Bruxism: No. It is NOT "just the same old GRIND "!

Posted by Amy McGlaughlin, RDH PHDHP on Apr 12th 2018

Bruxism: No. It is NOT "just the same old GRIND "!

As new research surrounding sleep bruxism emerges, there seems to be a delay in universally updating how it is treated. The first bruxism splint was designed by a German inventor in 1901. I was surprised to see the sketched model of his appliance very much resembling many we use today! Plenty of patients aren't seeing improvements with their night guard, and some are actually getting worse because of it.

What would you do?

Let's say I visit my dermatologist to have a mole on my face examined. This mole flakes easily, even bleeds at times. The dermatologist instructs me to cover that mole with a band aid, protecting it from physical irritation, then sends me on my way. Would I walk out of that appointment feeling good about this solution? Absolutely not. I would expect the doctor to run some tests, delve into my case more thoroughly, to learn the ultimate cause of my concerning mole.
So, am I comparing possible skin cancer to bruxism? Of course not. I realize one is a potentially fatal situation and the other, while it can cause and signal health problems, is indeed benign. I simply want to get everyone thinking with a more proactive mindset. I hope most of us would not passively accept a band aid for that mole. Nor should anyone accept being told all they need is to have an appliance made to wear over their teeth for their sleep grinding. Advocate for yourself by reading and researching (reputable sources, please, Dr. Google doesn't always have a degree!), ask questions, seek a second opinion, request further testing. It never hurts to be your own advocate when it comes to your oral health and overall health.

Same old song and dance deserves a second look

For the 20 plus years that I've been a dental hygienist observing bruxism symptoms in patients, the same chief complaints and clinical findings are documented in the patient chart, and the same, seemingly relevant, conversations are had. Frequently, the patient is told a custom night guard is needed. The primary purpose of a night guard has been to protect teeth from the damaging effects of grinding. Some patients proceed with the recommendation, and some don't. Some find success with their laboratory night guard, but many don't. Some sufferers even resort to buying a bulky, poorly fitting over-the-counter boil and bite night guard due to cost concerns.
Why are we so accepting of a band-aid solution? Doesn't anyone wonder WHY they grind their teeth in their sleep? Too often the practitioner and patient will discuss things like stress levels and attribute this as the cause of the sleep grinding. Sure, we all have stress, so we are inclined to accept this rationale and the treatment plan of a lab-made bruxism appliance. This can be quite costly, in more ways than one. There are too  many variables to cover adequately here, but missing teeth; misaligned teeth; malocclusion (poor jaw alignment); and sleep disordered breathing are a few that should be explored.

So, what's new?

While night guards can provide protection for many patients, current research is surfacing to warrant rethinking the traditional night guard treatment for bruxism. So much so that the most recent position statement issued by the American College of Prosthodontists advises careful consideration before making a patient night guard. A link between sleep disordered breathing (such as obstructive sleep apnea/OSA) and bruxism has been established. The ACP warns "Practitioners should screen patients for obstructive sleep apnea (OSA) prior to fabricating a maxillary night guard that increases the occlusal-vertical-dimension (OVD)..." Reflective of research finding that the greater increased opening (OVD), created by thicker night guards worn on the upper teeth, can actually worsen sleep apnea.

Common explanation of what occurs during sleep apnea

For some individuals, during certain sleep stages, and in an unconscious state, the airway somewhat collapses and breathing becomes hindered. Snoring will likely occur. As the brain senses breathing is more seriously compromised, it exits the deepest sleep stage to activate the jaw muscles to reopen the airway. This survival response from the brain signals the lower jaw to move forward to reestablish airflow. This cycle of airway collapse and lower jaw moving forward to reopen airway results in the grinding action of the jaws and teeth. This process can repeat anywhere from five to as many as 70 times throughout sleep. A thicker splint worn on the biting surfaces of the upper teeth can be especially harmful in this scenario because it can prevent the bottom jaw from sliding forward to reestablish adequate air flow. Note that nearly all over-the counter night guards are of moderate thickness, as well as some dental laboratory made night guards. A lot of factors play into the "why" of this compromised airway. Not everyone will be bruxing because of a sleep disorder, but it should be ruled out. Varying degrees of sleep disordered breathing exist. Having a sleep study performed does not mean you will automatically be wearing a CPAP device for life. However, leaving OSA undiagnosed and untreated can be detrimental to daily quality of life and result in serious health consequences. Many diagnosed with OSA felt they were sleeping fairly well until their sleep study concluded otherwise. STOP BANG is a  simple screening questionnaire. While not intended to provide any diagnosis, it may get you thinking about your own sleep health.

What can you do?

Assuming the dentist has ruled out obvious dental issues causing your sleep grinding, a good next step is asking your dentist and medical doctor for the appropriate referral(s) that can comprehensively assess for sleep breathing disorders. There will be times when a customized oral sleep appliance is indicated. A professional with additional specialized training should be consulted. It is worth reiterating that a thick guard could worsen OSA, if present. An ill-fitting guard could also potentially worsen bruxism, orofacial pain, TMD (temporomandibular joint dysfunction often referred to as TMJ), headaches, etc. Attempt to self-diagnose or self-treat is not recommended.

How to prevent damage to teeth and dental work until accurate diagnosis and appropriate treatment plan is made

We all know it could take a lot of time and patience until you see your dentist, then your medical doctor, request referral, get appointment to see specialist, get an evaluation, receive a diagnosis, and are given a treatment plan. Phew! You will likely want to protect your teeth and supporting structures in the meantime. Look for a quality product that will not affect your airway or bite significantly. I don't think it is necessary or wise to invest a lot of money in a custom laboratory appliance if it may not be used long-term, or at all, pending the outcome of your sleep study. An affordable, thin night guard would be an excellent choice for the interim. Look for one that offers a slim profile with added protective properties. A night guard I have found and recommended with promising feedback is the SOVA night guard. It meets the criteria for durable protection, custom fit, ease of use, and affordability while only increasing the opening of the bite slightly. SOVA will make wearing a night guard as easy as possible while you get to the "root" of your sleep-grinding.