a-attrition and bruxism

8/3/2019 A-Attrition and Bruxism

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Clinical

Tooth surface attrition and

bruxism: an overviewBruxism 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 treatmentfor bruxism, including the role of the dental nurse in the construction of a bite guard

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. Sheis also a committee member for the

National Examination for Dental

Nurses. She works part-time as a

dental therapist in general dental

practice

Email: [email protected]

Attrition can be defined as

the loss of teeth structure by

tooth-to-tooth or tooth-to-

restoration 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 mostoften occurs at night during sleep, but it

may also occur during the day.

Aetiology of bruxismThe 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

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, suchas 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

Figure 1. Attrition of tooth surface, indicative of bruxism

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Clinical

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 disorderssuch as Parkinsons disease, depression and

major anxiety. Children with cerebral palsy

often have signs of bruxism.

DiagnosisBruxism 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 contactsurfaces (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 ofmastication 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.

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.

PrevalenceBruxism is prevalent in both sexes,

but the symptoms are most common

Figure 2. The temporomandibular joint

Diurnal

Occuring during the day

Nocturnal

Occuring during the nightPrimary

No medical conditions present

Secondary

Medical condition present

Excessive wear facets on the molars and incisors

Gingival recession

Mobility of the teeth

Fractured teeth and/or restorations

Widened periodontal ligament

Table 1. Types of bruxism

Table 2. Tooth features of bruxism


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Clinical

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, andis 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.

Managementand treatmentManaging bruxism is complex and depends

upon the aetiology of the condition.

Treatment depends on the symptoms

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 paralyticeffects last for 36 months. 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

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.

The dental nurses role in

the construction of biteguardsThe 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,

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

Table 4. Joint and muscle features 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

Stiness in the shoulders

Pain on eating

Table 3. Patients symptoms of bruxism

Figure 3. In long-standing cases of

bruxism, bite guards or splints can beused

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Clinical

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.

Further informationFor 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.

ConclusionBruxism 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.

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 peoplewho 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 Pain15(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 Dent53(5): 6926

Walmsley AD, Walsh TF, Burke FJT, Shortall

ACC, Lumley PJ, Hayes-Hall R (2002)

Restorative Dentistry. Churchill-Livingston,

Edinburgh

K PTnBruxists are often unaware

of the habit of grinding andclenching their teeth duringsleep.

nThe cause of bruxism is mul-tifactorial but is often linked

with stress.

nThe Bruxism Association (www.bruxism.org.uk) is a good sourceof information and support.

nThe dental nurse, with appro-priate education and training,could construct bite guards forpatients with bruxism.


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