Bruxism

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Bruxism
DiseasesDB	29661
MedlinePlus	001413

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Overview

Bruxism is defined as repeated involuntary grinding and clenching of teeth which can occur either diurnal or nocturnally. In 1907 Marie Pielkiewics coined the french term 'La Bruxomanie" for bruxism. Bruxism can be classified into awake bruxism and sleep bruxism based on the physiological sleep status of the individual. The etiology of bruxism can be categorized into three groups psychosocial factors, peripheral factors, and pathophysiological factors. Multifactorial etiology causes involving brain neurotransmitters or basal ganglia. Bruxism affects men and women equally. Factors associated with an increased risk of bruxism include Obstructive sleep apnea, Alcohol abuse, caffeine intake, Smoking, Anxiety. The symptoms of bruxism, usually develop in the first decade of life, and start with symptoms such as the appearance of the first primary upper and lower anterior teeth. Common complications of bruxism are tooth wear, tooth hypersensitivity. Bruxism is primarily diagnosed based on the clinical presentation. H/o complains of disturbance from the clicking or grating sound by the accompanied partners. The most common symptoms of bruxism include Involuntary rhythmic contractions of the masticator muscles during sleep. Removal of any offending agent responsible for bruxism is the primary step in the management. Surgery is the mainstay of treatment in the management of bruxism.

Historical Perspective

• In 1907 Marie Pielkiewics coined a french term 'La Bruxomanie" for bruxism.
• In 1931, Frohman first coined the term English term bruxism.

Classification

Bruxism can be classified into awake bruxism and sleep bruxism based on the physiological sleep status of the individual.

Awake Bruxism/Diurnal Bruxism	Sleep Bruxism/Nocturnal Bruxism
Day Time /Awake	Sleep
Semi-Voluntary	Sterotyped
Clenching predominant	Teeth grinding

Definitions
American Academy of Orofacial Pain (2008)	Diurnal or nocturnal parafunctional activity including clenching, bracing, gnashing, and grinding of the teeth. I
The Academy of Prosthodontics (2005)	1. The parafunctional grinding of teeth. 2. An oral habit consisting of involuntary rhythmic or spasmodic non-functional gnashing, grinding or clenching of teeth, in other than chewing movements of the mandible, which may lead to occlusal trauma – called also tooth grinding, occlusal neurosis
The International Classification of Sleep Disorders (2005)	Sleep-related bruxism is an oral activity characterized by grinding or clenching of the teeth during sleep, usually associated with sleep arousals.

Causes

The etiology of bruxism can be categorized into three groups psychosocial factors, peripheral factors, and pathophysiological factors.

Etiology of Bruxism
Psychological	Common psychological factors responsible for bruxism include Stress induced bruxism Depression associated bruxism Anxiety related bruxism
Peripheral	Caffeine intake Smoking Alcohol consumption
Pathological	Problem with arousal mechanism during sleep Imbalance in the dopamine release in the basal ganglion

Pathophysiology

Pathophysiology

• Bruxism is caused by the activation of reflex chewing activity; it is not a learned habit.
• Chewing is a complex neuromuscular activity that is controlled by reflex nerve pathways, with higher control by the brain.
• During sleep, the reflex part is active while the higher control is inactive, resulting in bruxism. In most people, bruxism is mild enough not to be a health problem; however, some people suffer from significant bruxism that can become symptomatic.
• As stated bruxism is considered to have multifactorial etiology. Multifactorial etiology causes involving brain neurotransmitters or basal ganglia.
• Pathophysiological Factors
  • As bruxism often occurs during sleep, the physiology of sleep has been studied extensively especially the ‘arousal response’ in search of possible causes of disorder.
  • Arousal response is a sudden change in the depth of the sleep during which the individual either arrives in the lighter sleep stage or actually wakes up.
  • Such a response is accompanied by gross body movements, increased heart rate, respiratory changes, and increased muscle activity.
  • It is derived that disturbances in central neurotransmitter system may be involved in the etiology of bruxism.
  • It is hypothesized that the direct and indirect pathways of the basal ganglion, a group of five subcortical nuclei that are involved in the coordination of movements is disturbed in bruxer.
  • The direct output pathway goes directly from the stratum to the thalamus from where afferent signals project to the cerebral cortex. The indirect pathway on the other hand passes by several other nuclei before reaching it to the thalamus.
  • If there is imbalance between both the pathways, movement disorder results like Parkinson’s disease.
  • The imbalance occurs with the disturbances in the dopamine-mediated transmission of an action potential. In case of bruxism there may be an imbalance in both pathways.
  • Acute use of dopamine precursors like L-dopa inhibits bruxism activity and chronic long term use of l-dopa results in increased bruxism activity. SSRTs (serotonin reuptake inhibitors) which exert an indirect influence on the dopaminergic system may cause bruxism after long term use.
  • Amphetamine which increases the dopamine concentration by facilitating its release has been observed to increase bruxism.
  • Nicotine stimulates central dopaminergic activities which might explain the finding that cigarette smokers report bruxism two times more than the nonsmokers.

