Bruxim Theory And Practice Sanchez


Published on

Check chapter 14 Influence of trauma from occlusion on the periodontium

1 Comment
1 Like
No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Bruxim Theory And Practice Sanchez

  1. 1. Bruxism:Theory and Practice Editor: Daniel A. Paesani Contributors: Monica Andersen, Taro Arima, Lene Baad-Hansen, Marta M. Barreiro, Gunnar E. Carlsson, Fernando Cifuentes, Sergio Fuster, Jorge Mario Galante, Carlos Gianoni, Fernando Goldberg, Hans L. Hamburger, Faramarz Jadidi, Anders Johansson, Ann-Katrin Johansson, Takafumi Kato, Marcelo Kreiner, Stephanos Kyrkanides, Frank Lobbezoo, Ricardo L. Macchi, Daniele Manfredini, Arturo E. Manns Freese, Machiel Naeije, Luca Guarda Nardini, Ridwaan Omar, Claudia Restrepo, Xiomara Restrepo-J., Andres R. Sanchez, Guillermo Schinini, Teresa Cristina Barros Schütz, José T. T. de Siqueira, Peter Svensson, Ross H. Tallents, Sergio Tufik London, Berlin, Chicago, Tokyo, Barcelona, Beijing, Istanbul, Milan, Moscow, New Delhi, Paris, Prague, São Paulo, Seoul, and Warsaw
  2. 2. ForewordFor years the dental profession has been intrigued, wear might have occurred 20 years earlier and brux-fascinated, and sometimes even obsessed with the ism is no longer a contributing factor.phenomenon we call bruxism. It has been under- Clinicians have also developed a wide varietydiagnosed, overdiagnosed, and even misdiag- of treatments for bruxism, many with no scien-nosed. Some have described it as the most destruc- tific evidence. Dental treatments have rangedtive process affecting the masticatory structures, from selectively adjusting the occlusion to pros-while others refer to it as a benign routine activity. thetic or orthodontic therapies. We have de-Some suggest it is rare, while others say it is very veloped a wide variety of occlusal appliances,common. Some say it is a major contributor to most with limited to no supportive data. We havetemporomandibular disorders, while others say it suggested non-dental therapies such as medica-is not even related. tions, biofeedback, stress reduction, and acu- The etiology of bruxism has been hotly debated puncture. We have even used negative-feedbackfor years. Some believe it is a peripherally gener- devices including electric shocks, loud noises,ated activity associated with tooth contacts, while and taste aversion. It is obvious that we need toothers believe it is a central brainstem-driven understand and document the most effectiveprocess. There is a long list of suggested causes of method to manage bruxism.bruxism such as eccentric tooth contacts, dental It is quite evident that the profession needs amalocclusion, emotional stress, anxiety, sleep dis- comprehensive review of this complex phenom-turbances, genetic factors, medications, alcohol enon known as bruxism. Dr. Daniel Paesani rec-consumption, breathing disorders, allergies, men- ognized this need and has put together the mosttal disorders, and even pin worms. Bruxism is even thorough body of information ever created by thementioned in the Holy Bible as the “gnashing of profession. He has assembled some of our finestteeth” associated with anger and frustration. experts from around the world to contribute their The dental profession has learned that studying knowledge and insights to this text. His compre-bruxism is difficult and controversial. Most patients hensive list of chapters has left no stone unturned.are unaware of their bruxing activity and therefore This text is the most complete overview of bruxismdeny it. Bed partners are sometimes more reliable the profession has ever had opportunity to review.reporters. We dentists seem to inform all our There are several reasons why I am very pleasedpatients that they brux; they just don’t know it. We to have been asked to write the foreword to thismost probably do this because we see the evidence textbook. First, this text represents the first com-of tooth wear, yet timing may be a serious issue. For prehensive attempt to review bruxism, and theinstance, significant tooth wear in a 40-year-old profession needs to be enlightened and informedpatient may present as a dental problem; yet this about this important subject. I am also very pleased V
  3. 3. Forewordbecause I have known Daniel Paesani for almost product of just that. I believe it will serve our30 years and I know and appreciate his dedication profession the field. Dr. Paesani was one of my very firstinternational residents in our Orofacial Pain Jeffrey P. Okeson, DMDCenter and he came from Rosario, Argentina to Chair, Department of Oral Health ScienceLexington, Kentucky with much passion for the Director, Orofacial Pain Programfield and personal sacrifice. I have always admired University of Kentucky College of Dentistryhis dedication and work ethic, and this text is a Lexington, Kentucky, USAVI
