Bruxism can be defined as the involuntary, unconscious, and excessive grinding of teeth. There are 2 main types of bruxism. Bruxism which occurs when people are awake can be called wakeful or diurnal bruxism and at sleep can be called nocturnal bruxism. The main cause for bruxism has not been determined but is held to involve multiple factors. Professionals believe wakeful bruxism has different causes from nocturnal bruxism. In bruxism, there will be forceful contact between biting surfaces of maxillary and mandibular teeth. Bruxism can be subclassified into primary or secondary. Primary bruxism is not related to any other medical condition. Secondary bruxism is associated with neurological disorders, or it can be considered as an adverse effect of drugs.
The indications for bruxism management are as follows:
Bruxism management relies on the recognition of the potential causative factors associated with the development of bruxism. Diurnal bruxism may be confounded by stress and other psychosocial parameters. Diurnal bruxism can be managed by considering interventions such as habit modification, relaxation therapy, biofeedback. In patients with sleep bruxism (which does not appear to be impacted by psychological or psychosocial factors), appropriate intervention might include appliance therapy and medication. In patients with medication or drug-induced bruxism, medication withdrawal or a change of type of medication to a less likely cause of bruxism should be considered. If street drugs are being used, intervention should include psychological counseling.
Bruxism occurring in patients with a neurogenic abnormality such as dystonia may benefit from botox injection of the mastication muscles. Dietary counseling and management may be essential in some cases such as excessive use of caffeine and tobacco. The healthcare provider managing bruxism must understand that nocturnal or sleep bruxism is usually not cured by intervention.  The behavior is likely to diminish with age. Daytime bruxism can often be effectively eliminated via intervention, suggesting a cure, but recrudescence of the condition is common.
Methods to Manage Bruxism
If there is the presence of any prematurities or occlusal interferences, it should be corrected by coronoplasty. Before doing any occlusal adjustment, muscles should be brought back to their relaxed position for the jaw to resume its normal physiologic movements.
Splints can be used for the treatment of bruxism. Splints include night guards, occlusal splints, removable appliances or interocclusal orthopedic appliances and customized appliances. Removable splints are worn at night to guide the movement so that the periodontal damage is minimal. Occlusal splints are generally appreciated to prevent tooth wear and injury and reduce nighttime clenching. Splints should cover occlusal surfaces of all the teeth. With the use of splint, there will be a reduction in increased muscle tone. The appliance is helpful in managing the consequences of nocturnal bruxism is the flat-planed stabilization splint, also called an occlusal bite guard, bruxism appliance, biteplate, or nightguard. Appliances vary in appearance and features. It may be constructed in the dental office and or a laboratory and fabricated from the hard or soft material. The appliance typically covers either all of the maxillary or mandibular teeth. There is no significant differences exist regarding outcome between hard and soft splints, but some clinicians feel that soft splints can increase clenching behavior in some patients. Appliances are also used to retrain daytime clenching.
Bruxism may often be related to stress. Psychotherapeutic approaches should be done to foster calmness. Patient counseling can lead to decrease in tension and also create awareness of the habit. This will result in an increase in voluntary control and thus can reduce parafunctional tooth movements.
If there is severe attrition associated with bruxism, then pulpal therapy followed by full coverage crowns are recommended.
Physical therapy is recommended if bruxism is associated with muscle pain and stiffness.
In this method, the patient is trained to relax the muscle group voluntarily.
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 arousal and anxiety level. Low doses of tricyclic antidepressants may be used to inhibit the amount of REM sleep.
This technique utilizes positive feedback to enable the patient to learn tension reduction. It is accomplished by allowing the patient to view an EMG monitor while mandible is postured with a minimum of activity.
Electrogalvanic stimulation for muscle relaxation is currently used for the treatment of bruxism.
Bruxism may be due to malocclusion. This malocclusion should be corrected using orthodontic treatment.
Sleep bruxism has effects on the masticatory system and occlusion. As a result of the tremendous force applied to teeth and supporting tissues during sleep bruxism, it can have harmful effects on oral tissue and temporomandibular joint, stomatognathic system including teeth, periodontium, and muscles of mastication. In bruxism, there will be the presence of symptoms such as tooth wear, pain in temporomandibular joint dysfunction (TMJ) or jaw musculature, temporal headache, tooth hypersensitivity, tooth mobility, and poor sleep. Clinical signs include abnormal tooth wear, indentation on the surface of the tongue, the presence of linea alba along biting plane of buccal mucosa, gingival recession, masseter hypertrophy, and broken fillings or teeth. When occlusal forces of high intensity and duration overcome the body's adaptive capacity, a stomatognathic breakdown will occur. There is the development of increased wear facets in patients with sleep bruxism. Also, there is a 0.5 mm slide from centric occlusion to maximal intercuspation. Slightly increased movement of mandible while in centric relation from first occlusal contact to maximal intercuspation will lead to corresponding retrusive wear facets in patients with current sleep bruxism activity. Bruxism can result in tooth fractures. Due to the wearing of enamel and dentin, there will be hypersensitivity to teeth. Periodontal ligaments covering teeth will become inflamed, and there will be mobility of teeth. 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. There will be tenderness of TMJ which may manifest as otalgia.
Bruxism has many causes and is best managed by an interprofessional team that includes a dentist, mental health nurse, pediatrician, primary caregiver, neurologist, and a psychotherapist. Bruxism management relies on the recognition of the potential causative factors associated with the development of bruxism. Diurnal bruxism may be confounded by stress and other psychosocial parameters. Diurnal bruxism can be managed by considering interventions such as habit modification, relaxation therapy, biofeedback. In patients with sleep bruxism (which does not appear to be impacted by psychological or psychosocial factors), appropriate intervention might include appliance therapy and medication. In patients with medication or drug-induced bruxism, medication withdrawal or a change of type of medication to a less likely cause of bruxism should be considered. If street drugs are being used, intervention should include psychological counseling.
Bruxism occurring in patients with a neurogenic abnormality such as dystonia may benefit from botox injection of the mastication muscles. Dietary counseling and management may be essential in some cases such as excessive use of caffeine and tobacco. The healthcare provider managing bruxism must understand that nocturnal or sleep bruxism is usually not cured by intervention. The behavior is likely to diminish with age.
The outlook for most patients is guarded; despite treatment in many cases, the condition recurs. (Level V)
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