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UPSDJ Volume 28 (2)April 2010
U.P.STATE DENTAL ''''7~ JOURNAL
BRUXISM IN CHILDREN- A SYSTEMATIC REVIEW Dr. Ravi Shankar TL *, Dr. Anand Singh, ** , Dr. Varon Gupta***
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.
UPSDJ Volume 28 (2) April 2010
The following signs and symptoms may be seen individually or in different combinations and may be present at different times: tooth mobility, nonfunctional patterns of occlusal wear, muscular and TMJ fatigue, headaches, grind or tapping sounds and soft tissue trauma. These signs and symptoms of bruxism depend on: (I) frequency of bruxing, (2) the intensity with which the patient is bruxing, (3) the age of the patient which may be associated with the duration ofthe habit. Tooth mobility! Occlusal Trauma Bruxism can result in tooth mobility. Higher mobility values in the morning are observed which could be from bruxing activities during the sleeping period. It has been suggested that bruxism might be an essential factor for the spread of gingivitis into the deeper periodontal structures and alveolar bone loss.' Tooth Structure wear Nonfunctional patterns of occlusal wear can be observed as signs of bruxism. Bruxism can lead to increased tooth sensitivity from excessive abrasion of the enamel. The enamel prisms are fractured from high muscle forces generated during sleep and later ground down by the jaw movements. This is supported by the fact that people in industrialized countries are living on a rather soft diet and thus abrasion of tooth structure is from bruxism in most cases. In a study of7 to 15 year old children, it was found that attrition in the permanent dentition increased significantly with age in all regions except in the molar region on comparison between 11 and 15 years old children. In the oldest age group 14% had dentin visible on at least one incisor. This 14% attrition in older age groups included cuspid teeth.' The enamel of primary teeth is thin, and on occasion wear facets can be extensive even with normal wear. In some children most ofthe enamel and dentin is worn off by bruxism. Fortunately such attrition stimulates the odontoblasts to produce additional dentin which protects the pulp. Sometimes the pulp may be exposed which results in a dental abscess." However, facets on the cuspid of children may mean that wear is still taking place as the cuspids have recently erupted." Bruxism can occur periodically. It is possible for example, that the facets were caused by grinding while the tooth became adjusted to the occlusal plane and that bruxism later ceased.' Musculature Of all the oral structures stressed through bruxistic forces, pain can most easily be elicited in the musculature. The most common symptom ofbruxism is, therefore, tenderness of the jaw muscles, especially to palpation. Muscular tiredness upon awakening can also be a complaint. In addition to pain in the muscles, hypertrophy of the masseter muscle has also been described uni- or bilaterally. Fatigue of the muscles ofthe neck is also observed." In bruxism, isometric exercise of the elevator jaw muscles can generate intense muscle forces resulting in increased loads to the teeth and facial pains in children. Temporomandibular Joint TMJ disturbances and pain are in many cases the result of bruxism. Along with the pain in the joint itself, the associated muscles can also be painful. The pain is usually dull and mostly unilateral. Crepitation and clicking within the joint, restriction of mandibular movements and jaw deviations can often be observed.' In her study, Egermark-Eriksson" found TMJ disturbance occurred more frequently in girls than boys and more in 15 years old than the younger age groups. Muscle tenderness also increased with age. She also reported a positive correlation between subjective symptoms and muscular tenderness. Headaches Egermark-Eriksson" found a correlation between headaches and dental wear and observed that headaches increased with age, and in older children it is more common in girls. The headaches are often of the muscular contraction type, which suggests that pain in the muscles is the underlying cause. Other signs and symptoms Sounds of Bruxism: Grinding or tapping sounds of bruxism are usually reported by parents or a sibling. Except for children who have organic brain diseases, it is not common for children to brux with the same amount of audible intensity during the time that they are awake. Soft tissue trauma: Small ulcerations or ridging on the buccal mucosa opposite the molar teeth on one or both sides of the oral cavity has been observed in children." Etiology The etiology ofbruxism is still controversial. Many authors claim a multifactorial cause 12 Four groups of etiologic factors can be distinguished. 1. Morphologic factors (e.g., dental occlusion and anatomy ofthe orofacial skeleton) are thought to be involved in the etiology of bruxism. Local factors within the stomatognathic system malocclusions, faulty restorations, calculus and periodontitis and especially traumatic-occlusal relationships and functionally incorrect occlusions are mentioned as being responsible for bruxism.' Occlusal interferences or deflective occlusal contacts, which act as "triggers" that elicit bruxism are the most important local etiological factors. Three types of oeclusal anomalies significantly correlated with occlusal interferences: incisor crossbite, postnormal occlusion and buccal crossbite of the posterior teeth. Crossbites are found more in younger age group and in those with sueking habits. "These children are also found to have muscular tenderness more often." Lindqvist considered the cuspid teeth as an etiological factor in bruxism. She showed that children who had cuspid teeth in occlusion showed significantly more frequent extreme lateral contact facets, which could be from the cuspids preventing normal movement ofthe lower
