International consensus on the assessment of bruxism: Report of a work in progress.

In 2013, consensus was obtained on a definition of bruxism as repetitive masticatory muscle activity characterised by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible and specified as either sleep bruxism or awake bruxism. In addition, a grading system was proposed to determine the likelihood that a certain assessment of bruxism actually yields a valid outcome. This study discusses the need for an updated consensus and has the following aims: (i) to further clarify the 2013 definition and to develop separate definitions for sleep and awake bruxism; (ii) to determine whether bruxism is a disorder rather than a behaviour that can be a risk factor for certain clinical conditions; (iii) to re-examine the 2013 grading system; and (iv) to develop a research agenda. It was concluded that: (i) sleep and awake bruxism are masticatory muscle activities that occur during sleep (characterised as rhythmic or non-rhythmic) and wakefulness (characterised by repetitive or sustained tooth contact and/or by bracing or thrusting of the mandible), respectively; (ii) in otherwise healthy individuals, bruxism should not be considered as a disorder, but rather as a behaviour that can be a risk (and/or protective) factor for certain clinical consequences; (iii) both non-instrumental approaches (notably self-report) and instrumental approaches (notably electromyography) can be employed to assess bruxism; and (iv) standard cut-off points for establishing the presence or absence of bruxism should not be used in otherwise healthy individuals; rather, bruxism-related masticatory muscle activities should be assessed in the behaviour's continuum.

Different association between specific manifestations of bruxism and temporomandibular disorder pain.

INTRODUCTION: A growing body of evidence suggests that bruxism exists in two separate manifestations. However, little is known about the association between specific manifestations of bruxism and temporomandibular disorder (TMD) pain. AIM: The aim of our study was to analyze the association between TMD pain and specific diagnoses of bruxism (sleep, awake, and mixed diagnosis of sleep and awake bruxism). MATERIAL AND METHODS: 508 adult patients (296 women and 212 men), aged between 18 and 64 years (mean age 34±12 years), attending to a clinic for general dental treatment. Patients were asked to fill an anonymous questionnaire, consisting of three questions, verifying the presence of TMD pain and two forms of bruxism. All questions were based on the Polish version of the Research Diagnostic Criteria for Temporomandibular Disorders patient history questionnaire. Cross tabulation was done, and χ2 was used as a test of significance to find the association between the variables. RESULTS: Awake bruxism was associated with TMD pain only in men (χ2=7.746, p<0.05) while mixed diagnosis of bruxism was associated with TMD pain in both women (χ2=10.486, p<0.05) and men (χ2=4.314, p<0.05). There was no statistically significant association between sleep bruxism and TMD pain. Gender-related differences in the presence of all bruxism diagnoses were also statistically insignificant. CONCLUSIONS: Interaction between sleep and awake bruxism may increase the risk for TMD pain. We suggest considering concomitance as a confounder, when studying sleep or awake bruxism.

Bruxism defined and graded: an international consensus.

To date, there is no consensus about the definition and diagnostic grading of bruxism. A written consensus discussion was held among an international group of bruxism experts as to formulate a definition of bruxism and to suggest a grading system for its operationalisation. The expert group defined bruxism as a repetitive jaw-muscle activity characterised by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible. Bruxism has two distinct circadian manifestations: it can occur during sleep (indicated as sleep bruxism) or during wakefulness (indicated as awake bruxism). For the operationalisation of this definition, the expert group proposes a diagnostic grading system of 'possible', 'probable' and 'definite' sleep or awake bruxism. The proposed definition and grading system are suggested for clinical and research purposes in all relevant dental and medical domains.

Coincidence and awareness of oral parafunctions in college students.