• Psychosocial Factors
  • There is no proper description of conclusive nature of psychological factors role in bruxism because of the absence of large scale longitudinal trials.

Associated Factors

• Disturbed sleep pattern/other sleep disorders (obstructive sleep apnea, snoring, moderate daytime sleepiness)
• Malocclusion, in which the upper and lower teeth fit together in a dysfunctional way, typically through lateral asymmetry and dysocclusion of the front teeth through premature contact of back teeth.
• Relatively high levels of consumption of caffeinated drinks and foods, such as coffee, colas, and chocolate
• High levels of alcohol consumption
• Smoking
• High levels of anxiety and/or stress
• SSRIs
• Digestive problems
• Hypersensitivity of the dopamine receptors in the brain.
• Consumption of stimulant drugs and medications, such as those of the amphetamine-based family, such as MDMA
• Excessive use of (i.e., frequent redosing and dependency on) GHB and similar GABA-inducing analogues such as Phenibut
• Disorders such as Huntington's and Parkinson's diseases

History and Symptoms

Bruxism can result in abnormal wear patterns of the occlusal surface, abfractions and fractures in the teeth. This type of damage is categorised as a sign of occlusal trauma.

Over time, dental damage will usually occur. Bruxism is the leading cause of occlusal trauma and a significant cause of tooth loss and gum recession.

In a typical case, the canines and incisors of the opposing arches are moved against each other laterally, i.e. with a side-to-side action by the lateral pterygoid muscles that lie medial to the temporomandibular joints bilaterally. This movement abrades tooth structure, and can lead to the wearing down of the incisal edges of the teeth. People with bruxism may also grind their posterior teeth, which will wear down the cusps of the occlusal surface. Bruxing can be loud enough to wake a sleeping partner. Some individuals will clench the jaw without significant lateral movements.

Eventually, bruxing shortens and blunts the teeth being ground, and may lead to myofacial muscle pain and headaches. In severe, chronic cases, it can lead to arthritis of the temporomandibular joints.

Most bruxers are not aware of their bruxism and only 5-10% go on to develop symptoms such as jaw pain and headache. Teeth hollowed by previous decay (caries), or dental drilling, may collapse, as the cyclic pressure exerted by bruxism is extremely taxing on the tooth structure.

Diagnosis

Bruxism is not the only cause of tooth wear. Over-vigorous brushing, abrasives in toothpaste, acidic soft drinks and abrasive foods can also be contributing factors; each has characteristic wear patterns that a trained professional can identify.

The effects of bruxing may be quite advanced before sufferers are aware they brux. Abraded teeth are usually brought to the patient's attention during a routine dental examination. If enough enamel has been abraded, the softer dentine will be exposed and abrasion will accelerate. This opens the possibility of dental decay and tooth fracture, and in some people, gum recession. Early intervention by a dentist is advisable.

Treatment

There is no accepted cure for bruxism.A recently introduced device called the BiteStrip enables at-home overnight testing for sleep bruxism. It is proposed that this might help diagnose bruxism before damage appears on the teeth. The device is a miniature electromyograph machine that senses jaw muscle activity while the patient sleeps. A dentist can establish the frequency of bruxing, which helps in formulating a treatment plan. Anyone having major occlusal rehabilitation should be aware that bruxism can easily ruin prosthetic dental work.

Mouthguards and Repositioning Splints

Ongoing management of bruxism is based on minimizing the abrasion of tooth surfaces by the wearing of an acrylic dental guard or splint, designed to the shape of an individual's upper or lower teeth from a bite mould. Mouthguards are obtained through visits to a dentist for measuring, fitting, and ongoing supervision. There are four possible goals of this treatment: constraint of the bruxing pattern such that serious damage to the temperomandibular joints is prevented, stabilization of the occlusion by minimizing the gradual changes to the positions of the teeth that typically occur with bruxism, prevention of tooth damage, and the enabling of a bruxism practitioner to judge — in broad terms — the extent and patterns of bruxism, through examination of the physical indentations on the surface of the splint. A dental guard is typically worn on a long-term basis during every night's sleep.

