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The proper use of dental splints as a bruxism treatment remains an under-taught art in dentistry. That’s according to Dr Damian Teo, Director of the Melbourne Dental Sleep Clinic. He says some dentists don’t understand the link between sleep, stress and bruxism symptoms. Others may be unaware that using the wrong splint type can worsen sleep apnoea for some patients.
“To be honest, splints are very poorly taught in dentistry,” says Dr Teo. “Many of us graduate not knowing much about splints, how to use them, or the different aspects of bruxism.
“Bruxism is a speciality of its own in dentistry because there’s so much going on with it. There are so many associated health-related and sleep-related issues that we don’t know about. Even today, we’re still trying to figure out a lot more about bruxism.”
Dr Damian Teo is an experienced, sleep and bruxism TMJ dentist. He also consults out of the Melbourne TMJ & Facial Pain Centre, and previously worked in Darwin’s first official TMJ & Sleep Therapy Centre. He has a Masters of Dentistry from Latrobe University, and a Post Graduate Diploma in Dental Sleep Medicine from the University of Western Australia. Dr Teo is a member of the Australasian Sleep Association (ASA), and completed extensive postgraduate training with world-renowned sleep medicine and TMJ disorder specialists.
Dr Teo has special interests in snoring, sleep disorders, teeth grinding, TMJ bruxism disorders and airway-focused orthodontics. He advocates for a ‘beyond-the-mouth’ approach to treating bruxism symptoms and other bruxism TMJ disorders.
“As dentists, we’re in a very good position to screen for sleep apnoea because we look in people’s mouths every day,” says Dr Teo. “We often see patients every six to 12 months for checkups. Often people don’t see their GP that regularly, and their GP may not look in their mouths.”
Before we can diagnose sleep apnoea, we must take a few steps back to understand why sleep and stress are common bruxism causes.
While Dr Teo says that bruxism symptoms like teeth grinding and clenching are a common habit that most people engage in on a regular basis, it can be heavily induced during sleep by overstimulation of the brain caused by stress. He explains that it’s all to do with the fight or flight response.
“We know from sleep medicine research that sleep bruxism occurs when the fight or flight response is stimulated,” he says. “It’s our normal response to any stressors in the environment, whether that be fighting a lion or being stressed about being late for work. That can stimulate the brain to do certain things such as increase our breathing rate, increase our heart rate, dilate our pupils, and slow our digestion.”
Stressors experienced during the day can increase stress hormones in the body, such as cortisol. High cortisol levels can be carried over to our sleep, and this may cause sleep disturbances. Dr Teo calls these disturbances sleep arousals.
“When we do sleep studies at night, we notice that people clench or grind their teeth during a sleep arousal. This is when the brain is activating the fight or flight response during sleep. During sleep we should be in a parasympathetic state.”
Emotional and work-related stressors are common causes of sleep arousals, and the associated bruxism. But Dr Teo says there is a range of other stressors that can trigger sleep bruxism — including dietary intolerances, menopause and pregnancy.
“Basically any stressor to our body can stimulate clenching or grinding,” he explains. “That could be anything from diet and food intolerances, to an infection, getting sick or an injury. The chronic pain stimulates the nervous system while we sleep, which makes us clench and grind our teeth.
“There are also links between menopause and pregnancy and worsening sleep quality. Decreasing progesterone and oestrogen levels can affect the sleep/wake cycle. People might find it more difficult to fall and stay asleep. That can contribute to poor quality sleep, which has been linked with sleep bruxism.”
Sleep apnoea is another stressor that can trigger sleep bruxism. According to the Mayo Clinic, sleep apnoea is a “potentially serious sleep disorder in which breathing repeatedly stops and starts.” Dr Teo says sleep apnoea can manifest with snoring, fatigue or feeling unrefreshed after sleep. It can also trigger or worsen sleep bruxism. While sleep apnoea can be a serious medical condition, Dr Teo explains that it’s quite simple for dentists to screen for.
“We can start by simply asking questions such as ‘Do you snore at night?’, ‘Do you feel tired in the morning?’, and ‘Do you tend to get a good night’s sleep?’. We can also look at the throat and tonsils to see if anything is blocking the airway, and we can consider the Mallampati score.”
The Mallampati score is often used to diagnose obstructive sleep apnoea with a visual assessment of the throat. It is divided into four classifications.
The higher the patient is on the classification scale, the more likely it is that they suffer from sleep apnoea — and associated sleep bruxism.
Dr Teo says that if the dentist suspects sleep apnoea might be present, it’s important to encourage the patient to seek further assessment with a sleep study.
“There are quite a few sleep labs around Australia that do home sleep studies that don’t require referral from a GP or sleep doctor,” he explains. “Personally, I work with a dental sleep lab that mails sleep machines to patients around Australia. The patient sleeps with the machine at home for one night, and the next morning they mail the machine back to the lab. The results usually take two to three weeks to come back, and show whether the patient has snoring or sleep apnoea.”
Sleep studies can also be helpful for diagnosing the type of bruxism symptoms patients may be suffering from. Dr Teo says that a lack of tooth wear doesn’t necessarily mean the patient is not experiencing sleep bruxism. Sleep studies can also identify symptoms associated with bruxism vs TMJ.
