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![‘Bruxism’ …….. Brychein odontas ……grinding the teeth
‘Total parafunctional daily or nightly activity that includes
grinding, gnashing or clenching of teeth that takes place in the
absence of subjective consciousness and it can be diagnosed by
the presence of tooth wear facets which have not resulted from
chewing function.’ [AAOP]
Ramfjord (1966) - Defined bruxism as a habitual grinding of teeth
where individual is not chewing or swallowing.](https://image.slidesharecdn.com/bruxism-191219152747/75/Bruxism-and-its-effect-on-periodontium-4-2048.jpg)
![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.
• Bruxism appears in approximately 13% of 18- to 29- year-olds and then
significantly decreases with age .
• Studies shows that prevalence of awake bruxism is more in women compared
to men which is mainly associated with stress whereas sleep bruxism shows
no gender prevalence.[Shetty et al 2010]](https://image.slidesharecdn.com/bruxism-191219152747/75/Bruxism-and-its-effect-on-periodontium-6-2048.jpg)
![Bruxism [AASD]
Awake Sleep
Rhythmic jaw
muscle activity
Phasic
Tonic
Mixed
Task with
concentration
Emotionally
stressed](https://image.slidesharecdn.com/bruxism-191219152747/75/Bruxism-and-its-effect-on-periodontium-8-2048.jpg)
![Classification ……
According to WHO [2013] Revised Classification
• Primary
• Secondary
ICSD-R [2013]
According to severity
Mild
Moderate
Severe
According to duration
Acute
Subacute
Chronic](https://image.slidesharecdn.com/bruxism-191219152747/75/Bruxism-and-its-effect-on-periodontium-9-2048.jpg)
![Tooth wear index [Ekefeldt et al in 1990]
• 0: no wear or negligible wear of enamel
• 1: obvious wear of enamel or wear through the enamel to the dentine in
single spots
• 2: wear of the dentine up to one-third of the crown height
• 3: wear of the dentine up to more than one-third of the crown height;
excessive wear of tooth restorative material or dental material in the crown
and bridgework, more than one-third of the crown height.](https://image.slidesharecdn.com/bruxism-191219152747/75/Bruxism-and-its-effect-on-periodontium-14-2048.jpg)
![‘Oxidative stress and degenerative TMJ hypothesis’ abnormal mechanical stresses
on the TMJ may lead to generation of free radicals through hypoxia reperfusion
injury, microbleeding leading to haemoglobin deposition in intra-articular tissues,
phospholipid catabolism, and other mechanisms.This accumulation of free radicals
in the joint may lead to cartilage matrix degradation and elaboration of an
inflammatory response, ultimately affecting the biomechanical properties of
articular tissues.[Milam SB et al ,1998]
‘TMJ osteoarthrosis’-Abnormal joint loading may change the equilibrium between
cartilage degradation and synthesis,exceeding functional adaptive capacity of
tissues in the joint.Excessive joint loading can lead to proteoglycan degradation,
alterations in synovium, inflammation, and changes in synovial fluid leading to
impaired lubrication and nutrition of chondrocytes and ultimately cartilage
degradation.[steganga et al in 1989]](https://image.slidesharecdn.com/bruxism-191219152747/75/Bruxism-and-its-effect-on-periodontium-23-2048.jpg)
![Effect of bruxism in pediatric patients
• Anxiety and stress are the primary contributing factors to bruxism in children.
• Studies demonstrated that SB, snoring and obstructive sleep apnea are closely
related in children, but the mechanism behind this relationship remains
unknown. These sleep disorders are often associated with mouth breathing
and adenoid/tonsil hypertrophy/infection.[Lam et al 2011]
• Children with behavior and attention difficulties might exhibit more disruption
of sleep pattern with predisposition to bruxism[Beebe et al 2004]](https://image.slidesharecdn.com/bruxism-191219152747/75/Bruxism-and-its-effect-on-periodontium-24-2048.jpg)
![ICSD-R CRITERIA [2013]
The ICSD-R listed diagnostic criteria for sleep bruxism. The minimal criteria
include both of the following:
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).
E. The presence of other sleep disorders](https://image.slidesharecdn.com/bruxism-191219152747/75/Bruxism-and-its-effect-on-periodontium-32-2048.jpg)
Uploaded byRamya Ganesh
Bruxism and its effect on periodontium
This document provides an overview of bruxism, including its definition, etiology, classification, clinical features, effects on teeth, muscles, TMJ, and diagnosis and treatment approaches. Bruxism is defined as the habitual grinding or clenching of teeth and can occur during sleep (sleep bruxism) or while awake. The causes of bruxism are multifactorial, including genetic factors, stress, sleep disorders, and malocclusions. Bruxism can lead to tooth wear, muscle pain, headaches, and damage to dental restorations, implants, and the TMJ. Diagnosis involves assessing clinical signs and symptoms, with complementary methods including questionnaires, dental wear analysis, and polysomnography. Treatment
In this document
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Introduction to bruxism, definitions, and its historical background in the dental field.
