It describes about what are the complications of clenching teeth in sleep and also what are the various effect of that on face and other joints such as TMJ

1. BRUXISM AND ITS
MANAGEMENT
Prof. Dr.CHANDRASHEKHAR PATIL
Professor and HOD
Department of Orthodontics and Dento-facial
Orthopedics.
S.B.Patil Institute for Dental Sciences and Research.

2. DEFINITION
EPIDEMIOLOGY
ETIOLOGY
SYMPTOMS & SIGNS
MANAGEMENT

3. Historical perspective : gnashing of teeth has
been described in Bible. (Psalm 35:16,Psalm
112:10,Job 16:9).
Bruxomania – recorded in literature early in
twentieth century.
In 1931, dysfunctional mandibular movements
were described as bruxism, term mania was
removed, because the mandibular bruxist
behavior could not be related to
psychopathology.

4. DEFINITION
General – Forcible clenching or grinding of the
dentition or a combination of both.
American Academy of Orofacial Pain – Diurnal
or nocturnal parafunctional activity including
clenching,bracing,gnashing and grinding of
teeth.
American Sleep Disorders Association – Tooth
grinding or clenching during sleep plus one of
the following : tooth wear, sounds or jaw muscle
discomfort in absence of medical disorder.

5. EPIDEMIOLOGY
Highest in age group teen to forties.
Females > Males.
Self reporting during waking hrs – 20%.
During sleeping hrs – 10%.
Determination of actual prevalence is
difficult because this mandibular
parafunctional behavior is performed at a
subconscious level by most individuals.

6. ETIOLOGY
Cause is multifactorial and overlapping. Creates
difficulty for the practitioner in applying a
comprehensive ,effective management plan for
this mandibular parafunctional behavior.
1) Occlusal interferences – Assumption was that
the patient was making a subconscious attempt
at performing a self equilibration or adjustment
of his or her dentition to remove the occlusal
interference.
Not supported by more recent investigations.

7. 2) Periods of emotional or physical stress
– during times of concentration or
strenuous activities throughout the day,
individuals often occlude their teeth with a
concomitant application of force.
3) Sleep disorders.
4) Consumption of alcohol – aggravates it.
5) Disturbances of CNS.
6) Psychiatric medications

8. Why bruxism is a problem?
It has been stated that of all the functional
disorders of the dentition,bruxism is most
destructive.
Over time the complications of bruxism may
cause permanent damage to the teeth and
uncomfortable oral and facial pain. During sleep
the force of bruxing can be up to six times
greater than normal waking biting pressure,
approximately 250 pounds of force per square
inch, and last for up to 40 minutes per hour of
sleep.

9. The complications of bruxism include:
Damage to the teeth
Broken fillings and other dental work
Worsening of jaw joint problems
Limitation or difficulty in jaw opening and closing
Headaches
Tooth sensitivity
Tooth mobility

10. Signs ,Symptoms & Consequences
Sleep bruxism often exerts remarkably powerful
forces on teeth, gums, and joints. Almost ten
times — powerful enough to crack a walnut.
Why are these forces so high?
First, the bruxing activity is not under control of
the conscious, rational, brain, which might have
moderated or prevented the act from occurring.
Second, when one eats, the chewing force is
applied in part to the food, not to the teeth; but
when one bruxes, the entire force is applied
directly to the teeth.

11. Horizontal forces are applied instead of
normal vertical forces.
These horizontal forces which involve
mandibular eccentric movements are more
damaging to periodontium.
Bruxism usually associated with REM
stage of sleep.

12. 1) Chronic bruxism may lead to sensitive,
worn-out, decayed, fractured, loose, or
missing teeth .
Grinding or clenching break down the
enamel, sometimes, in long-term bruxers,
reducing teeth to stumps. Instead of a
white enamel cover, one often sees the
more yellowish and softer dentin. The
back teeth of some chronic bruxers often
lose their cusps and natural contours,
appearing instead flat, as if they had been
worked over with a file or sandpaper.