OBJECTIVE: The aim of the study was to determine the prevalence and awareness of particular types of oral parafunctions in young healthy students and any association with temporomandibular disorders (TMD). MATERIAL AND METHODS: The study was performed in a randomly selected group of 303 healthy students (mean age 18.8 years) from the vocational technical school in Wroclaw, Poland, who underwent a routine clinical examination and functional analysis of the mouth. On taking the history all subjects were asked about their awareness of various forms of parafunctional activity in their mouth. RESULTS: Almost all subjects revealed various oral parafunctions such as: bruxism, nail and pen biting, chewing gum, and biting the mucosa of lip or cheek. These habits were present singly or as double, triple or even fourfold coincidences in a single person. The most frequent oral parafunctions were habitual gum chewing and bruxism. Subjects were very seldom aware of the last parafunction. TMDs were more prevalent in the presence of bruxism than in other oral parafunctions. CONCLUSIONS: The studied students revealed various types of oral parafunctions, however most of them were not aware of clenching and grinding their teeth.

Risk of chipping or facings failure of metal ceramic fixed partial prostheses--a retrospective data record analysis.

This retrospective study investigated the frequency and time history of chipping or facings failure of three-unit and four-unit tooth-supported metal ceramic (MC) fixed partial prostheses (FPDs). Six hundred fifty-four MC FPDs were inserted according to a standardized treatment protocol at the Department of Prosthodontics of the Regensburg University Medical Center between 1984 and 2009. Frequency and time history of chipping or facings failure as well as possible risk factors were evaluated on the basis of historical clinical data. We estimated the survival times of FPDs by means of the Kaplan-Meier analysis. The 5-year survival rate (time to renewal of a FPD) of all MC FPDs was 94%; the 10-year survival rate was 87%. Twenty-eight (4.3%) MC FPDs showed chipping; the 5-year free-of-event rate of chipping was 95%, the 10-year rate was 94%. Possible risk factors had no statistically significant influence on chipping or facings failure. The annual hazard rate of MC chipping in the first year was 0.03, i.e., 3 out of 100 person-years of exposure showed chipping. The annual hazard rates for the next 6 years dropped to 0.009, 0.003, 0.007, 0.004, 0.005, and 0.007. Thus, about 3-9 out of 1,000 person-years of exposure showed chipping. Patients with MC FPD may expect a long survival rate of their restoration. During the first year, the risk of chipping may be higher than during the following years. Despite the long period of experience with MC FPDs, chipping of the facing will still occur.

Profiling the clinical presentation of diagnostic characteristics of a sample of symptomatic TMD patients.

BACKGROUND: Temporomandibular disorder (TMD) patients might present a number of concurrent clinical diagnoses that may be clustered according to their similarity. Profiling patients' clinical presentations can be useful for better understanding the behavior of TMD and for providing appropriate treatment planning. The aim of this study was to simultaneously classify symptomatic patients diagnosed with a variety of subtypes of TMD into homogenous groups based on their clinical presentation and occurrence of comorbidities. METHODS: Clinical records of 357 consecutive TMD patients seeking treatment in a private specialized clinic were included in the study sample. Patients presenting multiple subtypes of TMD diagnosed simultaneously were categorized according to the AAOP criteria. Descriptive statistics and two-step cluster analysis were used to characterize the clinical presentation of these patients based on the primary and secondary clinical diagnoses. RESULTS: The most common diagnoses were localized masticatory muscle pain (n = 125) and disc displacement without reduction (n = 104). Comorbidity was identified in 288 patients. The automatic selection of an optimal number of clusters included 100% of cases, generating an initial 6-cluster solution and a final 4-cluster solution. The interpretation of within-group ranking of the importance of variables in the clustering solutions resulted in the following characterization of clusters: chronic facial pain (n = 36), acute muscle pain (n = 125), acute articular pain (n = 75) and chronic articular impairment (n = 121). CONCLUSION: Subgroups of acute and chronic TMD patients seeking treatment can be identified using clustering methods to provide a better understanding of the clinical presentation of TMD when multiple diagnosis are present. Classifying patients into identifiable symptomatic profiles would help clinicians to estimate how common a disorder is within a population of TMD patients and understand the probability of certain pattern of clinical complaints.

