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Damaged teeth can be repaired by replacing the worn natural crown of the tooth with prosthetic [[Crown (dentistry)|crown]]s. 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 (anatomy)|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 [[Occlusion (dentistry)|occlusal]] guard should be fabricated to wear during sleep.
Damaged teeth can be repaired by replacing the worn natural crown of the tooth with prosthetic [[Crown (dentistry)|crown]]s. 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 (anatomy)|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 [[Occlusion (dentistry)|occlusal]] guard should be fabricated to wear during sleep.

==Epidemiology==
More data are available for the prevalence of sleep bruxism compared to bruxism generally. In a Scandinavian study of over 1000 people in the general population, 27.2% reported some form of bruxism,<ref name="Macedo 2009" /> however since many people with bruxism are not aware of their habit, self reported tooth grinding and clenching habits may be a poor measure of the true prevalence. The ICSD-R states that 85-90% of the general population grind their teeth to a degree at some point during their life, although only 5% will develop a clinical condition.<ref name=ICSD-R />

Children are reported to brux as commonly as adults. It is possible for sleep bruxism to occur as early as the first year of life - after the first teeth (deciduous incisors) erupt into the mouth, and the overall prevalence in children is about 14-20%.<ref name="Macedo 2007 (cochrane rv)" /> The ICSD-R states that sleep bruxism may occur in over 50% of normal infants.<ref name=ICSD-R /> Often sleep bruxism develops during adolescence, and the prevalence in 18 to 29 year olds is about 13%.<ref name="Macedo 2007 (cochrane rv)" /> The overall prevalence in adults is reported to be 8%, and people aver the age of 60 are less likely to be affected, with the prevalence dropping to about 3% in this group.<ref name="Macedo 2007 (cochrane rv)" /> For sleep bruxism, males are as equally affected as females,<ref name=ICSD-R /><ref name="Macedo 2007 (cochrane rv)" /> and 21-50% of people with sleep bruxism have a direct family member who had sleep bruxism during childhood, suggesting that there are genetic factors involved (although no genetic markers have yet been identified).<ref name="Macedo 2007 (cochrane rv)">{{cite journal|last=Macedo|first=CR|coauthors=Silva, AB; Machado, MA; Saconato, H; Prado, GF|title=Occlusal splints for treating sleep bruxism (tooth grinding).|journal=Cochrane database of systematic reviews (Online)|date=2007 Oct 17|issue=4|pages=CD005514|doi=10.1002/14651858.CD005514.pub2|pmid=17943862}}</ref>


==History==
==History==

Revision as of 12:59, 17 May 2013

Bruxism
SpecialtyDentistry Edit this on Wikidata

Bruxism (from the Greek βρυγμός (brygmós), "gnashing of teeth") refers to excessive grinding of teeth and/or excessive clenching of the jaw.[1] Bruxism It is an oral parafunctional activity.[1] Bruxism occurs in most humans at some time in their lives.[medical citation needed] In most people, bruxism is mild enough not to be a health problem.[2] While bruxism may be a diurnal or nocturnal activity,[3] it is bruxism during sleep that causes the majority of health issues; it can even occur during short naps. Bruxism is one of the most common sleep disorders.[4]

Classification

Definition

There is no widely accepted definition of bruxism, but some suggested definitions include:

"A movement disorder of the masticatory system charactized by teeth grinding and clenching during sleep as well as wakefulness."[1]

"A habitual behavior, and a sleep disorder."[5][verification needed]

"non-functional contact of the mandibular and maxillary teeth resulting in clenching or tooth grinding due to repetitive, unconscious contraction of the masseter and temporalis muscles."[6]

Bruxism can be subdivided into two types based upon when the para-functional activity occurs - during the night (termed "sleep bruxism", or during the day ("diurnal bruxism").[7] This distinction is most widely referred to since bruxism which occurs during sleep generally has different causes to that which occurs during wakefulness, although the affects of condition on the teeth are the same.[8] The treatment is also often dependent upon whether the bruxism happens during sleep or during wakefulness. For example, an occlusal splint worn during sleep in a person who only bruxes when they are awake will have no benefit.

Alternatively, bruxism can be divided into primary bruxism (also termed "idiopathic bruxism"), where the disorder is not related to any other medical condition, or secondary bruxism where the disorder is associated with other medical conditions.[7] Secondary bruxism includes iatrogenic causes, such as the side effect of prescribed medications (e.g. selective serotonin re-uptake inhibitors).