“People with very little tooth wear could be clenching a lot,” he explains. “Sleep studies measure a few different mechanisms — how the muscles are moving, how frequently the muscles are moving, and how with how much intensity they are moving. Clenching is when the patient is tensing and bracing the jaw muscles, whereas grinding is where we move the jaw from left to right or forward and back.
“You can have jaw bracing or jaw tensing where they are just tensing the muscles, but the teeth aren’t actually touching. That’s when we can have people who are big clenchers and grinders with jaw pain, but they will have no wear and tear on their teeth.”
In our article — Understanding Bruxism with Dr Neil Peppitt — specialist prosthodontist Dr Neil Peppitt talks bruxism meaning, and explains the four types of tooth wear dentists commonly see in patients.
Dr Peppitt sets our the four types of tooth wear:
Read the full article here for more information about the four types of tooth wear, and other bruxism treatment advice from Dr Neil Peppitt.
Dr Teo says there are four common scenarios in which he chooses to use a splint for bruxism treatment. But he points out that splints are not always the best treatment for sleep bruxism.
“I would generally use splints for sleep apnoea management, to protect the teeth from wear and tear, to treat muscle or jaw pain, or for jaw joint (TMJ) issues,” he says. “However, there might be other situations where the patient might not need a splint.
“For example, I see patients who are highly stressed and say when they go on holiday, their clenching and grinding goes away. In those cases, it’s important to address the underlying cause with stress management techniques. I might still make them a splint, but I’ll also suggest they work on meditation, mindfulness and other relaxation techniques.”
Dr Teo also notes that, when it comes to occlusal splints for bruxism, one type certainly doesn’t fit all cases. He says the dentist should understand the mechanics of the patient’s bruxism, and the underlying bruxism causes, in order to identify which splint type to use.
“Let’s say someone is clenching and grinding, and has a lot of pain in the temporalis muscles. That would typically be simple to manage using a flat plane occlusal splint for bruxism or maybe an anterior deprogramming splint.
“However, when we’re talking about TMJ, a flat plane bruxism splint or an anterior deprogramming splint may not be suitable. We might need to be more careful about how we set up the splint, how the bite is set up, whether we use splints on the top or bottom jaw, and whether the patient uses the splint during the day or at night.”
There are a wide range of occlusal bruxism splint types available. Hard acrylic splints are traditionally used to treat bruxism, however Dr Teo favours thermoformed dual laminate splints and 3D-printed nylon splints for bruxism treatment.
Other splint types include:
Read The Ultimate Guide to Occlusal Splints for Dentists to learn more about occlusal splint types, and the lastest splint materials and technology.
Dr Teo is also quick to point out that treating sleep apnoea patients with a standard occlusal flat plane hard / soft splint can worsen their condition. He says dentists should consider using a specialised sleep apnea splint, known as mandibular advancement splint (MAS). These are typically designed to advance the lower jaw in order to maintain an open airway while sleeping.
“If we use a normal occlusal flat plane splint in a patient with sleep apnoea, there is a chance it could worsen their sleep apnoea by up to 50 percent,” Dr Teo explains. “That’s why it’s very important that whenever we’re screening for bruxism, we ask the patient whether they have sleep apnoea or are snoring at night.
“Patients come and see me and tell me the splint they got from their dentist has caused even more jaw pain. Their dentist probably missed that they snore at night. It’s a very simple process. All we have to do is ask if they snore. If they say no, that’s fine, we can go ahead with an occlusal flat plane hard splint. But if they do snore, put the breaks on and do a sleep study before you go forward.”
An accurate fit is important for effective bruxism splint treatment. If the splint is too tight, it will cause the patient pain and they’ll be more likely not to use it. But if the splint is not retentive enough, it may become ineffective.
Dr Teo says partnering with a good dental lab can help dentists ensure their splints accurately fit their patients.
“Dental labs can be quite helpful,” he says. “They can identify if there is not enough undercut, or if a splint might need a bit more retention. They can pick things up that the dentist might not realise at the time.”
Avant’s occlusal splints for bruxism are custom-made appliances designed to protect natural teeth, crowns and implants from wear and grinding habits associated with bruxism. We accept digital scans for all types of restorations and appliances.
Dr Teo also points out that dentists need to understand the difference between normal tightness and a poor fit.
“When you insert the splint, you want to make sure it’s easy to take in and out and get the patient to try it themselves,” he says, “I never ask the patient if the splint feels tight, because it should feel tight. But I do ask them if the splint hurts in any places. That could tell you there’s a problem with the fit. It’s about the language we use with the patient.”
At Avant, our expert technicians will be by your side to make sure the entire bruxism splint design and manufacturing process is a success — from careful pre-planning to real-time design reviews in our virtual lab.
When it comes to treating sleep bruxism, Dr Teo’s final advice is to first do no harm: “If you’re unsure why you’re making a splint, don’t make it. We’re still trying to figure out a lot more about bruxism, so if you’re not confident about making a splint, ask for advice and learn about it. Don’t make a splint that makes the situation worse.”
Avant Dental has your essential bruxism resources. Read our Specialist’s guide to diagnosing and treating bruxism or watch our Free Dental Webinar: Bruxism diagnosis and treatment on-demand.
Find out more about partnering with Avant for all your bruxism splint needs by emailing [email protected] or phone 1800 287 336.