3. INTRODUCTION
• Derived from the Greek word “brychein” bruxism means tooth
grinding.
• The term first introduced in 1931, to describe involuntary,
excessive grinding, clenching, or rubbing of the teeth during
nonfunctional movements of the masticatory system.
• It refers to movements of the jaws that are outside of the normal
functional activity of the teeth and jaws (eg, speaking, chewing,
or swallowing).
• cannot be considered habit because almost all the times there is a
definite underlying etiologic factor e.g. occlusal discrepancies.
But if habitual grinding continues even after removal of
causative factor, then it can be considered as habit.
4. • In children, bruxing when awake, which manifests as clenching
of the teeth, often occurs without any cognitive awareness,
especially during stressful situations or intense concentration.
When the child is made aware of the activity, the bruxism can be
stopped or modified.
• On the other hand, sleep bruxism, which presents as grinding or
clenching of the teeth during sleep, cannot be consciously
stopped by the child.
• The International Classification of Sleep Disorders
reclassified bruxism in 2005 as a sleep-related movement
disorder, rather than its previous classification as a parasomnia,
which is an undesirable movement occurring during sleep.
5. DEFINITIONS
• Ramfjord (1966) - Defined bruxism as a habitual
grinding of teeth where individual is not chewing or
swallowing.
• Rubina (1986) - Defined the term bruxism to indicate
nonfunctional contact of teeth which may include
clenching, gnashing, grinding and tapping of teeth.
• Vanderas (1995) - Defined bruxism as non-functional
movement of mandible with or without an audible sound
occurring during day or night.
6. TYPES:
Day time /Diurnal bruxism: It is the conscious or
subconscious grinding of teeth usually during the day. It
can occur along with parafunctional habits such as
chewing pencils, nails, cheeks and lips. It is usually
silent except patients with an organic brain disease.
Nocturnal bruxism: It is the subconscious grinding of
teeth characterized by rhythmic patterns of masseter
EMG activity.
7. PREVALENCE
• The prevalence of bruxism in children is difficult to determine
because estimates are generally based on parental reporting or
clinical finding of tooth wear. The occurrence of bruxism may be
variable over time, so finding tooth wear is not necessarily
indicative of current tooth grinding.
• The prevalence of bruxism in children varies greatly—from 7%
to 88%. Children younger than 11 years are most affected with a
reported prevalence of 14% to 20%. (Prevalence of bruxism and
associated correlates in children as reported by parents. J Dent Child (Chic).
2005;72:67-73.)
8. • Bruxism may commence in infancy with the eruption of first primary
tooth. In healthy infants, sleep bruxism typically starts at about 1
year, soon after the eruption of the primary incisors.
• Infants with no teeth to oppose the newly erupted teeth have been
seen to lacerate the opposing gumpad. Bruxism may occur throughout
life; mostly seen to increase through the mixed dentition period and
then decreases later with age.
• Bruxism can occur at any stage of sleep; mostly during the transition
from a deeper stage to a lighter stage of sleep. It is also reported to
occur during the rapid eye movement stage, and is most damaging.
9. • Bruxism appears in approximately 13% of 18- to 29-
year-olds and then significantly decreases with age
(see Table ).
10. • The research is not definitive on the role of gender and
the prevalence of bruxism. While some studies indicate
there is no significant gender effect on the prevalence of
bruxism, others report that girls are more frequently
affected. (Temporomandibular disorders and bruxism in childhood and
adolescence: Review of the literature. Int J Pediatr Otorhinolaryngol.
2008;72:299-314)
• The role of genetics in bruxism is also unclear, however,
an association appears to exist between child and
parental bruxism. Based on self-reports, 20% to 50% of
sleep bruxism patients have an immediate family
member who experienced tooth grinding in childhood
(Bruxism physiology and pathology: an overview for clinicians. J Oral
Rehabil.2008;35:476-494.)
11. ETIOLOGY
• The etiology of bruxism is a controversial phenomenon, but the consensus
is that it is multifactorial.
• Basically two groups of etiological factors can be distinguished: peripheral
(morphological factors), and central (pathophysiological and
psychological) factors.
• Morphological factors include occlusal discrepancies and anomalies of
articulation of the orofacial region, however, research shows the
elimination of interferences in occlusion and articulation has no influence
on bruxism activities.
• Moreover, experimentally-placed deflective occlusal contacts do not seem
to elicit bruxism. Therefore, not every child with bruxism has occlusal
interferences, and not all children with such interferences have
bruxism.