Bruxism: is it a new sign of the cardiovascular diseases?

AIM: To determine the relationship between bruxism and cardiovascular diseases. MATERIALS AND METHODS: 120 patients who referred to the Dentistry Faculty with the complaint of bruxism were selected. All patients gave informed consent for participation in the study. All of the patients were examined and bruxism was classified. And also these were examined by B-mode ultrasound to measure the Intima Media Thickness (IMT) at the far wall of the common carotid artery. A wide range of vascular risk factors including age, gender, body mass index, and previous history were surveyed. Spearman correlation analysis was performed to ascertain quantitative comparison, Mann-Whitney U and Kruskal-Wallis test were used for comparison of means RESULTS: There were 66 (55%) male and 54 (45%) female patients, with a female to male ratio of 1/1.2. The mean age was 35.6 +/- 1,25 years (range 18-65 years). In the analysis of bruxism classification and IMT there was a statistical significance between bruxism classification subgroup 1, 2, 3 and IMT. There was no statistical significance between bruxism classification Subgroup 4 and IMT due to the small number of the patients (n = 12). CONCLUSIONS: Stressful situations can cause both bruxism and cardiovascular disease such as coronary artery diseases, hypertension, arrhythmias, cardiomyopathy. The statistical analysis supported this hypothesis. However, we need to new studies with large number of samples to confirm this hypothesis. Clearly, future studies in this field will need to take into consideration the influence of the following variables: age, use of medication or drugs, smoking habits, and other sleep disorders.

Estrogen replacement therapy among postmenopausal women and its effects on signs and symptoms of temporomandibular disorders.

The prevalence of temporomandibular disorders (TMD) is about two to five times higher in females than in males. Data for the higher prevalence of TMD in women and prevalence rates peak during the reproductive years and decrease after menopause. This indicated that female sex hormones may play a role in the etiology or maintenance of TMD. The aim of this study was to investigate the relationship between postmenopausal hormone use and TMD in Turkish postmenopausal women. One hundred-eighty (180), postmenopausal women, aged 42-72 years, were examined both clinically and by questionnaire with regard to the signs and symptoms of temporomandibular disorders, general health status and use of postmenopausal hormone replacement therapy in the preceding year. Ninety-one (91) postmenopausal women (50.6%) were on hormone replacement therapy (HRT). The remaining 89 (49.4%) postmenopausal women were not on hormone replacement therapy. There was no significant difference found in the signs and symptoms of TMD between postmenopausal women using hormone therapy and those not using postmenopausal hormones. There was no association between the use of postmenopausal hormones and the signs and symptoms of TMD in this study.

Behavior and orofacial characteristics of children with attention-deficit hyperactivity disorder during a dental visit.

ADHD is a neuropsychological disorder, affecting attention, impulsiveness and activeness. The study included 36 children with ADHD, 47 without, and two silent observers. A dental form, SNAP-IV and ADHDT symptom checklists were used. Statistically significant differences were observed in hospitalization histories, oral habits, tongue characteristics, and facial biotype. Differences in orofacial characteristics and behavior between the groups were confirmed.

Validity of an instrument assessing oral health problems in people with Down syndrome.

