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1Why Do Patients Grind – Steven Olmos DDS
Why Do Patients Grind Their Teeth?Steven R. Olmos DDS
Featured Speaker - BioRESEARCH Annual Conference - Milwaukee WI - April 30th
– May 2nd
2009
Founder
TMJ & Sleep Therapy Centres
Private Practice limited to the treatment of orofacial/craniomandibular/temporomandibular disorders and oral
appliance therapy for the treatment of obstructive sleep apnea
La Mesa, California
Many articles are available on how to make oral appliances (splints). Although some
of these articles provide very intricate details about the fabrication of the appliance,
most do not discuss the diagnoses that require the patient to need an appliance.
Therefore, readers are left to wonder why these patients are grinding their teeth.
The temporomandibular joints (TMJs) are the toughest joints in the body
(fibrocartilage, as opposed to hyaline for other joints). The TMJs break down because
of the continued compressive forces, day and night, from a struggle to breathe, the
discomfort of chronic pain, and anxiety.
Headaches, facial pain, limited mandibular opening, jaw noises (popping and clicking),
bruxism/attrition, broken teeth and obstructive sleep apnea (OSA) are all reasons that
patients seek dental care (Figure 1). The comorbidity and pathophysiology of these
ailments is well documented. This article will connect the dots and provide a simple
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2Why Do Patients Grind – Steven Olmos DDS
way to screen patients, so the dentist can develop a treatment plan for optimal dental
and physical health.
Orofacial PainOrofacial PainOrofacial PainOrofacial Pain
The head/face is the monitor of the health of the body. The muscles of mastication
(temporalis, masseter, medial pterygoid, and lateral pterygoid) are in balance with the
Figure 1 The patient presented with: teeth grinding, difficulty falling asleep, repeated
awakings, feeling unrefreshed in the morning, significant daytime drowsiness, dry
mouth on waking, tossing and turning frequently, fatigue, headache pain, sinuscongestion, and jaw joint noises.
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3Why Do Patients Grind – Steven Olmos DDS
of the neck. These muscles have activity and a level of tonus based on central
nervous system (CNS) stimulation. People clench, grind, or brux because of increased
CNS stimulation, which results from various amounts of pain, breathing dysfunction,
or anxiety.1,2 Various palliative medical/dental treatments, such oral appliances,
dental equilibration, medication regimens, and physical medicine treatments (botox),
often are prescribed without first determining why the patient is grinding his or her
teeth.
The patient may be clenching because of chronic pain, such as a painful nerve in the
foot, compressed inflamed disc in the spine, or an aching osteoarthritic hip. The
parafunctional activity may be the result of apnea (cessation of breathing for 10
seconds or longer) or sleep disturbance. It may be the result of life’s hurdles (divorce,
job, relationships), which are usually acute, or the pathologic mental disorder of
chronic anxiety.
Between 25% and 30% of the population suffers from chronic pain, with an estimated
drain to the American economy of $125 billion annually.3 The longer a person has
pain, the more pain that person feels because of the process of central sensitization.
The CNS is plastic and changes to receive and transmit more pain signals to the brain.
This results in more stimuli to the facial muscles to contract and predisposes the
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4Why Do Patients Grind – Steven Olmos DDS
patient to more headaches/facial pain. Light, unrestful sleep results in more pain
during the day; 1 pain during the day makes for unrestful sleep.
The International Headache Society (HIS) categorizes headaches into two
predominant types: primary and secondary. Secondary headaches are the result of
organic pathology, such as a tumor or bleeding of the vessels surrounding the brain.
These headaches are rare in the absence of major trauma. Primary headaches are
idiopathic (of unknown origin) and are categorized by frequency, location, duration, a
person’s response to it, and what medication relieves it. To be categorized as a
primary headache, the patient has had magnetic resonance imaging (MRI) and
computed tomography (CT) scans of the brain, and the test results are normal.