  4. 4. Preface and AcknowledgmentsOver my 12 years as Professor of Masticatory After preparing an extensive list of chapters, andSystem Physiology in the School of Odontology of with the purpose of addressing all the topics relat-the Universidad del Salvador/AOA (Buenos Aires, ed to bruxism, I invited a group of colleagues whoseArgentina), the biggest problem we have had to face brilliant professional careers, experience, and ded-has been the lack of scientific compilations on ication to the subject would a priori guarantee theirbruxism, which are needed for students to take addressing the specific topics with scientific andbruxism as an object of study. scholarly rigor. The premise was that each para- At first, we used to request students to visit the graph, each idea, each suggestion should be basedMedline web page – the most important biomed- on scientific evidence, so that the work, apart fromical-literature database worldwide – and perform being useful to college professors and students, issearches, but before long we realized that was not an interesting book for general practitioners, onethe right track. The students faced the difficulty that provides answers to the many questions aris-of having to select which pieces of information to ing in everyday dental practice. Also, specialists inuse from the thousands of publications retrieved craniomandibular disorders will benefit from theby search engines. Of course, since these were in-depth analysis of the subjects and the extensive,first-degree students, they were not yet suffi- up-to-date bibliographies contained herein, whichciently qualified to differentiate concepts that had provide a quick, well-organized way to access thebeen validated by scientific method from con- evidence they need in their professional practicecepts based simply on mysticism and dogma. We, and as a tool for planning future research. So, thethe professors, would spend long hours assisting volume is divided into three sections.them with these issues, and we would use the • The first section comprises eight chaptersscarce, precious time available to us to select and dealing with bruxism knowledge and guide-compile the study material rather than to teach. lines for diagnosis, sleep physiology, main This experience made me wonder why – etiological theories, influence of peripheralresearchers and published books being so many and and emotional factors, movement disorders,bruxism being such an important entity in the and bruxism in children.odontological field – not a single volume existed • The second section comprises nine chaptersdevoted exclusively to bruxism. When I found no and is devoted to the effects of bruxism on theanswer to this question, I started to think about tak- masticatory system components. Some of theing on the responsibility to compile information topics are: the noxious action of bruxism onwith the aim of publishing a volume exclusively dental pulp, periodontal ligament, temporo-devoted to bruxism and its treatment. mandibular joints, muscles, and its relation- VII
  5. 5. Preface and Acknowledgments ship with pain. Some bruxism effects that are Acknowledgments currently controversial are discussed, for I would like to express my gratitude to: which purpose a wide review of the literature • the contributing authors, whose valuable on the subject is provided. Special emphasis expertise and thorough dedication ensured has been placed on tooth wear and on the dif- the excellent coverage of a wide range of ferential diagnosis of bruxism’s several caus- topics related to bruxism es. One chapter has been specifically devoted • Professors Jeffrey Okeson, Ross Tallents, to dental erosion, and another chapter to Per-Lennart Westesson, and Annika Isberg endogenous erosion mechanisms, since gen- for introducing me to the marvelous world eral practitioners often mistake tooth wear of science caused by endogenous erosion for tooth wear • Quintessence Publishing for believing in this caused by bruxism. book and accepting it for publication• The third section comprises eight chapters • professional translators Ángela Giottonini and deals with various aspects related to the (Chapters 1, 15, and 21) and María Mirela treatment of bruxism. The pharmacological Perusia (Chapters 2, 9–14, 20, 23, and 25) for effects of certain central-action drugs and their brilliant translations of the original some peripheral-action drugs, such as botu- Spanish text into English linum toxin, are described. The text also deals • Valeria Castillo