Specialist’s guide to diagnosing and treating bruxism

Specialist’s guide to diagnosing and treating bruxism image

Dr Amanda Phoon Nguyen shares an oral health specialist’s perspective of bruxism.

At least one in three Australian adults suffer from bruxism. That means diagnosing and treating bruxism with splints has become a common part of daily practice for most dentists. But there are still some common bruxism misconceptions dentists need to be aware of. 

Perth-based Oral Medicine Specialist, Dr Amanda Phoon Nguyen, says expanding your bruxism knowledge begins with a clear understanding of the fundamental differences between bruxism and temporomandibular joint disorder (TMD). While bruxism and TMD are two distinct dental conditions that can affect the jaw and teeth, they have different causes and symptoms.

“There is a tendency to confuse the two conditions because bruxism and TMD can both cause jaw pain and headaches,” says Dr Phoon Nguyen. “But bruxism and TMD are very different, and they require very different management.” 

Bruxism is characterised by the involuntary and frequent grinding, clenching or gnashing of teeth during sleep. However, people with bruxism may also clench their teeth during the day, especially when they feel stressed or anxious. Bruxism can lead to worn, chipped or broken teeth, as well as jaw pain, headaches, and ear pain. If left untreated, it can also cause gum recession, tooth sensitivity and even tooth loss in severe cases.

TMD, on the other hand, is a disorder that affects the temporomandibular joint (TMJ), which connects the jawbone to the skull. The TMJ is responsible for enabling movements of the jaw such as chewing, speaking, and yawning. TMD can cause a range of symptoms such as jaw pain, difficulty opening or closing the mouth, clicking or popping noises when the jaw moves, ear pain, headaches, and neck pain. TMD can be caused by various factors such as injury to the jaw, arthritis, misalignment of teeth, stress, and teeth grinding.

While bruxism can contribute to the development of TMD, the two conditions are not the same. People with TMD may or may not have bruxism, and vice versa.

Identifying bruxism severity

Another common issue for dentists is diagnosing the extent or severity of the patient’s bruxism, and knowing when to treat the patient with splints and when to refer the patient to a specialist – such as an oral and maxillofacial surgeon or a prosthodontist – for treatment. Dr Phoon Nguyen says getting that right is all about identifying the underlying cause, the severity of the condition,  and any contributing factors that may add complexity to the treatment.   

“There can be medication-related bruxism, or other conditions like Oromandibular dystonia (OMD), Parkinson’s and Motor Neuron Disease (MND) where patients can experience similar symptoms or movements that are present in bruxism. So those are conditions that can make diagnosing bruxism more complicated.”

Dr Phoon Nguyen adds that an underlying sleep disorder such as sleep apnoea can also complicate bruxism diagnosis and treatment. “If sleep apnoea is present, treating a patient with a splint can actually make their condition worse. So if you suspect the patient may have a sleep disorder, it’s important to refer them for a sleep study before treating them with a splint.”

Dentists may also need to consider referring excessive bruxism cases to an oral health specialist. However, Dr Phoon Nguyen says determining the level of tooth damage or wear that suggests excessive bruxism is present can be problematic. 

“That’s the million dollar question,” she says. “As far as I know, there’s no universally accepted scale for determining what is excessive bruxism. But assessing tooth wear by age can be helpful. For example, heavy tooth wear in a 20 year old could indicate excessive bruxism. Or if you’ve been seeing the patient over time, assessing their oral photos can show if tooth wear has significantly increased.

There may also be lifestyle factors at play that can mimic bruxism, such as tooth wear caused by an overly acidic diet, digestive conditions like acid reflux, and recreational drug use. And Dr Phoon Nguyen emphasises that patients who develop jaw pain or locking should be referred to a specialist for additional investigation. 

Choosing the right split type and material

Dr Phoon Nguyen has several treatment tips for cases of mild to moderate bruxism that the dentist has determined is treatable with splints without specialist intervention. However, she points out that bruxism studies haven’t shown strong evidence for the effectiveness of one split type over the other. So splint treatment comes down to the individual dentist’s preferences and experience.  

“But my personal advice is to use full coverage flat splints, and I usually suggest using hard splints. I have seen some studies that suggest a soft splint or a hard splint with a soft liner may actually increase muscle activity. So if you use a soft splint on a patient who’s a clencher, they may end up clenching or grinding more.”

Unless mitigating circumstances are present, such as tooth sensitivity, an underlying condition or the patient simply can’t tolerate a hard splint, Dr Phoon Nguyen recommends choosing a more durable nylon material over traditional acrylic. 

“The nylons we have these days are a lot harder and tend to break a lot less than the acrylic splints,” she says. “But if you’re using a hard nylon splint, the accuracy of the fit is critical. If the splint fits poorly and there’s a chance that it will dislodge during the night, that’s not a safe splint. The patient shouldn’t be able to remove it easily with their tongue or anything like that.”

If the patient is suffering from sleep bruxism, Dr Phoon Nguyen also suggests encouraging the patient to consider some lifestyle changes that could help to reduce their bruxism. “That might involve avoiding caffeine, improving their sleep hygiene, and trying some stress management techniques.” 

Splint accuracy and treatment success

When it comes to ensuring accuracy of fit, Dr Phoon Nguyen says precision is key. She favours intraoral scanning over impressions for accuracy advantages, and says dentists must work closely with their dental lab to get the best results.

“It is vital to get good scans and take a bite registration. Taking photographs is also helpful as an additional reference,” she explains. “You need to gather as much information as you can, because sometimes the lab will come back to you and say the scan looks really off. In that case, we can look at the bite registration and look at the photographs and determine whether the patient may have been biting differently during the scan, or if the scan is actually showing the patient’s bite accurately.” 