Professional treatment is medically recommended to ensure proper fit, make ongoing adjustments as needed, and check that the occlusion (bite) has remained stable. Monitoring of the mouthguard is suggested at each dental visit.

Another type of device sometimes given to a bruxer is a repositioning splint. A repositioning splint may look similar to a traditional night guard, but is designed to change the occlusion, or "bite," of the patient. Randomly controlled trials with these type devices generally show no benefit over more conservative therapies and they should be avoided under most if not all circumstances.

The NTI-tss device is another option that can be considered. The NTI covers only the front teeth and prevents the rear molars from coming into contact, thus limiting the contraction of the temporalis muscle. The NTI must be fit by your dentist.

The efficacy of such devices is debated. Some writers propose that irreversible complications can result from the long-term use of mouthguards and repositioning splints.

Vitamin Supplements

There is limited evidence that suggests taking certain combinations of vitamin supplements may alleviate bruxism; calcium and vitamin C have been examined.

Biofeedback

Various biofeedback devices are currently available, but their effectiveness is as yet unproven. While anecdotal evidence suggests that they may be useful, some bruxism authorities remain unconvinced.

One biofeedback mechanism that has significant promise was developed by Moti Nissani, PhD and is called "The Taste-Based Approach to the Prevention of Teeth Clenching and Grinding." The therapy involves suspending sealed packets containing a bad-tasting substance (e.g. hot sauce, vinegar, denatonium benzoate, etc.) between the rear molars using an orthodontic-style appliance. Any attempt to bring the teeth together will rupture the packets and alert the user to the habit. While no cure exists for bruxism, this approach, if implemented properly and rigorously, has promise to be an effective treatment for bruxism. Importantly, the Taste-Based Approach does not suffer from the risk of desensitization that other available sound-based biofeedback approaches may have. (There is effectively no limit to the aversive taste of certain substances. We can therefore be sure that some harmless substance exists that will alert anyone to the habit.)

One of these devices, the Oralsensor, comprises a pneumatic pouch embedded in a soft polymer plate that fits over upper or lower teeth. When the teeth come together—to a threshold pressure set each night by the user—an alarm is sounded in an earpiece worn by the user. Another biofeedback device, GrindAlert, is a battery-powered device that sounds a tone when it senses EMG (electromyographic) muscle activity in the temporalis muscles of the forehead. This device delivers nightly data on the number of bruxism events that last for at least two seconds, and the total duration of those events. The volume of the alarm and the sensitivity of the piezo device to EMG signals from the muscles are adjustable.

In 2005, a new type of occlusive device was patented that produces a movement incompatible with teeth clenching. When nighttime bruxism occurs, people breathe through the nose. The device forces people to breathe through the mouth; by forcing the opening of the mouth, the device is claimed to stop clenching. The occlusive device has an electromyogram system that monitors the electric activity of the jaw muscle via wireless electrodes. These electrodes transfer jaw-muscle activity by radio frequency to an external monitoring system. Once the signal has been interpreted by the monitoring system, if a person clenches, the monitoring unit sends a radio frequency signal to a transceiver integrated in a mechanical actuator. The mechanical actuator has two occlusive flaps that block the nostrils, forcing breathing to occur through the mouth. Once the patient stops clenching, the flaps open, allowing breathing through the nose again. The occlusive device does not wake up people since it blocks nostrils slowly, and it never closes them completely to avoid sleep disruption.

Meditation and Relaxation Techniques

Sufferers may find that meditation and relaxation techniques may help to reduce teeth grinding. Hypnotherapy can also be very effective.

Repairing Damage to Teeth from Bruxism

Damaged teeth can be repaired by replacing the worn natural crown of the tooth with prosthetic crowns. Materials used to make crowns vary; some are less prone to breaking than others, and can last longer. Porcelain fused to metal crowns may be used in the anterior (front) of the mouth; in the posterior, full gold crowns are preferred. All porcelain crowns are now becoming more and more common and work well for both anterior and posterior restorations. To protect the new crowns and dental implants, an occlusal guard should be fabricated to wear during sleep.

References

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