Bruxism **Learning Outcomes:** Describe evolution, epidemiology, risk factors, aetiology and pathophysiology, clinical features, diagnosis and management of bruxism. **These lecture slides and associated module materials must not be reproduced, distributed or shared without prior permission. Unauthorised use of this material breaches UWA’s student conduct regulations and may also constitute a violation of the Copyright Act 1968.** **Dr Amanda Phoon Nguyen** BDSc (UniMelb), MRACDS (GDP), DClinDent (Oral Med) (UWA), MRACDS (OralMed), Cert ADL, FOMAA, FPFA, FICD,FADI, MAICD, GCHL, MICDA, FDSM Oral Medicine Specialist <div style="text-align: center;"> <img src="https://upload.wikimedia.org/wikipedia/commons/6/66/Australian_Dental_Association_logo.svg" width="100" alt="Australian Dental Association logo"> </div> <div style="display: flex; justify-content: space-around;"> <div style="text-align: center;"> <img src="https://upload.wikimedia.org/wikipedia/commons/thumb/e/e6/Perth_Oral_Medicine_%26_Dental_Sleep_Centre_logo.svg/1200px-Perth_Oral_Medicine_%26_Dental_Sleep_Centre_logo.svg.png" width="200" alt="Perth Oral Medicine & Dental Sleep Centre logo"> <p>Perth Oral Medicine & Dental Sleep Centre<br><small>Specialists in Oral Medicine</small></p> </div> <div style="text-align: center;"> <img src="https://upload.wikimedia.org/wikipedia/commons/6/6e/Perth_Children%27s_Hospital_logo.svg" width="100" alt="Perth Children's Hospital logo"> </div> <div style="text-align: center;"> <img src="https://upload.wikimedia.org/wikipedia/commons/thumb/c/cf/University_of_Western_Australia_logo.svg/1200px-University_of_Western_Australia_logo.svg.png" width="100" alt="University of Western Australia logo"> </div> <div style="text-align: center;"> <img src="https://upload.wikimedia.org/wikipedia/commons/thumb/6/68/Australian_Osteopathic_Association_logo.svg/250px-Australian_Osteopathic_Association_logo.svg.png" width="150" alt="Australian Osteopathic Association logo"> </div> <div style="text-align: center;"> <img src="https://upload.wikimedia.org/wikipedia/commons/7/72/OMAA_logo.svg" width="140" alt="Oral Medicine Academy of Australasia logo"> </div> <div style="text-align: center;"> <img src="https://upload.wikimedia.org/wikipedia/commons/2/28/Royal_Australasian_College_of_Dental_Surgeons_logo.svg" width="120" alt="Royal Australasian College of Dental Surgeons logo"> <p>Royal Australasian College of Dental Surgeons<br><small>Let knowledge conquer disease</small></p> </div> </div>  #### Learning Outcomes Upon completion of this module, you should be able to describe the following aspects of bruxism: - Evolution - Epidemiology - Risk factors - Aetiology and pathophysiology - Clinical features - Diagnosis - Management #### Presenter Information **Dr Amanda Phoon Nguyen** BDSc (UniMelb), MRACDS (GDP), DClinDent (Oral Med) (UWA), MRACDS (OralMed), Cert ADL, FOMAA, FPFA, FICD, FADI, MAICD, GCHL, MICDA, FDSM *Oral Medicine Specialist* Clinical close-up photograph of a human mouth showing teeth and lips, serving as the background for the lecture slide on 'Bruxism'. Who is the Bruxer? **60 year old male** Dentist noted excessive tooth wear and tongue scalloping **No pain**  #### Patient Profile - **Age/Sex:** 60-year-old male - **Clinical Findings:** Dentist noted excessive tooth wear and tongue scalloping - **Symptoms:** No pain Clinical photo of a patient's mouth showing the tongue. The image demonstrates 'tongue scalloping' (indentations along the lateral borders), which is a key visual finding for diagnosing bruxism in this case. 26 year old male Snoring and sleep disordered breathing  #### Patient Profile - **Age/Sex:** 26-year-old male - **Primary Complaint:** Snoring and sleep disordered breathing Clinical photo collage showing dental and facial features of a 26-year-old male with snoring and sleep-disordered breathing. The image includes four panels: top-left shows a frontal view of the mouth with teeth aligned using a cheek retractor; bottom-left displays a lateral view of the upper and lower dentition from the left side; bottom-right presents a similar lateral view from the right side. All images use a plastic cheek retractor to expose the oral cavity for examination. Assessment for OSA **ESS:** 7/24 **Stop-Bang:** 4/8 ### Anthropometrics and BP | | | | | | | | | :--- | :--- | :--- | :--- | :--- | :--- | :--- | | **Indications** | | | | | | | | Height (cm) | 177.0 | BMI (kg/m2) | 22.3 | Waist/Hip Ratio | 0.87 | Night BP mm 120/55 | | Weight (kg) | 70.0 | Neck (cm) | 37 | Malmatti class | | Morn BP mm 113/53 | ### Sleep Data | | | | | | | | :--- | :--- | :--- | :--- | :--- | :--- | | **Time in Bed (min/hrs)** | **427.7** | **7.13** | **REM Latency (min)** | **220.0** | **REM (N = 20-30%)** | **25.2%** | **71.5 min** | | **Sleep Time (min/hrs)** | **283.9** | **4.73** | **WASO (min)** | **121.0** | **Stage N1 (N ~ 5%)** | **4.1 %** | **11.5 min** | | **Sleep Efficiency %** | **66.4** | | **Alpha Intrusion** | - | **Stage N2 (N ~ 50%)** | **57.9 %** | **164.4** | | **Sleep Latency (min/hrs)** | **22.8** | **0.38** | | | **Stage N3 (N ~ 20%)** | **12.9 %** | **36.5 min** | ### Respiratory Events | | | **Units** | **Awake** | **REM** | **NREM** | **All Sleep** | | :--- | :--- | :--- | :--- | :--- | :--- | :--- | | **Sleep Disordered Breathing Severity** | | | | | | Moderate | | **Apnoea/Hypopnoea Index AHI (RDI)** | | **#/hr** | | | 26.9 (27.7) | 27.1 (28.5) | 27.1 (28.3) | | **Supine AHI (RDI)** | | **#/hr** | | 0.0 (0.0) | 0.0 (0.0) | | | | **Non-Supine AHI (RDI)** | | **#/hr** | | | | 27.05 (28.32) | | | **Time in Apnoeas/Hypopnoeas** | | **min** | | | | 87.0 | | | **Longest Apnoeas/Hypopnoea** | | **sec/sec** | | | | 50.5 / 116.0 | | | **Central/Mixed Apnoeas** | | **#/hr/#/hr** | | | | 0.2 / 0.0 | | | **Average/Minimum SpO2 Saturation** | | **%/%** | 97 | 96 | 96 | 96 / 84 | | | **ODI ($\ge$3%) Time SpO2 < 85%** | | **#/hr/min** | | | | 11.4 / 0.1 | | | **Snoring – loudness/peak dB** | | **grade/dB** | | | | + + / 59 | | | **Total duration with snoring** | | **min** | | | | 114.5 | | ### Sleep Disturbance | | | **Units** | **Awake** | **REM** | **NREM** | **Total Sleep** | | :--- | :--- | :--- | :--- | :--- | :--- | :--- | | **Arousal Index** | | **#/hr** | | 31.0 | 35.0 | 34.0 | | **Total number of Arousals** | | **#** | | 37 | 124 | 161 | | **Respiratory/Leg Arousal Index** | | **#/hr/#/hr** | | 24.3 / 2.5 | 23.4 / 0.8 | 24.9 / 1.3 | | **Arousals with Bruxism** | | **# (grade)** | | | | 0 (-) | | | **Awakenings** | | **#** | | 3 | 14 | 17 | | **Respiratory Awakenings** | | **#** | | 2 | 11 | 13 | ### Limb Movements | | | **Units** | **Awake** | **REM** | **NREM** | **Total Sleep** | | :--- | :--- | :--- | :--- | :--- | :--- | :--- | | **Limb movement index** | | **#/hr** | - | | | 1.9 | | **Total number of movements** | | **#** | | | | 13 | | **PLM index** | | **#/hr** | | | | 0.9 | Night Sedation: Nil Alcohol: Nil      #### OSA Assessment - **ESS:** 7/24 - **Stop-Bang:** 4/8 #### Anthropometrics and Blood Pressure - **Height:** 177.0 cm - **Weight:** 70.0 kg - **BMI:** 22.3 kg/m² - **Neck Circumference:** 37 cm - **Waist/Hip Ratio:** 0.87 - **Night BP:** 120/55 mmHg - **Morning BP:** 113/53 mmHg #### Sleep Data - **Time in Bed:** 427.7 min (7.13 hrs) - **Sleep Time:** 283.9 min (4.73 hrs) - **Sleep Efficiency:** 66.4% - **Sleep Latency:** 22.8 min - **REM Latency:** 220.0 min - **WASO:** 121.0 min - **Sleep Architecture:** - **REM:** 25.2% (71.5 min) - **Stage N1:** 4.1% (11.5 min) - **Stage N2:** 57.9% (164.4 min) - **Stage N3:** 12.9% (36.5 min) #### Respiratory Events - **Severity:** Moderate Sleep Disordered Breathing - **AHI (RDI):** 27.1 (28.3) - **Non-Supine AHI (RDI):** 27.05 (28.32) - **Time in Apnoeas/Hypopnoeas:** 87.0 min - **Longest Event:** 50.5 sec (Apnoea) / 116.0 sec (Hypopnoea) - **Central/Mixed Apnoeas:** 0.2 / 0.0 per hour - **SpO2 Saturation:** 96% average / 84% minimum - **ODI (≥3%):** 11.4 per hour - **Snoring:** Grade ++; 59 dB peak; 114.5 min total duration #### Sleep Disturbance - **Arousal Index:** 34.0 per hour (Total: 161) - **Respiratory Arousal Index:** 24.9 per hour - **Leg Arousal Index:** 1.3 per hour - **Arousals with Bruxism:** 0 - **Awakenings:** 17 total (13 Respiratory-related) #### Limb Movements - **Limb Movement Index:** 1.9 per hour - **PLM Index:** 0.9 per hour - **Total Movements:** 13 #### Additional Factors - **Night Sedation:** Nil - **Alcohol:** Nil Table containing Anthropometrics and BP data. Rows include Height (cm), Weight (kg), BMI (kg/m2), Neck (cm), Waist/Hip Ratio, Malmatti class, Night BP mm, and Morn BP mm. Corresponding values are provided for each metric. Table