Bruxism

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BRUXISM
GUIDED BY:
DR.S.R.GODBOLE
DR TRUPTI
DAHANE
1
PRESENTED BY:
DR.APURVA
DESHMUKH

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C
1.Introduction
2.Definitions
3.Epidemiology
4.Classification
5.Etiology of Bruxism
6.Signs and symptoms
7.Assessment of bruxism
8.Treatment
9.Summary
10.References.
CONTENTS
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I INTRODUCTIO
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Mosby's Dental Dictionary, 2nd edition.
The habitual movements that are normal motions associated with
mastication, speech, or respiratory movements and that result in worn facets
and other problems associated with occlusal trauma. Also called oral habits.
Medical Dictionary for the Dental Professions, 2012.
1. In dentistry, movements of mandible that are outside normal
function
2. Abnormal or disordered function.
PARA-FUNCTIONAL HABIT:
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The term parafunction was introduced by DRUM to suggest distinction
between
• occlusal stress exerted during mastication and swallowing ; and
• occlusal stress which are brought into action outside of the normal
function.
The former group of activities are called as “function” ; the latter
are “parafunction”.
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Parafunction is defined as a disordered or perverted function. GPT 9.
Oral para-functional habits may include
• Bruxism
• Tongue thrusting
• Fingernail biting
• pencil or pen chewing
• Mouth breathing
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Activities Normal Functional Parafunctional
Direction of
applied force
During chewing and swallowing, the
predominant forces applied to the
teeth are in a vertical direction
which is accepted well by the
supportive structures of the teeth.
During bruxism, when the mandible
shifts from side to side, heavy
horizontal forces are applied on the
teeth, which are not well- accepted.
These increase the chances of
damage to the teeth and/or supportive
structures.
Mandibular
position
Most of the functional activity of
mandible occurs at or near the
centric occlusion position. The
forces related to the functional
activity are distributed to many teeth
that minimize potential damage to a
single tooth.
Bruxism occurs in eccentric
positions. Few tooth contacts occur
during the activity and in this activity,
the mandibular position is far from its
stable position. This position causes
more strain on the masticatory system,
making it more susceptible to
breakdown. This causes the
application of heavy forces to a few
teeth.

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Farhanaz F et al. Psychosocial and bruxismInternational Journal of Health Sciences & Research 437 Vol.6;
PARA-FUNCTIONAL
HABIT:
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Activities Normal Functional Parafunctional
Muscle activity
Most functional activity occurring in
jaws consists of well-controlled,
rhythmic contraction and relaxation
of the muscles. This rhythmic activity
permits adequate blood flow, which
supplies oxygen to the tissues and
eliminates by- products accumulated
at the cellular level.
Bruxism results in sustained muscle
contraction for long periods. This reduces
oxygenation within the muscle tissues as
there is reduced blood flow. As a result, the
levels of carbon dioxide and cellular waste
by-products increase within the muscle
tissue creating the symptoms of fatigue,
pain, and spasms.
Neuromuscular
reflexes
It is present during functional
activities, protecting the dental
structures from damage.
It appears to be absent resulting in less
influence over muscle activity. This
increases the levels of parafunctional
activity that can cause a breakdown of the
structures involved.

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The term Bruxism refers to a non-functional contact of mandibular and
maxillary teeth often resulting in the clenching or grinding of teeth (Graf,
1969; Glaros and Rao, 1977).
This often occurs during sleep although it also may occur while awake
(Nadler, 1972; Bader et al., 1997).
It is an activity particularly important to the dentist because of breakage of
dental restorations, tooth damage, induction of temporal headache and
temporomandibular disorders.
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D
DEFINITION
S
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Bruxism (ca.1940):
1. The parafunctional grinding of teeth;
2. An oral habit consisting of involuntary rhythmic or spasmodic
nonfunctional gnashing, grinding, or clenching of teeth, in other than
chewing movements of the mandible, which may lead to occlusal trauma.
- GPT 9
Bruxism, derived from the Greek word brygmσs, meaning "gnashing of
teeth."
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The American Academy of Orofacial Pain in 2008, defined
bruxism as a diurnal or nocturnal parafunctional activity that
includes unconscious clenching, grinding or bracing of the teeth.
According to American Sleep Disorders Association,
Bruxism is defined as “Tooth grinding or clenching during sleep
plus one of the following: Tooth wear, sounds or jaw muscle discomfort in
the absence of medical disorder.”
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1901: Karolyi M - "Traumatic neuralgia"
1907: Marie Pietkiewicz - "Bruxomania"
1931: Frohman - "Bruxism"
1971: Ramjford & Ash - "Centric and eccentric bruxism."
1972: Drum -"Emotional loaded parafunction"
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NOMENCLATURE :

