Bruxism part / specialist in dentistry


Published on

Indian Dental Academy: will be one of the most relevant and exciting

training center with best faculty and flexible training programs

for dental professionals who wish to advance in their dental

practice,Offers certified courses in Dental

implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic

Dentistry, Periodontics and General Dentistry.

Published in: Education
  • Be the first to comment

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

No notes for slide

Bruxism part / specialist in dentistry

  1. 1. BRUXISM – ITS DIAGNOSIS AND TREATMENT INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Contents  Introduction  Definitions  History  Review of literature  Applied anatomy  Differences between bruxism and functional activity
  3. 3.  Prevalance  Etiology of Bruxism  Characteristics  Diagnosis  Treatment Summary Conclusion References
  4. 4. Prevalance  Surveys to determine the prevalance of bruxism in various communities have been carried over the last 25 years.
  5. 5. 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
  6. 6. 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)
  7. 7.  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%
  8. 8.  Other studies demonstrate that bruxism occurs in up to 90% in the general population.
  9. 9.  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
  10. 10.  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.
  11. 11.  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.
  12. 12. Etiology - Why people brux?
  13. 13.  The cause of bruxism is still controversial.  Over the years, a great deal of controversy has surrounded the cause of bruxism and clenching.
  14. 14.  . 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
  15. 15. 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.
  16. 16.
  17. 17.
  20. 20. 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.
  21. 21.  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.
  22. 22. Breakdown Malocclusion Increase in Physiologic Tolerance Increase in parafunctional Activity > Structural tolerance
  23. 23. 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.
  24. 24.  Stressors can be unpleasant (like loosing one's job) or pleasant (like leaving for a vacation).
  25. 25. 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)
  26. 26.  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."
  27. 27.  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.
  28. 28. 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
  29. 29. • Alcohol and bruxism
  30. 30. Heriditary
  31. 31. CNS disturbances
  32. 32. Post orthodontic treated patients
  33. 33. •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)
  34. 34. Sleep position  Research speculated that subjects did more bruxing while sleeping on their sides compared to sleeping on their backs.- “Controversy”
  35. 35. Sleep stages D sleep; Desynchronised or dreaming sleep, active sleep S- sleep, synchronised sleep, quiet sleep, Orthodox sleep
  36. 36. Diagnosis
  37. 37. Chief complaints:  Muscle tightness or fatigue upon waking
  38. 38. Hypersensitivity of teeth Headache
  39. 39. 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
  40. 40. Questionnaire?  Only 20% of the bruxers make sound during bruxism .  So cannot be identified in all persons
  41. 41. Drug history  D-amphetamine  leva dopa therapy  fenfluramine  Phenothaiazine
  42. 42. Habits  Severe alcoholic  Severe smoker  Drug addict
  43. 43. Clinical examination
  44. 44. 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
  45. 45. Flattening of cusp tips
  46. 46. Wear in Incisal edges of anterior teeth
  47. 47. 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.
  48. 48. 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.
  49. 49. Pulpitis and pulpal death - severe bruxism cases
  50. 50. Sharpened incisal edges – produce damage to the lip and cheek
  51. 51.  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.
  52. 52. If the patient is having fillings Fractured
  53. 53. Fractured tooth
  54. 54.  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.
  55. 55. 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
  56. 56.  However some others say that bruxism itself cannot initiate the periodontal lesion. However the phenomenon can aggravate the periodontal status.
  57. 57. Resorption of alveolar bone
  58. 58. Extra oral examination
  59. 59. Increased Tonus and Hypertrophy of Masticatory Muscles  Patients with bruxism often develop unilateral or bilateral hypertrophy of the masticatory muscles, especially the masseter muscles.
  60. 60. 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.
  61. 61. Radiographic findings
  62. 62.  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.
  63. 63. A prolonged silent period and sustained high EMG activity between contraction patterns are also suggestive of bruxism.
  64. 64. 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;)
  65. 65. Confirming diagnosis of nocturnal bruxism- HOW?
  66. 66. 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
  67. 67. 2. One week 5mg diazepam given at bed time temporarily rduces bruxism
  68. 68. 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
  69. 69. 4. Diagnostic splint – night guard  If symptoms are relieved – confirmation of bruxism
  70. 70. Treatment
  71. 71. 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.
  72. 72. 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.
  73. 73.  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.
  74. 74.  Tranquilizing agents  Hypnosis  Educate the patient about the restful uninterrupted sleep
  75. 75. 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
  76. 76.  Wet ice pack- 10 to 15 min 4 times daily  Soft diet  Muscle relaxants and analgesics
  78. 78.  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.
  79. 79.  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.
  80. 80.  The effect of bruxism is easy to eliminate if the flat anterior guidance can be maintained.
  81. 81. Break neuro muscular habit patterns
  82. 82.  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.
  83. 83. 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.
  84. 84.  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
  85. 85. 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.
  86. 86.  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.
  87. 87.  Whenever possible equilibration should result in multiple equal intensity stops in centric relation with immediate disclusion by the anterior guidance in all excursion.
  89. 89. 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.
  90. 90.  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.
  91. 91.  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.
  92. 92. 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
  93. 93. Principles Of Stabilization Bite Splint Therapy
  94. 94. 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.
  95. 95. Criteria Of An Acceptable Appliance
  96. 96. 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
  97. 97. 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
  98. 98.  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.
  99. 99. 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
  100. 100. 4. Splint Form  The splint should follow the normal anatomic contours of trie teeth and hard tissues that the appliance will cover.
  101. 101. Fabrication of splint.  The best occlusal biteplane splint is designed on casts mounted on an adjustable articulator.
  102. 102. Step1  The maxillary cast is mounted on the articulator using a facebow.
  103. 103. 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
  104. 104. 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.
  105. 105. 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
  106. 106.  a long centric pin and an offset pin are useful to develop freedom in splint centric.
  107. 107.  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.
  108. 108. Adjunctive Therapy
  109. 109. 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.
  110. 110. 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.
  111. 111. 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.
  112. 112. 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
  113. 113. Drug therapy  Tranquilizers
  114. 114. Summary
  115. 115. Conclusion
  116. 116. 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.
  117. 117.  Carranza Fermin A and Nowman Michael G: Clinical periodontology 1996. 8th edition.  4. Colquitt Tom : The sleep-wear syndrome. JPD 1987, 57, 1 : 33-
  118. 118.  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.
  119. 119.  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.
  120. 120. Thank you For more details please visit