Managing a Patient with Sleep Bruxism

Sleep Bruxism

• A common sleep disorder defined as a repetitive jaw–muscle activity characterized by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible during sleep.
• The pathophysiology of sleep bruxism (SB) is still unknown; however, it appears to be multifactorial.
• Iatrogenic or secondary SB is associated with exogenous factors (alcohol, nicotine, caffeine, medication and drug use) or with medical diseases (attention-deficit/hyperactivity disorder, movement disorders, dementia, epilepsy, gastroesophageal reflux disease and other sleep disorders).
• Conversely, idiopathic or primary SB is defined by the absence of medical causes.
• It is important for the clinician to be aware of this disorder since SB leads to numerous craniofacial complications, such as tooth damage (wear, fracture), muscle fatigue, orofacial pain, temporomandibular disorders (TMD) and headache (cephalea). Presence of SB can also affect dental treatment success.

Presentation

Population

• Children younger than 11 years old; prevalence decreases with aging
• May be concomitant with wake-time bruxism

Signs

• Hypertrophy of the masseter and temporalis muscles
• Tongue indentation
• Tooth wear (occlusal facets, noncarious cervical dental lesions)
• Fracture of tooth tissues or restorations
• Linea alba heavily marked along the occlusal plane

Symptoms

• Commonly associated with teeth grinding sounds, which are the pathognomonic sign of SB,

as reported by patients, bed partners, parents or siblings

• Cervical muscle pain
• Jaw muscle tenderness or pain on digital palpation
• Morning headache
• Temporomandibular joint pain and/or jaw opening limitations
• Tooth hypersensitivity

Investigation

1. Inquire whether there are grinding sounds during sleep, at least 3-5 nights per week in the last 3 to 6 months.
2. Obtain the patient's medical history in order to assess the presence/absence of comorbidities.
3. Perform a clinical examination and look for the signs and symptoms mentioned above.
   
   The use of questionnaires
   • Various questionnaires can be used to investigate the patient's general and oral health, sleep, and oral parafunctions, as well as the presence and characteristics of pain, headache, fatigue, depression, anxiety and stress.
   
   
   Some useful questions to assist with diagnosis
   • Are you aware of frequently or occasionally clenching or grinding your teeth while you are asleep?
   • Has anyone ever told you that you grind your teeth while you are asleep?
   • Do you notice tension or fatigue in your facial, neck or upper back muscles?
   • Do you notice any increased sensitivity to your teeth or gums when you wake up?
   • Do you wake up with a headache or pain in your upper back or neck?
   • Have you noticed wear on your teeth?
4. In the presence of any of the above-listed signs and symptoms, the differential diagnosis may require an objective measure of SB diagnosis, such as an ambulatory electromyography (EMG) recording of the masticatory muscles during sleep or a polysomnography.These recordings can differentiate masticatory motor activity from myoclonia (associated with Parkinson disease or epilepsy) and other orofacial activities occurring during sleep (swallowing, coughing, smiling, lip sucking, jaw movements).

Diagnosis

Based on the patient's dental and medical history and clinical evaluation, a diagnosis of sleep bruxism is determined.

Differential Diagnosis

• Restless legs syndrome
• Sleep apnea
• Rapid eye movement behaviour disorder
• Partial complex or generalized seizure disorders
• Idiopathic myoclonus
• Parasomnia (sleep talking, sleep walking)
• Familial nocturnal faciomandibular myoclonus
• Attention-deficit/hyperactivity disorder
• Dementia
• Gastroesophageal reflux disease

Treatment

Common Initial Treatments

• To date, no preventive therapy has been proven to effectively cure sleep bruxism (SB).
• Treatment approaches aim at managing and preventing the harmful consequences of SB to the orofacial structures.
• After SB management, the damaged teeth and restorations can be treated with a restorative dentistry approach.
  1. Educate the patient about sleep bruxism and the importance of maintaining proper sleep and oral hygiene habits.
  2. Consider an occlusal splint to prevent further damage to the orofacial structures and to reduce symptoms.
  3. In the presence of suspected/diagnosed sleep apnea or snoring, a mandibular advancement appliance (MAA) should be considered.
  4. In the presence of psychosocial risk factors (stress or anxiety), consider stress management, muscle relaxation techniques, cognitive behaviour therapy or biofeedback.
  5. In the presence of exogenous risk factors (alcohol, nicotine, caffeine, drug use or abuse), advise the patient to consider changing their lifestyle habits.
  6. If SB is associated with medication use, consider an occlusal splint or MAA.
  7. In the suspected or confirmed presence of medical comorbidities, refer the patient to a medical specialist (respirologist, neurologist, psychiatrist, pediatrician, sleep disorder specialist).
  8. Follow-up with the patient on the management of SB-related signs and symptoms.
  9. In the case of an acute phase of SB, prescribe a muscle relaxant temporarily until the above-mentioned SB management can be applied.

Treating children

• Provide both parents and the child with related information.
• As the orofacial structures are still developing, occlusal splint and MAA are contraindicated.
• If snoring or sleep apnea is suspected, refer the child to a medical specialist.

Advice

• Advise the patient to maintain good oral health, sleep hygiene and healthy lifestyle habits.
• Schedule regular checkups to prevent further damage to the orofacial structures.
• If a comorbidity is suspected, refer the patient to a medical specialist.

THE AUTHORS

	Dr. K.I. Afrashtehfar is a graduate resident in the prosthodontics and restorative dentistry department, faculty of dentistry, McGill University, Montreal, Quebec.
	Dr. C.D.M. Afrashtehfar is a Canadian physician with a private practice in Cuernavaca, Mexico.
	Dr. Huynh is a assistant research professor, oral health department, faculty of dentistry, University of Montreal and the CHU Sainte-Justine Research Center, Montreal, Quebec.

The authors have no declared financial interests.

This article has been peer reviewed.

Correspondence to: Dr. Huynh, Orthodontics, Faculty of Dentistry, Université de Montréal, 3525 Chemin Queen Mary, Montréal (QC), Canada H3V 1H9. Email: nelly.huynh@umontreal.ca

Acknowledgement:  The authors wish to thank Dr. Gilles Lavigne, dean of the University of Montreal faculty of dental medicine, for providing guidance throughout the course of this project.