12. • It is often difficult to determine in children whether tooth
attrition is due to bruxism because the occlusal surfaces of
primary teeth become ground physiologically.
• One theory about how bruxism starts in children is the
occlusion instability created during the replacement of the
primary teeth by the permanent dentition.
• Studies, however, have failed to show a significant role of
occlusal discrepancies in the genesis of sleep bruxism with
no evidence for a role of occlusion and articulation in its
etiology.( Lobbezoo F, Naeije M. Bruxism is mainly regulated
centrally, not peripherally. J Oral Rehabil. 2001;28:1085-1091)
13. Bruxism and Sleep
• Pathophysiological factors are believed to play a role in the
precipitation of bruxism. In younger children, bruxism may be
due to the immaturity of the masticatory neuromuscular system.
• Current thinking is that bruxism is part of an arousal response.
An arousal response is a sudden change in the depth of sleep
during which a person either arrives at a stage of lighter sleep or
wakes up. In young adults, more than 80% of sleep bruxism
episodes occur during sleep stages 1 and 2 of nonREM (light
sleep stages), and 5% to 10% in REM (deep stages). Many
bruxism episodes lead to a shift in sleep stage, usually toward
awakening or lighter sleep.[Bruxism physiology and pathology: an
overview for clinicians. J Oral Rehabil. 2008;35:476-494.]
14. • There appears to be a relationship with the autonomic nervous
system in that there is increased cortical and autonomic cardiac
activity preceding bruxism activity.
• The involvement of the dopaminergic system may play a role in
sleep bruxism, but this idea remains controversial.
• Hyperactivity is associated with bruxism and the amphetamines
used for managing attention deficit hyperactivity disorder can
also cause bruxism. (Temporomandibular disorders and bruxism in
childhood and adolescence: Review of the literature. Int J Pediatr
Otorhinolaryngol. 2008;72:299-314.)
15. Respiratory Factor
• Bruxism and habitual snoring are closely related. Sleep bruxism is
also a frequent complaint of parents of children who are mouth
breathers.
• One theory suggests there is a correlation between bruxism and upper
airway obstruction, with obstructive sleep apnea causing sleep
bruxism. Bruxism does appear to be more prevalent when sleeping in
a supine position, which correlates with a greater possibility of
airway obstruction.
• A link has also been made between bruxism and tonsillar
hypertrophy, which is strongly correlated to upper airway
obstruction. Adenotonsillectomy surgery has been shown to improve
bruxism in some children. Bruxism may also be caused by allergic
processes such as asthma and respiratory airway infection.
16. Other Pathophysiological Factors
• Pathophysiological factors implicated in bruxism among
adolescents include smoking, alcohol, illicit drugs, trauma,
disease, and medication. In addition, a host of diseases among
children have been linked to bruxism such as basal ganglia
infarction, cerebral palsy, Down syndrome, epilepsy, Leigh
disease, meningococcal septicemia, multiple system atrophy,
gastroesophageal reflux, and Rett syndrome.
17. Psychological Factors
• Stress and personality have been implicated in the etiology of
bruxism. Bruxism, either clenching while awake or grinding
during sleep, is associated with stress and anxiety. The exact
mechanism by which these and other psychological factors
contribute to the etiology of bruxism is still unknown.
Emotionally stressful states are often manifested physiologically
by an increase in the endogenous release of catecholamines
(epinephrine, norepinephrine, and dopamine). Patients with
bruxism have elevated levels of catecholamines in their urine in
comparison to patients without bruxism. But the majority of data
about the association between psychosocial disorders and
bruxism come from studies that use clinical or self-reporting to
achieve their diagnosis as opposed to sleep laboratory
investigations.
18. • One report studied bruxism as it relates to other factors such as
aggression and somatization (the process by which psychological
distress is expressed as physical symptoms). The report indicated that
an increased amount of aggression and somatization can already be
found in bruxing 5- and 6-year-olds. A study by Restrepo et al(Effects
of psychological techniques on bruxism in children with primary teeth.
JOralRehabil.2001;28:354-360.)
investigated the effectiveness of psychological techniques in children
with bruxism. They used different psychological techniques including
directed muscle relaxation for 6 months in children age 3 years to 6
years who had a history of bruxism. They found that the
psychological techniques used were effective in the reduction of signs
of bruxism in children with primary teeth.
19. • A case report by Antonio et al described two cases of children who
had tooth wear attributed to bruxism. In both cases, the condition was
believed to be triggered by psychological disturbances resulting from
harrowing experiences. Based on the emotional problems of the
children, they were referred for psychological monitoring.