AIM: The aim of this study was to validate a proxy measure of oral health designed to be completed by the English-speaking parents of people with Down syndrome (DS) aged four years or more. METHODOLOGY: Items were generated through literature review, interviews with parents of people with DS and professional experts and through frequency testing. Data were gathered from one population-based and two clinic-based samples for the separate aspects of validation. Validation consisted of evaluation of: i) internal reliability of the domain structure through Cronbach's alpha; ii) criterion validity against clinical indicators and a clinician's evaluation of some items; iii) construct validity involving an age-matched comparison of domain scores between people with DS and non-DS siblings, and within the DS group by health status indicators; and iv) test-retest reliability through the generation of intra-class correlation coefficients (ICC). RESULTS: A 20-item instrument with four domains (communication, eating, parafunction and symptoms) was developed. Cronbach's alpha by domain was 0.5-0.8. Indicators of criterion validity for domains against clinical indicators (Spearman's coefficient 0.1-0.4) and parent-rated items against clinician-rated items (weighted Kappa 0.1-0.8) were varied as anticipated. Indicators of construct validity (differences with non-DS siblings and correlations with medical status within the DS group) were excellent. Test-retest reliability was good (ICC range 0.64-0.84). CONCLUSION: These data suggest the test instrument is valid as a descriptive, discriminative, proxy English language measure of oral health problems in people with DS aged four years or more.

Bruxism secondary to chronic antidopaminergic drug exposure.

Eight cases of diurnal bruxism (DB) secondary to long-term antidopaminergic drug exposure are reported. Five exhibited a grinding pattern, one a clenching form, and two a mixed type. An odontological etiology was absent throughout. EMG recordings disclosed two distinct patterns of muscle activity, one with brief rhythmic, forceful contractions and the other featuring sustained prolonged contractions. Surface EMG and EEG monitoring during a 24-h period confirmed the absence of bruxism during sleep. Several drug trials failed to provide relief. Our findings support DB as a focal tardive dystonia syndrome.

Direct resin composite inlays/onlays: an 11 year follow-up.

OBJECTIVES: The aim of this study was to present an 11-year assessment of direct resin composite inlays/onlays. METHODS: One-hundred Class II direct resin composite inlays and 34 direct resin composite restorations were placed in 40 patients. The restorations were evaluated clinically, according to modified USPHS criteria, annually over a 11-year period. RESULTS: Of the 96 inlays/onlays and 33 direct restorations evaluated at 11 years, 17. 7% in the inlay/onlay group and 27.3% in the direct restorations group were assessed as unacceptable. The differences in longevity were not statistically significant. The main reasons for failure for the inlays/onlays and direct restorations were fracture (8.3 and 12. 1%, respectively), occlusal wear in contact areas (4.2 and 6.1%, respectively) and secondary caries (4.2 and 9.1%, respectively). Eight of the non-acceptable inlays/onlays and five of the direct restorations were replaced, while the other ones were repaired with resin composite. Unacceptable wear was observed in occlusal contact areas of six restorations, in patients who were severe bruxers. For the other restorations occlusal wear was not found to be a clinical problem and no difference was observed between the inlays/onlays and direct composite restorations. The marginal adaptation of the inlays/onlays was still good at the end of the study. Ditching was only observed in a few inlays. A higher failure rate was observed in molar teeth than in premolar teeth. CONCLUSIONS: Good durability was observed for the direct resin composite inlay/onlay technique. Excellent marginal adaptation and low frequency of secondary caries in patients with high caries risk were shown. No apparent improvement of mechanical properties was obtained by the secondary heat treatment of the inlays. Also, the difference in failure rate between the resin composite direct technique and the inlay technique was not large, indicating that the more time-consuming and expensive inlay technique may not be justified. The direct inlay/onlay technique is recommended to be used in Class II cavities of high caries risk patients with cervical marginal placed in dentin.

A clinical comparison of internal joint disorders in patients presenting disk-attachment pain: prevalence, characterization, and severity of bruxing behavior.

