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4/12/18
1
SLEEPBRUXISM:ISITTHEENTRYPOINTFORTHEDENTIST?THEUNKNOWNSLEEPDISORDER
Entry Point for the Dentist Into the World of Sleep Medicine
AND
Sleep Breathing Disorders
TheExpertonSleepBruxismGillesLavigne,DMD,PhD
FromJohnEdmeads,MD
“Most lectures are characterized by the information on the slides going from the mouth of the lecturer to the ears of the listener without
going through the minds of either”
SleepBreathingDisordersPresentintheDentalOfficeas
SleepBruxism
• Treatment is a Single Continuum of Care
• OSA presents in the Dental Office as
Increased BMI – Abdominal Girth
High Epworth Sleepiness Scale score
Increased Neck Size
FactsAboutthePrevalenceofOSA
• 1 of 5 dental patients in the dental office is either undiagnosed or untreated
• 1 in 4 young/middle aged men at risk for OSA
• 7 in 10 of Medicare population at risk for OSA
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SLEEP BRUXISM: A NEW PARADIGM
What We Need To Know
SLEEPBRUXISM
NoLongerAParasomnia
ICSD-3:AMovementDisorderSleepBruxism-327.54
60%SleepOnTheirBack
(LikeSnoringandSleepApnea)
Parasomnias
• Night Terrors (after 1st NREM period)
• Nightmare (associated with REM)
• Sleep walking
• Sleep talking
TheNightmareHenryFasellicirca1781
TeethGrindingLinkedtoSleepApnea
• 1 in 4 with OSA also have nocturnal Bruxism
• Study at Baylor: 300 people
25.6% had Bruxism
• 35% had GERD
Presented at CHEST 2009
Shyam Subramanian, MD
FromNa]onalSleepFounda]on(August24,2010)
• Three tips for Coping with Bruxism:
1. Ease symptoms: relax before bedtime to reduce stress
2. Proper sleep hygiene
3. Stay off the Back
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SLEEPBRUXISM
GreekWord:brychein(tognashtheteeth)
GnashingoftheTeethUsuallyDuringSleep
BRUXOMANIANeuro]cHabitPerformed
DuringtheDay
PrevalenceofBruxism5to8%inthegeneralpopula]on(Basedon
ReportsofAudibleGrinding)• Childhood:14to17%• Underage11:14to20%• Teens&YoungAdults:12%• MiddleAge:8%• Elderly:3%
SleepBruxismduringchildhoodpersistsin35-90%ofadults
InChildren-AssociatedFindings
• NailBi]ng 9-28%• ThumbSucking 21%• Snoring 14%
TypesofBruxism
• AwakeTime:toothclenching-tapping-Jawbracing
• SleepTime:toothgrindingphasic(rhythmic)tonic(sustained)mixed
TypesofBruxism
• Primary–Idiopathic NoKnownMedicalorDentalCause MaybePsychologicalinSomePa]ents IncludesDay]meClenching
• Secondary–Iatrogenic(assoc.withdrugintakeorwithdrawl)MovementDisorder(Parkinsons) OromandibularDystonia SleepRelatedDisorder NeurologicRela]onship-Tics ChemicalSubstancesorMedica]ons
Classifica]onofBruxismAwake]meBruxism(clenching)
Sleep]meBruxismPrimaryand/orIdiopathic
Secondary(Withmedicalcondi]on)Iatrogenic(followingdrugintake/withdrawl)
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AssociatedCondi]ons
• Clenching• OromandibularDystonia(OMD)have secondaryBruxismslow,sustained,twis]ng andrepe]]veorofacialac]vityofthe mandible,tongueandupperfaceOMDpa]entsmayreportburningmouthand/orTMJdisorder
Bruxismismainlyregulatedcentrally,notperipherally
J.OralRehab2001–Lobbozoo&Naieji
Partofasleeparousalresponse
LinkedtodisturbancesintheDopaminergicSystem
SleepBruxism
FromastudyinCHEST,Jan.2001
1/3oftheBruxismgroupwereSleepyduringtheday
OSASmoreprevalentinthetoothgrindinggroup(3.4%to4.8%)ascomparedtothosewithout(1.4%)
SB:RiskFactors Evidence• Craniofacialfeatures• Occlusion• Anxiety/Stress• Personality• Trauma/Injury• Gene]cs• Sleeprelatedarousal• Neurochemicals(dopamine• Medica]ons• Drugs• Chemicals
• None• None• Some• Some• Available• Some• Available• Available• Available• Available• Available• Available
SB:RiskFactorOddsRa]o• OSA• Loudsnoring• Snoring(lessloud)• ModSleepiness• Alcohol(1-2daily)• Alcohol>3daily)• Caeffineuse• Smoker• HighStress• Anxiety
• 1.8• 1.4• 1.2• 1.3• 1.5• 1.8• 1.4• 1.3• 1.3• 1.3
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RhythmicMas]catoryMuscleAc]vity(RMMA)
• ChewingMovementsDuringSleepWithoutToothGrinding–Foundin60%oftheNormalPopula]onataFrequencyof1.8perhour
• AssociatedwithSleepBruxism• MayberelatedtoSalivaryFlow–TemporarilyIncreasesSalivaFlowandLubrica]onSleepMedReview2002Vol16#3
RhythmicMas]catoryMuscleAc]vity(RMMA)
• NoBruxismin60%ofpa]ents• RMMAinSleepBruxismprecededbysequenceofmicroarousals4secondsbeforetheevent
