Clinical

Tooth surface attrition and bruxism: an overview

Bruxism can happen without any prior medical conditions, but what causes it and is the patient aware of having it? This article describes the signs, causes, symptoms and treatment for bruxism, including the role of the dental nurse in the construction of a bite guard

ttrition can be defined as the loss of teeth structure by tooth-to-tooth or tooth-torestoration friction as caused by the action of chewing or clenching of teeth. Attrition results more rapidly from a gritty diet and may be seen more commonly in immigrants from developing countries. Mild degrees of attrition are normal, but more severe signs of attrition commonly occur as a result of bruxism. Bruxism is the involuntary periodic grinding or clenching of the teeth. It most often occurs at night during sleep, but it may also occur during the day.

Aetiology of bruxism

The aetiology of bruxism is multifactorial, determined by an association of psychological, emotional, dental, systemic, occupational and idiopathic factors (Pavone, 1985). It is an oral para-functional activity that can happen to anyone, at any time. It can occur during the day as an unconscious habit during stressful Hazel J Fraser is a part-time lecturer in dental nursing, West Cheshire College, Chester and an examiner for the National Certificate for Dental Nurses. She is also a committee member for the National Examination for Dental Nurses. She works part-time as a dental therapist in general dental practice Email: hazel.fraser2@tesco.net

Figure 1. Attrition of tooth surface, indicative of bruxism situations. It occurs for only a few seconds at a time but happens many times during light sleep. See Table 1 for a breakdown of the different types of bruxism. Most nocturnal bruxists are unaware of their habit. It can result in a grinding noise, causing disturbed sleep and insomnia. In many cases, a sleeping partner or parent will notice the bruxism before the person experiencing the problem becomes aware of it. It has been shown that 10-20 per cent of the population suffers from teeth grinding or bruxism, but the incidence rises to 90 per cent when mild subconscious grinding during the day and night is included (Cawson and Odell, 2008). Nocturnal bruxism is recognised as being primarily one of the most common sleep disorders (Lobbezoo et al, 2001). It is often associated with other sleep disorders, such as snoring, obstructive sleep apnoea and sleep walking and talking. Smoking is a significant factor associated with bruxism for both men and women. It is estimated that smokers are five times more likely to have bruxism and grinding episodes than non-smokers. Nicotine is a neuro-chemically active substance and is associated with motor activity during sleep. Bruxism can be divided into primary or secondary. Primary bruxism occurs
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when there is no predisposing medical complaint present. Secondary bruxism can be associated with certain medications such as antidepressants or recreational drugs (cocaine and ecstasy), and disorders such as Parkinsons disease, depression and major anxiety. Children with cerebral palsy often have signs of bruxism.
Peter Lamb

Diagnosis

Bruxism can be identified by abnormal wear patterns of the occlusal surface (Figure 1), abfractions and fractures in the teeth. See Table 2 for tooth features of bruxism. Tooth attrition is also seen on the cusps of the molars, which are often flattened or rounded. There is wear on the incisal edges of the incisors and the canines. Generalised tooth substance loss is the result of several contributory factors. There may be an erosive component contributing to tooth tissue loss in a bruxist, especially in the case of a bruxist who is also consuming excessive amounts of carbonated drinks at bedtime (Walmsley et al, 2002). If this is the case, exposed dentine surfaces will be worn away more rapidly than the enamel, producing cupping of the contact surfaces (Murray et al, 2003). This can result in tooth sensitivity, particularly of the anterior teeth. The majority of bruxists experience no pain, but bruxism can lead to excessive strain on the temporomandibular joint (TMJ) (Figure 2), leading to dysfunction and degenerative changes. There might be pain or tenderness in the joint, clicking noises and restricted movement of the mandible. There may be pain in the muscles of mastication and this can, in turn, lead to spasm of the muscles, especially in the morning after waking (Table 3). The pain is similar to the pain after exercising. The bruxist may complain of tenderness in the muscles of mastication at times of stress. Hypertrophy of the masseter and anterior temporalis muscles is often present (Table 4). Sometimes there are fractured teeth or restorations and widened periodontal ligament spaces on radiographs.
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Figure 2. The temporomandibular joint

Table 1. Types of bruxism

Diurnal Occuring during the day Nocturnal Occuring during the night Primary No medical conditions present Secondary Medical condition present

Table 2. Tooth features of bruxism

Excessive wear facets on the molars and incisors Gingival recession Mobility of the teeth Fractured teeth and/or restorations Widened periodontal ligament Bruxism and tooth wear can lead to the loss of cuspal guidance resulting in the posterior teeth being prone to fracture, especially those that are heavily restored. Bruxism is associated with the ridging of the cheek mucosa along the occlusal plane, and scalloping of the lateral border of the tongue (Coulthard et al, 2003). The bruxist may complain of headaches and/or facial pain and stiffness in the shoulders, especially in the morning after waking.

Prevalence

Bruxism is prevalent in both sexes, but the symptoms are most common
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means that more time is spent in the deeper sleep stages and less arousals occur. There is no evidence concerning the effect of any of these treatments upon teeth wear. A bite guard can be worn at night only, initially for one month, to protect the maxilla and mandible from the grinding effects (Figure 3), and any wear is likely to be on the splint rather than on the teeth. Night guards are provided by the dentist. Impressions are taken of the upper and lower teeth and are then sent to the dental laboratory where the guard is made.