This study clinically documents the presence of disk-attachment pain (DAP) related to the severity of bruxism and to the prevalence of internal joint disorders in patients and controls. The sample consisted of 394 temporomandibular disorder (TMD) and bruxing behavior patients and 104 nonbruxer control subjects. The TMD group was subdivided in a group of 109 disk-attachment pain patients and 285 bruxing behavior-nonDAP groups. The second reference group was a sample of 104 nonbruxing behavior subjects. Comprehensive evaluations (including history of signs and symptoms), use of questionnaires, clinical examination, palpation of muscles and joints, classification of bruxing behavior by the degree of severity, and diagnostic tests were performed in patients and controls. There was a prevalence of disk-attachment pain in the group of TMD and bruxing behavior patients. The degree of jaw opening was lower in the DAP group as compared to the TMD/bruxism-nonDAP group and controls. The mean Visual Analog Scale (VAS) value for the joint pain complaints was slightly elevated in the DAP group as compared to the TMD/bruxism-nonDAP group. Specific masticatory disorders including difficulties to open, pain on opening, chewing pain, fatigue on chewing, jaw deviation to opening, and change to a soft diet, were significantly more prevalent in the DAP group as compared to the other reference groups. Our conclusions are based upon a review of the literature and on the results of this study: a. DAP is a relatively well defined stage of internal joint derangement (IJD); and b. compared to other groups, DAP patients as a subgroup are relatively more impaired by their masticatory and other functional disorders. This study provides strong support to other studies and demonstrates that DAP is a well-differentiated and severe internal joint disorder.

Profile of TMD and Bruxer compared to TMD and nonbruxer patients regarding chief complaint, previous consultations, modes of therapy, and chronicity.

This comparative study by groups assesses the profiles of TMD (temporomandibular dysfunction) and bruxism patients and TMD-nonbruxing patients regarding chief complaint, previous medical and dental consultations, duration of the chief complaint, previous medication, and use of splints. The sample consisted of a group of 340 TMD patients, 275 of whom were bruxers and 65 who were nonbruxers. Both patients and controls were consecutive referrals over a period of five years. The group of TMD and Bruxer was classified according to the degree of severity. One hundred eight (108), 84, and 83 patients demonstrated mild, moderate, and severe bruxism respectively. Information gathered included a set of questionnaires, history of signs and symptoms, and a clinical examination. The most common chief complaints in TMD bruxers and nonbruxers were facial, temporomandibular joint, headache and/or cervical pain, and joint noises. It was observed that the need for medical and dental consultations increased with the severity of bruxism. It was also apparent in this study that the need for medication (analgesics, muscle relaxants, and antidepressants), increased with the severity of bruxism. Moderate and severe subgroups of bruxers used significantly more splints compared to mild bruxers and to TMD-nonbruxer patients. Both groups of TMD + bruxism and TMD - nonbruxism sought medical and dental consultations with dentists (clinicians and specialists) neurologists, and otolaryngologists more frequently compared to other medical professionals. Since the need for health services increased with the severity of bruxism, this study urges the need to include a protocol or questionnaire to assess the severity of bruxing behavior in TMD patients in order to use a customized method of treatment/management. This study also reinforces the point of view that different subgroups of TMD and bruxism do exist and suggests a differentiated therapeutic approach. They show previously confirmed findings that pain is the major complaint of TMD and bruxer patients.

A clinical study of specific signs and symptoms of CMD in bruxers classified by the degree of severity.

Two hundred and seventy-six CMD patients referred consecutively for diagnosis and treatment over a period of four years were assessed. Two hundred and eleven were classified as bruxers according to the use of a questionnaire and clinical examination. One hundred (47.39%) presented clinical characteristics of mild bruxers, 66 (31.27%) presented moderate bruxism and 45 (21.32%) demonstrated severe bruxism. Severe bruxers presented the lowest degree of jaw opening (39.21 mm) and highest prevalence of capsulitis (97.77%), retrodiskal pain (84.44%) and disk-attachment pain (48.88%). As compared to the mild and moderate groups, severe bruxers also demonstrated significantly higher prevalence of protective splinting and transient locking or recent history of intermittent locking, masticatory pain, reciprocal clicking and signs and symptoms of Myofascial Pain Dysfunction Syndrome (MPDS). Because higher prevalence of specific muscle and joint disorders were observed in bruxers and such prevalence was progressive from the mild to the moderate and severe group, it may be concluded that bruxing behavior is a significant factor in the etiology and progression of muscle and joint disorders. Based on the review of the literature, the analysis of our data in comparison to other studies allowed us to conclude that severe bruxers are more impaired by muscular and joint disorders as compared to mild and moderate bruxers.