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E EPIDEMIOLO
GY
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The ICSD-R states
• 85-90% of the general population grind their teeth to a degree at
some point during their life, although only 5% will develop a clinical
condition.
• Awake bruxism (AB) affects females more than males,
• Sleep bruxism (SB), males are as equally affected as females.
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EPIDEMIOLOGY:

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A 2013 systematic review of the epidemiological reports of bruxism concluded
-
• a prevalence of about 22 - 31% for AB,
• 9.7 - 16% for SB,
• and an overall prevalence of about 8 - 31.4% of bruxism generally.
The review overall concludes that bruxism
• affects males and females equally
• affects elderly people less commonly
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Manfredini D, Epidemiology of bruxism in adults: a systematic review of the literature. J Orofac Pain. 2013 Spring;27(2):99-
110. doi: 10.11607/jop.921.

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C
CLASSIFICATI
ON
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Sleep bruxism Awake bruxism
Pattern While asleep While awake
Pain pattern
Worst on waking, then slowly gets
better
Worsens throughout the day, may
not be present on waking
Noises Commonly associated Rarely associated
Bruxism pattern Clenching and grinding
Usually clenching, occasionally
clenching and grinding
Relationship with stress
Unclear, little evidence of a
relationship
Stronger evidence for a
relationship, but not conclusive
Prevalance 9.7-15.9% 22.1-31%
Gender distribution Equal Mostly females
Hereditary Some evidence Unclear
A. By when it occurs:‘By Takafumi Kato et al 2001

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B. By etiology:
• Primary, essential or idiopathic bruxism : For which no apparent cause is known.
• Secondary bruxism:
1. Secondary to diseases (coma, icterus, cerebral palsy)
2. Medicinal products (e.g. antipsychotic medication, cardioactive medication)
3. Drugs (e.g. cocaine, ecstasy).
C. According to severity - By Denis R Bailey (1997)
• Mild Bruxism - not nightly + exhibits no dental injury
• Moderate severity - nightly + some psychosocial impairment
• Severe Bruxism - nightly + demonstrates evidence of dental injury, periodontal
breakdown, musculoskeletal pain, or temperomandibular disorders.
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D. By motor activity type:
• Tonic: Muscular contraction sustained for more than 2sec.
• Phasic: Brief, repeated contractions of the masticatory musculature with three
or more consecutive bursts of electromyographic activity that last between 0.25
- 2 sec apart.
• Combined: Alternating appearance of tonic and phasic episodes.
Approximately, 90% of the episodes of SB are phasic or combined, unlike in
AB, where episodes are predominantly tonic.
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E ETIOLOG
Y
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The etiology of bruxism is uncertain, but the hypotheses fall into four major
categories:
1. Local factors
BRUXISM is interpreted as an automatic reaction of the body to occlusal
interferences with the purpose of eliminating them by grinding.
In a 1961 study, Ramfjord found that “some kind of occlusal interference will
be found in every patient with bruxism.”
It has been my clinical experience that the signs and symptoms of bruxing
seems to disappear completely with careful elimination of all occlusal
interferences” - Peter. E. Dawson
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Malocclusion
Increase in physiologic intolerance
Increase in parafunctional activity > Structural Intolerance.
Breakdown.
2. Psychosocial factors
This includes anxiety, stress and characteristics of personality.
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3. Medications
Several medications that have been shown to elicit bruxism:
- Amphetamines
- L- dopa
- Neuroleptics/Antipsychotic agents which frequently cause
dyskinesias.
- Selective serotonin re-uptake inhibitors (SSRls),
- Recreational drugs (heroin, cocaine, ecstasy, marijuana, crack,
LSD, methadone).
4. Neurological factors
Some neurological pathologies may be associated with parafunctional oral
activity such as - Dyskinesias, Parkinson’s disease, and other extrapyramidal
disorders.
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S
SIGNS &
SYMPTOMS
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1. Abnormal tooth wear and occlusal trauma
2. Tongue on cheek indentation
3. Linea alba along the biting pane
4. Gum recession
5. Increase in muscle activity (this is recorded by the polysomnography)
6. Presence of masseter muscle hypertrophy on voluntary muscle
contraction.
7. Reduction of salivary flow
8. Breakage of fillings and/or teeth
9. Limitation of mouth-opening ability.
SIGNS
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1. Grinding of the teeth accompanied by a characteristics
sound that may even awaken the bruxers bed partner.
2. Headache (especially in the temporal zone when the patient
wakes up in the morning)
3. Pain, Clicking or locking of temporomandibular joint
4. Pain in the masticatory and cervical muscles
5. Tooth or teeth hypersensitive to cold air or liquid
6. Excessive tooth mobility
7. Poor sleep quality : tiredness.
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SYMPTOMS