Definition and etiology of bruxism, historical context, and prevalence statistics.
Factors causing bruxism including occlusal issues, psychosocial influences, and classification by WHO.
Understanding tooth contact processes during sleep and wakefulness, linked to bruxism.
Clinical signs, tooth wear indexes, and effects of bruxism on periodontium and associated structures.
Impact of bruxism on alveolar bone and muscles, including pain and dysfunction in TMJ.
Influence of anxiety and sleep disorders on bruxism in children, highlighting associated issues.
Methods for diagnosing bruxism including clinical assessments and criteria outlined by ICSD-R.
Various treatment strategies including therapy, medications, botulinum toxin, and splints.
Orthodontic and occlusal management of bruxism effects on dental implants and occlusion.
Summarization of bruxism as a complex issue in dental practice, with references for further reading.
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Bruxism and its effect on periodontium
- 1. BRUXISM DR RAMYA GANESH SENIORLECTURER MALABAR DENTAL COLLEGE AND RESEARCH CENTRE
- 2. CONTENTS• Introduction • Definition •Etiology • Classification • Clinical features in bruxism • Physiologic process of tooth contact while asleep and awake • Tooth wear and bruxism • Periodontium and bruxism • Muscles and bruxism • TMJ and bruxism • Bruxism and implants • Diagnosis • Treatment • Conclusion • Reference
- 3.
- 4. ‘Bruxism’ …….. Brycheinodontas ……grinding the teeth ‘Total parafunctional daily or nightly activity that includes grinding, gnashing or clenching of teeth that takes place in the absence of subjective consciousness and it can be diagnosed by the presence of tooth wear facets which have not resulted from chewing function.’ [AAOP] Ramfjord (1966) - Defined bruxism as a habitual grinding of teeth where individual is not chewing or swallowing.
- 5. History "La bruxomaniae”- byMarie Pietkiewics in 1907. In 1931, Frohman first coined the term bruxism. In the 1960s, Sigurd .P. Ramfjord put forward the theory that occlusal factors were responsible for bruxism. Use of PSG in detection of SB -Velly et al in 1992. Use of bite force detectors –Holmgren et al in 1993. Use of EMG in detection of SB-Lavigne et al in 1997.
- 6. Prevalence • The prevalenceof 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. • Bruxism appears in approximately 13% of 18- to 29- year-olds and then significantly decreases with age . • Studies shows that prevalence of awake bruxism is more in women compared to men which is mainly associated with stress whereas sleep bruxism shows no gender prevalence.[Shetty et al 2010]
- 7. ETIOLOGY Morphologic • Occlusion andarticulation • Orofacial anatomy Psychosocial • Sleep-related factors • Neurochemical factors • Heredity • Trauma and diseases • Stress • habits
- 8. Bruxism [AASD] Awake Sleep Rhythmic jaw muscle activity Phasic Tonic Mixed Task with concentration Emotionally stressed
- 9. Classification …… According toWHO [2013] Revised Classification • Primary • Secondary ICSD-R [2013] According to severity Mild Moderate Severe According to duration Acute Subacute Chronic
- 10. Physiologic process oftooth contact during sleep
- 11. Physiologic process oftooth contact in awake bruxism
- 12.
- 13. Effect of Bruxismin teeth
- 14. Tooth wear index[Ekefeldt et al in 1990] • 0: no wear or negligible wear of enamel • 1: obvious wear of enamel or wear through the enamel to the dentine in single spots • 2: wear of the dentine up to one-third of the crown height • 3: wear of the dentine up to more than one-third of the crown height; excessive wear of tooth restorative material or dental material in the crown and bridgework, more than one-third of the crown height.
- 15. Effects of bruxismin periodontium Tooth mobility Pathologic migration Gingival recession
- 16. Effects of bruxismin periodontium….
- 17. Effects of bruxismin periodontium
- 18. Effect of bruxismin periodontium In 1954,Mecapanpan and Weinmann reported that excessive pressure and tension produced alterations in pdl and inflammation passed in to the altered area and resulted in necrosis of periodontium. This necrotic tissue would act as a barrier preventing inflammation from extending in to underlying periodontal tissues. Postulated that when inflammation spreads beyond marginal gingiva and combines with occlusal trauma , they become interrelated co- destructive factors in periodontitis.
