Continuing Education Activity
Bruxism can be defined as the involuntary, unconscious, and excessive grinding of teeth. Bruxism may occur while awake, and it is then called wakeful or diurnal bruxism, and also during sleep, which is known as nocturnal bruxism. The main cause for bruxism has not been determined but is held to involve multiple factors. This activity reviews the cause, pathophysiology, presentation of bruxism and highlights the role of the interprofessional team in the managing these patients.
- Describe the pathophysiology of bruxism.
- Describe the presentation of a patient with bruxism.
- Summarize the treatment options for bruxism.
- Outline the importance of improving care coordination among interprofessional team members to improve outcomes for patients affected with bruxism.
Bruxism can be defined as the involuntary, unconscious, and excessive grinding of teeth. During bruxism, there is forceful contact between the biting surfaces of maxillary and mandibular teeth. Bruxism may occur while awake, and it is then called wakeful or diurnal bruxism, and during sleep, known as nocturnal bruxism. The main cause of bruxism has not yet been determined, but it is believed to be multifactorial.. Researchers believe wakeful bruxism has different causes from nocturnal bruxism.
Bruxism can be subclassified into primary and secondary, whereas primary bruxism is not related to any other medical condition; secondary bruxism is associated with neurological disorders or is considered an adverse effect of drugs.
The recommended approach to managing bruxism includes three angles. The use of an occlusal splint - preferably the hard acrylic-resin devices - works more as a protector of the teeth, preventing further damage. A behavioral approach to increase the patient’s awareness of the disorder, relaxation, lifestyle, and sleep hygiene instruction, and the use of drugs, which should be limited to short periods and severe cases where occlusal devices and psychological methods were ineffective.
The treatment of bruxism is indicated when there are any of these possible consequences:
- Mechanical wear of the teeth, which results in loss of occlusal morphology and flattening of the occlusal surfaces
- Hypersensitive teeth
- Loss of periodontal support
- Tooth fractures
- Restorations fractures, usually class I and class II restorations, fracture of crowns and fixed partial prosthesis
- Restorations or dental implants failure
- Hypertrophy of masticatory muscles
- Tenderness and stiffness in jaw muscles
- When bruxism leads to limited mouth opening
- Temporomandibular pain
- Pain in the preauricular region
- Clicking and tenderness of the temporomandibular joint
- When headaches occur as a result of muscle tenderness associated with the temporalis muscle
- Unpleasant loud noises during sleep, causing sleep disturbances
Bruxism management relies on the recognition of the potential causative factors associated with the development of the condition. Diurnal bruxism can be managed by considering interventions such as habit modification, relaxation therapy, and biofeedback. In patients with sleep bruxism, which does not appear to be impacted by psychological or psychosocial factors, appropriate intervention might include appliance therapy. In patients with medication or drug-induced bruxism, medication withdrawal or substitution should be considered. If recreational drugs are being used, intervention should include psychological counseling.
Bruxism occurring in patients with neurogenic abnormalities such as dystonia may benefit from botox injection of the mastication muscles, which seems to decrease the frequency of the parafunctional activity. Still, concerns have been raised regarding plausible adverse effects. Dietary counseling and management may be essential in some cases, such as excessive use caffeine and tobacco use.
Nocturnal bruxism is not usually cured by an intervention, the behavior is likely to diminish with age. On the other hand, daytime bruxism can often be eliminated via intervention, suggesting a cure, but recrudescence of the condition is common.
Methods to Manage Bruxism
Premature contacts or occlusal interferences have been associated with the development of bruxism in some studies in the past. Some dental clinicians still believe that occlusal adjustments are required in the management of bruxism. But, there seems to be no basis in evidence for performing such irreversible occlusal adjustments since the etiology of the disorder is now known to be mainly regulated centrally (psychosocial factors), not peripherally.
The proposed idea that bruxism may be due to malocclusion makes orthodontic treatments viable options in managing the condition. But, this is still a controversy among dental clinicians and researchers .