presenting Sleep Data metrics. Includes Time in Bed, Sleep Time, Sleep Efficiency %, Sleep Latency, REM Latency, WASO, Alpha Intrusion, Stage N1, Stage N2, Stage N3 percentages and durations. Table detailing Respiratory Events. Columns show Units, Awake, REM, NREM, and All Sleep. Rows list Sleep Disordered Breathing Severity, Apnoea/Hypopnoea Index AHI (RDI) with sub-indices, Time in Apnoeas/Hypopnoeas, Longest Apnoeas/Hypopnoea, Central/Mixed Apnoeas, Average/Minimum SpO2 Saturation, ODI, Snoring details, and Total duration with snoring. Table summarizing Sleep Disturbance. Columns include Units, Awake, REM, NREM, and Total Sleep. Rows cover Arousal Index, Total number of Arousals, Respiratory/Leg Arousal Index, Arousals with Bruxism, Awakenings, and Respiratory Awakenings. Table outlining Limb Movements. Columns are Units, Awake, REM, NREM, and Total Sleep. Rows detail Limb movement index, Total number of movements, and PLM index. Who is the Bruxer? No tooth wear No sleep disordered breathing, snoring or OSA Some daytime tiredness Masseter and temporalis hypertrophy No jaw clicking or deviation, locking or pain. Occasional tenderness to palpation of muscles of mastication #### Clinical Findings - **Dental:** No tooth wear - **Respiratory:** No sleep disordered breathing, snoring, or OSA - **Muscular:** Masseter and temporalis hypertrophy; occasional tenderness to palpation of muscles of mastication - **TMJ:** No jaw clicking, deviation, locking, or pain - **Systemic:** Some daytime tiredness # Who is the Bruxer? # Patient presents with a toothache. # Tonsillar hypertrophy noted on clinical examination  #### Clinical Presentation - Patient presents with a toothache. - Tonsillar hypertrophy noted on clinical examination. Clinical photo of an oral examination showing the oropharynx with visible tonsillar hypertrophy. A gloved hand is retracting the cheek to expose the area. The image includes a watermark 'A Spoonful of Oral Medicine' and demonstrates a physical finding relevant to diagnosing bruxism-related issues. # Who is the Bruxer? - 60 year old male - Dentist noted **excessive tooth wear** and **tongue scalloping** - No pain ## Questions: - Is management required? - Are there any other possible diagnoses?  #### Case Summary - 60-year-old male - Dentist noted excessive tooth wear and tongue scalloping - No pain #### Clinical Considerations - Is management required? - Are there any other possible diagnoses? Clinical photo of a patient's mouth showing the tongue and lower lip. The image demonstrates 'tongue scalloping' (indentations along the lateral borders of the tongue) and likely excessive tooth wear on the mandibular incisors, consistent with the OCR context describing a 60-year-old male bruxer. **26 year old male** **Snoring and sleep disordered breathing** **Does bruxism affect our management or treatment plan?** <br*>Patient with snoring and SDB presenting for orthodontic consultation. Note generalized splint wear and flattened mandibular molars suggesting occlusal history.*</br>    #### Case Summary - 26-year-old male - Snoring and sleep disordered breathing #### Clinical Considerations - Does bruxism affect our management or treatment plan? - Patient presenting for orthodontic consultation. - Clinical observation: Generalized splint wear and flattened mandibular molars suggesting occlusal history. Clinical photo of a patient's mouth with a cheek retractor. The image shows the maxillary and mandibular anterior teeth in occlusion. Visible findings include generalized splint wear (mild opacities on enamel) and flattened mandibular molars, consistent with the OCR context noting an 'occlusal history'. Clinical close-up photo of the lower left quadrant showing the buccal view of the mandibular teeth. A cheek retractor is visible. The image demonstrates the tooth alignment and gingival health. Clinical close-up photo of the lower right quadrant showing the buccal view of the mandibular teeth. A cheek retractor is visible. The image demonstrates the tooth alignment and gingival health.    Clinical photo showing a dental study model with a dual-layer occlusal splint (yellow and blue) fitted over the teeth. A separate green plastic component with a metal pin is visible in front. Close-up clinical photo of a white anatomical dental structure, likely a tooth root or cast, resting on a textured gray surface. Clinical photo of a clear acrylic maxillary orthodontic appliance featuring a central attachment mechanism. **Who is the Bruxer?