Sleep bruxism

This type of bruxism is also termed "sleep-related bruxism",[8] "nocturnal bruxism",[8] or "nocturnal tooth grinding".[8] According to the International Classification of Sleep Disorders revised edition (ICSD-R), the term "sleep bruxism" is the most appropriate since this type occurs during sleep specifically rather than being associated with a particular time of day, i.e. if a person with sleep bruxism were to sleep during the day and stay awake at night then the condition would not occur during the night but during the day.[8] The ICDS-R defined sleep bruxism as "a stereotyped movement disorder characterized by grinding or clenching of the teeth during sleep",[8] classifiying it as a parasomnia. The second edition (ICSD-2) however reclassified bruxism to a "sleep related movement disorder" rather than a parasomnia.[7]

Signs and symptoms

Long term effects of severe bruxism on an anterior tooth, revealing the dentin and pulp which are normally hidden by enamel

Most people who brux are unaware of the problem. Only an estimated 5% go on to develop symptoms, such as jaw pain and headaches.[9] A sleeping partner or parent may notice the behavior first (e.g. if there is a grinding noise during sleep), although sufferers may notice pain symptoms without understanding the cause.

Bruxism can result in occlusal trauma, the abnormal wear patterns of the occlusal surface, abfractions and fractures in the teeth. Over time, dental damage increases. Bruxism is the leading cause of occlusal trauma and a significant cause of tooth loss and gum recession. Bruxism can be loud enough to wake a sleeping partner. Some individuals clench without significant lateral movements.[citation needed]

In a typical case involving lateral motion (side to side grinding), the canines and incisors of the opposing arches are moved against each other laterally, i.e., with a side-to-side action by the medial 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 wears down the cusps of the occlusal surface. Most (but not all) bruxism includes clenching force provided by masseter and temporalis muscle groups; but some bruxers clench and grind front teeth only, which involves neither masseter nor temporalis muscle groups. Teeth hollowed by previous decay (caries), or dental drilling, may collapse from bruxism's cyclic pressures.[citation needed]

Bruxism may cause a variety of signs and symptoms, including:

The symptoms of sleep bruxism are usually most intense immediately after waking, and then slowly get better, and the symptoms of a bruxing habit which occurs mainly while awake tend to slowly get worse throughout the day, and may not be present

Causes

Bruxism is a habit rather than a reflex chewing activity.[citation needed] Reflex activities happen reliably in response to a stimulus, without involvement of subconscious brain activity.[citation needed] Chewing and clenching are complex neuromuscular activities that can be controlled either by subconscious processes or by conscious processes within the brain. During sleep, (and for some during waking hours while conscious attention is distracted) subconscious processes can run unchecked, allowing bruxism to occur.[citation needed] Some bruxism activity is rhythmic with bite force pulses of tenths of a second (like chewing), and some have longer bite force pulses of 1 to 30 seconds (clenching).

Historically, many believed that problems with the bite were the only causes for bruxism. For example a new dental restoration on a tooth (e.g. a crown) which has a slightly different shape or position to the original tooth may cause the bite to change. Other problems with the bite may be developmental, e.g. malocclusion - which refers to less than perfectly positioned teeth - although the modern view is that there is no ideal occlusion and it is "normal to be abnormal".[1] It was often claimed that a person would grind at the interefering area, in a subconscious attempt to wear this down and "self equiliberate" the occlusion. However, occlusal intereferences are extremely common and usually do not cause any problems. People with bruxism may be aware of a problem with their bite, and even blame this for their habit, but removal of the occlusal interference does not always work.

There is now considerable evidence that nocturnal bruxism is instead caused by central mechanisms, involving sleep arousal and dopaminergic abnormalities. Underlying these factors may be psychosocial factors including daytime stress which is disrupting peaceful sleep.[1] Some research suggests that there may be a degree of inherited susceptibility to develop bruxism.[1] In a Finnish twin study, the heritability of liability to sleep-related bruxism was estimated at 52%, with the rest of the variance attributed to non-shared environmental effects.[14][non-primary source needed]

Certain drugs, including both prescribed (e.g. selective serotonin re-uptake inhibitor]]s) and recreational (e.g. amphetamines), may cause bruxism to develop.[1] Rarely, neurological or psychiatric disorders may show bruxism as a feature.[1]

Research findings have suggested various other causes, from allergic reactions,[medical citation needed] to trauma (such as a car crash)[medical citation needed] to a period of unusual stress;[medical citation needed] however, once symptomatic bruxism sets in, it is often unaffected by the removal any such factor.