for proofreading the original with the treatment of bruxism involving den- Spanish text tal implants and appliances constructed with • the staff of the library of the Asociación dental materials particularly recommended Odontológica Argentina (Dental Association for bruxers. Topics related to dental occlu- of Argentina) for their valuable help in sion are discussed with the aim of facilitating obtaining the innumerable bibliographical understanding of the concepts needed to references I have used enter the fascinating world of complex oral • my assistants Liliana Rivalta, Gabriela Allo, rehabilitation. One chapter deals with tech- and Patricia Peloso for their endless patience niques used for the reconstruction of teeth and dedication and their invaluable help in affected by significant wear. the management of the numerous patients and in the process of obtaining the clinicalThe volume also includes a review of the scientif- photographsic evidence on the treatment of bruxism, especial- • my family, Triana, Guido, Julia, Pedro,ly bruxism splints. The different procedures used Susana, and Candela, who, in all their love,for protecting the masticatory system against the gave up sharing many irretrievable days witheffects of bruxism are described and illustrated by me.means of case reports. Daniel Angel Paesani EditorVIII
  6. 6. List of all contributorsEditor Marta M. Barreiro, DDS, Dr Dent Professor of Dental MaterialsDaniel A. Paesani, DDS School of DentistryProfessor of Stomatognathic Physiology University of Buenos AiresSchool of Dentistry Buenos Aires, ArgentinaUniversity of Salvador/AOABuenos Aires, Argentina Gunnar E. Carlsson, LDS, Odont Dr/ PhD, Dr Odont hc, Dr Dent hc, FDSRCSContributors Professor Emeritus Department of Prosthetic Dentistry/Monica Andersen, PhD Dental Materials ScienceAssociate Professor Specialist in Prosthodontics and TMD/Department of Psychobiology Orofacial PainSchool of Medicine Institute of OdontologyUniversidade Federal de São Paulo The Sahlgrenska Academy(UNIFESP) University of GothenburgSão Paulo, Brazil Göteborg, SwedenTaro Arima, DDS, PhD Fernando Cifuentes, DDSAssistant Professor Assistance ProfessorDepartment of Oral Rehabilitation Department of Stomatognatic PhysiologyGraduate School of Dental Medicine School of DentistryUniversity of Hokkaido University of Salvador/AOASapporo, Japan Buenos Aires, ArgentinaLene Baad-Hansen, DDS, PhD Sergio Fuster, MDAssociate Professor Gastroenterology SpecialistDepartment of Clinical Oral Physiology Private Practice, Rosario, ArgentinaSchool of DentistryAarhus University Jorge Mario Galante, DDSAarhus, Denmark Associate Professor School of Dentistry University of Buenos Aires Buenos Aires, Argentina IX
  7. 7. List of all contributorsCarlos Gianoni, MD Takafumi Kato, DDS, PhDGastroenterology Specialist Associate ProfessorPrivate Practice Institute for Oral ScienceRosario, Argentina Graduate School of Oral Medicine Matsumoto Dental UniversityFernando Goldberg, DDS, PhD ChiefProfessor Dental Sleep Medicine ClinicDepartment of Endodontics Matsumoto Dental University HospitalSchool of Dentistry Matsumoto, JapanUniversity of Salvador/AOABuenos Aires, Argentina Marcelo Kreiner, DDS Professor and ChairmanHans L. Hamburger, MD, PhD Department of General and Oral PhysiologyNeurologist School of DentistryDepartment of Clinical Neurophysiology Universidad de la RepúblicaAmsterdam Center for Sleep-Wake Studies Montevideo, UruguaySlotervaart HospitalAmsterdam, The Netherlands Stephanos Kyrkanides, DDS, MS, PhD Professor and ChairmanFaramarz Jadidi Department of OrthodonticsPhD student and Pediatric DentistryDepartment of Clinical Oral Physiology School of Dental MedicineSchool of Dentistry, Aarhus University Stony Brook UniversityAarhus, Denmark Stony Brook New York, NY, USAAnders Johansson, DDS, Odont Dr/PhDProfessor Frank Lobbezoo, DDS, PhDDepartment of Clinical Dentistry - Prosthodontics ProfessorSpecialist in Prosthodontics and TMD/ Department of Oral FunctionOrofacial Pain Academic Centre for Dentistry AmsterdamFaculty of Medicine and Dentistry (ACTA), Amsterdam, The NetherlandsUniversity of BergenBergen, Norway Ricardo L. Macchi, DDS, MS, Dr Dent Professor Emeritus of Dental MaterialsAnn-Katrin Johansson, DDS, Odont Lic/MSc, School of DentistryOdont Dr/PhD University of Buenos AiresAssociate Professor and Head of Cariology Buenos Aires, ArgentinaDepartment of Clinical Dentistry - CariologySpecialist in Pediatric Dentistry Daniele Manfredini, DDSFaculty of Dentistry, University of Bergen Visiting ProfessorBergen, Norway TMD Clinic Department of Maxillofacial Surgery University of Padova, Padova, ItalyX
