David Winkler discusses some practical considerations for tackling the destructive effects of unchecked bruxism.
How often does a patient present with specific wants, needs, or expectations? Yet after extensive interviews, intraoral and extraoral examinations, diagnoses, and all treatment plan options presented for informed consent, they respond with: ‘But I don’t grind my teeth!’
Despite all our visual aids – both electronic and hard models – and how obvious the tooth wear is (not to mention the possible problems in the form of TMD symptoms, headaches or back pain), patients still don’t believe that there can be a correlation between the subjective and objective findings and their ‘non-existent’ bruxism.
Silent but deadly
Bruxism and clenching can be ‘silent but deadly’ with minimal apparent attrition and very few or no symptoms until the damage is done and the financial and biological costs to treat them are great. The forces generated in the masticatory system during bruxism can exceed those within the tolerances of already compromised teeth or restorations, leading to further restorative treatment to repair or replace prematurely failed crowns, veneers, inlays and the like. Often, simple to complex restorative treatment is carried out in patients with moderate bruxism symptoms without addressing the problem, with no form of tooth protection post-restorative phase, leaving subsequent remedial repair work necessary – leading to dissatisfaction for the patient and distress for the treating dentist!
Many studies have shown that there can be a correlation between some types of migraine headaches and muscular tension-type headaches, and bruxism and clenching. By examining the patient for muscular dysfunction, dentists can contribute to the physician’s examinations in dealing with patients with these difficult to diagnose/treat problems. In many cases, simple anterior splint therapy, such as the Bitesoft appliance, can provide a cost-effective, non-medicinal and effective treatment modality with no side effects for this group of patients.
Diagnosis and treatment
To help the dentist in diagnosing bruxism, and assisting in putting forward an effective treatment plan, the following questions and observations are appropriate:
- Is there a pattern, or history of toothgrinding several times weekly?
- Is there evidence of attrition, flattening, or fractures of teeth or restorations?
- Is there any tenderness in the muscles in the jaw, or in the temples when clenching, or clicking of the TMJ?
- Is there any discomfort when eating?
When the answer to these questions is affirmative, splint therapy should be considered both for diagnostic as well as palliative purpose. Many devices have been devised to help dentists in providing this important treatment option. Although many of them theoretically work and relieve the symptoms, the major problem seems to be compliance on behalf of the patient, as most splints tend to be bulky and require quite a long period of adjustment.
Small anterior splints, to just cover the incisors, have been introduced to the profession, and in the case of our patients at Castleview Dental, seem to be better tolerated – sometimes the best therapy is the simplest therapy that a patient will continue to use!
For the past several years, we have been using the laboratory-fabricated Bitesoft appliance, which has an internal surface of a pliable acrylic that slips over the teeth more easily and is more comfortable than the more traditional hard acrylic splints.
Case study one
In the case of this female patient in her 30s, a young medical physician, her chief complaints were the aesthetics of her natural teeth, the attempt to reshape the natural upper right canine with composite restorations to give the illusion of the congenitally missing upper right lateral incisor, and the reshaping of the upper left lateral incisor.
Upon examination, it was discovered that she suffered periodically from mild to moderate headaches with tension in several areas of the masticatory musculature. The amount of wear of her natural teeth was minimal. However, she seemed to clench her teeth fairly often, and especially when stressed – and we can all empathise with the amount of stress when dealing with a waiting room full of patients!
After having thoroughly discussed her various treatment options, it was decided to first bleach her teeth to give her the ‘white’ smile that her boyfriend desired! After 10 days of take-home bleaching, we achieved a baseline shade of B1, which she was content with, and there was a discernible difference with the previous placed composite restorations on UR3 and UL2 (Figures 1-3).
She was also interested in closing the gap between the UR4 and UR3. Orthodontic treatment was suggested, which would also have helped to alleviate the discrepancy in the gingival margins, and if we had extruded the UR3, we would be able to have a narrower cervical area to harmonise with the UL2.
However, orthodontics were not appropriate, as she wanted/needed (to appease the boyfriend) instant gratification.
We then removed the composite restorations from the UR3 and UL2 and prepped the remaining UR5, UR4, UR1 and UL1, UL3, UL4 for porcelain veneers. We attempted to keep all the preparations in enamel, although after removal of the composite from the UR3, it was obvious that some of the previous preparation had been in dentine (Figures 4 and 5).
We then fitted the eight veneers, which satisfied the patient’s cosmetic needs (although her boyfriend wanted them brighter) for closing the gap between UR4 and UR3 and gave her a better shade match with the previously restored UR3 and UL2 (Figures 6 and 7).
We provided her at the fitting appointment with a Bitesoft anterior appliance to help alleviate her headaches. At her three-month review, she expressed her satisfaction with both the cosmetic results, explained that her headaches were neither as intense or as frequent as before… and she had moved on from her boyfriend!
Case study two
Robert, a pensioner in his late 70s, presented with no subjective dental symptoms other than the psychological problems of having very worn teeth, and the inability to smile. There was tenderness and clicking in the muscles and the TMJ. Most of the wear was in the maxilla. There was a fistula at the apex of the UR2, which he was unaware of. He suffered frequently from tension-type headaches. He wanted therapy to restore his upper teeth to a natural appearing smile and hopefully to alleviate his headaches (Figures 8-10).
We discussed his various options and decided to restore his lower posteriors with a single implant and a couple of crowns, and to rebuild the upper dentition with single crowns and a small three-unit bridge to replace the failing UR2. Robert was in provisional restorations for six months in order to assess the effects of the increased vertical dimension with regard to both the headaches and the aesthetics.
After fitting of the final restorative work, Robert was also fitted with a Bitesoft appliance as a precautionary measure, which he continued to wear religiously. The results, two years after fi tting, were satisfactory (Figures 11-14).
Bitesoft has become an invaluable part of our restorative treatment options, as it’s easy for the patient to wear and get accustomed to, and appears to help alleviate many of the symptoms attributed to bruxism and clenching.