Certain medical conditions can trigger bruxism, including digestive ailments and anxiety.[15][medical citation needed]

Bruxism can also be regarded as a disorder of repetitive, unconscious contraction of a complex set of myofacial muscles; this typically involves the masseter and anterior temporalis (the large outer muscles that clench), and the lateral pterygoids, relatively small bilateral muscles that act together to perform sideways grinding.

Associated factors

The following factors may be associated with bruxism (whether by cause or effect):

Complications

Eventually, bruxism with lateral movements shortens and blunts the teeth being ground and may lead to myofascial muscle pain, temporomandibular joint dysfunction and headaches. If enough enamel has been abraded, the softer dentin 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. In severe, chronic cases, bruxism can lead to arthritis of the temporomandibular joints. The jaw clenching that is often part of bruxism can be an unconscious neuromuscular daytime activity, which should be treated as well, usually through physical therapy (recognition and stress response reduction)

Diagnosis

A diagnosis of bruxism is usually made clinically.[12] Bruxism is not the only cause of tooth wear, making it difficult to diagnose by visual evidence alone. Abraded teeth are usually brought to the patient's attention during a routine dental examination.[citation needed]

The most reliable diagnostic technique is measuring EMG (electromyography). These measurements pick up electrical signals from the chewing muscles (masseter and temporalis). This method is commonly used in sleep labs. Three forms of EMG measurement are available outside of sleep labs.

"Bedside" EMG units are similar to those used by sleep labs. These units pick up their signals from facial muscles through wires connecting the bedside unit to electrodes that are adhesively attached to the user's face. TENS electrodes or ECG electrodes may be used.

A biofeedback headband may be used in silent mode to record the total number of clenching incidents and the total clenching time each night. These two numbers easily distinguish clenching from rhythmic grinding and allow dentists to quantify severity levels. Biofeedback headbands do not require adhesive electrodes or wires attached to the face. They do not record the exact time, duration, and strength of each clenching incident as bedside EMG monitors do.

Bedside EMG units and biofeedback headbands can both be used either as a diagnosis measurement or in biofeedback mode as a treatment to help patients reduce their bruxism.

"Disposable" EMG monitors adhesively mount to the side of the face over the masseter muscle. They monitor one night and provide a single-digit measure of bruxism severity.

ICSD-R Diagnostic criteria

The ICSD-R listed diagnostic criteria for sleep bruxism.[8] The minimal criteria include both of the following criteria:

  • A. symptom of tooth-grinding or tooth-clenching during sleep, and
  • B. One or more of the following:
    • Abnormal tooth wear
    • Grinding sounds
    • Discomfort of the jaw muscles

With the following criteria supporting the diagnosis:

  • C. polysomnography shows both:
    • Activity of jaw muscles during sleep
    • No associated epileptic activity
  • D. No other medical or mental disorders (e.g., sleep-related epilepsy, which may cause abnormal movement during sleep).
  • E. The presence of other sleep disorders (e.g., obstructive sleep apnea syndrome).

Management

If diagnosed early, finding and eliminating the original cause(s) may cure bruxism. Later on, habitual bruxism can be treated by habit-modification.[25] Treating associated factors can reduce or eliminate the behavior in cases where bruxism has not become habitual.[18]

Dental guards and splints

A dental guard or splint can reduce tooth abrasion. Dental guards are typically made of plastic and fit over some or all of upper and/or lower teeth. The guard protects the teeth from abrasion and can reduce muscle strain by allowing the upper and lower jaw to move easily with respect to each other. Treatment goals include: constraining the bruxing pattern to avoid damage to the temporomandibular joints; stabilizing the occlusion by minimizing gradual changes to the positions of the teeth, preventing tooth damage and revealing the extent and patterns of bruxism through examination of the markings on the splint's surface. A dental guard is typically worn during every night's sleep on a long-term basis. However, a meta-analysis of occlusal splints (dental guards) used for this purpose concluded "There is not enough evidence to state that the occlusal splint is effective for treating sleep bruxism."[26]

