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Teaching patients how to stop bruxing habits
C L I N I C A L
Teaching patients how to stop bruxing habits JEREMY SHULMAN, D.D.S., M.S.
linicians and researchers widely agree that temporomandibular disorders, or TMDs, are a rather special group of orthopedic medical problems that can stem from numerous combinations of physical and psychological causes. There also is widespread agreement that bruxing and other nonfunctional jaw movement or posturing habits are major contributing causes of TMD that should be clinicians’ primary therapeutic focus. Occlusal modifications and splints are the most common initial therapies. For many years, splints were
C
used only as bruxing guards for protection of tooth structure, but as TMD therapies have evolved, various types and designs of splints have been developed to help counteract the dysfunctional effects of bruxing habits, as aids in correction of nonideal jaw and occlusal relationships, or both. Regardless of the splint design and purpose, we tend to follow our dental training mindset to do something physical to “fix” the patient’s problem. To this end, treatment usually is focused on correcting the most visible and easily identifiable findings, such as occlusal and jaw relationship
D I R E C T I O N S
abnormalities, or it focuses on guarding against further damage. Exact treatment decisions vary, depending on our training, biases, clinical experience and the therapeutic modalities currently in vogue. What seems to be unexplained is that virtually no one is heeding the cardinal rules of medical management. Nowhere in the literature have I seen a TMD study or even anecdotal treatment recommendations to the effect that after an accurate diagnosis has been made, and any prevalent parafunctional habits have been identified, then proper treatment is to eliminate as many of the direct physical causes as possible. I believe it is almost universally assumed that bruxism, once established as a habit, cannot be changed and that TMD has to be managed by alleviating symptoms, correcting related abnormalities, or both. I
Do you have a time- or work-saving clinical technique to share with your colleagues? Submit it to JADA’s Clinical Directions department. A Clinical Directions item should be a maximum of two double-spaced typed pages and should include no more than one figure or illustration. Submit items to Clinical Directions, JADA, 211 E. Chicago Ave., Chicago, Ill. 60611.
JADA, Vol. 132, September 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.
1275
C L I N I C A L
D I R E C T I O N S
have been unable to find a single report or study of therapy designed solely to stop the parafunctional bruxing habits themselves, which would allow scientific evaluation of symptom remission following elimination of these destructive habits. NEED FOR PATIENT EDUCATION AND MODIFIED BIOFEEDBACK TRAINING
If we educate patients about the mechanism whereby bruxing habits physically overstress the masticatory system beyond its ability to adapt (as so beautifully explained by Hans Selye1), they come to understand their role in unknowingly causing the symptoms, and also that they can expect immediate relief from symptoms if these harmful habits are eliminated. The key to success is effective communication with patients so that they thoroughly understand the problem and are provided with detailed instructions on how to stop the bruxing habits. Therapy starts with a complete explanation of the dysfunctional symptoms and the cause-and-effect mechanisms of bruxing. This is followed by precise instruction in techniques for habit modification, both during the day and especially during sleep when clenching and grinding habits are prevalent. Clinicians should stress the importance of daytime awareness of bruxing or posturing habits, and instruct patients to say “Mississippi” every time the jaw is not in a resting posture, as is attained at the end of the word. To help in this reprogramming, a splint should be constructed, but dentists should not identify it as a guard, but as a nighttime (and daytime when needed) aid that 1276
serves as a tool for modified biofeedback training. Selective awareness. Clinicians need to teach patients that the mind and senses work all night long, but that we have programmed the mind to ignore or react to the continuous sensory input. Examples are waking to certain noises (an infant crying) while ignoring others, waking on pressure from the bladder while ignoring other pressures on the body, waking at set times without an alarm, and waking if someone shines a
If the patient is properly educated and motivated, this training technique is amazingly successful.