13. When anterior teeth are affected, their
biting surfaces are damaged. As well, the
absence of enamel makes it easier for
bacteria to penetrate the softer part of the
teeth and produce cavities. With time, the
condition may lead to bridges, crowns,
root canals, implants, partial dentures, and
even complete dentures.
Interproximal diastema & food impaction
can also result from severe wear of
posterior dentition.

16. As long as bruxism continues, the situation
keeps getting worse. Thus, "by 40 or 50 years of
age, most bruxers have worn their teeth to the
degree that extensive tooth restorations must be
performed" .
Implant complications are more likely in people
who habitually clench or grind their teeth. More
than 75% of observed implant fractures have
occurred in patients with signs and histories of
chronic bruxism.
Hence, in cases of untreatable severe bruxism,
the use of implants is strongly counterindicated
(Rangert et al., 1995.; reviewed by Nishimura et
al., 1997).

17. Long-term bruxism often causes changes of
appearance, in at least three different ways –
a) Damaged, worn-out teeth are not as
appealing as healthy teeth.
b) As the teeth wear out, they become shorter.
As a result, when the mouth is closed, the upper
and lower jaws are nearer than they used to be,
and so are the nose and chin. The skin now may
bag below the eyes and curl around the lips,
causing the lips to seemingly disappear . The
chin recedes, and the person looks
comparatively old.

19. C) Bruxism involves excessive muscle use,
leading to a build-up or enlargement
(hypertrophy) of facial muscles. Ex - Masseter.
In long-term bruxers, this build-up may lead to a
characteristic, square-jaw, appearance.
Some patients resort to removing part of the
masseter muscle by surgery or injections of toxic
materials to reduce muscle size and thus
partially regain their former, more aesthetically
pleasing, looks .

21. Long-term bruxers sometimes experience jaw
tenderness; jaw pain; fatigue of facial muscles;
headaches; neck aches; earaches; and hearing
loss.
Our body is not built to sustain, night in and night
out, the tremendous pressures of bruxing.
The teeth, as we have seen, are affected, but in
some cases other parts of the head suffer too.
We need to note, in passing, that such aches
and pains are a functional, healthy,
response. It’s the body's way of sending a
message: stop bruxing, or else!

22. Occasional inflammation and blockage of some
salivary glands.
Bruxism involves muscle overuse. In this case,
the masseter muscle become disproportionately
overdeveloped and block the opening of the
nearby parotid glands.
They thus interfere with the flow of saliva into
the mouth, causing the saliva to accumulate in
the glands. This in turn may lead to periodical
swelling, pain, inflammation, and abnormal
dryness of the mouth.

23. Damage the temporomandibular joint. Bruxism
is therefore believed by most researchers to be
one of the leading causes of temporomandibular
disorders . (Glaros, Tabacchi, & Glass, 1998;
Israel et al., 1999; Yustin et al., 1993).
First warning signs of TMDs are - TMJ
discomfort or pain, soreness of jaws and
muscles, clicking or popping sounds when
opening the jaws or while chewing, and
difficulties in fully opening the mouth.

24. If bruxism continues at this point, these
symptoms become more severe. TMDs
are often associated with chronic pain
which may last months or years.
A sufferer may wake up, for example,
totally unable to open the mouth. Or the
jaw may suddenly lock or dislocate during
chewing.
Eventually, a difficult surgery of uncertain
efficacy may be required .

25. Malocclusion, or bad bite, is more common
among bruxers than in the general population.
Misaligned teeth may serve as the cause of
bruxism, not as its consequence.
Bruxism may often involve more pressure on one
side of the mouth than on the other, thereby
causing malocclusion.
As well, as the teeth wear out and the distance
between the upper and lower jaws decreases,
over closure may develop - when bruxers close
their mouth the front upper teeth do not meet the
front lower teeth, but get in front of them.

26. Apart from wide belief studies have
showed that occlusal contact pattern does
not influence nocturnal bruxism.
Rugh et al – Placed high crown
deliberately in 10 subjects, most of
subjects had a significant reduction in
bruxism during first 2 to 4 nights followed
by return to normal bruxing levels.
A high posterior occlusal contact does not
necessarily increase muscle activity.