Headaches in this category are the ones most commonly treated: migraine, tension
type, cluster, etc. Migraine prevalence in men is 6% and women 18%, and the rate in
children is increasing rapidly.4 The Nuprin Pain Report (a national epidemiologic study
on the prevalence of headache, conducted in 1985) found that headache prevalence
in the United States is 78% for adult women and 68% for adult men.
Migraine, cluster headache, hypnic headache, and morning (tension) headache in
adults 1,5 and children are all related to apnea or disturbed sleep.6 Headache has
been found in 65% of patients with nocturnal bruxism.7,8 All people parafunctionally
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contract with greater force (approximately 57,600 lbs/sec/day) than normal function
(approximately 17,200 lbs/sec/day).2 Patients with temporomandibular disorder
(TMD) brux longer, 38.7 minutes, compared with control patients, 5.4 minutes.9
Diurnal and nocturnal parafunctional (bruxing) activities occur at a subconscious
(brainstem/autonomic) level; therefore, unawareness of the activity is common.10-12
People brux more when they are on
their backs (supine),13-15 and they
have more obstructed apnea in that
position (Figure 2). Therefore, to
determine the position of worst
apnea, sleep laboratories have the
patient sleep in different positions.
More than 75 million Americans
(25%) have sleep apnea, and many
more have sleep disturbances.16 A
survey of the literature demonstrates the prevalence of TM symptoms in the general
population is 41% and those showing a sign is 56%.2 The most frequent symptom
(96%) of TM dysfunction (inflammation/capsulitis, disc displacement, etc) is right-
Figure 2 The mandible and the base of thetongue fall back when the patient in the
supine position, blocking the airway.
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7Why Do Patients Grind – Steven Olmos DDS
sided back-of-head pain (occipital cephalgia).17 The body assumes a forward head
posture when there is inflammation in the TMJs. When the inflammation/dysfunction
is corrected through decompression (day and night orthotics using the sibilant
phoneme technique), there is a return of head posture by 4.43 inches.18 The forward
head posture places increased stress on the cervical spine and the insertion of the
muscles at the back of the neck/head (Figure 3). This forward head posture changes
occlusion.19-21
For these reasons, the American Dental Association (ADA) and the
American Academy of Orofacial Pain (AAOP) recommend that no permanent occlusal
Figure 3 Forward head posture, the result of TMJ inflammation, changesocclusion and causes increased pain in the neck .
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8Why Do Patients Grind – Steven Olmos DDS
therapy (equilibration) be performed
on a patient with TMJ inflammation.
Botox injections for migraine are
given at the base of the skull (Figure
4A). However, many patients
receiving this and other treatments
are misdiagnosed with migraine
when they suffer from TMJ injuries
(inflammation). If treated for TMJ
(inflammation resolved), abortive,
preventative medication regimens
or debilitating therapies would not
be requires. Botox injections also
are given for clenching, a result of
pain in the body or breathing
distress, in the temporalis and
masseter muscles (Figure 4B), and
Figure 4A Botox treatment for migraine is at
the base of the skull with the patient’s head in a
forward posture.
Figure 4B Elevator muscle (temporalis andmasseter) injections for the treatment of
clenching from brain stimulation from pain in
the body or breathing distress.
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9Why Do Patients Grind – Steven Olmos DDS
for compression of the cervical
vertebrae, a result of forward head
posture, in the carpal tunnel (Figure
4C).
The Dentist’s ResponsibilityThe Dentist’s ResponsibilityThe Dentist’s ResponsibilityThe Dentist’s Responsibility
Because orofacial pain patients are
seen regularly in the dental practice,
the author devised a simple triage
system that is based on intake data collected from one form, which screens for
chronic pain, airway disorders, malocclusion, and anxiety. The patient questionnaire to
identify origins for the parafunctional activity, combined with the clinical examination
form to prevent overlooking any signs/symptoms, provides the dentist an easy-to-
follow flow chart for treatment (Figure 5). These forms are printable from the TMnDx™
software (TMJ & Sleep Therapy International, LLC, La Mesa, CA), which the author
developed to combine the necessary dental and medical components, and to meet
the medical model for report generation and insurance billing. The software allows the
dentist to print reports and referrals to the other healthcare providers necessary to
Figure 4C A median nerve (carpaltunnel) injection for the treatment of
compression of the cervical vertebrae (C5
through 7 origin of this nerve), the result
of forward head posture.