light in our eyes, but not when it gets light outside. Biofeedback splint. The splint is full coverage and flat plane, is absolutely smooth and shiny with no indentations, has no anterior occlusion (most bruxers grind on the front teeth and this possibility is eliminated), is adjusted to a height that allows the jaw to move and rest physiologically, and usually is mandibular for maximum comfort.2 Patients should be taught that teeth normally touch only during chewing or swallowing, and that opposing teeth rarely touch even during chewing (because of the food between them). The dentist needs to explain that it is proper for the teeth to touch the splint only at each swallow, and that the lower jaw should be in a resting position when not in function. The clinician teaches the patient that any jaw posturing
habits or tooth contacts other than those involved in chewing or swallowing are parafunctional. Patients must understand that the appliance serves to remind them of any such contact, since its mere presence as well as the difference in tooth contact sensation between when the splint is in place and when it is not in place present a sensory input to which they must react by dropping the mandible into a resting posture. At no time should dentists even suggest that the splint is a guard that is going to make them stop bruxing. Patients need to understand that it is just an inert piece of plastic designed to act only as a training aid to help them gain control by stopping the causes of discomfort. Contact between teeth and the splint during swallowing has no effect on the plastic. Any greater pressures, such as those that occur with bruxing, will produce dents (clenching) or grooves (grinding) that serve as valuable feedback in the morning. Clinicians should instruct patients to focus on not making any marks on the plastic (rather than thinking about teeth and bruxing); the last act before retiring is to concentrate on keeping the plastic smooth with no tooth marks, and the first act on awakening is to check their success. If the patient is properly educated and motivated, this modified biofeedback training technique is amazingly successful. In my practice, approximately one-half of all patients never make the first mark. Follow-up appointments. I see all patients one week after they receive their splints, and any dents in the previously flat plastic are polished smooth.
JADA, Vol. 132, September 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.
C L I N I C A L
This procedure is repeated until there are no marks and it is firmly established that the patient is symptom-free and parafunctional habits have ceased. About 90 percent of my patients are symptom-free within three or four appointments. Even before the splint is delivered, most patients report symptomatic relief, because they have become self-disciplined during the day after learning about their role in causing the problem. Some are even able to wake themselves at night when bruxing. In my practice, it is highly unusual for a patient to experi-
ence no relief, and in such cases, other therapeutic modalities are added. It might be hard to believe that such a simple, quick and noninvasive treatment really works, but once the proper diagnosis is made and major bruxing habits are eliminated, then the dysfunction is controlled and the symptoms disappear. This protocol has proven successful in my practice, with no other treatment necessary in more than 90 percent of all cases. Reported relapses usually are associated with periods of increased psychological stress and almost always are controllable by the patient.
D I R E C T I O N S
CONCLUSION
I note the excellent article on treating bruxism by Christensen.3 But why do we think we have to treat it? Why don’t we just teach patients to stop it? ■ Dr. Shulman is in private periodontic practice, 213 Janaf Office Building, Norfolk, Va. 23502. Address reprint requests to Dr. Shulman. 1. Selye H. The stress of life. New York: McGraw-Hill; 1956. 2. Shulman J, Zeno A. A new technique for making occlusal devices. J Prosthet Dent 1990;68:482-5. 3. Christensen GJ. Treating bruxism and clenching. JADA 2000;131:233-5.
Reduced discomfort during palatal injection WILLIAM R. ASLIN, D.D.S.
e know that palatal injections can be very uncomfortable for some patients. I would like to describe my technique for anesthetizing an upper first molar region when palatal numbness is needed. Using this technique, I have found that effective palatal anesthesia can be achieved with minimal discomfort.
W
into the distal buccal gingival papilla and once more into the mesiobuccal gingival papilla. Look for blanching of the lingual palatal tissue. Next, administer a normal palatal injection or inject into the blanched palatal area, which First, inject one carpule of usually is gingival to the pre2 percent lidoferred injection caine with site, and follow This technique 1:100,000 with a normal can be used for all epinephrine, folpalatal injection. lowing the textThis technique maxillary teeth. book technique for can be used for all buccal infiltration maxillary teeth, in the molar region. Then click and any pressure syringe should be effective. ■ once with the intraligamentary syringe (such as N-Tralig, Dr. Aslin is in private general practice, Miltex Instrument Co. Inc.) 200-C E. Main, Crowley, Texas 76036. (containing 2 percent lidocaine Address reprint requests to Dr. Aslin. with 1:100,000 epinephrine)
JADA, Vol. 132, September 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.