- 19. Effects of bruxismon alveolar bone • Buttressing bone - New bone formation takes place as an attempt to compensate for lost bone. Central BBF Buttressing bone formation occurs within the jaw ,the buttressing endosteal cells deposit new bone which restores bony trabeculae and reduces size of marrow spaces. Peripheral BBF Mainly occurs in facial and lingual surfaces of alveolar plate. Lipping Depending on severity, peripheral buttressing may produce a shelf like thickening of alveolar margin.
- 20. Effect of bruxismin muscles • bFunctional disturbance of jaw dynamics Pain during jaw movement Hypertonicity or muscle hyperactivity -Trismus -Myofascial pain -Myospasm -Swelling
- 21. Stress + occlusaldysharmony Hyperactivity and muscle pain sensitivity Myalgia Muscle spasm Local vasoconstriction Anaerobic glycolysis Nociceptive catabolites + edema
- 22. Effect of bruxismin TMJ
- 23. ‘Oxidative stress anddegenerative TMJ hypothesis’ abnormal mechanical stresses on the TMJ may lead to generation of free radicals through hypoxia reperfusion injury, microbleeding leading to haemoglobin deposition in intra-articular tissues, phospholipid catabolism, and other mechanisms.This accumulation of free radicals in the joint may lead to cartilage matrix degradation and elaboration of an inflammatory response, ultimately affecting the biomechanical properties of articular tissues.[Milam SB et al ,1998] ‘TMJ osteoarthrosis’-Abnormal joint loading may change the equilibrium between cartilage degradation and synthesis,exceeding functional adaptive capacity of tissues in the joint.Excessive joint loading can lead to proteoglycan degradation, alterations in synovium, inflammation, and changes in synovial fluid leading to impaired lubrication and nutrition of chondrocytes and ultimately cartilage degradation.[steganga et al in 1989]
- 24. Effect of bruxismin pediatric patients • Anxiety and stress are the primary contributing factors to bruxism in children. • Studies demonstrated that SB, snoring and obstructive sleep apnea are closely related in children, but the mechanism behind this relationship remains unknown. These sleep disorders are often associated with mouth breathing and adenoid/tonsil hypertrophy/infection.[Lam et al 2011] • Children with behavior and attention difficulties might exhibit more disruption of sleep pattern with predisposition to bruxism[Beebe et al 2004]
- 25. Diagnosis Clinical history Psychological assessmentin terms of anxiety and hyperactivity Treatment Behaviour change: parents should be taught the techniques of relaxation and sleep hygiene Occlusal splints Stainless steel crowns
- 26. Effects of bruxismin implants - Bruxism can lead to implant failure by loss of integration and screw fracture. -Studies by Richter et al concluded that forces more than 1 Mpa causes peak cervical stress leading to fracture of implants. Early integration loss • Are spontaneous avulsions of implants that are not yet osseointegrated. Late integration loss • Fibrous repair occurs more than bone formation which leads to fracture of implants that are partially osseointegrated. Delayed integration loss • Occurs in already integrated and prosthetically restored implants.
- 27. Prosthetic rehabilitation inbruxism patient Single implant Partially edentulous Fully edentulous In posterior segment- implants of wider diameter with a wide prosthetic platform and internal connection . In anterior segment- implant should contact only during maximum tooth clenching Splinted restorations are used in adjoining Implants ,the support area should be increased to the maximum to counteract the effect of potential overload. For maxilla, ceramic-on metal prosthesis cemented to multiple implants and mandible implants should be in fuse as the resin in occlusal surface might wear away.
- 28. Diagnosis of bruxism Clinicaldiagnosis Symptoms Questionnaires and personal interview Signs Tooth wear Fracture Complementary methods Intraoral devices Tooth wear quantification and bite force detectors Devices Masseter EMG Sleep PSG Bite strip
- 29.
- 30. Signs for diagnosisof bruxism
- 31.
- 32. ICSD-R CRITERIA [2013] TheICSD-R listed diagnostic criteria for sleep bruxism. The minimal criteria include both of the following: 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). E. The presence of other sleep disorders
- 33. TREATMENT Relaxation therapy Psychotherapy Restorative Botulinum toxin Bruxismsplint Pharmacological Biofeedback Electric method Acupuncture
- 34.
- 35.
