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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