  8. 8. List of all contributorsArturo E. Manns Freese, DDS, PhD Guillermo Schinini, DDSProfessor of Oral Physiology and Occlusion Clinical Assistant ProfessorSchool of Dentistry, University of the Andes Department of PeriodontologySantiago, Chile Maimonides University Private PracticeMachiel Naeije, PhD Rosario, ArgentinaProfessor and ChairDepartment of Oral Function Teresa Cristina Barros Schütz, DDS, PhDAcademic Centre for Dentistry Amsterdam Researcher(ACTA), Amsterdam, The Netherlands Department of Psychobiology School of MedicineLuca Guarda Nardini, MD, DDS Universidade Federal de São Paulo (UNIFESP)Director São Paulo, BrazilTMD Clinic, Department of Maxillofacial SurgeryUniversity of Padova, Padova, Italy José T. T. de Siqueira, DDS, PhD Head of Orofacial Pain TeamRidwaan Omar, BSc, BDS, LDSRCS, MSc, Dentistry DivisionFRACDS, FDSRCSEd Hospital das Clínicas, School of MedicineProfessor and Head of Prosthodontics Universidade de São Paulo (USP)Vice Dean for Academic & Clinical Affairs ResearcherDepartment of Restorative Sciences Department of PsychobiologyFaculty of Dentistry, Kuwait University School of MedicineKuwait Universidade Federal de São Paulo (UNIFESP) São Paulo, BrazilClaudia Restrepo, DDSPediatric Dentist Peter Svensson, DDS, PhD, Dr OdontTeacher, Postgraduate Program of Pediatric ProfessorDentistry and Preventive Orthodontics Department of Clinical Oral PhysiologyDirector of the CES-LPH Research Group School of Dentistry, Aarhus UniversityCES University, Medellin, Colombia Aarhus, DenmarkXiomara Restrepo-J., DDS Ross H. Tallents, DDSGeneral Practice Resident Professor of DentistryDepartment of General Dentistry Department of Orthodontics and ProsthodonticsEastman Institute for Oral Health Eastman Institute for Oral HealthRochester, NY, USA Rochester, NY, USAAndres R. Sanchez, DDS, MS Sergio Tufik, MD, PhDPrivate Practice, Eden Prairie, MN, USA ProfessorFormer Assistant Professor in Periodontics Department of PsychobiologyMarquette University School of Dentistry School of MedicineMilwaukee, WI, USA Universidade Federal de São Paulo (UNIFESP) São Paulo, Brazil XI
  9. 9. ContentsPART 1: OVERVIEW OF THE PROBLEMChapter 1 - Introduction to Bruxism 3Daniel A. Paesani Introduction 3 The Importance of Bruxism in Daily Care 3 Oral Habits 4 Classification of Bruxism according to the Type and Timing of Activity 4 Etiology 5 Genetics 5 Epidemiology 10 Bruxism Variability 15 References 15Chapter 2 – Diagnosis of Bruxism 21Daniel A. Paesani Introduction 21 Clinical Diagnosis 22 Complementary Methods for Diagnosis 31 References 38Chapter 3 – Sleep Physiology and Bruxism 41José T. T. de Siqueira, Teresa Cristina Barros Schütz, Monica Andersen, and Sergio Tufik Introduction 41 Basic Facts of Sleep Physiology and Pathophysiology 42 Sleep Architecture 44 The Sleep Laboratory 47 Understanding Bruxism in a PSG 47 Conclusion 50 References 51 XIII
  10. 10. ContentsChapter 4 – Etiology of Bruxism 53Frank Lobbezoo, Hans L. Hamburger, and Machiel Naeije Introduction 53 Categories 55 Morphologic Factors 55 Psychosocial Factors 57 Pathophysiologic Factors 58 Conclusion 61 References 62Chapter 5 – Role of Peripheral Sensory Factors in Bruxism:A Physiologic Interpretation for Clinical Dentistry 67Takafumi Kato Introduction 67 Basic Knowledge of Orofacial Sensorimotor Systems 68 Which Event Comes First: Tooth Contact or Jaw Muscle Activity? 72 Sensory Stimuli and Sleep Bruxism 76 Can the Peripheral Sensory System Explain the Role of an Oral Splint in SB Management? 79 Conclusion 81 References 81Chapter 6 – Emotional Factors in the Etiology of Bruxism 87Daniele Manfredini Introduction 87 Literature Search 88 Bruxism and Stress 89 Psychosocial Aspects of Bruxism 91 The Relationship between Bruxism and Pain 91 Sleep versus Awake Bruxism, and Grinding versus Clenching 93 Conclusion 95 References 95Chapter 7 – Movement Disorders in the Dental Office 99Frank Lobbezoo, Hans L. Hamburger, and Machiel Naeije Introduction 99 Literature Search 100 Dyskinesias 100 Conclusion 105 References 106XIV
  11. 11. ContentsChapter 8 – Bruxism in Children 111Claudia Restrepo Introduction 111 Etiology of Bruxism in Children 111 Epidemiology of Bruxism in Children 113 Factors Associated with Bruxism 113 Diagnosis of Bruxism in Children 115 Effect of Bruxism on the Dentition of Children 115 Effect of Bruxism on Craniofacial Morphology 117 Bruxism in Children with Special Characteristics 117 Management of Bruxism in Children 118 References 118PART 2: EFFECTS ON THE MASTICATORY SYSTEMChapter 9 – Tooth Wear 123Daniel A. Paesani Introduction 123 Etiology of Tooth Wear 124 Types of Attrition 125 Physiologic Attrition 125 Tooth Wear Quantification 126 Factors Involved in Tooth Wear 129 Tooth Wear Patterns 132 Interpretation of Tooth Wear 138 Conclusion 145 References 147Chapter 10 – Dental Erosion 149Daniel A. Paesani Introduction 149 Prevalence 149 Clinical Features and Diagnosis of Erosion 150 Classification of Erosion according to Its Magnitude 155 Classification of Erosion according to Etiology 155 Etiopathogenic Mechanism and Conditioning Factors 169 Salivary Secretion and Buffering Capacity Quantification 176 References 183 XV