Oral jaw behaviors in TMD and bruxism: a comparison study by severity of bruxism.

The purpose of this study was to document the prevalence of oral jaw behaviors concomitant to bruxism in TMD+bruxing behavior patients and in nonbruxer controls. Clinical examination, questionnaires, and specific criteria to allocate patients to mild, moderate, and severe groups of TMD and bruxers were used. The sample consisted of 274 TMD+bruxing behavior patients and 52 control non-bruxing behavior groups evaluated at the Center for the Study of TMD. The mean age of the TMD+bruxing behavior group was about 33.11 years old (range 16.66, SD = 11.52) as compared to 34.90 years old (range 17-67, SD = 14.26) in the control group. Oral jaw behaviors were assessed in the mild, moderate, and severe TMD+bruxing groups, and in the corresponding control group. It was found that the prevalence of oral jaw behaviors was higher in the TMD+bruxing behavior group as compared to the control. Hence, concomitant oral jaw behaviors predominated in bruxers and increased with its severity. The data reinforce the need to assess TMD patients in terms of the presence of bruxism, its severity, and concomitant oral jaw habits. Such approach will enable the clinician to have better understanding about the role of these behaviors in TMD. Epidemiological data was also provided regarding jutting the jaw forward (a rarely-described oral jaw habit) in a relatively large sample of TMD+bruxing patients, suggesting a more clinical intervention in children and adolescents. This study is the first to document the prevalence of specific oral jaw habits in a relatively large sample of TMD+bruxing behavior classified by degree of severity. Results suggest that TMD+bruxing patients may present many other additional oral jaw habits which may concur to increase masticatory muscle activity thus leading to TMD signs and symptoms. Factors responsible for the increased frequency of oral jaw habits with the severity of bruxism behavior remain unknown and therefore further studies are needed.

The relation of bruxism and dermatoglyphics.

With the aim to examine the dermatoglyphic patterns of finger and palm, 38 bruxism patients, 18 being female were studied. Fingerprint patterns in bruxism has previously been discussed in a few papers, but this is the first paper about dermatoglyphic patterns of palm in bruxism. The aim of this study of finger and palm prints in patients with bruxism were to discuss the importance of dermatoglyphic patterns in the diagnosis and etiology of the disease. Bruxism patients demonstrated an increase in frequency of whorls and a decrease in frequency of ulnar loops than the controls. Patients with bruxism demonstrated a lower frequency of atd angle than controls. Augmentation of I loops and t triradii and diminution of IV, H and t" triradii were observed in bruxism patients. Furthermore, the main line A ended more frequently in sector 5' in bruxism patients when compared with controls. There is no significant difference between the total finger ridge counts (TRC) and a-b ridge counts the subjects with bruxism and that of the controls. The dermatoglyphic patterns of finger and palm was significantly different in children with bruxism. When combined with other clinical features in bruxism, dermatoglyphics can serve to strengthen a diagnostic impression.

Clinical survey of cervical tooth lesions in first-appointment patients.

OBJECTIVE: To investigate the relationship between cervical lesions and patient age, brushing method and bruxism based on a clinical survey of first-appointment patients. METHODS: Two hundred and nine patients (118 male, 91 female) who had unfilled cervical lesions were examined. Information on patient age, teeth with lesions, classification of the lesions, brushing method and bruxism was obtained. The data were analysed statistically. RESULTS: Cervical lesions started to develop in the first premolar teeth in the early twenties and became more prevalent with age. A habit of bruxism was associated with an increase in cervical lesions. Brushing was not directly associated with the development of cervical lesions. CONCLUSION: This study suggests that cervical lesions should be treated at an early stage to prevent further problems.