1277
Teaching patients how to stop bruxing habits JEREMY SHULMAN, D.D.S., M.S.
linicians and researchers widely agree that temporomandibular disorders, or TMDs, are a rather special group of orthopedic medical problems that can stem from numerous combinations of physical and psychological causes. There also is widespread agreement that bruxing and other nonfunctional jaw movement or posturing habits are major contributing causes of TMD that should be clinicians’ primary therapeutic focus. Occlusal modifications and splints are the most common initial therapies. For many years, splints were
C
used only as bruxing guards for protection of tooth structure, but as TMD therapies have evolved, various types and designs of splints have been developed to help counteract the dysfunctional effects of bruxing habits, as aids in correction of nonideal jaw and occlusal relationships, or both. Regardless of the splint design and purpose, we tend to follow our dental training mindset to do something physical to “fix” the patient’s problem. To this end, treatment usually is focused on correcting the most visible and easily identifiable findings, such as occlusal and jaw relationship
D I R E C T I O N S
abnormalities, or it focuses on guarding against further damage. Exact treatment decisions vary, depending on our training, biases, clinical experience and the therapeutic modalities currently in vogue. What seems to be unexplained is that virtually no one is heeding the cardinal rules of medical management. Nowhere in the literature have I seen a TMD study or even anecdotal treatment recommendations to the effect that after an accurate diagnosis has been made, and any prevalent parafunctional habits have been identified, then proper treatment is to eliminate as many of the direct physical causes as possible. I believe it is almost universally assumed that bruxism, once established as a habit, cannot be changed and that TMD has to be managed by alleviating symptoms, correcting related abnormalities, or both. I
Do you have a time- or work-saving clinical technique to share with your colleagues? Submit it to JADA’s Clinical Directions department. A Clinical Directions item should be a maximum of two double-spaced typed pages and should include no more than one figure or illustration. Submit items to Clinical Directions, JADA, 211 E. Chicago Ave., Chicago, Ill. 60611.
JADA, Vol. 132, September 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.
1275
C L I N I C A L
D I R E C T I O N S
have been unable to find a single report or study of therapy designed solely to stop the parafunctional bruxing habits themselves, which would allow scientific evaluation of symptom remission following elimination of these destructive habits. NEED FOR PATIENT EDUCATION AND MODIFIED BIOFEEDBACK TRAINING
If we educate patients about the mechanism whereby bruxing habits physically overstress the masticatory system beyond its ability to adapt (as so beautifully explained by Hans Selye1), they come to understand their role in unknowingly causing the symptoms, and also that they can expect immediate relief from symptoms if these harmful habits are eliminated. The key to success is effective communication with patients so that they thoroughly understand the problem and are provided with detailed instructions on how to stop the bruxing habits. Therapy starts with a complete explanation of the dysfunctional symptoms and the cause-and-effect mechanisms of bruxing. This is followed by precise instruction in techniques for habit modification, both during the day and especially during sleep when clenching and grinding habits are prevalent. Clinicians should stress the importance of daytime awareness of bruxing or posturing habits, and instruct patients to say “Mississippi” every time the jaw is not in a resting posture, as is attained at the end of the word. To help in this reprogramming, a splint should be constructed, but dentists should not identify it as a guard, but as a nighttime (and daytime when needed) aid that 1276
serves as a tool for modified biofeedback training. Selective awareness. Clinicians need to teach patients that the mind and senses work all night long, but that we have programmed the mind to ignore or react to the continuous sensory input. Examples are waking to certain noises (an infant crying) while ignoring others, waking on pressure from the bladder while ignoring other pressures on the body, waking at set times without an alarm, and waking if someone shines a
If the patient is properly educated and motivated, this training technique is amazingly successful.