27. Explanation – On contact with poorly fit
crown, significant painful
peripheral input inhibit CNS
induced bruxing activity.
As the patient accommodates to the tooth
movement & tooth sensation decreases,
bruxing resumes.
This inhibitory effect is the mechanism by
which occlusal appliance therapy
decreases bruxism.

28. There is some evidence of higher levels of
mercury in the blood of some bruxers with
mercury fillings .
Indentations of the lateral borders of tongue.
Grinders find themselves in a more
uncomfortable position, for many people find the
grinding sound unpleasant, irritating, or
disturbing . It may wake up light sleepers, for
instance, and keep them awake for a long time.

29. Excessive forces can be generated for
extended periods of time that exceed
approx. 20 min. of functional tooth
contacts, during 24 hr. period
Average working force for a natural tooth
– 175 psi.
Nocturnal bruxist activity – increase to
300 psi.
Reported cases of 100,000 to 175000 psi.

30. Average of 25 bruxist episodes/night.
Each episode with durtion of 8 – 9 sec.,
but can go up to 5 min.
Total average bruxing time/sleeping period
– 42 sec.
One case have been reported of 162 min.

31. MANAGEMENT
Objectives include –
a) Reduction of psychological stress.
b) Treatment of signs & symptoms of mandibular
parafunction.
c) Reduction of occlusal irritations.
d) Cessation of patterns of neuromuscular habits.

32. Reduction of
psychological stress –
Stress management
program can be short or
long term management
strategy, include
biofeedback counseling,
hypnosis,
progressive relaxation,
and
occupational & lifestyle
changes.

33. Occlusal adjustment is indicated only when there
is an obvious deflective interference during
mandibular excursions, such as supererupted
mandibular 2nd molar during a protrusive function
of the mandible.
But, to begin with, the role of malocclusion in
causing bruxism is in doubt. Also, this technique
is irreversible, for it involves the grinding down of
some teeth (and artificially restoring others).

34. Even if malocclusion triggered the bruxing
habit, there are no guarantees that its
removal will eliminate or decrease bruxing,
for by now the habit may have become
entrenched and self-sustaining.
“No reliable evidence has demonstrated
that occlusal interference can cause
nocturnal bruxism, or stop it, if the
naturally occurring interferences are
removed" (Clark et al., 1999).

35. SPLINT THERAPY
Defined as the art & science of establishing
neuromuscular harmony in masticatory system &
creating a mechanical disadvantage for
parafunctional forces.
Properly constructed – Supports a harmonious
relation among muscles of mastication, disk
assemblies, joints, ligaments, bones, teeth &
tendons.

36. Functions –
1) To relax muscles.
2) To allow condyle to seat in CR.
3) To provide diagnostic information.
4) To protect teeth & associated structures
from bruxism.
5) To mitigate periodontal ligament
proprioception.
6) To reduce cellular hypoxia levels.

37. Can be classified as –
a) Permissive – Allows the teeth to move on
splint unimpeded, which in turn allows the
condylar head & disk to function anatomically.
Ex – bite planes, stabilization splints.
b) Non permissive – is a repositioning splint. Ex
– Anterior repositioning appliance.
c) Pseudo permissive – Soft splints, hydrostatic
splints.

38. Stabilization or muscle relaxation splint –
provides stabilization of TMJ, protection of
dentition, redistribution of occlusal forces,
relaxation of elevator masticatory muscles,
decrease in symptoms,reduction of bruxism.
Design – Full arch , acrylic resin, flat plane, can
be fabricated for maxillary or mandibular arch.
Mandibular is advantageous from perspective of
aesthetics & phonetics.
Worn during sleeping hrs, may be necessary
during waking hrs especially in acute cases.

41. Anterior Repositioning Appliance
Fabricated from hard
acrylic.
Can be worn only on
maxillary teeth, its
only occlusal contacts
are with the
mandibular anterior
teeth.