• Followedbyautonomic-cardiacac]va]on(1secondbeforeRMMA)thenRMMAintheMasseters
Descrip]vePhysiologicDataonaSleepBruxismPopula]onBader,etal,Sleep,1997
CommonFindings:1.Alphaac]vity10secondspriortoabruxingevent2.Tachycardiadevelopedatonset& lastedfor10seconds3.Meannumberofshimsinsleep staging=70
SleepBruxism-Facts
• 1/3aresleepyduringtheday• AlphaEEGac]vity10secondspriortobruxingevent• 4secondspriortobruxingevent!EEGac]vity• Tachycardiadevelopedatonset-lastsfor10seconds• Meannumbersleepshims=70• 1secondpriortobruxing!heartrate
SleepBruxism
AssociatedwithmicroarousalsOccursduringN2andREM
Bruxism–TMD–SleepDisorders
BruxismaMovementDisorderBruxismaSleepDisorder
Occursduring:N2andREM
RelatedtoDopamineAc]vityACentrallyRelatedMechanism
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PSGFindings Medica]ons
• Amphetamines-Ritalin-othersforADD/ADHD
• An]psycho]cs-Lithium-Thorazine• An]depressants-SSRIs• Cardioac]veCalciumblockersAn]arrhythmics
TMDPa]entsatRiskforCVDisease
• Exhibitsleepdysfunc]onassociatedwithpersistentpain
• Associatedwithincreasedtendencytobacksleep(stayofftheside)
• Effectsofacute&persistentpainuponautonomic&motorcontrolimpose"CVrisk
• Increasedmandibularmovementcontributestogenioglossusac]vity NHLBIReportDec3-4,2001
DuringSleep:SleepBruxismAssociatedWith:
• RestlessLegSyndrome(RLS)10%haveSleepBruxism
• PeriodicLimbMovementDisorder(PLMD)• SleepApnea• REMSleepBehaviorDisorder• NightTerrors
Medica]onsandSubstancesthatAffectBruxism
• Alcohol• Cigarepes(nico]ne)• Caffeine• Cocaine• Amphetamines• SSRIs
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ReportsofSSRI-AssociatedBruxism
• WellDocumented• ImpactmainlyonDopamineCentersintheBrain
• TheAn]dote:BuSpar
JOrofacialPain2001;15:340-346
Management• Behavioral: Biofeedback/Hypnosis PhysicalTherapy(improveposture) StressManagement
• Dental: Splints-NightGuards-Ortho]cs
• Pharmacologic: Manymedica]onshavebeentried
ManagementofBruxism
• SplintTherapy(noSBD)• OralApplianceifOSAS• Occlusal/BiteAdjustment(controversial)• BotoxAinjec]ons• Medica]ons(noteffec]ve–omen apempted)
SingleArchBiteSplint
RiskofAggrava]onofSleepApneawithOcclusalSplint
• 10pa]entstudy:4pa]entsdevelopedmoresevereapneawithsplint
• AHIincreased>50%• Conclusion:ques]onpa]entsaboutSRBDpriortosplinttherapy
IADRMarch10-13,2004
PharmacologicManagement
• Valium(casereports)• A]van(shorttermuse)• Clonidine(riskhypotension)• BotoxA(unproven)• BetaBlockers(effec]ve-respiratory
depression)• Klonopin-Gabitril• Future-Medica]onsforRLS/PLMD?
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Clonazepam(Klonopin)forSleepBruxism
• Improvedsleepquality• Improvedsleepefficiency• LessBruxism(improvedby1/3)• KlonopinisaMusclerelaxerSleeppromo]ngDecreasesanxiety EurArchPsychiatryClinNeurosci(2010)260:163-174
Gabapen]nvsSplintforSB• N=20–10withsplintand10usedmedica]on• Bothtreatmentssignificantlyreducedtheintensityofmassetermusclecontrac]onsduringSB
• ThosetreatedwithGabapen]nshowedsignificantimprovementintotalsleep]me,SWSandsleepefficiency
• Gabapen]nhelpfulespeciallyinthosewithpoorsleepquality JProsthodon]c2013Feb;22(2)
ManagementofSleepBruxism
• UsuallyAssociatedWithaSleepBreathingDisorder–TheOralApplianceSelectedShouldAddressBothissues–PosteriorSupportandAllowFreeMovement
• IfaSingleProblem–UsetheAppropriateBiteSplint
ClinicalFeaturesofBruxism• Duringsleep:ToothGrinding-Tapping• Awake: Toothwear Jaw/musclepain Musclehypertophy #jawmobility Toothhypersensi]ve Crena]ons(scalloped)tongue Burningtongue
ClinicalFindingsinBruxism Abfrac]onsorErrosion
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SecondaryEffectsofSleepBruxism
• Headaches
• JawPain
• TMD
Myofascial Pain & Trigger Points
Myofascial Pain & Trigger Points VapocoolantSprayandStretch
VapocoolantSprayandStretchHelpstoDifferen]ateMPDfromTMJ
ToLearnMore
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SleepBruxisminChildren
Outcomes
ToothWearDisturbed/Non-Restora]veSleep
DeepBitesProgressiveAirwayObstruc]on
TongueThrus]ng
BruxismandADHD• TeensdiagnosedwithADHDearlierinlifemorelikelytohavesleepproblemsanddisorders:insomnia,sleepterrors,snoringandbruism
• SleepproblemsoccurredanddidnotcorrelatetotheseverityoftheADHDsymptomsSleep2009ReportedinClinPsychReview2012
WhattheBrainDoesNotKnow
TheEyeCannotSee
WilliamOsler,MD