Professional Documents
Culture Documents
Founder
TMJ & Sleep Therapy Centres
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
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
1
Why Do Patients Grind – Steven Olmos DDS
way to screen patients, so the dentist can develop a treatment plan for optimal dental
Orofacial 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, sinus
congestion, and jaw joint noises.
2
Why Do Patients Grind – Steven Olmos DDS
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,
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
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
3
Why Do Patients Grind – Steven Olmos DDS
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.
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
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
in the United States is 78% for adult women and 68% for adult men.
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
4
Why Do Patients Grind – Steven Olmos DDS
5
Why Do Patients Grind – Steven Olmos DDS
contract with greater force (approximately 57,600 lbs/sec/day) than normal function
(TMD) brux longer, 38.7 minutes, compared with control patients, 5.4 minutes.9
population is 41% and those showing a sign is 56%.2 The most frequent symptom
6
Why Do Patients Grind – Steven Olmos DDS
Figure 3 Forward head posture, the result of TMJ inflammation, changes
occlusion and causes increased pain in the neck.
sided back-of-head pain (occipital cephalgia).17 The body assumes a forward head
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
7
Why Do Patients Grind – Steven Olmos DDS
therapy (equilibration) be performed
8
Why Do Patients Grind – Steven Olmos DDS
for compression of the cervical
4C).
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
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
9
Why Do Patients Grind – Steven Olmos DDS
Figure 5 Flowchart of treatment options. Depending on the initial complaint, the
dentist can determine a sequence for treatment using the color-coding.
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
“The dentist should consider a differential disease classification that may include
10
Why Do Patients Grind – Steven Olmos DDS
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.
The ADA further states: “Before restorative and/or occlusal therapy is performed, the
11
Why Do Patients Grind – Steven Olmos DDS
12
Why Do Patients Grind – Steven Olmos DDS
dentist should attempt to reduce, through the use of reversible modalities, the
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,
Nonsurgical therapy for chronic headaches (migraine), facial pain, and TMD has been
chronic pain patients do not need a permanent stabilization therapy (phase II dental
with a patient that presents with headaches. The flowchart in Figure 7 outlines the
13
Why Do Patients Grind – Steven Olmos DDS
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.
14
Why Do Patients Grind – Steven Olmos DDS
Conclusion
(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
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 unstable
bite.
4. Follow the TMnDx flowchart for diagnosis and treatment. If unfamiliar, seek
additional education and, if uncomfortable treating, then refer.
15
Why Do Patients Grind – Steven Olmos DDS
Disclosure
References
1. Lavigne G, Sessle BJ, Choiniere M, et al, eds. Sleep and Pain. Seattle, WA: IASP Press;
2007:311-340.
2. Oekson JP. Management of Temporomandibular Disorders and Occlusion. 6th ed. St.
4. Lipton RB, Stewart WF. Prevalence and impact of migraine. Neurol Clin. 1997;15(1):1-
13.
6. Carotenunto M, Guidetti V, Ruju F, et al. Headache disorders as risk factors for sleep
8. Camparis CM, Siqueira JT. Sleep bruxism: clinical aspects and characteristics in
16
Why Do Patients Grind – Steven Olmos DDS
patients with and without chronic orofacial pain. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2006;101(2):188-193.
Rehabil. 1979;6(1):81-87.
10. Rugh JD, Solberg WK. Electromyographic studies of bruxist behavior before and during
11. Solberg WK, Clark GT, Rugh JD. Nocturnal electromyographic evaluation of bruxism
12. Clark GT, Beemsterboer PL, Solberg WK, et al. Nocturnal electromyographic evaluation
Assoc. 1979;99(4):607-611.
13. Okeson JP, Phillips BA, Berry DT, et al. Nocturnal bruxing events in subjects with sleep-
14. Okeson JP, Phillips BA, Berry DT, et al. Nocturnal bruxing events: a report of normative
15. Okeson JP, Phillips BA, Berry DT, et al. Nocturnal bruxing events in healthy geriatric
17
Why Do Patients Grind – Steven Olmos DDS
16. Hiestand DM, Britz P, Goldman M, et al. Prevalence of symptoms and risk of sleep
apnea in the US population: results from the National Sleep Foundation Sleep in America
17. Simmons HC 3rd, Gibbs SJ. Anterior repositioning appliance therapy for TMJ disorders:
specific symptoms relieved and relationship to disk status on MRI. Cranio. 2005;23(2):89-99.
18. Olmos SR, Kritz-Silverstein D, Halligan W, et al. The effect of condyle fossa relationships
dimensions, head posture and bite force in children selected for orthodontic treatment. Eur J
Orthod. 2001;23(2):179-192.
20. Kibana Y, Ishijima T, Hirai T. Occlusal support and head posture. J Oral Rehabil.
2002;29(1):58-63.
21. Yamaguchi H, Sueishi K. Malocclusion associated with abnormal posture. Bull Tokyo
2008.
18
Why Do Patients Grind – Steven Olmos DDS