  12. 12. ContentsChapter 11 – Gastroesophageal Reflux as a Cause of Dental Erosion 187Sergio Fuster and Carlos Gianoni Introduction 187 Anatomophysiology of the Upper Digestive Tract 187 Definition of Reflux 190 Pathophysiology of Reflux 191 Clinical Manifestations of Reflux 192 Diagnosis of Reflux 196 Role of Dental Practitioners in Diagnosing Reflux 200 Treatment of Reflux 200 Conclusion 202 References 202Chapter 12 – Controversies on the Effects of Bruxism 207Daniel A. Paesani Introduction 207 Effects on Dentition 207 Effects on Soft Tissues 220 Effects on Bone 222 References 229Chapter 13 – Effects of Bruxism on Teeth and Its Relationship with Endodontics 233Fernando Goldberg Introduction 233 Pulp and Peri-radicular Alterations 233 Alterations in Crown and Root Structural Integrity 243 References 254Chapter 14 – Influence of Trauma from Occlusion on the Periodontium 257Guillermo Schinini and Andres R. Sanchez Introduction 257 Periodontal Lesions 258 Occlusal Trauma Lesions 258 Effect of Occlusal Trauma on the Healthy Periodontium 259 Effect of Occlusal Trauma on the Diseased Periodontium 262 Human Clinical Evidence 264 Conclusion 267 References 268XVI
  13. 13. ContentsChapter 15 – Effects of Bruxism on Muscles 271Arturo E. Manns Freese Introduction 271 Principles of Skeletal Muscle Physiology 272 Ultrastructure of Skeletal Muscle 275 Comparing Normal Function and Parafunction 280 Pathophysiology of Muscular Disorders and Related Pain 282 Types of Muscular Pain 283 Conclusion 293 References 294Chapter 16 – Temporomandibular Joint Dysfunction and Bruxism 297Xiomara Restrepo-Jaramillo, Ross H. Tallents, and Stephanos Kyrkanides Introduction 297 Definitions 297 Prevalence Studies 298 Etiology 299 Pathways to Joint Degeneration 300 The Role of Bruxism 301 Conclusion 304 References 304Chapter 17 – Pain and Bruxism 309Peter Svensson, Faramarz Jadidi, Taro Arima, and Lene Baad-Hansen Introduction 309 Overview of Pain Mechanisms 309 Sex-related Differences in Pain Experience 313 Pain Genetics 314 Experimental Bruxism and Craniofacial Pain 314 Clinical Studies of Bruxism and Craniofacial Pain 317 Intervention Studies of Bruxism 320 Conclusion 321 References 322PART 3: CLINICAL APPROACHESChapter 18 – Pharmacologic Considerations in Bruxism 327Marcelo Kreiner Introduction 327 XVII
  14. 14. Contents Anxiolytic Drugs 328 Antidepressant Drugs 329 Neuroleptics 331 Addictive Social Drugs 332 Adrenergic Antagonists and Agonists 334 Agonists of Dopaminergic Receptors 334 Antiepileptics 335 References 336Chapter 19 – Dental Materials for the Bruxing Patient 339Marta M. Barreiro and Ricardo L. Macchi Introduction 339 Criteria for Material Selection 340 General Wear Processes 343 Evaluation of Wear Behavior 348 Degradation of Restorative Materials 350 Conclusion 355 References 355Chapter 20 – Evidence Related to the Treatment of Bruxism 359Daniel A. Paesani Introduction 359 Treatments for Sleep Bruxism 359 Awake Bruxism 374 References 378Chapter 21 – Introduction to Complex Oral Restoration 383Daniel A. Paesani and Fernando Cifuentes Introduction 383 Centric Relation 383 Axis of Rotation of the Mandible 394 The Anterior bite Plane Method 398 References 412Chapter 22 – Restoration of the Worn Dentition 415Anders Johansson, Ann-Katrin Johansson, Ridwaan Omar, and Gunnar E. Carlsson Introduction 415 Historical Aspects 415 Epidemiology 416XVIII
  15. 15. Contents Etiology of Tooth Wear 418 Principles and Management Strategies for Tooth Wear 419 Rehabilitative Strategies 423 Maintenance Phase 436 Conclusion 436 References 437Chapter 23 – Effects of Bruxism on Restorative Implant-assisted Prosthesis Treatments 439Jorge Mario Galante Introduction 439 Peri-implant Pathology Classification 441 Classification of Complications of IAP Restorative Treatments 449 Prosthetic Rehabilitation with Implants in Bruxers 454 Conclusion 464 References 464Chapter 24 – Botulinum Toxin in the Treatment of Bruxism 467Daniele Manfredini and Luca Guarda Nardini Introduction 467 History of Botulinum Toxin as a Therapeutic Drug 467 Mechanism of Action 468 Fields of Application 469 Safety of Botulinum Toxin Treatments 469 Orofacial Pain Relief 470 Temporomandibular Disorders 470 Botox and Bruxism 471 Conclusion 473 References 473Chapter 25 – Clinical Treatment of Bruxism 477Daniel A. Paesani and Fernando Cifuentes Canine Guidance in the Control of Bruxism Effects 477 Bruxism Splints 484 Fabrication of the Bruxism Splint 490 Bruxism Splint Maintenance 515 Treatments with Botulinum Toxin 516 References 522Index 525 XIX