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10Why Do Patients Grind – Steven Olmos DDS
treat the real cause of the symptoms: sleep physicians, physical therapists,
chiropractors, etc.
Specific diagnostic criteria can be complex and are beyond the scope of this article.
However, the importance of determining the true cause of the patient’s pain can not
be understated. The ADA dental practice parameters of treatment (1997) state22:
“The dentist should consider a differential disease classification that may include
Figure 5 Flowchart of treatment options. Depending on the initial complaint, the
dentist can determine a sequence for treatment using the color-coding.
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11Why Do Patients Grind – Steven Olmos DDS
neuromuscular pain, myofascial pain, neurogenic pain, neurovascular pain,
sympathetic and/or referred pain involving the trigeminal and/or oropharyngeal
systems, or other medical conditions, which may contribute to or mimic TM disorders.”
The ADA further states: “Before restorative and/or occlusal therapy is performed, the
Figure 6 The “ON” series of appliances are night appliances used to either
decompress or maintain a mandibular position in the supine, improve
oropharyngeal breathing, or all of the above. ON = Olmos Night.
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dentist should attempt to reduce, through the use of reversible modalities, the
neuromuscular, myofascial and temporomandibular joint symptoms.”
Knowing who, why, and when to treat is key, and most importantly, knowing when to
refer to other practitioners for conditions that manifest in the head/face. Palpate the
lateral poles of the condyles and the posterior joint space with the mouth open to
check for inflammation (capsulitis). Use a ruler to measure maximum opening. Ask if
the patient experiences headaches, wakes fatigued, or uses medications for pain or
sleep aids. If the teeth are worn, the patient should be referred to an otolaryngologist,
a pulmonologist, or a sleep laboratory for an overnight sleep study.
Nonsurgical therapy for chronic headaches (migraine), facial pain, and TMD has been
shown to be reproducibly effective in the author’s clinics. At these clinics, 70% of
chronic pain patients do not need a permanent stabilization therapy (phase II dental
rehabilitation or orthodontics). The flowchart in Figure 6 outlines the steps to follow
with a patient that presents with headaches. The flowchart in Figure 7 outlines the
steps to follow for a patient with limited opening.
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14Why Do Patients Grind – Steven Olmos DDS
Figure 7 The “OD” series of appliances are functional day appliances designed to hold a
mandibular position. Cold spray is used to make the muscles relax so that limited mandibular opening can be diagnosed as to muscle splinting or intracapsular pathology. OD = Olmos Day.
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15Why Do Patients Grind – Steven Olmos DDS
ConclusionConclusionConclusionConclusion
Dentists have a tremendous role in the treatment of chronic pain, headaches
(migraine), and OSA obstructed sleep apnea. These are common problems. Most
dental school education prepared dentists for acute TMJ injury treatment (pain control
and occlusal splint therapy for 2 weeks), but did not prepare dentists for sleep
disordered breathing or how TMJ dysfunction, chronic pain, OSA, and sleep disorder
breathing interrelate. Based on an internationally tested protocol of data collection
and treatment, dentists should:
1. Refer patients with attrition for sleep study before performing any restorative
dental procedures.
2. Screen patients by asking them if they have headaches, jaw pain, or unstablebite.
3. Institute a comprehensive clinical examination and data-collection protocol,covering sleep and TMJ pathology.
4. Follow the TMnDx flowchart for diagnosis and treatment. If unfamiliar, seekadditional education and, if uncomfortable treating, then refer.
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DisclosureDisclosureDisclosureDisclosure
The author is an owner of TMnDx Software.
ReferencesReferencesReferencesReferences
1. Lavigne G, Sessle BJ, Choiniere M, et al, eds. Sleep and Pain. Seattle, WA: IASP Press;
2007:311-340.