** **Is a splint always the right or best management?** No tooth wear No sleep disordered breathing, snoring or OSA Some daytime tiredness Masseter and temporalis hypertrophy No jaw clicking or deviation, locking or pain. Occasional tenderness to palpation of muscles of mastication    #### Management Considerations - Is a splint always the right or best management? #### Clinical Findings - No tooth wear - No sleep disordered breathing, snoring, or OSA - Some daytime tiredness - Masseter and temporalis hypertrophy - No jaw clicking or deviation, locking, or pain - Occasional tenderness to palpation of muscles of mastication Clinical photo of a patient sleeping with eyes closed while using a laptop on their chest. Contextually associated with the 'Bruxer' question and symptoms like daytime tiredness. Close-up clinical photo of a lower face showing the nose and upper lip area. Likely demonstrating hypertrophy or facial structure related to bruxism. Close-up clinical photo of the mouth and teeth. Demonstrates dental occlusion or tooth wear (or lack thereof) in the context of identifying a 'Bruxer'. # Who is the Bruxer? Patient presents with a toothache. Tonsillar hypertrophy noted on clinical examination. As holistic thinking dental professionals, what else should we consider? Referred for sleep study **AHI- 84.8!**  #### Clinical Presentation and Follow-up - Patient presents with a toothache. - Tonsillar hypertrophy noted on clinical examination. #### Diagnostic Considerations - As holistic thinking dental professionals, what else should we consider? - Referred for sleep study. - **Result:** AHI- 84.8! Clinical photo of a patient's lower face and jaw area. Visible features include facial hair (stubble), skin texture, lips, and the chin. A blue medical examination glove is visible on the left side, indicating an intraoral or clinical examination context. The image serves as a visual reference for a case study regarding a patient with toothache and tonsillar hypertrophy. Definitions Sleep bruxism is a masticatory muscle activity during sleep that is characterised as rhythmic (phasic) or non-rhythmic (tonic) and is not a movement disorder or a sleep disorder in otherwise healthy individuals. Awake bruxism is a masticatory muscle activity during wakefulness that is characterised by repetitive or sustained tooth contact and/or by bracing or thrusting of the mandible and is not a movement disorder in otherwise healthy individuals. Lobbezoo F, Ahlberg J, Raphael KG, Wetselaar P, Glaros AG, Kato T, Santiago V, Winocur E, De Laat A, De Leeuw R, Koyano K, Lavigne GJ, Svensson P, Manfredini D. International consensus on the assessment of bruxism: Report of a work in progress. J Oral Rehabil. 2018 Nov;45(11):837-844. doi: 10.1111/joor.12663. Epub 2018 Jun 21. PMID: 29926505; PMCID: PMC6287494. #### Sleep Bruxism Sleep bruxism is a masticatory muscle activity during sleep that is characterised as rhythmic (phasic) or non-rhythmic (tonic) and is not a movement disorder or a sleep disorder in otherwise healthy individuals. #### Awake Bruxism Awake bruxism is a masticatory muscle activity during wakefulness that is characterised by repetitive or sustained tooth contact and/or by bracing or thrusting of the mandible and is not a movement disorder in otherwise healthy individuals. | | | |---|---| | **Bruxism in Adults** | Dr Amanda Phoon Nguyen. Not an exhaustive list. Please do not reproduce without permission. | | Commonly noted by dental professional because of: <br> Clinical signs and Symptoms, Patient self-report | | Tooth wear and bruxofacets, Masseter hypertrophy, Tongue Indentations, Linea Alba, <br> Tooth fractures, Dental pulp alterations, Jaw Pain, Headache, Tooth pain and mobility <br> Possible: Torus and exostosis, Dental Crowding | Bruxism: Spectrum of behaviors | | Bruxism is not the complete diagnosis! |  #### Clinical Identification Bruxism is commonly noted by dental professionals through clinical signs, symptoms, and patient self-reports. It is important to note that bruxism represents a spectrum of behaviors and is not the complete diagnosis. #### Common Signs and Symptoms - Tooth wear and bruxofacets - Masseter hypertrophy - Tongue indentations - Linea alba - Tooth fractures - Dental pulp alterations - Jaw pain - Headache - Tooth pain and mobility #### Possible Associated Findings - Torus and exostosis - Dental crowding Flowchart diagram titled 'Bruxism in Adults' (attributed to Dr Amanda Phoon Nguyen). The diagram uses a top-down structure with arrows connecting nodes. Key visual elements include: a central box listing clinical signs and symptoms such as 'Tooth wear and bruxofacets', 'Masseter hypertrophy', 'Tongue Indentations', 'Linea Alba', 'Jaw Pain', and 'Headache'. It includes callouts for 'Patient self-report' and notes that 'Bruxism is not the complete diagnosis!' at the bottom. A yellow star highlights the text 'Bruxism: Spectrum of behaviors'. ### **Bruxism in Adults** *Dr Amanda Phoon Nguyen. Not an exhaustive list. Please do not reproduce without permission.* --- ### **Signs of Bruxism** #### **Toothwear and Bruxofacets** * Not caused exclusively by bruxism * Erosion is usually the main cause * Not reliable as a single diagnostic indicator * *Remember spectrum of bruxism and definition* #### **Tongue Scalloping** * **Causes of macroglossia** * More common in population than % of bruxers * Not reliable as a single diagnostic indicator   #### Toothwear and Bruxofacets - Not caused exclusively by bruxism. - Erosion is usually the main cause. - Not reliable as a single diagnostic indicator. - Consideration of the spectrum of bruxism and its formal definition is required. #### Tongue Scalloping - Associated with causes of macroglossia. - More common in the general population than the percentage of bruxers would suggest. - Not reliable as a single diagnostic indicator. Flowchart titled 'Bruxism in Adults'. The diagram lists clinical signs and symptoms such as tooth wear, bruxofacets, masseter hypertrophy, tongue indentations, linea alba, tooth fractures, dental pulp alterations, jaw pain, headache, tooth pain, mobility, torus, exostosis, and crowding. It includes a note to refer to another flowchart for children and emphasizes that bruxism is not a complete diagnosis. Clinical photograph of a person's mouth with the tongue extended, showing scalloping along the lateral edges where the tongue indents against the teeth. This visual supports the text section on 'Tongue Scalloping' which notes it can be caused by macroglossia but is not reliable as a single diagnostic indicator for bruxism.  Close-up clinical photo of a person's face, showing the cheek area. The individual is pointing with their index finger to a specific spot on the right side of their cheek (viewer's left), likely indicating a lesion, swelling, or anatomical landmark for diagnostic or educational purposes. # Signs of Bruxism Contd * Masseter hypertrophy- usually asymptomatic, may be unilateral or bilateral * Masticatory muscle hyperactivity cannot be verified in all instances of masseter hypertrophy ## Linea alba * Thought to be associated most with clenching. Common clinical finding, specificity not known * Tooth fractures- common! Nocturnal bite force may exceed maximum amplitude in the day time. #### Masseter Hypertrophy - Usually asymptomatic. - May be unilateral or bilateral. - Masticatory muscle hyperactivity cannot be verified in all instances of masseter hypertrophy. #### Linea Alba - Thought to be associated most with clenching. - A common clinical finding, though its specificity is not known. #### Tooth Fractures - A common finding. - Nocturnal bite force may exceed the maximum amplitude recorded during daytime hours. Flowchart: Diagnosis of Bruxism | | | | | | :--- | :--- | :--- | :--- | | **Bruxism is not the complete diagnosis!** | | | | Select one category from each | | 1. Is it Bruxism? | 2. What type of bruxism is prevalent? | 3. Consider the definition of bruxism and classify (not mutually exclusive). | 4. AB or SB Primary or Secondary? | | | Awake/Sleep Bruxism (AB/SB) | 1. Not a risk or protective behaviour; is a harmless behaviour | | | Consider differential diagnoses | | 2. Risk factor: associated with 1 or more negative health outcomes | | | | | 3. Protective factor: associated with 1 or more positive health outcomes | | | I need to know *!