- 36. Restorative materials Composite resins GIC Dentalporcelains Amalgams
- 37. Occlusal splints/Night guards •When closing mouth simultaneous occlusion of all vestibular cusps and lower incisors should occur on surface of splint. • During lateral movements, contact should exist only at level of canine on working side. • During protrusion, only contact in anterior segment of splint should occur.
- 38. Pharmacologic considerations Anxiolyticdrugs-BZDs, buspirone Neuroleptics – chlorpromazine Beta blockers- propranolol Antidepressant drugs- venlafaxine
- 39. Pharmacologic considerations……….. Vapo coolantssuch as ethylchloride for pain within the TMJ area,local anaesthetic injections directly into the TMJ or into the muscles,sedatives and muscle relaxants are used Placebo may be used to rule out the psychological etiology Medications can be prescribed for few days to alter the sleep arousal and anxiety level,eg.,diazepam.
- 40. Botulinum toxin injection Derivedfrom Clostridium botulinum –a gram negative spore forming anaerobic bacterium. 7 neurotoxic types …BTX-A,B,C1,D,E,F,G. MOA- toxin binds to receptors on cholinergic terminals….molecuele is internalized by endocytosis…..it interferes with release of cholinergic vesicles…….… muscle contractions.
- 43.
- 44.
- 45. Orthodontic corrections Malocclusions suchas class II and class III relation, open bite and crossbite when associated with functional maloclussion may create a predisposition to bruxism.
- 46. Occlusal adjustments • Anyprematurities or occlusal interference in restorations which is not able to withstand the forces of bruxism. • Coronoplasty • However extensive occlusal adjustments are contraindicated. • Before any occlusal adjustments are done the muscles should be brought back to a relaxed position to allow the jaw to resume its normal physiologic movements
- 47. CONCLUSION Bruxism is aharmful parafunctional habit seen in both children and adults. The diagnosis and treatment of bruxism is a very challenging aspect in dentistry as the etiology is multifactorial and treatment is multispeciality and multidisciplinary in nature. There should be a good co-operation between the dentist and the patient so that a dentist can intervene and treat the habit at right time.
- 48. REFERENCE • Textbook ofperiodontology by Carranza ,10th edition. • Textbook of bruxism theory and practice by Daniel A ,1st edition. • Bruxism and prosthetic treatment:a critical review by Anders et al 2011 • Relationship between bruxism and TMJ disorders:a systematic review of literature from 1998 to 2008 by Daniel et al 2010. • Epidemiology of bruxism in adults-a systematic review of literature by Daniele manfredini et al 2011. • Bruxism physiology and pathology:an overview for clinicians –G.J.Lavigre et al 2008. • Bruxism multiple causes and its effects on dental implants-an updated review Lobbezo et al 2006.
- 49. • Review articleon principles of management of bruxism by Lobbezo et al in 2008. • Pharmacology of sleep bruxism –Macedo C.R et al 2008. • Is bruxism a risk factor for dental implants :a systematic review of literature Daniele et al 2014.
Editor's Notes
- #4 Bruxism is one of the most parafunctional habbits commonly seen in adults and children …current studies reveal that etiology is unknown but is multifactorial……. …….one of the major challenges of dentists is to diagnose bruxism restore the functional occlusion and oral hygiene back to normal stage….
- #9 Sleep bruxism originates in CNS and is associated with lightening of sleep or so called micro arousal……awake bruxism is seen in day time …….Phasic-corresponds to last three muscle contraction bursts of 0.25 to 2.0 seconds of duration separated by two inter-burst intervals. Tonic-muscle contraction bursts that lasts for more than 2 seconds Mixed-a combination of phasic and tonic episodes separated by a 30 sec interval.
- #10 Primary –not related to any medica conditions…..secondary- side effect of prescribed medications…. International classification of sleep disorders revised mild as occurring less than nightly, with no damage to teeth or psychosocial impairment; moderate as occurring nightly, with mild impairment of psychosocial functioning; and severe as occurring nightly, and with damage to the teeth, tempormandibular disorders and other physical injuries, and severe psychosocial impairment.[13] namely acute, which lasts for less than one week; subacute, which lasts for more than a week and less than one month; and chronic which lasts for over a month.[13]
- #14 Tooth wear is a term referring to different processes which either individually or in association lead to irreversible loss of tooth hard tissue. When occlusal forces exceed 300 newtons in molar area results in wearing away of teeth structures….cuspal fracture and attrition are one of the most clinical signs of tooth wear seen in relation to bruxism….dentinal hypersensitivity to cold or hot foods….. Studies by Shetty et al in 2010 has shown tooth wear in 78 % of subjects cuspal fracture in 12 % of subjects muscle and TMJ pain in 7 %of subjects and 3% due to drugs…..
