olmos teeth grinding

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1Why Do Patients Grind – Steven Olmos DDS

Why Do Patients Grind Their Teeth?Steven R. Olmos DDS

Featured Speaker - BioRESEARCH Annual Conference - Milwaukee WI - April 30th

– May 2nd

2009

Founder

TMJ & Sleep Therapy Centres

Private Practice limited to the treatment of orofacial/craniomandibular/temporomandibular disorders and oral

appliance therapy for the treatment of obstructive sleep apnea

La Mesa, California

Many articles are available on how to make oral appliances (splints). Although some

of these articles provide very intricate details about the fabrication of the appliance,

most do not discuss the diagnoses that require the patient to need an appliance.

Therefore, readers are left to wonder why these patients are grinding their teeth.

The temporomandibular joints (TMJs) are the toughest joints in the body

(fibrocartilage, as opposed to hyaline for other joints). The TMJs break down because

of the continued compressive forces, day and night, from a struggle to breathe, the

discomfort of chronic pain, and anxiety.

Headaches, facial pain, limited mandibular opening, jaw noises (popping and clicking),

bruxism/attrition, broken teeth and obstructive sleep apnea (OSA) are all reasons that

patients seek dental care (Figure 1). The comorbidity and pathophysiology of these

ailments is well documented. This article will connect the dots and provide a simple




way to screen patients, so the dentist can develop a treatment plan for optimal dental

and physical health.

Orofacial PainOrofacial PainOrofacial PainOrofacial Pain

The head/face is the monitor of the health of the body. The muscles of mastication

(temporalis, masseter, medial pterygoid, and lateral pterygoid) are in balance with the

Figure 1 The patient presented with: teeth grinding, difficulty falling asleep, repeated

awakings, feeling unrefreshed in the morning, significant daytime drowsiness, dry

mouth on waking, tossing and turning frequently, fatigue, headache pain, sinuscongestion, and jaw joint noises.




of the neck. These muscles have activity and a level of tonus based on central

nervous system (CNS) stimulation. People clench, grind, or brux because of increased

CNS stimulation, which results from various amounts of pain, breathing dysfunction,

or anxiety.1,2 Various palliative medical/dental treatments, such oral appliances,

dental equilibration, medication regimens, and physical medicine treatments (botox),

often are prescribed without first determining why the patient is grinding his or her

teeth.

The patient may be clenching because of chronic pain, such as a painful nerve in the

foot, compressed inflamed disc in the spine, or an aching osteoarthritic hip. The

parafunctional activity may be the result of apnea (cessation of breathing for 10

seconds or longer) or sleep disturbance. It may be the result of life’s hurdles (divorce,

job, relationships), which are usually acute, or the pathologic mental disorder of

chronic anxiety.

Between 25% and 30% of the population suffers from chronic pain, with an estimated

drain to the American economy of $125 billion annually.3 The longer a person has

pain, the more pain that person feels because of the process of central sensitization.

The CNS is plastic and changes to receive and transmit more pain signals to the brain.

This results in more stimuli to the facial muscles to contract and predisposes the




patient to more headaches/facial pain. Light, unrestful sleep results in more pain

during the day; 1 pain during the day makes for unrestful sleep.

The International Headache Society (HIS) categorizes headaches into two

predominant types: primary and secondary. Secondary headaches are the result of

organic pathology, such as a tumor or bleeding of the vessels surrounding the brain.

These headaches are rare in the absence of major trauma. Primary headaches are

idiopathic (of unknown origin) and are categorized by frequency, location, duration, a

person’s response to it, and what medication relieves it. To be categorized as a

primary headache, the patient has had magnetic resonance imaging (MRI) and

computed tomography (CT) scans of the brain, and the test results are normal.

Headaches in this category are the ones most commonly treated: migraine, tension

type, cluster, etc. Migraine prevalence in men is 6% and women 18%, and the rate in

children is increasing rapidly.4 The Nuprin Pain Report (a national epidemiologic study

on the prevalence of headache, conducted in 1985) found that headache prevalence

in the United States is 78% for adult women and 68% for adult men.

Migraine, cluster headache, hypnic headache, and morning (tension) headache in

adults 1,5 and children are all related to apnea or disturbed sleep.6 Headache has

been found in 65% of patients with nocturnal bruxism.7,8 All people parafunctionally




contract with greater force (approximately 57,600 lbs/sec/day) than normal function

(approximately 17,200 lbs/sec/day).2 Patients with temporomandibular disorder

(TMD) brux longer, 38.7 minutes, compared with control patients, 5.4 minutes.9

Diurnal and nocturnal parafunctional (bruxing) activities occur at a subconscious

(brainstem/autonomic) level; therefore, unawareness of the activity is common.10-12

People brux more when they are on

their backs (supine),13-15 and they

have more obstructed apnea in that

position (Figure 2). Therefore, to

determine the position of worst

apnea, sleep laboratories have the

patient sleep in different positions.

More than 75 million Americans

(25%) have sleep apnea, and many

more have sleep disturbances.16 A

survey of the literature demonstrates the prevalence of TM symptoms in the general

population is 41% and those showing a sign is 56%.2 The most frequent symptom

(96%) of TM dysfunction (inflammation/capsulitis, disc displacement, etc) is right-

Figure 2 The mandible and the base of thetongue fall back when the patient in the

supine position, blocking the airway.




sided back-of-head pain (occipital cephalgia).17 The body assumes a forward head

posture when there is inflammation in the TMJs. When the inflammation/dysfunction

is corrected through decompression (day and night orthotics using the sibilant

phoneme technique), there is a return of head posture by 4.43 inches.18 The forward

head posture places increased stress on the cervical spine and the insertion of the

muscles at the back of the neck/head (Figure 3). This forward head posture changes

occlusion.19-21

For these reasons, the American Dental Association (ADA) and the

American Academy of Orofacial Pain (AAOP) recommend that no permanent occlusal

Figure 3 Forward head posture, the result of TMJ inflammation, changesocclusion and causes increased pain in the neck .




therapy (equilibration) be performed

on a patient with TMJ inflammation.