A repositioning splint is designed to change the patient's occlusion, or bite.[citation needed]

Another option is an NTI (nociceptive trigeminal inhibitor) dental guard. Nociceptor nerves sense and respond to pressure. The trigeminal nerve supplies the face and mouth. The NTI appliance snaps onto the front teeth. Normally when the mouth is closed, the upper and lower front teeth overlap: The NTI prevents this overlap and translates the bite force from attempts to close the jaw normally into a forward twisting of the lower front teeth. The intent is for the brain to interpret the nerve sensations as undesirable, automatically and subconsciously reducing clenching force. Unfortunately, for patients who do not subconsciously clench less using an NTI device, the NTI can lead to more severe damage from clenching. The NTI device must be fitted by a dentist.[27] 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. Randomly controlled trials with these type devices generally show no benefit over other therapies.[28][29][30] Clenching hard while wearing an NTI device may cause worse damage, because the NTI changes the forces on the teeth and the tempormandibular joint. NTI patients require ongoing monitoring by a dentist.

In a 2010 review in Journal of Orofacial Pain of 47 publications that involved 44 randomized controlled trials with a total of more than 2200 participants, Fricton et al. concluded: "Hard stabilization appliances, when adjusted properly, have good evidence of modest efficacy in the treatment of TMJD pain compared to non-occluding appliances and no treatment. Other types of appliances, including soft stabilization appliances, anterior positioning appliances, and anterior bite appliances, have some RCT evidence of efficacy in reducing TMJD pain. However, the potential for adverse events with these appliances is higher and suggests the need for close monitoring in their use."[31]

Biofeedback

The principle behind biofeedback in treating bruxism is to automatically detect bruxing behavior, and provide a conscious or subconscious awareness signal to the user so that the user can decrease that behavior, preferably even while asleep. Some clinical trials have shown nighttime biofeedback to be effective at reducing nighttime bruxism behavior[32] (though daytime biofeedback alone has not been shown to be effective at altering nighttime behavior[33]).

The first wearable nighttime EMG biofeedback device (the biofeedback headband) became available in 2001. The awareness signal it provides is a sound which comes on quietly and gradually gets louder until the clenching incident stops, or until a maximum volume level (set by the user) is reached. Daytime practice is advised to facilitate responding in sleep without waking.

The biofeedback headband also tallies nightly data on the number of events that last for at least two seconds and the total accumulated duration of those events. A "fast-response" headband catches events that last for as little as 0.2 seconds. Since the same muscles used in clenching are also used in yawning and swallowing, a fast-response headband may sound during yawns and swallowing, so a standard-response headband is better for use during sleep, and will not include swallowing incidents in its time and clench count tallies. Studies indicate that the reduction in bruxism available during ongoing use of nighttime biofeedback relapses if biofeedback is discontinued,[34][35] so this treatment should be considered long-term just as mouth guards are if long-term benefit is desired.

Another type of wearable EMG biofeedback device became available in 2005. It uses a mild electric shock as the biofeedback, producing an undesirable sensation intended to interrupt bruxing. The shock current is referred to by the manufacturer as "contingent electrical stimulation". The manufacturer's marketing literature speaks of triggering an "inhibitory reflex", but the only inhibitory reflex from the nerves stimulated is a pain reflex, and normally the device is not set to a high enough level to trigger such a reflex. If the shock current is set lower so the user can remain asleep through the shock, the response is less of a reflex response and requires conscious or subconscious participation on the part of the user, similar to the acoustic biofeedback headband. Some patients report desensitizing of nerves after a night of use. Some users report referred pain that appears to come from non-facial locations when the facial shock happens. Bruxism reduction clinical trial results[32][36] are similar to those for the biofeedback headband. Typical consumer cost of an electric stimulation biofeedback device is about $1000. Electric stimulation units are not available in headband form in the US due to patents on the biofeedback headband, but rather are arm-band mounted, with a wire that runs to a disposable three-contact electrode which attaches adhesively to the face (typically over the masseter muscle at the jaw joint).

The NTI dental guard is technically also a biofeedback device (translating physical bite force into an uncomfortable feeling in the front teeth), so it is mentioned here as well as above in the section on dental guards and splints.