* | | | | | Examples: Epilepsy, Movement disorders (**Parkinsons**, Oromandibular dystonia, Tardive dyskinesia), TBI, oromandibular myoclonus, Huntington's or other *other neurodegenerative conditions**, *Morsicatio buccarum**, developmental disabilities, other sleep disturbances, REM behaviour disorder, endocrine disorders. | | | | | | | | | | ***Some Relevant Medical History*** | | | | | | Medications, Alcohol, Cigarette smoking, Caffeine, Recreational drug use, **Sleep disordered breathing**, Gastroesophag eal reflux, Sleep related movement and other sleep disorders, Psychosocial factors and Psychiatric disorders. | | | | | | | | | Consider investigations targeted towards the medical history or differential diagnosis, or referral if indicated. | |**Sleep:** OSA 50, STOP BANG, Epworth Sleepiness Score | |  #### Diagnostic Steps 1. **Is it Bruxism?** - Consider differential diagnoses. - Rule out: Epilepsy, movement disorders (Parkinson's, Oromandibular dystonia, Tardive dyskinesia), TBI, oromandibular myoclonus, Huntington's or other neurodegenerative conditions, Morsicatio buccarum, developmental disabilities, sleep disturbances, REM behaviour disorder, and endocrine disorders. 2. **What type of bruxism is prevalent?** - Determine if it is Awake Bruxism (AB) or Sleep Bruxism (SB). 3. **Classification of Behavior** - Harmless behavior: Not a risk or protective behavior. - Risk factor: Associated with one or more negative health outcomes. - Protective factor: Associated with one or more positive health outcomes. 4. **Primary or Secondary?** - Determine if the AB or SB is primary or secondary to other conditions. #### Medical History and Risk Factors - Medications and recreational drug use - Alcohol, cigarette smoking, and caffeine - Sleep-disordered breathing (e.g., Gastroesophageal reflux, OSA) - Psychosocial factors and psychiatric disorders #### Investigations and Referrals - Targeted investigations based on medical history. - Sleep assessments: OSA 50, STOP BANG, Epworth Sleepiness Score. - Referral if indicated. Flowchart: Diagnosis of Bruxism. The diagram begins with a header stating 'Bruxism is not the complete diagnosis!'. It branches into four decision steps: 1. Is it Bruxism? (with differential diagnoses like Epilepsy, Parkinsons, TBI), 2. What type of bruxism is prevalent? (Awake/Sleep), 3. Consider definition and classify (Risk/Protective factors), and 4. AB or SB Primary or Secondary?. Below these steps are sections for 'Some Relevant Medical History' (Medications, Sleep disordered breathing, etc.) and 'Consider investigations targeted towards the medical history or differential diagnosis', which points to specific sleep assessments like OSA 50, STOP BANG, and Epworth Sleepiness Score. <table> <thead> <tr> <th><p style="text-align: center;"><span>Bruxism is not</span></p></th> </tr> </thead> <tbody> <tr> <td><p><strong>Is it Bruxism?</strong></p><br/>Consider differential diagnoses</td> <td><p><strong>What type of bruxism is prevalent?</strong><br/>Awake/Sleep Bruxism (AB/SB)</p></td> </tr> <tr> <td colspan="2" style="text-align: center; vertical-align: top;">Examples: Epilepsy, Movement disorders (<u>Tardive dyskinesia</u>), TBI, oromandibular myoclonus, Huntington's or other neurodegenerative conditions, <u>Morsicatio buccarum</u>, developmental disabilities, other sleep disturbances, REM behaviour disorder, endocrine disorders.</td> </tr> </tbody> </table>  #### Differential Diagnosis Screening **Is it Bruxism?** Consider differential diagnoses including: - Epilepsy - Movement disorders (e.g., Tardive dyskinesia) - Traumatic Brain Injury (TBI) - Oromandibular myoclonus - Huntington's or other neurodegenerative conditions - Morsicatio buccarum - Developmental disabilities - Sleep disturbances (e.g., REM behaviour disorder) - Endocrine disorders **Prevalence Type** - Awake Bruxism (AB) - Sleep Bruxism (SB) Clinical decision tree or flowchart diagram illustrating the diagnostic process for Bruxism. The diagram is structured with a top-level header 'Bruxism is not the c...' (cut off), followed by two main branching boxes: 'Is it Bruxism? Consider differential diagnoses' and 'What type of bruxism is prevalent? Awake/Sleep Bruxism (AB/SB)'. Below these branches is a large yellow highlighted section listing examples of differential diagnoses such as Epilepsy, Movement disorders (Parkinsons, Oromandibular dystonia, Tardive