Occlusal splints are worn at night to guide the occlusal movement so that the periodontal damage is minimal. The appliance covers all the maxillary or mandibular teeth, but it is mostly worn in the upper maxilla. Occlusal splints are generally appreciated to prevent tooth wear, injuries and reduce nighttime clenching. Splints should cover the occlusal surfaces of all the teeth. With the use of a splint, there will be some reduction in muscle tone. The appliance that helps manage the consequences of nocturnal bruxism is the flat-planed stabilization splint, also called occlusal bite guard, bruxism appliance, biteplate, or nightguard.
Appliances vary in appearance and features. They may be constructed in the dental office or a laboratory and fabricated from hard or soft materials. Hard acrylic-resin stabilization splints are suggested to be more effective in reducing bruxism activity than soft splints. Soft-resin splints are more difficult to adjust than the hard acrylic-resin devices and prevent inadvertent tooth movements. Also, some professionals believe that soft splints increase the clenching behavior in some patients. These appliances are also utilized to retrain daytime clenching.
Bruxism may often be related to stress. Psychotherapeutic approaches should be made to foster calmness. Patient counseling can lead to a decrease in tension and also create awareness of the habit. This will increase voluntary control and thus reducing parafunctional movements.
Physical therapy may be recommended if bruxism is associated with muscle pain and stiffness.
In this method, the patient is trained to relax the muscle group voluntarily.
If there is severe attrition associated with bruxism, then endodontic therapy, where necessary, is recommended. Composite restorations or full-coverage crowns (depending on each case) restore vertical dimension and function.
The use of drugs in treating bruxism should be limited to short periods and severe cases where occlusal devices and psychological approaches were ineffective.
Pharmacological management includes the use of antianxiety agents, tranquilizers, sedatives, and muscle relaxants. Medications such as diazepam can be prescribed for a few days to alter the sleep disturbance and anxiety level. Low doses of tricyclic antidepressants may be used to inhibit the amount of rapid eye movement (REM) sleep.
This technique utilizes positive feedback to enable the patient to learn tension reduction. It is based on the idea that bruxers can unlearn their behavior. It is accomplished by allowing the patient to view an electromyography (EMG) monitor while the mandible is postured with minimum activity. For nocturnal bruxism, auditory, vibratory, or taste stimuli may be used.
Electrogalvanic stimulation for muscle relaxation is currently used for the treatment of bruxism.
Botulin toxin, a neurotoxin synthesized by Clostridium botulinum, is currently used to treat various medical conditions, including bruxism, and for cosmetic purposes. It works by impeding acetylcholine production and blocking calcium channels in nerve endings, temporarily inhibiting muscle contraction.
Botulin toxin A injections in the masseter and temporal muscles have been demonstrated to improve the quality of life of patients with bruxism. Also, doses of <100UI carry a low chance of adverse effects. This neurotoxin decreases the frequency of bruxism episodes, the severity of pain, and the intensity of the masticatory force.
Complications of bruxism are wide-ranging. A stomatognathic breakdown will occur when occlusal forces of high intensity and duration overcome the body's adaptive capacity, and the consequences of bruxism will appear. To mentions some, tooth wear, tooth hypersensitivity, tooth mobility, pain in the temporomandibular joint (TMJ) or jaw musculature, temporal headache, and poor sleep. Indentation on the tongue's surface, the presence of linea alba along the biting plane of the buccal mucosa, and gingival recessions are also clinical signs of this habit.
Bruxism may be associated with other parafunctional activities such as cheek biting or lip biting. There will be hypertrophy of masseter muscle accompanied by tenderness or fatigue of masticatory muscles. Tenderness of the TMJ may manifest as otalgia.
Bruxism has been linked to the development of temporomandibular disorders (TMD), tooth wear, dental mobility, changes in oral soft tissues and mandible, among others. Bruxism is also associated with technical challenges when constructing and placing a dental prosthesis.
Enhancing Healthcare Team Outcomes
Because bruxism is a multifactorial condition, an interprofessional team should work together to manage the disease better and improve patients' quality of life, including dentists, mental health nurses, pediatricians, primary caregivers, neurologists, and psychotherapists.
Bruxism management relies on the recognition of potential causative factors. Nocturnal bruxism is usually not cured by an intervention. The behavior possibly diminishes with age.
The outlook for most patients is guarded; despite treatment, in many cases, the condition recurs. [Level V]