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C
ASSESSMEN
T OF
BRUXISM
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Although bruxism is not a life-threatening disorder, it can influence the
quality of human life, especially through dental problems, such as tooth
wear, frequent fractures of dental restorations and pain in the oro-facial
region.
Hence its early assessment is very essential. Some of the methods to
assess bruxism are -
29DETECTION AND RECOGNITION OF BRUXISM, SAMUEL.S.NADLER, VOL 61, OCTOBER 1960.

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In Nadler’s paper, he details the examination for diagnosis of bruxism :
1. Do you grind, clench or click your teeth during the day or night?
2. Do your jaws feel tired when you get up in the morning?
3. Do you notice any bleeding when you awaken?
4. Do you have pain when opening or closing your mouth?
5. Do your jaws ever click or lock?
6. Do you ever have pain in front of your ears?
7. Do you have teeth that feel high or long? If yes, do you try to wear them down?
8. Do your jaws feel tired at the end of the day?
9. Do you grind, clench or click your teeth during sleep? Has anyone said that you do?
10.Are you wearing dentures or removable bridges ? If yes, are they comfortable ? Are
they loose ?
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A. Questionnaires
DETECTION AND RECOGNITION OF BRUXISM, SAMUEL.S.NADLER, VOL 61, OCTOBER 1960.

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1. Tooth Wear
Tooth-Wear Index is used to the rank persons with regard to incisal and
occlusal wear.
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B. CLINICAL EVALUATION
López-Frías FJ, Clinical measurement of tooth wear: Tooth Wear Indices. J Clin Exp Dent. 2012;4(1):e48-53.