Botox injections for migraine are

given at the base of the skull (Figure

4A). However, many patients

receiving this and other treatments

are misdiagnosed with migraine

when they suffer from TMJ injuries

(inflammation). If treated for TMJ

(inflammation resolved), abortive,

preventative medication regimens

or debilitating therapies would not

be requires. Botox injections also

are given for clenching, a result of

pain in the body or breathing

distress, in the temporalis and

masseter muscles (Figure 4B), and

Figure 4A Botox treatment for migraine is at

the base of the skull with the patient’s head in a

forward posture.

Figure 4B Elevator muscle (temporalis andmasseter) injections for the treatment of

clenching from brain stimulation from pain in

the body or breathing distress.




for compression of the cervical

vertebrae, a result of forward head

posture, in the carpal tunnel (Figure

4C).

The Dentist’s ResponsibilityThe Dentist’s ResponsibilityThe Dentist’s ResponsibilityThe Dentist’s Responsibility

Because orofacial pain patients are

seen regularly in the dental practice,

the author devised a simple triage

system that is based on intake data collected from one form, which screens for

chronic pain, airway disorders, malocclusion, and anxiety. The patient questionnaire to

identify origins for the parafunctional activity, combined with the clinical examination

form to prevent overlooking any signs/symptoms, provides the dentist an easy-to-

follow flow chart for treatment (Figure 5). These forms are printable from the TMnDx™

software (TMJ & Sleep Therapy International, LLC, La Mesa, CA), which the author

developed to combine the necessary dental and medical components, and to meet

the medical model for report generation and insurance billing. The software allows the

dentist to print reports and referrals to the other healthcare providers necessary to

Figure 4C A median nerve (carpaltunnel) injection for the treatment of

compression of the cervical vertebrae (C5

through 7 origin of this nerve), the result

of forward head posture.




treat the real cause of the symptoms: sleep physicians, physical therapists,

chiropractors, etc.

Specific diagnostic criteria can be complex and are beyond the scope of this article.

However, the importance of determining the true cause of the patient’s pain can not

be understated. The ADA dental practice parameters of treatment (1997) state22:

“The dentist should consider a differential disease classification that may include

Figure 5 Flowchart of treatment options. Depending on the initial complaint, the

dentist can determine a sequence for treatment using the color-coding.




neuromuscular pain, myofascial pain, neurogenic pain, neurovascular pain,

sympathetic and/or referred pain involving the trigeminal and/or oropharyngeal

systems, or other medical conditions, which may contribute to or mimic TM disorders.”

The ADA further states: “Before restorative and/or occlusal therapy is performed, the

Figure 6 The “ON” series of appliances are night appliances used to either

decompress or maintain a mandibular position in the supine, improve

oropharyngeal breathing, or all of the above. ON = Olmos Night.




dentist should attempt to reduce, through the use of reversible modalities, the

neuromuscular, myofascial and temporomandibular joint symptoms.”

Knowing who, why, and when to treat is key, and most importantly, knowing when to

refer to other practitioners for conditions that manifest in the head/face. Palpate the

lateral poles of the condyles and the posterior joint space with the mouth open to

check for inflammation (capsulitis). Use a ruler to measure maximum opening. Ask if

the patient experiences headaches, wakes fatigued, or uses medications for pain or

sleep aids. If the teeth are worn, the patient should be referred to an otolaryngologist,

a pulmonologist, or a sleep laboratory for an overnight sleep study.

Nonsurgical therapy for chronic headaches (migraine), facial pain, and TMD has been

shown to be reproducibly effective in the author’s clinics. At these clinics, 70% of

chronic pain patients do not need a permanent stabilization therapy (phase II dental

rehabilitation or orthodontics). The flowchart in Figure 6 outlines the steps to follow

with a patient that presents with headaches. The flowchart in Figure 7 outlines the

steps to follow for a patient with limited opening.




Figure 7 The “OD” series of appliances are functional day appliances designed to hold a

mandibular position. Cold spray is used to make the muscles relax so that limited mandibular opening can be diagnosed as to muscle splinting or intracapsular pathology. OD = Olmos Day.




ConclusionConclusionConclusionConclusion

Dentists have a tremendous role in the treatment of chronic pain, headaches

(migraine), and OSA obstructed sleep apnea. These are common problems. Most

dental school education prepared dentists for acute TMJ injury treatment (pain control

and occlusal splint therapy for 2 weeks), but did not prepare dentists for sleep

disordered breathing or how TMJ dysfunction, chronic pain, OSA, and sleep disorder

breathing interrelate. Based on an internationally tested protocol of data collection

and treatment, dentists should:

1. Refer patients with attrition for sleep study before performing any restorative

dental procedures.

2. Screen patients by asking them if they have headaches, jaw pain, or unstablebite.

3. Institute a comprehensive clinical examination and data-collection protocol,covering sleep and TMJ pathology.

4. Follow the TMnDx flowchart for diagnosis and treatment. If unfamiliar, seekadditional education and, if uncomfortable treating, then refer.




DisclosureDisclosureDisclosureDisclosure

The author is an owner of TMnDx Software.

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