  16. 16. Part 1 Overviewof the problem
  17. 17. Chapter 1 Introduction to Bruxism Daniel A. PaesaniIntroduction refer to the grinding of the teeth and described it as the cause of a periodontal condition by thenIn the glossary of terms of the American Academy called pyorrhea.2 The term “bruxism” comes fromof Orofacial Pain, bruxism is defined as a “total the Greek expression brychein odontas that meansparafunctional daily or nightly activity that grinding the teeth. In French, bruxomanie was usedincludes grinding, gnashing, or clenching of the for the first time by Marie and Pietkiewicz inteeth. It takes place in the absence of subjective 1907.3 Then, Frohman was responsible for the firstconsciousness and it can be diagnosed by the pres- publication in the odontological literature whenence of tooth wear facets which have not resulted he referred to “bruxomania” as a pure psycho-from the chewing function”.1 logical state.4 In order to understand the remoteness of the actof “gnashing the teeth”, we can cite the following The Importance of Bruxismpassages from the Bible: in Daily Care Psalm 35:16 “Like profane mockers at a feast,they gnash at me with their teeth” Bruxism may be considered a normal habit; but Psalm 112:10 “The sinner shall see and be under certain circumstances, such as an increase inangry, he shall gnash his teeth and consume away” the frequency of episodes and the strength of mas- Job 16:9 “he grinds his teeth at me” seter contractions, it may turn into a phenomenon Matthew 8:12 “But the children of the king- with pathological consequences.5 Bruxism maydom shall be cast out into outer darkness: there dramatically change the result and the duration ofshall be weeping and gnashing of teeth” the delicate and careful treatments performed by At the beginning of the twentieth century, clinicians. Whereas a soft form of bruxism hardlyKarolyi used the term “traumatic neuralgia” to ever affects oral structures, a hard manifestation 3
  18. 18. Daniel A. Paesani Table 2-1 Questionnaire for detection of bruxism. Yes No Don’t know Do you grind your teeth when you sleep? Has anybody heard you grind your teeth while you sleep? On waking up, do you usually find that you are clenching your teeth? When you wake up, do you usually have jaw pain or jaw fatigue? When you wake up, do you usually have the feeling that your teeth are loose? When you wake up, do you usually have sore teeth and/or sore gums? When you wake up, do you usually have a headache in the temples? When you wake up, do you usually have a jaw lock? Have you ever found that you were clenching your teeth in the daytime? Have you ever found that you were grinding your teeth in the daytime?• complementary methods: use of intraoral devices Clinical Diagnosis for tooth wear quantification (splints; Brux- core®, Boston, MA, USA) and bite force detec- Symptoms tors; masseter electromyography (EMG, ambu- A rapid way of collecting information is to request latory EMG, disposable EMG devices such as the patient to answer a questionnaire. It is the most BiteStrip®); and sleep polysomnography. widely available method to be used in everyday practice. Chapter 1 has already discussed the advan- tages and disadvantages of this method in the diag- nosis of bruxism symptoms. Questionnaires are very useful for obtaining a great amount of information in a short time. A good questionnaire should include a wide range of ques- tions concerning the patient’s general health status, diseases, medication, etc. Of course, as the main subject of this book is bruxism, we will just be deal- ing with the questions that specifically refer to it. Table 2-1 shows sample questions that can be added to the general questionnaire usually used during the patient’s first appointment; such a gen-Fig 2-1 Enamel fracture in both central incisors, as a result of eral questionnaire is simply about a collection ofbruxism in the protrusive direction. Note also the abrasive symptoms that can be attributed to bruxism. It iswear of vestibular enamel, caused by hard tooth brushing. advisable to include “Don’t know” among the22
