets of the intra-oral appliance (ii) measurement of bite force loaded on the intraoral appliance

 Bruxcore Plate- The Bruxcore Bruxism-Monitoring

Device (BBMD) is an intra-oral appliance that was introduced as a device for measuring sleep bruxism activity objectively and the Bruxcore plate evaluates bruxism activity by counting the number of abraded microdots on its surface and by scoring the volumetric magnitude of abrasion.
Pieree and Gale in their study did not find any

significant co relation between the duration of bruxism analyzed with the EMG data and that with the bruxcore plate scores.

 Detection of Bite Force Takeuchi et al. developed a recording device for

sleep bruxism, an intra-splint force detector (ISFD) this transducer is best at detecting rapid changes in force, not static forces.

Masticatory Muscle Electromyographic Recording

The EMG recording has been commonly used to

measure actual sleep bruxism activity directly. Portable EMG Recording Device Miniature Self-Contained EMG Detector Analyser- Bitestrip and Grindcare. Polysomnography

INDICATOR LIGHT ELECTROCHEMICA L DISPLAY

0 no sleep bruxism (<40 events) 1 mild sleep bruxism (40-74 events) 2 moderate (75-124 events) 3 severe (>125 events) E - error

polysomnography

MANAGEMENT OF BRUXISM
Occlusal Therapy-

Occlusal Interventions Occlusal Appliances Biofeedback Bruxism During Wakefulness/Daytime Sleep bruxism Pharmacological Approach

Occlusal appliance
occlusal guard, bite guard, night guard or occlusal

appliance These splints are made of hard acrylic resins, worn in maxillary arch. Hard splints are generally preferred over soft splints for practical reasons (e.g. soft splints are more difficult to adjust than hard ones), to prevent inadvertent tooth movements, and because hard splints are suggested to be more effective in reducing bruxism activity than soft splints.

 The following reasons justify the use of occlusal

splints1. To protect the teeth in bruxing patients. 2. To protect the cheek and/or tongue in patients with oral parafunctions. 3. To stabilize unstable occlusion. 4. To promote jaw muscle relaxation in patients with stress related pain symptoms like tension headache and neck pain of muscular origin. 5. To test the effect of changes in occlusion on the TMJ and jaw muscle function before extensive restorative treatment. 6. To eliminate the effect of occlusal interferences

Types:
According to Okeson

1) Muscle relaxation appliance/ stabilization

appliance used to reduce muscle activity 2) Anterior repositioning appliances/ orthopedic repositioning appliance Other types: Anterior bite plane Pivoting appliance Soft/ resilient appliance

According to Dawson: 1. Permissive splints/ muscle deprogrammer 2. Directive splints/ non-permissive splints 3. Pseudo permissive splints (e.g Soft splints, Hydrostatic splint)

MAXILLARY OR MANDIBULAR SPLINT?

Most splints are maxillary- more stable

more retentive less likely to break increased stability because all mandibular contacts are on flat surfaces. mandibular splint more esthectic and easier for the patient to speak with it in place.

 Before any permanent therapy is begun, one

needs to be aware that there are six general features common to all devices that may be responsible for decreasing muscle activity and symptoms. 1. Alteration of the occlusal condition 2. Alteration of the condylar position 3. Increase in the vertical dimension 4. Cognitive awareness 5. Placebo effect: 40% of the patients suffering from certain TM disorders respond favorably to such treatment. 6. Increased peripheral input to the CNS: Any change at the peripheral input level seems to have an inhibitory effect on this CNS activity

Biofeedback
Biofeedback is based on the principle that

bruxers can unlearn their behaviour when a stimulus makes them aware of their adverse jaw muscle activities (aversive conditioning). Awake bruxism- Mittleman described an EMG technique that provides the daytime clencher with auditory feedback from his/her muscle activity letting him know the degree of muscle activity or relaxation that is taking place.

 For the use of biofeedback in the management of

sleep bruxism, Cherasia and Parks published a prescription. Their technique used contingent arousal from sleep with actual awakenings Nissani used a taste stimulus to awaken the patient. This stimulus was caused by the bruxismrelated rupture of capsules, filled with an aversive substance (agreed upon with the patient) in the dental appliance. A sound blast was applied as the aversive stimulus.

Pharmacological approach
Drugs that have paralytic effect on the muscles

through an inhibition of acetylcholine release at the neuromuscular junction (botulinum toxin) decreases bruxism activity especially in severe cases with comorbidities like coma, brain injury, amphetamine abuse, Huntingtons disease and autism. Many of the studies showed that the catecolamine precursor L-dopa exerted a modest attenuating effect on sleep bruxism. Antidepressant drugs.

Conclusion
Bruxism is a sleep related, centrally mediated

disorder with the psychosocial factors having a little role in its etiology. There are no reliable methods for assessing it clinically. Many devices have been proven to be useful clinically but in the absence of definitive evidence, bruxism can be managed by occlusal appliances, counselling, change in lifestyle and pharmacological interventions.

References
1.

Bruxism: A Literature Review- J Indian Prosthodont Soc (July-Sept 2010) 10(3):141148 TMJ Disorders and Occlusal Splint Therapy A Review International journal of dental clinics: 2 (2):22-29 Dental erosion and bruxism. A tooth wear analysis from South East Queensland- Australian Dental Journa 1998;43:(2):117-27 Principles for the management of bruxism-Journal of Oral Rehabilitation 2008 35; 509523 Bruxism :theory and practice- Daniel paesani Functional occlusion from TMJ to Smile design- Dawson, 333 and 379 Treatment of functional disturbances of masticatory system- Okesson, pg- 507

2. 3.

4. 5. 6. 7.