• Bruxism is found in those who suffer from post-traumatic stress
disorder, further suggesting that a psychological etiology may be
involved. A recent systematic review by Manfredini et al (Role
of psychosocial factors in the etiology of bruxism. J Orofac Pain.
2009;23:153-166).
concluded that while wake clenching seems to be associated with
psychological factors and a number of psychopathological
symptoms, there was no evidence to support that these factors
were implicated in sleep bruxism.
20. Table . Symptoms of bruxism.
•Anxiety, stress, and tension
•Depression
•Earache
•Eating disorders
•Headache
•Hot, cold, or sweet sensitivity in the
teeth
•Insomnia
•Sore or painful jaw
21. DIAGNOSIS
• History is very important. Patient is asked about muscular
tenderness in morning. Occasionally patient may not be aware of
habit if only nocturnal bruxism in present. In those cases parents
may provide information regarding habit.
• Examination: Typical wear facets on occlusal table are evident.
By using articulating paper, underlying occlusal disharmony
may be find out.
22. MANIFESTATION
• The signs and symptoms of bruxism depend on:
• Frequency of bruxing
• Intensity
• Age of patient associated with duration of habit.
23. CLINICAL FEATURES
• 1) Occlusal trauma: Resulting in mobility (more in the
mornings).
• 2) Tooth structure: Results in nonfunctional occlusal wear;
sensitivity; atypical shiny wear facet with sharp edges; Pulpal
exposure; # crown, restoration.
• 3) Muscular tenderness: Lateral pterygoid, masseter on
palpation; fatigue on waking, hypertrophy of masseter.
• 4) TMJ disturbances: Crepitation, clicking, restriction of
mandible movement; deviation of chin; pain ( dull , unilateral ).
24.
25. • 5) Headache : Muscular contraction type.
• 6) Other signs and symptoms: Sounds-(grinding and
tapping);soft tissue trauma ; small ulceration or ridging
on buccal mucosa opposite the molar teeth.
26. TREATMENT
• Occlusal splints and occlusal adjustments are usually
sufficient to correct habit. Occlusal splints are indicated to
reprogramme the existing muscular pattern. Soft splints are
advisable with flat occlusal surfaces so that mandibular
movements will be free in all planes which breaks the reflex
response of muscles established during habit.
28. • Relaxing training
• Tensing and relaxing exercise
• Voluntary relaxation
• Hypnosis
• Behavior Conditioning
• Drugs
• Placebo
• Vapo coolants – Ethyl chloride for pain -TMJ
• Local anesthetics - TMJ
• Tranquilizers, sedatives, muscle relaxants
• Diazepam – Anxiety and alteration of sleep arousal*/
• Tricyclic antidepressants
• Biofeedback
• Positive feedback for Learning of tension reduction
29. • Electrical method
• Electro galvanic stimulation
• Acupuncture
• Muscle relaxation
• Orthodontic correction
• Class II, III, Ant. Openbite, Crossbite.
30. • Bruxism in children with nasal obstruction: International
Journal of Pediatric Otorhinolaryngology (2008) 72:391-
396.
• The objective of the study was to investigate the occurrence of bruxism in
children with nasal obstruction and to determine its association with other
factors. Sixty children with nasal obstruction seen at the
Otorhinolaryngology Outpatient Clinic of the University Hospital of
Ribeira˜o Preto participated in the study.
• The participants were divided into two groups: group with bruxism (GB) as
reported by the relatives and with the presence of tooth wear detected by
clinical evaluation, and group without bruxism (GWB), consisting of
children with none of the two symptoms of bruxism mentioned above
• It was concluded that Bruxism and deleterious oral habits such as biting
behavior (objects, lips and nails) were significantly present, together with
the absence of suction habits, in the children with nasal obstruction.
31. Therapies most frequently used for the management of
bruxism by a sample of German dentists: Journal of Prosthet
Dent (2011)105:194-202
• The purpose of study was to determine the most commonly applied
therapies used for the management of bruxism by German general dentists
(GDs) and dental specialists.
• A 13-item questionnaire was developed and mailed to all active members
of the statutory dental insurance providers of the German North Rhine and
the German Westphalia-Lippe area.
• Results showed that Occlusal splints were by far the most frequently
prescribed therapy for the management of bruxism, followed by relaxation
techniques, occlusal equilibration, physiotherapy, and prosthodontics
reconstruction.
32. LIP HABITS
Normal lip anatomy and function are important for
speaking, eating and maintaining a balanced
occlusion. Lip habit may involve either of lips but
predominantly lower lip is involved.