42. Purpose – to allow for disclusion of the
posterior teeth at all times.
Effective for management of bruxism with
symptoms of myofascial pain that are
directly contributory to the parafunctional
behavior.
Anterior bite plate reduces temporal
muscle activity during deglutition in
patients with tmj dysfunction.

43. Because of the possibility of supraeruption
of posterior teeth, with continuous
wearing, it is worn only during sleeping
hrs, when parafunctional habits are most
likely.
Patient’s occlusion should be monitored
closely.

44. Hydrostatic splint - a water-bearing pressure-
equalizing appliance sold under the commercial
name "Aqualizer" and manufactured by Jumar
Corp., Arizona .
This prefabricated splint does not require dental
impressions or the manufacture of customized
appliances. Instead, this disposable splint can
be purchased through a dentist, ready-made for
use, and is claimed to fit the mouths of most
users.

46. Regarding material of fabrication – Hard splint is
more likely to be successful than a soft type
splint..
Soft material is not as effective in reducing
myofascial pain symptoms as hard acrylic.
It can contribute to inadvertent tooth movement
& occlusal changes, more difficult to adjust.
Indicated – emergency situation like acute
retrodiscitis, also as athletic mouthguard.

47. Okeson (1982) found that acute or chronic
symptoms of muscle hyperactivity were
lessened signif. with a 24 hr. splint wear.
Rugh et al (1989) compared a canine versus
molar guidance appliance in eight chronic
bruxist patients. The appliances were used for
10 to 14 nights. The two appliances provided
nearly equivalent effects on nocturnal bruxism in
seven of eight subjects. Clinical examination and
subjective pain ratings did not differ with the two
guidance patterns.

48. Long-term reductions in symptoms of bruxism
were noted even in patients who wore the splint
for six months (Sheikholeslam, Holmgren, and
Riise, 1986).
Occlusal splints worn at night did not
significantly reduce bruxing-clenching activity in
bruxing subjects" (Kydd and Daly, 1985).
Pierce and Gale (1988) found that bruxing
decreased by about 50% during two weeks of
splint therapy, but that, following withdrawal of
treatment, it returned to baseline levels.

49. Klineberg (1994) concludes that occlusal
splints "will protect the teeth, but will not
alter the habit in the long term’’.
Complications – Occlusal derangement
Decay – caries, gingival
inflammation,
Degenerative joint disease.

51. Thus, the splint may or not stop bruxism
for a while, it partially protects the teeth,
and it moderates grinding sounds.

52. Alternative methods
Wakeful EMG Feedback - increased activity or tenseness can
in turn be measured with an electromyograph .
During treatment sessions at home or the laboratory, the patient sits
or reclines comfortably. One or more pairs of recording electrodes
are then attached to the surface of the skin, in close contact to
appropriate muscles (e.g., masseter muscles).
These electrodes transmit information about the level of muscle
activity to a computer monitor. The patient is instructed to
consciously lower that level below a threshold line (also visible on
the screen). Gradually, by becoming alert to the presence of muscle
tension, patients may develop techniques for reducing that tension,
and hence, bruxism.

53. Massed Negative Practice - Here the patient is told to
voluntarily clench the jaw for five seconds, relax it for five
seconds, and repeat this procedure five times in
succession, six different times a day, for two weeks.
Alternatively, the duration of the clenching period may be
individually tailored to each patient, with each clench
continuing to the point of discomfort .
Exercise - Quinn (1995) and many others suggest
isokinetic and stretching exercises of the mandible. Such
exercises may or may not help alleviate bruxism, and
they may perhaps be used to complement other
approaches

54. Drugs - Use of anti-anxiety agents, muscle
relaxers, and other drugs .
Sleep Feedback - Sleep feedback may involve
electromyographic activated alarms.
The electrodes of this instrument are placed on
the facial area where muscles are located.
When the tenseness in muscles due to bruxism
exceeds a certain, predetermined, level, the
alarm goes off.