Another type of biofeedback therapy relies on stimulating the taste buds.[37] The therapy involves suspending sealed packets containing a harmless but bad-tasting substance (e.g. hot sauce, vinegar, denatonium benzoate, etc.) between the rear molars using an orthodontic-style appliance. Attempts to bring the teeth together ruptures the packets, alerting the user. One major difference between this biofeedback method and all the others is that the undesirable sensation (taste) does not go away immediately when clenching stops. Thus this method is more likely to wake the user.

Botox

Botulinum toxin (Botox) has been suggested as a treatment for bruxism, however there is only one randomized control trial which has reported that Botox reduces the myofascial pain symptoms.[6] This scientific study was based on thirty people with bruxism who received Botox injections into the muscles of mastication and a control group of people with bruxism who received placebo injections.[6] Normally multiple trails with larger cohorts are required to make any firm statement about the efficacy of a a treatment. In 2013, a further randomized control trial investigating Botox in bruxism started.[6] There is also little information available about the safety and long term follow up of this treatment for bruxism.[7]

Botox injections are employed on the theory that a dilute solution of the toxin will partially paralyze the muscles and lessen their ability to forcefully clench and grind the jaw, whilst aiming to retain enough muscular function to enable normal activities such as talking and eating. This treatment typically involves five or six injections into the masseter and termporalis muscles, and less often into the lateral pterygoids, (given the possible risk of decreasing the ability to swallow).[38] It takes a few minutes per side, and the patient may start feeling the effects by the next day, and may last for about three months. Occasionally, bruising can occur, but this is quite rare. The dose of toxin used depends upon the person, and a higher dose may be needed in people with stronger muscles of mastication. With the temporary and partial muscle paralysis, atrophy of disuse may occur, meaning that the future required dose may be smaller or the length of time the effects last may be increased.[39][40][non-primary source needed]

Dietary supplements

Some suggest that taking certain combinations of dietary supplements may alleviate bruxism; pantothenic acid,[citation needed] magnesium,[41][medical citation needed] and calcium.[citation needed] Calcium is known to be a treatment for gastric problems, and gastric problems such as acid reflux are suggested to increase bruxism by some.[42][non-primary source needed] Others suggest that certain GI infections may cause bruxism.[citation needed]

Repairing damage

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.

Epidemiology

More data are available for the prevalence of sleep bruxism compared to bruxism generally. In a Scandinavian study of over 1000 people in the general population, 27.2% reported some form of bruxism,[7] however since many people with bruxism are not aware of their habit, self reported tooth grinding and clenching habits may be a poor measure of the true prevalence. The ICSD-R states that 85-90% of the general population grind their teeth to a degree at some point during their life, although only 5% will develop a clinical condition.[8]

Children are reported to brux as commonly as adults. It is possible for sleep bruxism to occur as early as the first year of life - after the first teeth (deciduous incisors) erupt into the mouth, and the overall prevalence in children is about 14-20%.[43] The ICSD-R states that sleep bruxism may occur in over 50% of normal infants.[8] Often sleep bruxism develops during adolescence, and the prevalence in 18 to 29 year olds is about 13%.[43] The overall prevalence in adults is reported to be 8%, and people aver the age of 60 are less likely to be affected, with the prevalence dropping to about 3% in this group.[43] For sleep bruxism, males are as equally affected as females,[8][43] and 21-50% of people with sleep bruxism have a direct family member who had sleep bruxism during childhood, suggesting that there are genetic factors involved (although no genetic markers have yet been identified).[43]

History

Frohman first coined the term bruxism in 1931.[7]

Society and culture

Clenching the teeth is generally displayed by humans and other animals as a display of anger, hostility or frustration. It is thought that in humans, clenching the teeth may be an evolutionary instinct to display teeth as weapons, thereby threaten a rival or a predator.

In the 2005 film Beowulf & Grendel, a modern reworking of the Anglo-Saxon poem Beowulf, Selma the witch tells Beowulf that the troll's name Grendel means "grinder of teeth", stating that "he has bad dreams", a possible allusion to Grendel traumatically witnessing the death of his father as a child, at the hands of King Hrothgar. The Geats (the warriors who hunt the troll) alternatively translate the name as "grinder of men's bones" to demonize their prey.

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