- #16 Mainly characterised by…..
- #17 Traumatic forces can occur in normal periodontium with normal height of bone, normal periodontium with reduced ht of bone and marginal periodontitis with rduced ht of bone……In injury body attempts to repair the inury and restore the periodontium which occurs if occlusal forces are diminished if forces are chronic the periodontium will remodel to cushion this impact.in repair stage ,the periodontium tries to repair the damaged part by new CT cells and fibers ,bone and cementum and forced remain traumatic only if damage produced exceeds reparative capacity of tissues.In adaptive remodelling stage, here is a widening pdl which is funnel shaped in crest and angular defects in bone with no pocket formation,and thus the involved teeth becomes loose.
- #18 As long as inflammation is confined to gingiva the inflammatory forces is not affected by occlusal forces but when it extends to supporting periodontal tissues plaque induced inflammation enters the zone influenced by occlusion which Glickman has called as zone of co-destruction.
- #19 Bruxism is being classified as a form of chronic trauma fron occlusion which occurs in periodontium due to gradual changes in occlusion produced by tooth wear,drifting movement,extrusion combined with parafunctional habitKarolyi was the first person to associate bruxism with periodontal lesion….and was hypothesized excessive occlusal forces will cause irreparable periodontal breakdown……
- #20 Bbf buttressing bone formation
- #21 Normal muscular function may be interrupted or altered by bruxism ….when the physiologic mechanism of adaptation and tissur resisitance are overstreched it is possible to trigger a state of muscular pathophysiology involving muscular disorders. This s wen the pt will manifest the foll symptoms such as:
- #23 Internal derangement of TMJ has been defined as an abnormal relationship of articular disc relative to the mandibular condyle,fossa and articular eminence.-disc displacement with reduction and disc displacement without reduction
- #26 Occusal splints shud not alter the growth pattern….in cases of attrition stainless steel crowns can be used. Clinical history to detect pre existing disease like migraine, sleep apnea syndrome, temporomandibular disorders, respiratory problems, need for tonsillectomy, daytime sleepiness and in these cases send the child to specialist competence
- #30 Questionnaire …..personal interview
- #31 Attrition…….cuspal fracture associated with extensive occlusal forces,,,,,,,fractured amalgam restorations………..implant fracture………
- #32 Polysomnographic (sleep laboratory) recordings for sleep bruxism generally include electroencephalogram, EMG, electrocardiogram and thermally sensitive resistor (monitoring air flow) signals along with simultaneous audio–video recordings. Sleep bruxism activity is assessed based on EMG activity in the masticatory muscles (masseter and/or temporalis). Because the sleep laboratory setting offers a highly controlled recording environment, other sleep disorders (e.g. sleep apnoea and insomnia) can be ruled out .Bite strip is A miniature self-contained EMG detector–analyser (BiteStrip) was developed as a screening test for moderate to high level bruxers [46]. The device, which is comprised of EMG electrodes, an amplifier, a central processing unit (CPU) with software, a display which presents the outcome in the morning, a light emitting diode and a lithium battery records the number of masseter muscle activities above a preset threshold.Grind care is comprised of EMG and stimulation electrodes, a microprocessor, a memory for data storage, a display for user interface, light-emitting diodes, a rechargeable battery, a plug-in USB connector for data connection to computer to a battery charger, and a strap for carrying the apparatus around the forehead. It enables the online recording of EMG activity of the anterior temporalis muscle, online processing of EMG signals to detect tooth grinding and clenching and also biofeedback stimulation for reducing sleep bruxism activities.
- #33 International classification of sleep disorders revised criteria
- #35 hypnosis…voluntary relaxation…..excercise
- #36 Counselling….habit awareness and hence voluntary control
- #37 Based on severity of tooth wear ….restorative materials are selected ………..either restorative materials such as amalgams and if pulpal involvement is there rct and crown is necessary………..
- #38 Whilw fabricating splint care shud be taken that
- #39 Anxiolytic-muscle relaxing effect and have a greater safety margin with regard to drug toxicity and have a long half life of 100 hrs. Neuroleptics-make synaptic alterations in basal ganglia levels ,on prolonged intake leads to production of free radicals relaxes the muscle and reduces the pain.
- #41 Botulinum toxin type a is commonly used in treating bruxism cases.
- #42 Botulinum toxin is injected in 5 prominent points in masseter muscle below the imaginary line drawn from tragus to commissure of lips.10 units ……
- #45 On masseter muscle…..is usually a form of Chinese medicine in which microneedles are used which helps in relieving stress from nerves…