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THE CLINICAL MANAGEMENT OF

AWAKE BRUXISM

Ronald E. Goldstein, DDS; Wendy Auclair Clark, DDS, MS


Journal of the American Dental Association (2017)
Volume 148(6), Pg – (387-391)
CONTENTS
• Introduction
• Risk Factors
• Recognition and Diagnosis
• Correlations and comorbidities
• Treatment modalities
Occlusal appliances and considerations
Psychosocial approaches
Medical treatments
• Conclusion
• References
INTRODUCTION

• Bruxism is the parafunctional grinding of teeth; an oral habit


consisting of involuntary rhythmic or spasmodic nonfunctional
gnashing, grinding, or clenching of teeth, in other than
chewing movements of the mandible, which may lead to
occlusal trauma.(GPT – 9)

• Also called occlusal neurosis, tooth grinding.

Bruxism

Diurnal Nocturnal
CAUSES OF BRUXISM
Central factors

• 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
bruxism patients.

• An imbalance between both the pathways, results in


movement disorder like Parkinson’s disease and this
imbalance occurs with the disturbances in the dopamine
mediated transmission of action potential. In case of bruxism
there may be an imbalance in both the pathways.

F. Lobbezoo & M. Naeije. Bruxism is mainly regulated centrally, not peripherally. Journal of Oral
Rehabilitation 2001; 28: 1085-1091
Psychosocial factors

• Awake bruxism or diurnal bruxism can be associated with


stress due to familial responsibility or work pressure.

Peripheral factors

• Bruxism is commonly considered to be related to deviations in


dental occlusion and articulation. Giffin et al has mentioned
that for an effective management of bruxism, establishment
of harmony between maximum intercuspation and centric
relation is required.

F. Lobbezoo & M. Naeije. Bruxism is mainly regulated centrally, not peripherally. Journal of Oral
Rehabilitation 2001; 28: 1085-1091
HOW TO ASSESS BRUXISM ?
QUESTIONNAIRE

Are you ever


aware or have
you been told of
clenching your
teeth

Has anyone Do you feel


heard you QUESTIONS fatigue or
grinding your soreness in your
teeth? jaw?

Do you ever feel


your teeth or
gums being sore?
CLINICAL EXAMINATION

Presence of tooth
wear seen in
normal and
eccentric jaw
movements

Parafunctional
oral activity INDICATORS OF Masticatory
waxing in BRUXISM muscle
wakefulness and ACTIVTY discomfort,fatiq
waning in sleep ue,stiffness

Clicking or locking
of TMJ
• Awake bruxism has been reported to have an estimated
prevalence of 22.1–31% among the adult population.

• In the absence of subjective awareness, past bruxism can be


inferred from presence of clear wear facets that are not interpreted
to be the result of masticatory function. Contemporary bruxism can
be observed through sleep laboratory recordings.(American
Academy of Orofacial Pain 2008).

• It is much more difficult to discriminate awake bruxism with or


without TG from early signs of Parkinson’s disease or other
neurodegenerative diseases .

• Dentists need to be able to recognize the oromandibular


manifestations of the movement disorders so that patients can be
referred to a neurologist for diagnosis and management.

G. J. Lavigne et al. Bruxism physiology and pathology: an overview for clinicians. Journal of Oral
Rehabilitation 2008; 35: 476–494
RISK FACTORS FOR AWAKE BRUXISM

• Psychological stress/Anxiety
• Selective serotonin reuptake inhibitors(SSRI)
• Drug abuse (Cocaine,Amphetamine,Ecstasy)

Takafumi Kato et al.Current knowledge on Awake and Sleep Bruxism:Overview.Alpha Omegan


.2003;96:24-28
RECOGNITION AND DIAGNOSIS

• Parafunctions during an awake state can be diagnosed by


means of direct questions and visual observation of patient
behaviour.

• Another critical way for clinicians to identify a patient with a


parafunctional habit is by damage to tooth structure.
The patient had an awake bruxism habit—
grinding his anterior teeth in times of stress.

H/O awake and sleep bruxism.While clenching his


teeth during a strenuous situation, he fractured
his right maxillary canine through the fiber post
and core.
• Other intraoral signs include indentations along the side of
the tongue, as well as bony exostoses or tori.

• Periodontal changes, including widening of the periodontal


ligament, tooth mobility, and recession,also may occur.

• Oromandibular movements can be described as usual,unusual


but acceptable or abnormal.

• It is important for the clinician to discern what that habit


specifically is.
• The dentist can prescribe easy to use electromyographic
devices to use to confirm muscle activity (BiteStrip).

