general dentistry message board How Did This Happen? Townies discuss sleep bruxism and how to prevent occlusal wear Dentaltown.com > Message Boards > TMD & Occlusion, Sleep Apnea / Snoring and Appliance Therapy. > TMD and Occlusion > How Did This … cormac Member Since: 10/08/09 Introduction: Post: 1 of 34 This has me puzzled. In December 2015 I saw this 45-year-old female with extensive occlu- sal and incisal wear but no pain. We agreed that she should be wearing something at night to prevent further wear. In light of her overjet I made her an upper NTI and lower slide bar. In 10 months she has managed to wear through the slide bar and created a deep notch in the disclud- ing element of the NTI. Even in this condition, when they are both in place I can’t detect any posterior contact. Am I missing something here or has anyone seen this happen before? Thanks. Related Message Boards Bruxism Worse With Splint Bruxism Splint Sleep Bruxism and Appliances Sleep Bruxism 10/3/2016 38 NOVEMBER 2016 // dentaltown.com I had a patient that snapped Cowhorn Prophy Member Since: 05/19/09 two NTI’s in half after a day or Post: 2 of 34 two of use. Guy could bend rebar with his teeth more than likely. Was amazed that someone could be able to generate that much force in the anterior. n 10/3/2016 Welcome to the world of twmdds Member Since: 02/16/04 sleep bruxism. Better start asking Post: 3 of 34 some questions. n 10/3/2016 There’s a percentage of mack1238 Member Since: 02/13/07 people where NTI’s don’t work. Post: 4 of 34 My wife is one of them. Before I do an NTI I usually have the patient bite on their back teeth hard and I feel their temporalis muscles. Then I have them put their teeth end to end and clench. If I can feel the temporalis con- tracting close to the same, I won’t use one. n 10/3/2016 Thanks for replying. What cormac Member Since: 10/08/09 kind of questions do you have in Post: 5 of 34 mind? n 10/4/2016 Do you snore? Daytime twmdds Member Since: 02/16/04 tiredness? Sleep quality? Any Post: 10 of 34 gasping? Had a sleep study? Reflux? Check the airway? n 10/5/2016 Just looking at this quickly drbglass guys. Great thought process in Member Since: 10/16/01 Post: 11 of 34 terms of the slide bar and the use of a maxillary appliance. That being said, please look at the angle of the DE once the mandibular teeth slide edge to edge. See how it continues to increase vertical at a non-parallel angle to the mandibular teeth? I suspect that is at the heart of this change you’re seeing. n 10/6/2016 What Barry said. Plus, what Michael Melkers leads to structural destruction Member Since: 09/09/00 Post: 12 of 34 from a mechanical aspect? Force, resistance and friction. When I see wear like that I am also FREE FACTS, circle 28 on card dentaltown.com \\ NOVEMBER 2016 39 general dentistry message board looking for rough spots on the NTI that opposes the slider. That being said, just an Essix slider is pretty thin. That is where and why I started beefing them up with acrylic.n 10/6/2016 cormac Member Since: 10/08/09 Thanks Barry, I see what you’re getting at. I’ll talk to Matt in S4S about how to avoid this Posts: 13 & 14 of 34 happening again. The slide bar was solid acrylic not just an Essix. n 10/7/2016 eeznogood Member Since: 02/23/06 One lecturer, who is becoming an authority on the matter in my area, claims that it is about Post: 16 of 34 5 percent of the population. Can you still brux in the delta phase of the sleep cycle? Any input on that Barry perhaps? It seems true that there is a small number of folks who still grind through anything we give them, and rather fast sometimes. n 10/8/2016 drbglass Member Since: 10/16/01 1. The statistics about the percentage of bruxers ranges from 5–10 percent. Having said Post: 18 of 34 that, there is reason to believe when we look at the quality of the studies and the methods that these numbers are not accurate. In addition, we must keep in mind that there is not a direct relationship between bruxism, pain and dysfunction. There are some patients whose RMMA’s will not be recognized as bruxism, but in fact may be related to symptoms. 2. Delta bruxing is extremely rare. I’ve never observed it. I’ve never seen reports of it. And of course one learns never to say never. Not sure why its relevant. 