light in our eyes, but not when it gets light outside. Biofeedback splint. The splint is full coverage and flat plane, is absolutely smooth and shiny with no indentations, has no anterior occlusion (most bruxers grind on the front teeth and this possibility is eliminated), is adjusted to a height that allows the jaw to move and rest physiologically, and usually is mandibular for maximum comfort.2 Patients should be taught that teeth normally touch only during chewing or swallowing, and that opposing teeth rarely touch even during chewing (because of the food between them). The dentist needs to explain that it is proper for the teeth to touch the splint only at each swallow, and that the lower jaw should be in a resting position when not in function. The clinician teaches the patient that any jaw posturing
habits or tooth contacts other than those involved in chewing or swallowing are parafunctional. Patients must understand that the appliance serves to remind them of any such contact, since its mere presence as well as the difference in tooth contact sensation between when the splint is in place and when it is not in place present a sensory input to which they must react by dropping the mandible into a resting posture. At no time should dentists even suggest that the splint is a guard that is going to make them stop bruxing. Patients need to understand that it is just an inert piece of plastic designed to act only as a training aid to help them gain control by stopping the causes of discomfort. Contact between teeth and the splint during swallowing has no effect on the plastic. Any greater pressures, such as those that occur with bruxing, will produce dents (clenching) or grooves (grinding) that serve as valuable feedback in the morning. Clinicians should instruct patients to focus on not making any marks on the plastic (rather than thinking about teeth and bruxing); the last act before retiring is to concentrate on keeping the plastic smooth with no tooth marks, and the first act on awakening is to check their success. If the patient is properly educated and motivated, this modified biofeedback training technique is amazingly successful. In my practice, approximately one-half of all patients never make the first mark. Follow-up appointments. I see all patients one week after they receive their splints, and any dents in the previously flat plastic are polished smooth.
JADA, Vol. 132, September 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.
C L I N I C A L
This procedure is repeated until there are no marks and it is firmly established that the patient is symptom-free and parafunctional habits have ceased. About 90 percent of my patients are symptom-free within three or four appointments. Even before the splint is delivered, most patients report symptomatic relief, because they have become self-disciplined during the day after learning about their role in causing the problem. Some are even able to wake themselves at night when bruxing. In my practice, it is highly unusual for a patient to experi-
ence no relief, and in such cases, other therapeutic modalities are added. It might be hard to believe that such a simple, quick and noninvasive treatment really works, but once the proper diagnosis is made and major bruxing habits are eliminated, then the dysfunction is controlled and the symptoms disappear. This protocol has proven successful in my practice, with no other treatment necessary in more than 90 percent of all cases. Reported relapses usually are associated with periods of increased psychological stress and almost always are controllable by the patient.
D I R E C T I O N S
CONCLUSION
I note the excellent article on treating bruxism by Christensen.3 But why do we think we have to treat it? Why don’t we just teach patients to stop it? ■ Dr. Shulman is in private periodontic practice, 213 Janaf Office Building, Norfolk, Va. 23502. Address reprint requests to Dr. Shulman. 1. Selye H. The stress of life. New York: McGraw-Hill; 1956. 2. Shulman J, Zeno A. A new technique for making occlusal devices. J Prosthet Dent 1990;68:482-5. 3. Christensen GJ. Treating bruxism and clenching. JADA 2000;131:233-5.
Reduced discomfort during palatal injection WILLIAM R. ASLIN, D.D.S.
e know that palatal injections can be very uncomfortable for some patients. I would like to describe my technique for anesthetizing an upper first molar region when palatal numbness is needed. Using this technique, I have found that effective palatal anesthesia can be achieved with minimal discomfort.
W
into the distal buccal gingival papilla and once more into the mesiobuccal gingival papilla. Look for blanching of the lingual palatal tissue. Next, administer a normal palatal injection or inject into the blanched palatal area, which First, inject one carpule of usually is gingival to the pre2 percent lidoferred injection caine with site, and follow This technique 1:100,000 with a normal can be used for all epinephrine, folpalatal injection. lowing the textThis technique maxillary teeth. book technique for can be used for all buccal infiltration maxillary teeth, in the molar region. Then click and any pressure syringe should be effective. ■ once with the intraligamentary syringe (such as N-Tralig, Dr. Aslin is in private general practice, Miltex Instrument Co. Inc.) 200-C E. Main, Crowley, Texas 76036. (containing 2 percent lidocaine Address reprint requests to Dr. Aslin. with 1:100,000 epinephrine)
JADA, Vol. 132, September 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.
1277