• After initial screening and suspicion of a parafunctional habit,


more in-depth patient questionnaires and at-home journaling
can help further identify what type of parafunctional activities
the patient engages in and how often.
Very low bruxism – Less than 40 events
Mild bruxism - 40-74 events
Moderate bruxism – 75-124 events
Severe bruxism - 125 or more events
E (Error) - Study too short or other
problems

Bite Strip

Bite Strip placed over Masseter


muscle
GRADING OF AWAKE BRUXISM
• For a grading of ‘definite’ awake bruxism
Self-report
Clinical examination
Electromyographic recording
are needed, preferably combined with the so-called ecological
momentary assessment methodology, which enables a true
estimate to be obtained of, amongst others, the frequency of
tooth contacts during wakefullness.
CORRELATIONS AND COMORBIDITIES
• A strong correlation exists between temporomandibular
disorders (TMDs) and bruxism.

• Studies shows that diurnal bruxism exacerbates TMD


symptoms,including headache, muscle and joint pain, and jaw
locking.

• Any patient who self-reports TMD, morning masticatory


muscle pain or stiffness, or joint noises should be considered
a possible bruxer and then identified as a sleeping or awake
bruxer.
• The activity of bruxism results in muscle hyperactivity,
particularly the masseteric sling muscles (masseter and
medial pterygoid) and the lateral pterygoids.

• Therefore, myalgia and muscle spasm can result, as well as


temporal headaches.

• Carlsson and colleagues found that most self identified adult


bruxers were also bruxers as children.

• Specifically, awake bruxers continued to exhibit awake


bruxism.
TREATMENT MODALITIES
• Lobbezoo and colleagues conducted a thorough systematic
review of the treatment modalities for both waking and
sleeping bruxism.

• They summarized the best approach as the “triple-P”


approach: plates, pep talk, and pills.

• Specifically, they referred to stabilization splints, counselling,


and short-term pharmacotherapy
OCCLUSAL APPLIANCES AND
CONSIDERATIONS
• This treatment is noninvasive and is a popular first treatment
option.

• The splints usually are made of hard acrylic because soft


splints are more difficult to adjust and actually may encourage
parafunctional activity.

Example of a waking appliance. The thin material allows for


normal function.
PSYCHOSOCIAL APPROACHES
• Treatment modalities include stress reduction,
counseling, lifestyle changes, and hypnotherapy.

• Cue conditioning or cuing is another treatment option,


particularly with children and people who are mentally
challenged.

• With this treatment, vocal or physical cues are repeated


when a patient bruxes.
• Another alternative treatment option involves biofeedback to
curb the behavior.

• A small electric impulse is emitted during the muscle activity,


ultimately stopping the action of bruxism
MEDICAL TREATMENTS
• Medications such as muscle relaxants are used.

• Clinicians should prescribe these medications for only short


periods.

• Another pharmacologic approach involves the use of


botulinum toxins in the treatment of bruxism.

• The clinician injects botulinum toxins into the masticatory


muscles that are triggered with bruxism, including the
temporalis and masseter.
• Studies indicate that the use of this treatment can cause
some bruxism-related muscle pain to subside and may reduce
bruxism events.

• Clinicians should advocate it only after attempting more


minimally invasive approaches.
GENERIC NAME AVERAGE DAILY DOSE MAXIMUM DAILY DOSE

Cyclobenzaprine 10 mg tid 60 mg/day


Metaxalone 800 mg 3-4 times/day 2400 mg/day
Methocarbamol 1000 mg qid 8000 mg/day
Carisoprodol 250 mg tid 1400 mg/day
max 2-3 weeks
Chlorzoxazone 250-500 mg tid 1500 mg/day
(750 mg max
single dose)
CONCLUSION
• Identification and treatment of awake bruxism can present a
challenge for the clinician.

• Because awake bruxism is linked more closely to emotional


stress than is nocturnal bruxism, psychological treatment may
be indicated in conjunction with dental treatment.

• In addition, lifestyle changes are recommended.

• A concrete plan of patient education is a first step to solving


the problem of awake bruxism.

• Once aware of the bruxism events, the patient can begin to


make the necessary change in behavior.
• If behavioral change is not successful, a daytime appliance not
only to prevent damage but also to promote awareness is
recommended.

• When possible, it is best to prevent the need for extensive


dental treatment.

• Inhibiting bruxism, both awake and sleeping, is in the patient’s


best interest.

• Thus, it is imperative for the dentist, hygienist, and dental


assistant to educate and reeducate the patient during and
after any restorative treatment.
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