3. No appliance stops bruxism. They alter the force vectors in terms of magnitude and direction. When one tests using palpation to determine the degree of reduction of magnitude in terms of the voluntary awake clench, that is certainly a very approx- imate method. It is very rare when we test with EMG’s that we don’t see reductions in the anterior temporalis and masseter during the clench—usually in the range of 75 percent reduction in the AT and 50 percent reduction in the masseter. That being said, there are patients where the reduction is less. I have never seen it where there isn’t a reduction. Now, the question is what level is required to alter the symptoms. And, of course, that is dependent on many variables including the patient’s adaptive capacity. And furthermore, in many cases simply altering the direction of the force vectors can make a significant difference in the patient’s symptoms. Hope that helps. n 10/9/2016 twmdds Great questions. Barry knows Member Since: 02/16/04 all these answers in greater detail Post: 19 of 34 than I. Sleep bruxism occurs in FREE FACTS, circle 29 on card 40 NOVEMBER 2016 // dentaltown.com a greater percentage of the population than has been reported. In kids it seems to be related to restricted air- way, so that can be extrapolated to adults if you want. It’s researched by measuring contractions electronically, so clenching counts. It’s not generally believed that inter- vention really changes a minute of movement, although we can alter the intensity. n 10/10/2016 Did you ever think that mostofthosewho … Member Since: 06/04/04 maybe this patient needs pos- Post: 21 of 34 terior contacts heavier than the anterior contacts once you figure out the best six-dimensional position for the mandible? n 10/14/2016 I was at a course a few dkdocterry Member Since: 09/17/07 years ago and the speaker said Post: 22 of 34 when they were doing sleep tests they were surprised that the patients were gen- erating more than twice the pressure when they were grinding while asleep compared to the pressures they generated when awake. He was quite amazed when they discovered this during their research on grinding and sleeping. n 10/15/2016 When? What position is drbglass Member Since: 10/16/01 it that we as dentists “choose” Post: 24 of 34 is best for the patient? When they are in MIP? In rest? Functioning? What position is their head in when we choose that position? How do we consider all the factors involved in that position including feedback mechanisms to the trigeminal and mesencephalic nucleus? When does the patient “need” these posterior contacts? Just curious. n 10/16/2016 In our research we noted drbglass Member Since: 10/16/01 about a 25 percent increase in Post: 25 of 34 the potential during nocturnal bruxism (using sEMGs) over the maximum voluntary clench. It is agreed there is increased EMG potential at night. Add that increased intensity to the frequency and duration, and nocturnal bruxism becomes potentially very damaging to the components of the cranioman- dibular system. n 10/16/2016 FREE FACTS, circle 3 on card dentaltown.com \\ NOVEMBER 2016 41 general dentistry message board Dr Mac Lee What is the definition of a Member Since: 04/14/00 delta bruxer? I had a physical Post: 30 of 34 therapist who worked with TMD patients who said the only appliance she ever saw a study on that stopped nighttime bruxing was a lower appliance with barbs that stuck into the palate on full closure. She said the study showed great results but the appliance was too draconian. n 10/16/2016 drbglass The first mention of delta Member Since: 10/16/01 bruxism comes from Parker Post: 31 of 34 Mahan and was then referenced in the Dawson text. The concept was that elimination of inter- ferences stopped bruxing. This was the assumption when equilibration led to altered signs and symptoms. The con- cept of altered force vectors from a continuing bruxism event was not considered. Now there had to be an explanation for those “rare” patients who did not respond to equilibration— even those in the hands of the experts. Many patients did not respond to the adjustment, and it was often assumed that they just weren’t equilibrated well. But even the experts agreed that on rare occasions they adjusted patients without response. (Note the lack of a diag- nosis in any of this discussion.) The only explanation can be that they continued to brux despite a perfect equilibration. The rare patients were considered to have “centrally mediated” bruxism as opposed to the others who bruxed in an “erasure” attempt with interferences.