  19. 19. Diagnosis of Bruxism a b Fig 2-2 (a) Fracture line in a mandibular molar (arrow) caused by bruxism of the clenching type. (b) No frac- ture is evident in the periapical radiograph, although a reactive area in the interradicular space can be seen (arrow). (c) Opening of the molar reveals that the frac- c ture has reached the pulp chamber (arrow).possible choices; this will prevent false-positive sleep (witness statements based on two episodesand false-negative answers from patients who are per week) has been studied. When checked againstnot sure of how to respond. At the first appoint- polysomnography, they showed a sensitivity ofment, during history taking, it is recommended 78% and a specificity of 98%.1that the clinician quickly asks the patient the samequestions from the questionnaire again in order to Tooth wearconfirm the accuracy of the patient’s answers. Although this has a strong association with bruxism, it is not a specific sign since there are many causes ofSigns tooth wear. Grinding causes the teeth to deteriorateIn the clinical examination, some signs may be in a specific way (attrition). Tooth wear can be stud-present to suggest bruxism. The character of these ied by direct visual inspection of the mouth, bysigns (and symptoms) is “relative”, since they alone examining plaster models of the patient’s teeth, andare not sufficient evidence of bruxism; although by taking a look at intraoral pictures. This subject isfrequently mentioned in the literature, the fact is discussed in detail in Chapter 9.that they have not yet been validated by scientificmethod. Future controlled investigations will have Fracturesto determine the corresponding sensitivity and There may be fractures in natural teeth, prosthe-specificity values for each of them. So far, only the ses, dental implants, and dental restorations (Figsclinical validity of tooth-grinding sounds during 2-1 to 2-11). 23
  20. 20. Marta M. Barreiro and Ricardo L. Macchi a bFig 19-10 Proximal contact between restorations with different hardnesses: (a) porcelain–metal, and (b) porcelain–composite.Several mechanisms are present – two-body, three-body, and corrosive wear. In the case of bruxism, two-body wear or attrition is found. Tooth surfaces come into direct contact, the frequency of sliding is incremented as well as the loads that are applied, and all these factors lead to significantly greater wear and increased possi- a bility of fatigue failure.15 Evaluation of Wear Behavior Laboratory simulator and clinical studies can be used to evaluate intraoral wear. b In-vitro Laboratory Studies The use of in-vitro studies provides an approxi-Fig 19-11 (a and b) Proximal wear in teeth with proximalcomposite resin restorations. This type of wear is also seen on mation of the evaluation of wear of new materialsenamel and is increased in the presence of periodontal mobil- before their clinical application.31,32ity. (Modified from Söderholm.28) Is the prediction of wear behavior of dental materials possible? One important point to keep inlubricant that acts in each case can be seen in Table mind when evaluating lab studies is the difficulties19-3. The contacts can be tooth against tooth, that appear when attempting to simulate conditionstooth against restoration, restoration against present in the oral cavity. The very many variablesrestoration, as well as a tooth brush or other foreign that participate in wear make its measurement withbody – which includes foods. a single parameter difficult, even when variations Corrosive wear or erosion can take place when seen from patient to patient are not considered.31a chemical process is added, as happens by the The weak correlation that is seen betweeneffect of acid in bulimic patients. Wear by superfi- mechanical properties and wear is remarkable.cial fatigue can be the consequence of a habit such Some physical properties such as water sorptionas biting on a solid object (e.g., a pen), which can give just a hint of potential wear, particularlyinvolves the application of high compressive loads. when corrosive wear is considered.348
  21. 21. Dental Materials for the Bruxing Patient Table 19-3 Most frequent wear types within the oral cavity: comparison between dental and materials science terminology (modified from Vale Antunes and Ramalho3).Causes of wear Dental term Material terminology Lubricant/abrasivePhysiologicWithout occlusal contact Abrasion Three-body Saliva/foodDirect contact Attrition Two-body SalivaContact and sliding Attrition Two-body SalivaPathologicBruxism Attrition Two-body SalivaXerostomia Attrition Two-body –Chemical attack Erosion Corrosion SalivaNegative habits Attrition/abrasion Two- or three-body –HygieneTooth brushing Abrasion Three-body Water/dentifriceClinical Studies Indirect methods use impressions and models,Understanding clinical wear requires studies in which are evaluated, or epoxy resin replicas thatwhich the different factors that interact are