dyskinesia), TBI, oromandibular myoclonus, Huntington’s, neurodegenerative conditions, Morsicatio buccarum, developmental disabilities, sleep disturbances, REM behaviour disorder, and endocrine disorders. Some terms like 'Tardive dyskinesia' and 'Morsicatio buccarum' are underlined in red. **55 year old female** • Referred from GP • Presenting problem as per GP letter 7/10/16 • “Fronto-temporal dementia with difficulty cooperating with dental procedure or treatment” • Can walk but cannot speak or follow instructions. • Verbal commands will be ok but patient cannot cooperate in any way •“Chronic bruxism needing splint and dental exam”  #### Patient Profile - **Age/Gender:** 55-year-old female - **Referral:** Referred from General Practitioner (GP) on 07/10/16 #### Clinical Presentation - **Diagnosis:** Fronto-temporal dementia. - **Functional Status:** Patient can walk but cannot speak or follow instructions; unable to cooperate with dental procedures or treatment. - **Primary Concern:** Chronic bruxism requiring a dental examination and splint therapy. Pink silhouette icon representing a female figure. This visual is pertinent to the patient demographics (55 year old female) and serves as an illustrative element for the clinical case presentation. # Medical History - Thyroidectomy (total, performed in India) Benign causes - B12 deficiency anaemia (2007) - T2DM (2013) - Fronto temporal dementia (2014) - Vitamin D deficiency (2016) - Penicillin allergy. - Currently on **Aspirin 100mg**, **Thyroxine 100mcg** - Other supplements- fish oil, magnesium, melatonin, Vitamin D, lecithin - Was on escitalopram 20mcg - Was on **risperidone** 1mg ½ a night #### Medical History - **Endocrine/Metabolic:** - Total thyroidectomy (performed in India for benign causes) - Vitamin D deficiency (2016) - **Hematologic:** B12 deficiency anaemia (2007) - **Neurological/Psychiatric:** - Fronto-temporal dementia (2014) - Type 2 Diabetes Mellitus (T2DM) (2013) - **Allergies:** Penicillin #### Current Medications and Supplements - **Prescriptions:** - Aspirin 100mg - Thyroxine 100mcg - **Supplements:** Fish oil, magnesium, melatonin, Vitamin D, lecithin - **Previous Medications:** - Escitalopram 20mcg - Risperidone 1mg (½ a night) **Timeline** **1.Dentist** * Managed for bruxism * Splint was made, unable to be worn as patient cannot tolerate. #### Treatment Timeline 1. **Dental Management** - Initial management for bruxism. - An occlusal splint was fabricated but could not be worn as the patient was unable to tolerate it. # Oromandibular dystonia * Prevalence about 3 to 30 per 100,000 * Possibly F>M * Mean age of symptom onset between 31 and 58 years. * ODs are **intermittent** and present as short, sustained muscle contractions resulting in abnormal muscle movements and posturing. * Focal dystonias may be primary (idiopathic) or secondary e.g. underlying central nervous system pathology, such as infarctions and tumors. #### Epidemiology and Characteristics - **Prevalence:** Approximately 3 to 30 per 100,000 individuals. - **Demographics:** Possible female predilection (F>M); mean age of symptom onset is between 31 and 58 years. - **Clinical Presentation:** Oromandibular dystonias (ODs) are intermittent, presenting as short, sustained muscle contractions that result in abnormal movements and posturing. #### Etiology - **Primary:** Idiopathic focal dystonias. - **Secondary:** Resulting from underlying central nervous system pathology, such as tumors or infarctions. **Oromandibular dystonia** Jaw-opening, jaw-closing, jaw-deflecting, or jaw-retruding dystonia, or a combination of any of these. The uncontrolled or involuntary mandibular movements may be repetitive or sustained. Most ODs are idiopathic in etiology, accounting for 63% of cases reported. #### Clinical Classifications Oromandibular dystonia may present as: - Jaw-opening dystonia - Jaw-closing dystonia - Jaw-deflecting dystonia - Jaw-retruding dystonia - A combination of the above #### Movement Patterns Involuntary or uncontrolled mandibular movements can be characterized as either repetitive or sustained. #### Statistical Etiology Most cases of OD are idiopathic, accounting for 63% of reported cases. **Drug related?