2. Oekson JP. Management of Temporomandibular Disorders and Occlusion. 6th ed. St.
Louis, MO: Mosby; 2007.
3. Sessle BJ. Pain costs. J Orofac Pain. 2008;22(1):5-6.
4. Lipton RB, Stewart WF. Prevalence and impact of migraine. Neurol Clin. 1997;15(1):1-
13.
5. Alberti A. Headache and sleep. Sleep Med Rev. 2006;10(6):431-437.
6. Carotenunto M, Guidetti V, Ruju F, et al. Headache disorders as risk factors for sleep
disturbances in school aged children. J Headache Pain. 2005;6(4):268-270.
7. Bader D, Lavigne D. Sleep bruxism: an overview of an oromandibular sleep movement
disorder. Sleep Med Rev. 2000;4(1):27-43.
8. Camparis CM, Siqueira JT. Sleep bruxism: clinical aspects and characteristics in
8/7/2019 Olmos Teeth Grinding
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17Why Do Patients Grind – Steven Olmos DDS
patients with and without chronic orofacial pain. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2006;101(2):188-193.
9. Trenouth MJ. The relationship between bruxism and temporomandibular joint
dysfunction as shown by computer analysis of nocturnal tooth contact patterns. J Oral
Rehabil. 1979;6(1):81-87.
10. Rugh JD, Solberg WK. Electromyographic studies of bruxist behavior before and during
treatment. J Calif Dent Assoc. 1975;3(9):56-59.
11. Solberg WK, Clark GT, Rugh JD. Nocturnal electromyographic evaluation of bruxism
patients undergoing short term splint therapy. J Oral Rehabil. 1975;2(3):215-223.
12. Clark GT, Beemsterboer PL, Solberg WK, et al. Nocturnal electromyographic evaluation
of myofascial pain dysfunction in patients undergoing occlusal splint therapy. J Am Dent
Assoc. 1979;99(4):607-611.
13. Okeson JP, Phillips BA, Berry DT, et al. Nocturnal bruxing events in subjects with sleep-
disordered breathing and control subjects. J Craniomandib Disord. 1991;5(4):258-264.
14. Okeson JP, Phillips BA, Berry DT, et al. Nocturnal bruxing events: a report of normative
data and cardiovascular response. J Oral Rehabil. 1994;21(6):623-630.
15. Okeson JP, Phillips BA, Berry DT, et al. Nocturnal bruxing events in healthy geriatric
subjects. J Oral Rehabil. 1990;17(5):411-418.
8/7/2019 Olmos Teeth Grinding
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18Why Do Patients Grind – Steven Olmos DDS
16. Hiestand DM, Britz P, Goldman M, et al. Prevalence of symptoms and risk of sleep
apnea in the US population: results from the National Sleep Foundation Sleep in America
2005 poll. Chest. 2006;130(3):780-786.
17. Simmons HC 3rd, Gibbs SJ. Anterior repositioning appliance therapy for TMJ disorders:
specific symptoms relieved and relationship to disk status on MRI. Cranio. 2005;23(2):89-99.
18. Olmos SR, Kritz-Silverstein D, Halligan W, et al. The effect of condyle fossa relationships
on head posture. Cranio.2005;23(1):48-52.
19. Sonnesen L, Bakke M, Solow B. Temporomandibular disorders in relation to craniofacial
dimensions, head posture and bite force in children selected for orthodontic treatment. Eur J
Orthod. 2001;23(2):179-192.
20. Kibana Y, Ishijima T, Hirai T. Occlusal support and head posture. J Oral Rehabil.
2002;29(1):58-63.
21. Yamaguchi H, Sueishi K. Malocclusion associated with abnormal posture. Bull Tokyo
Dent Coll. 2003;44(2):43-54.
22. American Dental Association. Dental practice parameters: temporomandibular
(craniomandibular) disorders. Revised 1997. Available at:
http://www.ada.org/prof/prac/tools/parameters/tmd.asp#parameters. Accessed Jul 10,
2008.