Of course, it’s also important to monitor the patient’s progress with regular follow-up appointments, and make any necessary adjustments to the splint. This will ensure that the splint is working effectively and can be adjusted as needed.

Proper documentation of treatment is crucial for both the dentist and the patient. Keep records of the diagnosis, treatment plan, and any adjustments made to the splint. This documentation can be used to track progress, make future treatment decisions, and to ensure that the patient is aware of their treatment plan.

“Obviously, if the patient is not tolerating the splint, that needs to be addressed. And you should be regularly looking for any cracks or breaks in the splint, and if there are any wear points on the splint,” says Dr Phoon Nguyen. “However, sometimes the patient will say it’s fine, but there may still be signs that the splint is not working. If damage is continuing to occur despite the patient being compliant with using their splint, the grinding or clenching might be happening during the day in addition to or rather than during their sleep.”

In that case, Dr Phoon Nguyen says further investigation may be required: “It’s possible that something may have been missed. For example, is the tooth damage actually acid erosion? Or are there lifestyle factors at play? This could be a point where a dentist could consider referring the patient to an oral health specialist to investigate for an underlying condition or a contributing illness.” 

Recommending bruxism management tools like BruxApp to your patients can also be helpful, says Dr Phoon Nguyen. BruxApp has been designed to increase patients’ awareness of bruxism activities so they can avoid or correct negative habits and make patients aware of the possible clinical consequences of bruxism. Dentists can also use the app to help assess the presence of teeth clenching or grinding, jaw clenching, and rate the severity of the patient’s bruxism.

Understanding sleep apnoea and bruxism

While sleep apnoea and bruxism are often mentioned in the same breath, Dr Phoon Nguyen says it’s important to understand that they are separate conditions.

“Sleep apnoea and bruxism only have a very weak association with each other,” she explains. “So awareness of sleep apnoea is good, but there’s no need to send every patient for a sleep study just because bruxism may be present. Rather, dentists need to understand what sleep apnoea is and be able to identify the signs of sleep apnoea so they can screen for it separately from a bruxism assessment.”

Sleep apnoea is a common sleep disorder characterised by pauses in breathing or shallow breathing during sleep. These pauses can last for a few seconds to several minutes and can occur multiple times throughout the night, leading to disrupted sleep and daytime sleepiness.

There are three main types of sleep apnoea: obstructive sleep apnoea (OSA), central sleep apnoea (CSA), and complex sleep apnoea syndrome (also known as treatment-emergent central sleep apnoea).

Obstructive sleep apnoea (OSA) is the most common type and occurs when the muscles in the back of the throat fail to keep the airway open during sleep, causing a blockage or narrowing of the airway. This can lead to snoring, gasping, and choking during sleep.

Central sleep apnoea (CSA) occurs when the brain fails to send the proper signals to the muscles that control breathing during sleep, resulting in a pause or cessation of breathing. This type of sleep apnoea is less common than OSA.

Complex sleep apnoea syndrome occurs when a person initially has OSA, but continuous positive airway pressure (CPAP) therapy, which is commonly used to treat OSA, leads to the development of CSA.

Sleep apnoea can have a negative impact on overall health and quality of life if left untreated. Treatment options may include lifestyle changes, such as weight loss and exercise, as well as the use of continuous positive airway pressure (CPAP) therapy, oral appliances, surgery, or other treatments depending on the severity and type of sleep apnoea.

Screening for sleep apnoea

Dr Phoon Nguyen says the most important thing for dentists is to know not to treat bruxism with splints if sleep apnoea is present because this can make the patient’s sleep apnoea worse. That means, while sleep apnoea and bruxism are separate conditions, dentists may need to make sure sleep apnoea is not present in the patient before proceeding with a splint treatment. 

Dr Phoon Nguyen recommends dentists consider following a three-step sleep apnoea screening process: 

1. Medical history: Ask patients about their medical history, including any symptoms or conditions that may be associated with sleep apnoea, such as loud snoring, excessive daytime sleepiness, and obesity.

2.Physical examination: Examine the patient’s oral cavity, tongue, and throat to look for signs of narrow airways or other abnormalities that may contribute to sleep apnoea.

3. Questionnaires: Consider using validated questionnaires to screen for sleep apnoea, such as the Berlin Questionnaire or the Epworth Sleepiness Scale. These questionnaires ask patients about their sleep habits, snoring, and daytime sleepiness, among other factors.

“If you suspect the patient may have sleep apnoea after the screening process, then I’d recommend suspending any splint treatments and referring them to an oral health or sleep specialist for further investigation,” says Dr Phoon Nguyen. “That’s because, in my opinion, sleep apnoea trumps other conditions like bruxism. Patients with sleep apnoea may have an increased risk of stroke and other potentially serious health conditions, so it needs to be addressed with a specialist as quickly as possible.” 

The final word

Mild to moderate bruxism is a very common condition and treatable with splints. However, dentists can consider referring severe bruxism cases to an oral health specialist. Complications like TMD and sleep apnoea should be ruled out before proceeding with a splint treatment – and appropriately treating TMD and sleep apnea will likely require specialist intervention regardless of whether bruxism is also present. 

When treating mild to moderate bruxism with no contributing complications or underlying health issues present, Dr Phoon Nguyen recommends using full coverage flat plane hard splints. However, she emphasises that accuracy of splint fit is also critical for successfully treating bruxism. Intraoral scans typically provide greater precision than impressions, and working with expert dental lab technicians can help ensure you consistently achieve the best bruxism treatment outcomes. 

 

Want to learn more about bruxism? Watch our free dental webinar on bruxism diagnosis and treatment, or read more at our ultimate guide to sleep bruxism.

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