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• Occlusal wear- shiny occlusal surfaces
• Antagonist pairs of facets can be matched - used to diagnose direction of
bruxism
• Hypersensitivity of teeth – dentin exposure.
2. Wear Facets of Intra-oral Appliance
• Even after adjustment of the splints, repetitive wear facets/pattern
reappeared on the occlusal splint in the same location with a similar
pattern and direction.Hence intra oral appliances may be used to detect
bruxism.
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A. POLYSOMNOGRAPHY (SLEEP LABORATORY)
1. This offers a highly controlled recording
environment wherein sleep disorders like sleep apnoea,
insomnia can be ruled out and sleep bruxism can be
discriminated from other orofacial activities (e.g. myoclonus, swallowing and coughing) that
occur during sleep.
2. Physiological changes related to sleep bruxism (e.g. micro arousal, tachycardia and
sleep-stage shift) can also be monitored.
INVESTIGATIO
NS
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B. Masticatory Muscle Electromyographic Recording
1. Sleep bruxism activity is assessed based on EMG activity in the
masticatory muscles (masseter and/ or temporalis).
2. Since 1970s, sleep bruxism episodes were measured at patient’s home with the
use of EMG recording devices which can measure masticatory muscle activity.
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3. Bite-Strip
• It’s a diagnosis-only device stuck to the masseter muscle at night.
• At the end of the night, it shows a bruxism severity level indicating how severe
the patient’s bruxism was that night (no bruxism, mild, moderate, severe).
• It is a disposable bruxism test and can be used for a single night only.
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2. Bruxoff : It is a diagnosis-only device which
includes EMG sensors and heart-rate
sensors.
3. Sleepguard : It is a headband which uses a
couple of electrodes to detect clenching
and uses an audio biofeedback signal.
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4. GrindCare V1 : The device consists of a base station with an LCD
screen, and a small wearable unit.
The feedback consists of a small electric shock which unconsciously
discourages the clenching action of the temporal muscle.
5. Grindcare V2 : Each time the patient grinds or clenches teeth, the
device transmits a mild electric impulse which stimulates a natural reflex
in the jaw muscles, relaxing them in order to reduce grinding without
disturbing sleep.
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6. Bruxane -
• It is a custom-built mouthguard with a built-in vibration
motor.
• A micro controller records the grinding activity.
• When the chewing pressure is applied, a vibration in the
palate area and a sound is generated which conditions
the patient's body subconsciously to stop the gnashing of
teeth.
• As soon as the chewing pressure subsides, the vibration
stops.
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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
One week 5mg diazepam given at bed time temporarily reduces bruxism.
RADIOGRAPHIC FINDINGS -
• Funnel-shaped widening of the periodontal space toward the alveolar crest
and around the apex - suggestive of bruxism.
• Increased mobility of the teeth - little or no evidence of periodontal disease.
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Others ways of confirming diagnosis of nocturnal bruxism

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T TREATMEN
T
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Approaches for management of bruxism are :
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DENTAL APPROACHES
BEHAVIOURAL & COGNITIVE
APPROACH TO ADDRESS
PSYCHOSOCIAL FACTORS
PHARMALOGICAL
APPROACH
Occlusal splint
appliances.
Biofeedback Orofacial pain management
Anterior bite planes
Arousal and overcorrection
procedures (operant conditioning).
Management of involuntary
orofacial movements
Occlusal therapy Suggestive hypnotherapy
Stress management

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A. Occlusal splints
• Indicated in patients who require protection of their teeth from the further damage, to reduce
tooth grinding sounds during sleep, or to manage orofacial pains.
• Treatment goals include:
• Constraining the bruxing pattern to avoid damage to the TMJs;
• Stabilising the occlusion by minimizing gradual changes to the positions of the teeth.
• avoiding tooth damage and revealing the extent and patterns of bruxism through
examination of the markings on the splint's surface.
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DENTAL APPROACH

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B. Anterior bite plane
• A repositioning splint is designed to change the
occlusion or bite of the patient.
C. NTI 2.0 Winged deprogrammer.
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D. Occlusal therapy
• As occlusal factors are not clearly stated as etiologic factor for sleep
bruxism, this treatment is not considered a first line approach in its
management.
• It is considered more appropriate if there are functional, post -
orthodontic, post -surgical, or post - restorative occlusal issues.
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A. Biofeedback
• It provides individuals with information about their bodily functions with the intention
of promoting changes in behaviour that result in improved health or performance.It
aims to generate a learned response that persists even after the technique is
discontinued.
• Electronically detected physiological measurements are coupled with a feedback
signal that is initiated when pre-specified criteria are met and terminated only when
the desired change in behaviour occurs.
• It has been reported to reduce Sleep bruxism but the effect does not persist after
withdrawal of the treatment.
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Behavioural and cognitive
approaches

