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Sleep Bruxism_Final
- 2. Sleep Bruxism
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• Sleep Bruxism is no longer considered a
parasomnia
• Bruxism is considered to be primarily a sleep
related movement disorder with yet to be
determined multifactorial etiology involving
multisystem physiological processes
- 3. Classification of Bruxism
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Bruxism can be divided into two distinct entities
◦ Awake
◦ Sleep bruxism
- 4. Sleep Bruxism
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• Sleep Bruxism is no longer simply related to
mechanistic factors such as occlusal
discrepancies, or psychological issues such as
stress, anxiety or depression
• Sleep Bruxism is considered to be primarily a
sleep related movement disorder with a yet to be
discerned multifactorial etiology
- 5. Sleep Bruxism Definitions (AASM)
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• 1990 (ICSD) “Sleep Bruxism is a stereotyped
movement disorder characterized by grinding and
clenching of the teeth.
• 2005 (ICSD) “Sleep Bruxism is defined as oral para
functional activity characterized by tooth grinding or
jaw clenching during sleep usually associated with
sleep arousals.
• Third Edition (ICSD) “Sleep Bruxism a repetitive jaw
muscle activity characterized by clenching and
grinding of the teeth and/or by bracing and thrusting
of the mandible.”
• Sleep related bruxism. In: International classification of sleep disorders. 3rd ed. Darien, IL.: American Academy of Sleep
Medicine; 2014.
- 6. Bruxism Classification
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• Primary Bruxism
• Idiopathic Bruxism (no known cause)
• Secondary Bruxism which is related to socio-
psychological or medical condition (movement or
sleep disorder including PLMS, rhythmic moving
disorders such as head banging, sleep disordered
breathing due to upper airway resistance or
apnea hypopnea events)
- 7. Diagnostic Grading System for
Sleep and Wake Bruxism
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Possible – Based on self report using a
questionnaire and/or the anamnestic part of clinical
exam.
Probable – Based on self report plus the inspection
report of the clinical examination.
Definite – Based on self report, a clinical
examination, a polysomnographic recording
preferably containing audio/visual recordings or a
medical grade sleep bruxism monitor.
- 8. Diagnostic Criteria for
Sleep Related Bruxism (ICSD third edition)
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• Presence of regular or frequent tooth grinding
sounds occurring during sleep
• Presence of one or more of the following clinical
signs
◦ Abnormal tooth wear consistent with above reports of
tooth grinding during sleep
◦ Transient morning jaw muscle pain or fatigue; and/or
temporal headache; and/or jaw locking on awakening
consistent with the above reports of tooth grinding during
sleep
- 9. Tooth Wear as a Diagnosis of
Sleep Bruxism
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• Causes of tooth wear
◦ Oral habits
◦ Food consistency
◦ Acid Reflux
• Occlusal attrition does not reliably confirm sleep
bruxism without report of tooth grinding as
witnessed by a bed partner.
• Tooth wear is present in 100% of sleep Bruxism
patients it also occurred in 40% of asymptomatic
individuals.
- 10. Scoring Rules for Sleep Bruxism
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• EMG, 10-100 Hz band-pass filtered, AASM 2007
criteria
◦ Bruxism may consist if the chin EMG activities are at least
twice the amplitude of the background EMG.
◦ Calculation of Bruxism Episodes Index or BEI calculates all
bruxism events per hour of sleep
◦ Types of bruxism episodes:
• PHASIC: at least 3 EMG bursts lasting ≥ 0.25 seconds and < 2
seconds
• TONIC: 1 EMG burst lasting > 2 seconds
• MIXED : phasic and tonic bursts
Note: EMG bursts must not be separated by > 3 seconds to
be considered part of the same episode.
- 11. Medical Grade Sleep Bruxism Monitor
Nox T3 by CareFusion
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- 12. © 2015 CareFusion Corporation or one of its subsidiaries. All rights reserved.
• Sounds
◦ Teeth grinding and exclusion of other oro-facial activities
by listening.
◦ Additionally autonomic arousals can be marked in the
following manner:
• Mark spontaneous arousals if the pulse wave amplitude (PWA)
drops by 30% or more in a 20 second period before Rhythmic
Masticatory Muscle Activity (RMMA).
Scoring Rules for Sleep Bruxism
- 13. Bruxism Episodes Index - BEI
• Bruxism episode index: number of episodes per
hour of sleep (phasic, tonic and mixed)
• Bruxism burst index: number of EMG bursts per
hour of sleep
• Apnea to bruxism index: number of episodes per
hour of sleep (phasic, tonic and mixed) where
apnea is scored after each episode of bruxism.
• Arousal to bruxism index: number of episodes per
hour of sleep (phasic, tonic and mixed) where
arousal is scored after each episode of bruxism.
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- 14. Placing the EMG Leads on a patient
Option 1
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- 15. © 2015 CareFusion Corporation or one of its subsidiaries. All rights reserved.
Placing the EMG Leads on a patient
Option 2
- 16. © 2015 CareFusion Corporation or one of its subsidiaries. All rights reserved.
Placing the EMG Leads on a patient
Option 3
- 17. Examples of Nox T3 EMG
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- 18. Examples of Nox T3 EMG
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- 19. Bruxism Report from Nox T3
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- 20. Stress and Psychological Factors
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• Sleep Bruxism cases are more likely to deny the
impact of life events because of coping style or
personality.
• EMG activity increased during sleep following
days with emotional or physical stressors.
• PSG studies report no association between sleep
bruxism and anxiety or depression however the
link with insomnia exists.
- 21. Current Hypotheses
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• Bruxism-RMMA episodes occur during transient (3-
10s) arousal associated with brain and cardiac activity
as shown by a rapid increase in heart rate at the onset
of RMMA during frequent micro arousal episodes.
• Micro arousals are natural activities during sleep that
consist of a repetitive rise in heart rate, muscle tone
and brain activity 8-15 times/hr of sleep.
• Most sleep bruxism episodes are observed during light
non REM sleep
• 10% of episodes occur during REM sleep in association
with sleep arousal
- 22. Role of Respiration in
Sleep Bruxism
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• Respiration in Sleep Bruxism is not well
understood however it may play a role in some
patients.
• RMMA tends to occur with large breaths and oral
appliances used to improve airway patency help
to reduce bruxism-RMMA frequency.
• Direct cause and effect relationship between
breathing disorders and sleep bruxism cannot be
assumed.
- 23. Treatment
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• Sleep Bruxism can be managed through behavioral
strategies including risk factor avoidance (smoking,
alcohol and drugs).
• Patient education, relaxation and sleep hygiene.
• Biofeedback aimed at reducing EMG activity in the
temporalis without disrupting sleep shows promise.
• Occlusal appliances to remove occlusal interference,
protect dentition and relax masticatory muscles are in
routine clinical use however no evidence supports their
role in stopping sleep bruxism.
◦ 20% of patients report an increase in EMG activity during sleep
when they wear an occlusal appliance especially the soft mouth
guard type.
- 24. References
• Journal of Canadian Dental Association 2015;81f2
◦ http://www.jcda.ca.php5-9.dfw1-
2.websitetestlink.com/article/f2
• Sleep Bruxism Customer Support Document –
Nox Medical
◦ 22-Sleep Bruxism.pdf
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