taken can reproduce worn surfaces, and scanning elec-into account. Clinical studies are the best option in tron microscopy observation.the actual evaluation of wear, but they are expen- Loss of vertical dimension is commonly meas-sive and need to be long term.33–35 ured in clinical studies. Visual examination is fast Clinical wear can be expressed by the amount and no additional cost is required, but it is prone(in micrometers) of material loss per year, using to subjective variation; often just changes innormal tooth wear for comparison. For example, anatomic force are registered without any quan-the American Dental Association considers that a tification. Special optical or scanning electronloss no greater than 50 μm per year has to be estab- microscopes and profilometers allow for greaterlished by means of systematic clinical studies if a precision in the evaluation of material loss. Surfacematerial is to be used in posterior restorations. changes in exposed cavity walls can be evaluated so Both direct and indirect methods are used in as to establish the types of wear that are present.these studies. Most of the direct studies follow cri- Many discrepancies are seen between resultsteria that have been established by Ryge:36 color from in-vitro lab studies and observation in long-matching, marginal integrity, secondary caries, term clinical studies. The evaluation of actualanatomic form, and surface roughness. Some behavior with reliable measurements is still a prob-changes in categorization are introduced according lem to be solved. Present efforts are focused on theto each study’s specific needs. Inter-examiner vari- use of wear simulators for wear studies, and theseability is the main limitation to obtaining adequate results have be corroborated later by clinical stud-discrimination in the use of scales. ies.31 349
  22. 22. Daniel A. Paesani and Fernando Cifuentes Splint attachment problems are much simpler to solve, since only retainer tightening is required. In order to perform splint occlusal adjustment, it is advisable not to polish the surface of the splint fully. Another option is to request the laboratory to deliver the splint with a coarse surface, or to remove the splint’s gloss by using thin sandpaper in order to better visualize occlusal contacts. Once the patient is in the dorsal recumbent position, a they are requested to give a series of quick taps with their teeth on the splint, while articulating paper is made to come between splint and teeth (Fig 25-32). An acrylic bur is used to wear out all the premature contact points. This procedure is repeated as many times as necessary, until all the vestibular cusps and incisal edges simultaneously occlude on the surface of the splint. The simul- taneous contacts obtained during mouth closure are comparable to maximum intercuspation at a dental level. Thus, each of these points (closure b stops) will be responsible for the stability of its respective antagonist tooth. Also, the combined action of all of them guarantees a steady position of the jaw during mouth closure and, especially, during tooth clenching episodes while the bruxer is wearing the splint. Next, the aim is to make anterior guidance har- monious (Figs 25-33 and 25-34). To do this, it is advisable to use articulating paper of a different color. Articulating paper is placed between the teeth and the splint while having the patient make c lateral and protrusive movements. Any contact inFig 25-32 Occlusal adjustment of the splint. (a) Ask the the posterior segment should be carefullypatient to close their mouth repeatedly and give a series of taps removed, with the exception of those contactswith their teeth on the splint, while articulating paper is placedbetween the splint and the teeth. (b and c) The aim is to obtain matching the ones obtained in the previous stepone contact point per cusp or antagonist incisal edge. (closure stops). In short, during closure, one con- tact per cusp or lower incisal edge should occur in the splint; during eccentric movements (lateral movement and protrusion), the anterior guidance should prevent premolar and molar cusps from coming into contact with the surface of the splint.502
  23. 23. Clinical Treatment of Bruxism a bFig 25-33 (a) With articulating paper of a different color, anterior guidance functioning is tested. (b) The white arrows indicatethe trajectories created during lateral movements; the black arrows indicate protrusive movement trajectories. a bFig 25-34 (a–c) Correct functioning of the anterior guid-ance of the splint causes the posterior segments to separate andprotects them against premature wear during tooth grinding cepisodes. 503