UPSDJ Volume 28 (2)ApriI2010
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
UPSDJ Volume28 (2) April 2010
counselling and supplementing any deficiencies especially vitamins and minerals and proper referrals must be made if any systemic factor is suspected. CONCLUSION Oral habits in children usually initiate a normal reflex which may be pleasant or unpleasant. Most habits disappear when a child reaches school age. In rare instances, a habit is no longer just a habit, but may be the result or the cause ofphysical or psychological problem. The habit which has been initiated in the early age will attain a fixation if the child is psychologically affected. If these habits are practiced with more frequency, and for longer duration, the muscle imbalance ofthe growing dental structure will cause malocclusion, facial and speech maldevelopment. In treating children it must be remembered that they are in a state of dynamic growth which is influenced by many factors. Children's are adapting to these physical and psychological changes. So the treatment modalities have to be modified and in many cases, the decision may be taken to "wait" and keep the child under observation. Most children adjust to changes and those who are bruxers may stop when they have overcome the difficult stages. In some cases, it may be helpful to counsel the parents in providing both physical and emotional support that will help their child in maturing into a healthy individual. REFERENCES: 1. Rubina Ahmad, Bruxism in Children. J of Pedo. 1986; 10 (2): I05-126. 2. Ramfjord, S.P. Bruxism, a clinical and electromyographic study. 1. Am.Dent. Assoc. 1961;62:21-44. 3. Scharer, P. Bruxism. Front Oral Phsioll974; 1:293-322. 4. Lindqvist, B. Bruxism in children. Odontologisk RevyI971; 22:413-24. 5. Kuch EV et al. Bruxing and non-bruxing children. A comparison oftheir personality traits. Pediatr Dent1979; 1(3):182-7. 6. Clarke, N.G. et al. Bruxing patterns in man during sleep. JOral Rehabil 1984; 11(6):529-34. 7. Egennark-Eriksson, 1. Malocclusion and some functional recordings ofthe masticatory system in Swedish school children. Swed Dent Journ 1983; 5:125-128. 8. Schneider, P.E. Oral Habits: Considerations in management. Pediatr Clin North Am, 1982; 29(3 ):523-46. 9. Lindqvist, B. et al. Bite forces in children with bruxism. Acta Odontol Scand 1973; 31 :255-59. 10. Egennark-Eriksson, 1. et al. Prevalence of mandibular dysfunction and orofacial parafunction in 7-, 11-, and 15- year old Swedish children. Eur J Orthod 198 I; 3: I63-72. 11. Marks, M.B. Bruxism in allergic children. Am J Orthod 1980; 77(1 ):48-59. 12.F.Lobbezoo, J. Van Der Zaag, M. Naeije, Bruxism: its multiple causes and its effects on dental implantsan updated review, J. Oral Rehabil. 2006;33(4):293-300. 13.Egermark-Eriksson, 1., and IngervalJ, B. Anomalies of occlusion predisposing to occlusal interferences in children. Angle Orthod. 1982; 52(4):293-299. 14. Lindqvist, B. Bruxism in twins, Acta Odontol Scand ]974;32:177-87. ]5.S.P.Ramfjord, Bruxism: a clinical and electromyographic study, J. Am. Dent. Assoc. 1961;62:21-44. 16. T. Negoro, J. Briggs, O. Plesh, 1. Nielsen, C. McNeill, A.J. Miller, Bruxing patterns in children compared to intercuspal clenching and chewing as assessed with dental models, electromyography, and incisor jaw tracing: preliminary study, J. Dent. Child. 1998;65 (6): 449-458. I7.G.M. Macaluso, P. Guerra, G. Di Giovanni, M. Boselli, L. Parrino, M.G. Terzano, Sleep bruxism is a disorder related to periodic arousals during sleep, 1. Dent. Res. 1998;77 (4):565-573. 18. A.G. Antonio, V.S. Pierro, L.M. Maia, Bruxism in children: a warning sign for psychological problems, 1. Can. Dent. Assoc. 2006; 72 (2): 155 160. 19. Rosa izela gonzaliz flores et al. Risk factors for bruxism in Japanese dental students. The Journal ofApplied Research 2003; 3(4):420-428. 20. G. Bader, G. Lavigne, Sleep bruxism; an overview of an oromandibular sleep movement disorder, Sleep Med. Rev. 2000;4 (1 ):27-43. 21.Arnold M. Bruxism & the occlusion. Dent Clin North Am l vx l ; 25(3):395-407. 22. Kampe T, Tagdae T, Bader G, Edman G, Karlsson S. Reported symptoms and clinical findings in a group of subjects with longstanding bruxing behaviour. J Oral Rehabil1997; 24:581587. 23.A.P. Vanderas, M. Menenakou, T. Kouimtzis, L. Papagiannoulis, Urinary catecholamine levels and bruxism in children, J. Oral Rehabil. ] 999; 26 (2): 103-] 10. 24. A Kalamir, H Pollard, AVitiello, R Bonello. TMD and the problem of bruxism. A review. J Bodyw MovTher2007; 11(3):183-93. 25. Barbosa Tde S, Miyakoda LS, Pocztaruk Rde L, Rocha CP, Gaviao MB. Temporomandibular disorders and bruxism in childhood and adolescence: review ofthe literature. Int J Pediatr Otorhinolaryngol 2008; 72(3):299-314. 26. Restrepo CC, Alvarez E, Jaramillo C, Velez C, Valencia 1.Effects ofpsychological techniques on bruxism in children with primary teeth. J Oral Rehabil2001; 28(4):354-60. 27.Ingerslev, H. Functional disturbances of the masticatory system in school children. J Dent Child 1983; 50(6):445-450.
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