Table 3. Patients symptoms of bruxism

Sensitivity of anterior teeth Pain or tenderness in front of the ear Clicking noises in front of the ear Restricted movement of the jaws Headaches Stiffness in the shoulders Pain on eating

Table 4. Joint and muscle features of bruxism

Degenerative changes in the temporomandibular joint (TMJ) Pain and tenderness in the TMJ Clicking noises in the TMJ Restricted movement in the TMJ Pain in the muscles of mastication Hypertrophy of the muscles of mastication in young women and people who are anxious and under emotional stress, either experienced or anticipated. Tooth grinding is also a response to frustration and can become a habit. It is more common in young adults, aged 2544 years, and becomes less common after middle age. It can even be seen in people with full dentures. Statistics show that one in two staff members of the armed forces serving in the second Gulf War suffered from post-traumatic stress disorder, a major symptom of which is bruxism. Bruxism is common in children, and is more noticeable in children with an intellectual and/or physical disability. It may result in great wear of the primary teeth, producing pulpal exposure and subsequent infection of the pulp. Most children show some degree of bruxism. and may include anxiolytic drugs, such as diazepam. The safety of their use is still in question as severe morning hypotension (low blood pressure) has been noted in 20 per cent of patients (Bruxism Association, 2010). Psychological counselling, physiotherapy or occlusal splint therapy (either hard or soft) to prop open the occlusion are also used. Botulinum toxin is a biological toxin which acts as a paralytic. Although it is highly toxic, it is used in minute doses both to treat painful muscle spasms and as a cosmetic treatment. It is administered by intramuscular injection and the paralytic effects last for 36months. However, one study found that patients needed several treatment sessions and even then the researchers were unclear as to whether the response was favourable (Bruxism Association, 2010). Stress management, such as relaxation, hypnosis or sleep advice, may be recommended. Avoiding stimulants, such as tea, coffee or cigarettes, for several hours before bed and maintaining a regular sleep schedule promotes better sleep which

The dental nurses role in the construction of bite guards

The General Dental Councils (2009) guidance document, Scope of Practice who can do what in the dental team, states that dental nurses prepare, mix and handle dental materials. This would include the alginate impression material required for the construction of a bite guard. The guidance document also states that an additional skill the dental nurse could develop is, with appropriate training, taking impressions to the prescription of a registered dentist or a clinical dental technician, where appropriate, i.e. pouring, casting and trimming of study models for the construction of a mouth guard to the prescription of a registered dentist. Mouth guards do not stop bruxism but they do protect teeth and dental work from the damage that often results from clenching and grinding. They are also known as bite-raising appliances,
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Management and treatment

Managing bruxism is complex and depends upon the aetiology of the condition. Treatment depends on the symptoms
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Figure 3. In long-standing cases of bruxism, bite guards or splints can be used

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bite plates, night guards and occlusal bite guards. If there is no improvement, treatment should be discontinued to prevent any adverse effects on the soft tissues and the occlusion. The patient may also complain of pain in the temporomandibular joint, headaches, fractured fillings and/or teeth and pain in the muscles of mastication. Bruxism is particularly prevalent in people who are suffering stressful situations and it is also seen in children. Bite guards, which are worn at night, are one of the treatments options available to try to correct the habit and protect the teeth. DN
Cawson RA, Odell EW (2008) Cawsons Essentials of Oral Pathology and Oral Medicine. 7th edn. Elsevier Limited, Philadelphia Coulthard P, Horner K, Sloan P, Theaker E (2003) Oral and Maxillofacial Surgery, Radiology, Pathology and Oral Medicine. Elsevier Limited, Philadelphia General Dental Council (2009) Scope of Practice - who can do what in the dental team. GDC, London Lobbezoo F, van Denderen RJ, Verheij JG, Naeije M (2001) Reports of SSRI-associated bruxism in the family physicians office. Orofac Pain 15(4): 3406 Murray JJ, Nunn JH, Steele JG (2003) Prevention of Oral Disease. 3rd edn. Oxford, New York Pavone BW (1985) Bruxism and its effect on the natural teeth. J Prosthet Dent 53(5): 6926 Walmsley AD, Walsh TF, Burke FJT, Shortall ACC, Lumley PJ, Hayes-Hall R (2002) Restorative Dentistry. Churchill-Livingston, Edinburgh

Further information

For further information and assistance, contact the Bruxism Association (www. bruxism.org.uk), a not-for-profit organisation dedicated to helping sufferers and their bed partners improve their sleep. They will be able to help with information about teeth grinding, its causes, and products that enable teeth grinders to manage their condition.

Key PoinTs
n Bruxists are often unaware of the habit of grinding and clenching their teeth during sleep. n cause of bruxism is mulThe tifactorial but is often linked with stress. n Bruxism Association (www. The bruxism.org.uk) is a good source of information and support. n dental nurse, with approThe priate education and training, could construct bite guards for patients with bruxism.

Conclusion

Bruxism is likely to occur during light periods of sleep and the noise of grinding can wake a sleeping partner. It results in tooth attrition with tooth surface loss, particularly noticeable on occlusal surfaces, incisal edges and molar cusps.

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