55. The patient is advised to fully wake up after each bruxing
episode and to stay awake for a few minutes, usually by
performing such meaningless, harmless tasks as hand
washing or recording time in a bruxism log .
This procedure may fail to correct any bruxing behavior
which is associated with muscle tension lower than the
predetermined intensity or duration threshold.
Another obvious problem is that muscle tension may
occur in the absence of bruxism: "numerous other types
of orofacial movements unrelated to bruxism . . . can
easily be confused with bruxism if only EMG criteria are
used for scoring" .

56. To bypass this problem, many United
States patents rely on an alarm system,
but take the more reliable bruxing activity
itself (instead of enhanced muscle activity)
as their point of departure .
A commercially available new device, the
OralSensor, manufactured by Cycura
Corp. of Rocklin, CA, similarly produces
an audible tone when bruxism occurs.

58. Taste-Based Approach to the
Prevention of Bruxism
Intraoral release of an unpleasant-tasting, safe,
substance whenever a patient attempts to brux,
thereby drawing the patient's conscious attention
to, and precluding, teeth clenching or grinding.
Following initial consultation with a bruxing
patient, dental impressions of both lower and
upper teeth are taken.
The impressions are sent to a lab, where an
appropriate removable dental appliance is
constructed

60. A dental appliance equipped with posterior rods (22) to
which a capsule can be attached, a curl (26) in one
posterior rod to prevent slippage of capsule, hinges
(30) to secure the appliance to the teeth, and anterior
connection (34) of the two sides to preclude mobility or
swallowing of the appliance

61. The substance is derived from one or more
natural or synthetic, palatable, materials such as
hot peppers (capsaicinoids), horseradish,
quinine, mustard, ginger, garlic, onion, salt, or
denatonium benzoate.
The aversive substance is dissolved or
suspended in water, vinegar, or other safe,
digestible, barely-compressible, fluids.

64. The liquid is then inserted into, and sealed in, the
sleeved capsules, so that each capsule contains little or
no air. At its center, the liquid is high enough (roughly 4
mm) to rupture the capsule when the user clenches or
grinds, but is not so high as to seriously inconvenience
the user or prevent lip contact.
The capsule only bursts when the user attempts to bring
the maxillary and mandibular teeth together, but not
upon mere tooth contact. Experience suggests that such
capsules contain enough liquid to reach many taste
buds, but not enough to cause any discomfort other than
the one associated with unpleasant taste.

65. CONCLUSION
The practitioner needs to distinguish the
wear patterns caused by abrasion during
normal mastication or oral habits with
those caused by bruxism.
Patient should be made to understand
that, there is no cure for bruxism, instead
the condition needs to be managed.

66. REFERENCES
1) Ronald Attanasio : An overview of bruxism
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241.
2) Arnold M : Bruxism and the occlusion. DCNA,
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3) Glaros AG, Rao SM : Effects of bruxism.A
review of literature. J Prosthetic Dent,1977,38;
149 -157.
4) Kydd, W. L. and Daly, C : Duration of
Nocturnal tooth contacts during bruxing. Journal
of Prosthetic Dentistry, 1985, 53(5): 717-721.

67. 5) Pierce, C. J. & Gale, E. N : A comparison of different
treatments for nocturnal bruxism. JDR, 1988, 67; 597-
601.
6) Ramfjord, S. P. : Bruxism, a clinical and
electromyographic study. JADA, 1961 2; 21-44.
7) Rugh, J. D., Graham, G. S., Smith, J. C., & Ohrbach,
R. K. : Effects of canine versus molar occlusal splint
guidance on nocturnal bruxism and craniomandibular
symptomatology. Journal of Craniomandibular Disorders,
1989 3; 203-210.
8) Okeson JP, Kemper JT, Moody TM : A study of use of
occlusal splints in treatment of acute & chronic patients
with craniomandibular disorders. J Prosthetic Dentistry,
1982,48; 708 -712.

68. 9) Tim J.Dylina : A common sense
approach to splint therapy. J Prosthetic
Dent,2001,86; 539 – 545.
10) Jeffery P Okeson : Management of
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Occlusion. 3rd edtn, Mosby, St.Louis; Pg-
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