33. • DEFINITION:
• Lip habit may be defined as those habits that involve
manipulation of lip/ lips and perioral structures.
• Types of lip habits:
• Two types of lip habits
• - wetting the lips with tongue
• pulling the lips into mouth between the teeth (Schneider 1982)
34. ETIOLOGY
• Malocclusion.-In angle’s Class II division I with a large overbite
and overjet, the habit develops when the child wants to produce a
normal lip seal during swallowing by placing the lower lip
posterior to the maxillary incisors.
• Habits-can occur in conjunction with other habits such as thumb/
digit sucking habit. The digit habit may result in a large overbite
and overjet situation and again the child will attempt to create an
oral seal by placing the mandibular lip directly behind the
maxillary incisors.
• Emotional Stress –This may increase the intensity and duration
of lip sucking. Children in such situations have an increased
salivary output, thus increasing the number of swallows and lip
seals required. occasionally, this habit becomes a compulsive and
gratificational activity during sleeping hours.
35. MANIFESTATION
• Protrusion of maxillary incisors and retrusion of mandibular incisors.
• Lip sucking can be recognized by reddened, irritated and chapped
area below the vermilion border. In some cases, a chronic herpes
infection with areas of irritation and cracking of the lip appear.
• The mentolabial sulcus becomes accentuated.
• Lip sucking and lip biting can maintain an existing malocclusion.
36. TREATMENT
• The lip habit is not self-correcting and may become more deleterious with
age ,because of
• muscular forces interacting with the child’s growth. Treatment of a lip
sucking habit should be
• directed initially towards the etiology of the habit.
Correction of malocclusion:
• In case of CLASS II division I malocclusion or an excessive overjet
problem, the abnormal lip activity may be adaptive to the dentoalveolar
morhology.in such cases, it is deemed wise to correct the malocclusion
before going on to break the habit/
CLASS I malocclusion with increased overjet-fixed or removable appliance
to tip the teeth back.
CLASS II –growth modification procedures to treat the malocclusion.
37. • Treating the Primary habit:
• Can be corrected by aligning the dental arch using Hawley’s retainer with a
labial bow to retract incisors and an acrylic plate can be used as a habit
reminder.
• Appliance therapy:
• A lip bumper may be used as an adjunctive therapy in both comprehensive
and interceptive regimens. The Lip Bumper is a fixed (non-removable) wire
that fits into large tubes on the outside of the lower first molar bands
(cemented). It sticks out from the lower teeth about 1/4 of an inch and has a
plastic pad in front which "bumps" the lip. This thick wire and plastic
bumper keep the cheeks and lip away from the teeth to allow the tongue to
gently push the teeth forward and sideways, thus creating a broader arch
and more space for crowded teeth. The strong lower lip muscle (the
mentalis) pushes against the bumper to upright and push back the banded
molars, which also creates more space.
• The bumper wire can be removed and adjusted by the orthodontist but it is
a fixed, full time appliance for the patient. It is usually left in for six to nine
months and then removed and replaced with a lower holding arch or full
braces.
38.
39. CHEEK BITING
This is an abnormal habit of keeping or biting the
cheek muscles in between the upper and lower
posterior teeth. It may injure the soft tissue malposition
in the buccal segment where a persistent cheek biting
habit exists.
40. CLINICAL FEATURES
• Ulcer at the level of occlusion
• Open bite
• Tooth malposition in the buccal segment
41. TREATMENT
• A removal crib may be constructed to break the habit.(FIG.a)
• A vestibular screen may also be used. FIG.b)
• Buccal shields: Can be used to prevent the habit of sucking or
chewing of the cheeks. While it may not address the underlying
of the problem, the appliance is useful to controlling the habit
and allowing the tissue to heal. FIG.c)
42. An unusual appliance to intercept cheek biting habit :
Dayanand Shirol, Rahul Lodaya,Chetan Bhat,Sachin C.
Gugwad,Preetam Shah . Int. Journal of Contemporary
Dentistry NOVEMBER, 2010 • 1(2)
• This case report describes the use of an unusual removable prosthesis to
prevent cheek biting habit in healthy 12-year-old girl who did not have
any of the commonly related conditions.
•
Intraoral photograph showing linea alba Removable habit breaking appliance with wire
on left cheek mucosa and acrylic shield
43. The appliance seated in place
with teeth in occlusion
After one month of therapy
44. NAIL BITING
Nail biting is one of the most common habits in children and adults.
It is a sign of internal tension.
