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BRUXISM IN CHILDREN- A SYSTEMATIC REVIEW Dr. Ravi Shankar TL *, Dr. Anand Singh, ** , Dr. Varon Gupta***
ABSTRACT
KEY WORDS: Bruxism, Bruxofacets, Grinding, Oral Habit INTRODUCTION At the present time, bruxism is the term applied to either the static or dynamic contact or occlusion ofthe teeth at times other than normal functions such as mastication and swallowing, which may include clenching, gnashing, grinding and tapping of teeth. Although bruxism was introduced in the dental literature as "bruxomania" by Marie and Pietkiewkz in 1907', where it was described as the habit of grinding the teeth, it has become a subject of intense investigation since then. The term "bruxism" was introduced in the dental literature by Frohman in 1931. In 1936, Miller suggested that the term "bruxomania" be used to denote day time habitual grinding of the teeth, while the term "bruxism" be used to denote nocturnal grinding. Previous studies have focussed mainly on the adult population. Only recently has interest been shown in this phenomenon occurring in children and a number of studies proved that bruxism is an oral habit that is indulged in by many children. Bruxism usually refers to a nocturnal subconscious activity, but can occur during the day or night and may be petformed consciously or subconsciously.' It is a conscious activity when parafunctional activities are included in the definition, e.g., chewing of pencil, nails, cheeks and lips. The terms "neuralgia traumatica", "karolyi-effect" and "occlusal habit neurosis" have all been used to refer to some form of teeth-grinding, clenching, tapping, or pressing ofthe teeth day or night. The aim ofthis review is to assess the current state of literature regarding clinical features, current etiological concepts and therapies of bruxism in children. Material &Method: In the literature more than 400 articles on the bruxism in children are available. However, we have considered studies on children aged between 3yrs 12yrs. Studies were included fromPubMed, Google Seholar Search, Medline Database and the College library. Case reports, reports with review and systematic review articles written in English, were
included for consideration in our review. The reported incidence of bruxism in children varies from 5% to 81% which is comparable to 15% to 88% reported in adults.' However, the incidence of bruxism as determined by the signs of bruxism and not through questioning alone is much higher as in the study of Lindqvist who reported that 47% of the children had atypical wear facets compared to 15% reporting from-parents: Kuch showed 15.4% of the children showed clinical evidence ofwear facets, but no history from the parents.' Physiology of Bruxism Bruxism occurs during sleep from the disturbance of the normal physiological rest position of the mandible resulting from the forceful rhythmical contractions of the masseter, temporal is and the lateral pterygoid muscles. Scharer stated that in animals' grinding like movements are elicited primarily by stimulation of the amygdaloid nucleus, i.e., from the limbic system.' the limbic system is considered as the connecting brain structure between the conscious and voluntary cortex and the vegetative centres of the hypothalamus. This is an area with the close proximity of stimulated reactions like aggression or fright. Tranquilizers used often in bruxing patients are also effective within the limbic system. Therefore, it has been speculated that tensions in man, which manifest themselves through bruxism, originate partially within the limbic system.' Bruxism is performed on subconscious reflex controlled level. Various studies deal with the relationship between bruxism and sleep patterns. Takahama first showed from EEG that bruxism usually occurs during light sleep with brain wave changes evidencing inereased activity of the cortex. He considered bruxism to be related to the Autonomous Nervous System because of irregular breathing and increased pulse rate. Clarke & Townsend" suggested bruxism may be associated with the REM phase ofsleep that has been said to occur on average every 90 minutes during the night and to last for between 5 & 20 minutes. But others studies have stated that there is no relation. Clinical features ofbruxism
'Reader Dept. of Preventive & Community Dentistry. ".lR-II. Dept. of Oral Medicine & Radiology,"'JR-JI Dept. of Preventive & Community Dentistry, Kothiwal Dental College Moradabad.