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B. Arousal and overcorrection procedures (operant conditioning)
• Patients are awakened when they have bruxism episodes (arousal
procedure), and they are required to perform positive behaviours
(e.g., hand washing, brushing teeth) as an overcorrection.
• The combination of arousal and overcorrection procedures has
been suggested to be more effective than arousal procedures
alone.
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C. Suggestive hypnotherapy
• A hypnotherapist assists the patient into a state of hypnosis and then presents
with verbal suggestions and visualisations designed to help achieve any
desired positive changes; then that process is called Hypnotherapy.
• Patients are instructed to clench their teeth repeatedly until they feel
discomfort and then relax. In this way, patients recognise that cessation of
their habit releases jaw muscle fatigue and discomfort.
• It is reported to reduce masseter activity during sleep.
D. Stress management
• Stress management or changing a life style has been suggested if patients are
experiencing stress or anxiety.
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A. Orofacial pain management
• Benzodiazepines, central muscle relaxant,
anticonvulsants, beta blockers, dopamine agents,
antidepressants.
• Some types of physical medicine
(Transcutaneous electrical nerve stimulation,
acupuncture.) and alternative/naturopathic
medicine that are suggested.
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Pharmacologic approaches:

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B. Management of involuntary orofacial movements
• Injections of botulinum toxin A is an effective treatment.
• It is been reported to reduce masseter hypertrophy associated with
clenching and in the treatment of patients with bruxism related to
oromandibular movement disorders.
• Mechanism of action - Botox injections are used in bruxism on the
theory that a dilute solution of the toxin will partially paralyze the
muscles and lessen their ability to forcefully clench and while aiming
to retain enough muscular function to enable normal activities such
as talking and eating, grind the jaw.
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S
SUMMAR
Y
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Bruxism is a parafunctional oromotor habit which involves forcible clenching or
grinding of the teeth or a combination of both. It has a high prevalence in the
general population.
The signs and symptoms of bruxism are detectable, but unfortunately, exact
etiology of bruxism is still a controversy. It is considered to be multifactorial in
nature.
At present, there is no effective treatment to eliminate bruxism permanently.
Therefore, the therapeutic approach is steered towards attempting to prevent
damage and to treat the pathological effects of bruxism on the structures of the
masticatory system.
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R
REFERENCE
S
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• Glossary of Prosthodontic terms - 9.
• American Academy of Orofacial Pain: Guidelines for Assessment.
2008;22;190-200.1
• Farhanaz F et al. Psychosocial and bruxismInternational Journal of Health
Sciences & Research 437 Vol.6; Issue: 9; September 2016
• Persaud R, Garas G, Silva S, Stamatoglou C, Chatrath P, Patel K. An
evidence-based review of botulinum toxin (Botox) applications in non-cosmetic
head and neck conditions. JRSM Short Rep 2013;4:10.
• Shetty S, Pitti V, Satish Babu CL, Surendra Kumar GP, Deepthi BC. Bruxism:
A literature review. J Indian Prosthodont Soc 2010;10:141-8.
• Bader G, Lavigne G. Sleep bruxism; an overview of an oromandibular sleep
movement disorder. Review article. Sleep Med Rev 2000;4:27-43.
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• Bruxism and orofacial movements during sleep’ .Takafumi Kato et al DCNA - Sleep
Disorders, dentistry’s role Oct 2001
• ‘Sleep Bruxism : Validity of clinical research diagnostic criteria in a controlled
polysomnographic study’ GI Lavigne , Rompre. J D Research 75(1):546-552
• “Treating severe bruxism with botulinum toxin” Eng King Tang . JADA Vol 131
• “The Social and psychological factors of Bruxism” Gina Pictoris. J Prosthodent
1991;65:443-446
• Manfredini D, Epidemiology of bruxism in adults: a systematic review of the
literature. J Orofac Pain. 2013 Spring;27(2):99-110. doi: 10.11607/jop.921.
• DETECTION AND RECOGNITION OF BRUXISM, SAMUEL.S.NADLER, VOL 61,
OCTOBER 1960.
• López-Frías FJ, Clinical measurement of tooth wear: Tooth Wear Indices. J Clin Exp
Dent 2012;4(1):e48-53.
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55. THANK YOU