AGE OF OCCURRENCE:
Nail biting is absent before 3 years of age. The incidence rises
sharply from 4-6 years and remain at a fairly constant level
between 7 and 10 years and rises again to a peak during
adolescence
45. • ETIOLOGY:
• Persistent nail biting may be indicative of an emotional problem.
• After the age of 15, the biting habit is replaced by pencil biting, hair
twirling or gum chewing.
• EFFECTS:
• Dental effects: The common effect of nail biting on the teeth are crowding,
rotation and attrition of incisal edges of the mandibular incisors.
• Effects on the nails: Inflammation of the nail and nail beds.
46. MANAGEMENT
• Mild cases; no treatment is indicated.
• Avoid punitive methods such as scolding, nagging and
threats.
• Treat the basic emotional factors causing the act.
• Encourage outdoor activities which may help in easing
tension.
• Application of nail polish, light cotton mittens as a
reminder.
47. FRENUM THRUSTING
This habit is rarely seen is also a form of self-injurious habit. If the
maxillary incisors are slightly spaced apart, the child may lock his
labial frenum between these teeth and permit it to remain in this
position for several hours. On constant repetition this may turn into a
habit which may displace the tooth.
48. TREATMENT
• Treatment should first be initiated towards psychotherapy. Some
children experience a feeling of neglect, abandonment and loneliness
and through the use of self-injurious behaviour attempt to solicit
attention and love. Treatment of self-injurious behaviour generally
requires a multidisciplinary approach. Care should be taken in dealing
with this form of behaviour because of the underlying emotional
component. Continued concern for the habit may support or reinforce
the habit.
• Palliative treatment: Adjunctive therapy in the form of bandages for
any oral ulcerations will help in healing of the wounds as well as
serve as a habit reminder.
• Mechanotherapy: An oral shield will also deter the child from the
unconscious continuation of the habit. Treatment for self-mutilation
may also include use of restraints and protective padding.
49. BOBBY PIN OPENING
• Usually seen in teen age girls wherein opening bobby pin with
anterior incisors is done. Clinically we seen notched incisors and
partially denuded labial enamel. At this age, calling attention to
the harmful habit is generally all that is necessary to stop the
habit.
50. SELF-MUTILATION
• Repetitive acts that result in physical damage to the person, is
extremely rare in the normal child.
• It has been suggested that self-mutilation is a learned behavior
• A frequent manifestation of self-mutilation is biting of the lips,
tongue and oral mucosa.
• Any child who willfully inflicts pain or damage to himself should be
considered psychologically abnormal.
• Such children should be referred. Besides behavior modification
treatment for self mutilation includes use of restraints, protective
padding and sedation.
51. • Functional oral self-mutilation in physically healthy
pediatric patients: Case report and analysis of 27 literature
cases: Laura C. Hildebrand et al; International Journal of
Pediatric Otorhinolaryngology (2011)
• Oral self-mutilation is not uncommon. A literature search conducted in the
PubMed database using the term oral self- mutilation yielded 296 papers.
However, only 14 of these articles were found to describe cases of
functional mutilation in non- syndromic pediatric patients. In cases of oral
self-mutilation, the gingival area is the site most frequently affected,
typically among pediatric female patients.
52. • Two most common methods of gingival self-inflicted injury are pocking with
a pencil or scratching with fingernails, and etiologic factors usually include
an emotional component, e.g. parent divorce, problems at school, birth or
death of a sibling, or an unhappy home environment. Treatment is based on
correct diagnosis after a careful and thorough clinical examination, once
functional oral self-mutilation is often denied or hidden by both the patient
and family members. Patients need to cease the habit, and psychological
therapy acquires special importance in this process.
53. CONCLUSION
• Oral habits in children have concerned dentists for many years.
Dentists see in these habits the possibility of harmful unbalanced
pressures which may be brought to bear upon the position of teeth
and occlusion which may become decidedly abnormal if habits are
continued for long periods of time.
• Interested in these problems are the pediatrician, the psychiatrist, the
psychologist, the speech pathologist, as well as the parents of the
children. The dentists and speech pathologists are interested more in
oral structural changes resulting from prolonged habit patterns. The
pediatrician and psychologist may place more importance on the
deeper seated behavioural problems of the child, of which the oral
habit may be only a symptom. The parents appear to be more
concerned that a child with an oral habit is exhibiting an act which is
socially unacceptable.
54. • The management of habits always be a multi-disciplinary in
nature. There should be a good corporation between the dentist,
parent and the patient so that what we will achieve is the perfect
smile. Therefore, as the famous proverb is:
A stitch in time saves nine
Interception in right time saves thirty two