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jaw and causing extreme movements." Occlusal discrepancies (e.g., a slide between retruded contact position and intercuspal position), were historica1l considered the most common cause of bruxism 11 More recently, the role of occlusion has been debated and contested" in part because it has been demonstrated that experimentally placed deflective occlusal contacts do not elicit bruxism 16. 2. Pathophysiologic factors may be involved in the precipitation of bruxism. For example, it has been claimed that bruxism is part of an arousal response, thus linkin psleep-related bruxism to the field ofsleep disorders. ' There is also evidence that, in younger children, bruxism may be a consequence of the immaturity of the masticatory neuromuscular system". Altered brain chemistry (e.g., an asymmetric nigrostriatal dopaminergic function) has been associated with bruxism as well". Other pathophysiologic factors that have been implicated in bruxism in adolescents and adults are the effects of cigarette smoking", alcohol, illicit drugs, trauma, disease and medication". 3. Psychologic factors Tischler (1928) by calling bruxism "oral habit neurosis," gave first the indication that psychologic factors can be responsible. Since the mouth is the means of receiving food and the earliest means of exploring the environment, it is intimately tied to emotions such as satisfaction, frustration, anxiety and anger. These early associations are significant and seem to last a lifetime, and are the reason why the individual reverts to the mouth during periods of stress bX smoking, eating, chewing gum and bruxing. Lobbezoo et al." considered that the level of stress and personality type have been included in the etiology of bruxism. However, the exact contribution of psychological factors remains debatable, and they consider that bruxism is mainly centrally, not peripherally mediated. These findings have been previously observed by Kampe et al." who also demonstrated the presence ofa higher level of anxiety in a group of people with bruxism. Vanderas et al." have demonstrated that stress and anxiety may be directly related to bruxism, as patients showed a higher catecholamine level, generally ascribed to emotional stress. TMD sufferers tend to have a higher incidence of psychological disturbances such as stress, anxiety, and depression. As mentioned earlier this factors could lead to the parafunctional habits":". The union oftwo or more etiological factors is needed to produce bruxism, but the magnitude of these factors is not important in relation to the magnitude of bruxism". 4. Occupational Factors These factors rarely be considered in children, but an over anxious student or compulsive overachievers may start bruxing. Competitive sports lead to clenching and may be significant. Thus a combination of age, occlusal interferences and psychological factors seem to be of main importance for the development of bruxism in
children. Therapy The first step in treating bruxism should be to determine the underlying cause. The range of symptoms resembles many other ailments, especially when considering headache and facial pain. Attention should be directed at possible loci in the teeth, mucosa and the bony structures. Ears, nose and throat regions should be eliminated as well for tumors and neurologically related pain. Lindqvist' observed that bruxism can be misdiagnosed because: (1) bruxofacets are not always present with muscle tenderness which could be from the fact that the child has adapted to the intercuspal position and finds it without sliding via primary contacts, a movement pattern which can fatigue the muscles, (2) palpation of the lateral pterygoid muscle can sometimes be mistakenly experienced as painful, (3) bruxism may be a recent habit, which has not resulted in wear facets, and (4) clenching might also occur in or near the intercuspal position not giving bruxofacets. Psychotherapy This includes counseling, auto suggestion, hypnosis, conditioning, relaxation exercises and biofeedback. It is indicated for subjects in whom bruxism is due to a central cause. Drugs Vapocoolants such as Ethyl Chloride for pain within the TMJ area, local anaesthetic injections directly into the TMJ on the muscles, tranquilizers and sedatives and muscle relaxants are used. Placebos may be used to rule out psychological etiology. Occlusal adjustment It is believed that before any occlusal adjustments are done, the muscles should be brought back to a relaxed position to allow the jaw to resume its normal physiological movements. This can be achieved by a bite plate. Ingerslev" recommends the use ofsoft bite splints. This splint corresponds to the posterior molars and is therefore, well-suited to children, where cooperation in fitting may be minimal. After this occlusal prematurities and interferences between centric occlusion and centric relation should be removed. Some believe that occlusal adjustment has no effect upon the incidence ofbruxism even though it relieves the symptoms of myofacial pain dysfunction. Restorative Procedures These should be performed with great care with the aim to create an ideal occlusion. Care should also be taken to create no prematurities when inserting restorations and these restorations should be able to withstand the forces of bruxism as well as distribute tliem, Electrical Methods Electro galvanic stimulation for muscle relaxation & ultrasounds are being used. Other methods include; oral exercises, Acupressure, desensitising solutions may be used for thennal sensitivity, heat may supplement occlusal correction, nutritional
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