** **Tardive or medication-induced extrapyramidal syndrome reactions** | Table 2 | Drug-induced extrapyramidal syndrome reactions | |---|---| | Dystonia | Involuntary, sustained, patterned, and often repetitive muscle contractions causing twisting movements or abnormal postures | | Akathisia | A subjective report and objective manifestations of restlessness in the form of movement of the limb | | Parkinsonism | Bradykinesia (slowness of movement) associated with at least one of rigidity, tremor, or postural instability | **Table 1** **Medications associated with tardive dyskinesia** | Medication class | Medication | |---|---| | Conventional antipsychotics | Chlorpromazine | | | Haloperidol | | | Perphenazine | | | Pimozide | | | Trifluoperazine | | Atypical antipsychotics | Clozapine | | | Olanzapine | | | Risperidone | | Antiemetics | Metoclopramide | | | Promethazine | | Antiparkinsonian agents | Levodopa | | | Benztropine | | | Trihexyphenidyl | | Anticonvulsants | Phenytoin | | | Carbamazepine | | Antihistamines | Diphenhydramine | | Tricyclic antidepressants | Ranitidine | | | Amitriptyline | | | Doxepin | | Selective serotonin reuptake inhibitors | Fluoxetine | | | Paroxetine | | | Sertraline | Cornett EM, Novitch M, Kaye AD, Kata V, Kaye AM. Medication-Induced Tardive Dyskinesia: A Review and Update. The Ochsner Journal. 2017;17(2):162-174.   #### Extrapyramidal Syndrome Reactions | Reaction Type | Clinical Manifestation | | :--- | :--- | | **Dystonia** | Involuntary, sustained, patterned, and often repetitive muscle contractions causing twisting movements or abnormal postures. | | **Akathisia** | Subjective reports and objective manifestations of restlessness, typically involving limb movement. | | **Parkinsonism** | Bradykinesia (slowness of movement) associated with at least one of: rigidity, tremor, or postural instability. | #### Medications Associated with Tardive Dyskinesia - **Conventional Antipsychotics:** Chlorpromazine, Haloperidol, Perphenazine, Pimozide, Trifluoperazine - **Atypical Antipsychotics:** Clozapine, Olanzapine, Risperidone - **Antiemetics:** Metoclopramide, Promethazine - **Antiparkinsonian Agents:** Levodopa, Benztropine, Trihexyphenidyl - **Anticonvulsants:** Phenytoin, Carbamazepine - **Antihistamines:** Diphenhydramine - **Tricyclic Antidepressants:** Amitriptyline, Doxepin - **SSRIs:** Fluoxetine, Paroxetine, Sertraline - **Other:** Ranitidine Table 2: Drug-induced extrapyramidal syndrome reactions. Lists three conditions—Dystonia, Akathisia, and Parkinsonism—with their corresponding clinical definitions based on OCR context. Table 1: Medications associated with tardive dyskinesia. A two-column table listing medication classes (e.g., Conventional antipsychotics, Atypical antipsychotics) and specific medications under each class. Figure 3: Clinical photograph showing maxillo-mandibular fixation with elastics Figure 1: Computed tomography images showing dislocation of the left and right TM joints.   - Clinical photograph showing maxillo-mandibular fixation with elastics. - Computed tomography images showing dislocation of the left and right TM joints. Clinical photograph showing maxillo-mandibular fixation with elastics. The image displays a patient's face with an intraoral appliance (likely an acrylic splint or archwire) secured by multiple elastic bands connecting the upper and lower dental arches to immobilize the jaw. Computed tomography images showing dislocation of the left and right TM joints. The panel contains two sagittal cross-sections of the temporomandibular joints, revealing anatomical misalignment consistent with bilateral joint dislocation. <img>Lateral view of a male patient's head showing loose skin on the scalp  Lateral view of a male patient's head showing loose skin on the scalp. Clinical photo: Lateral view of a male patient's head showing loose skin on the scalp | Bruxism is not the complete diagnosis! | | :--- | | Is it Bruxism? | What type of bruxism is prevalent? | Consider the definition of bruxism and classify (not mutually exclusive). | AB or SB Primary or Secondary? | | Consider differential diagnoses | Awake/Sleep Bruxism (AB/SB) | 1. Not a risk or protective behaviour; is a harmless behaviour | | | Examples: Epilepsy, Movement disorders (**Parkinsons**, Oromandibular dystonia, Tardive dyskinesia), **.**TBI, oromandibular myoclonus, Huntington’s or other other neurodegenerative conditions, **Morsicatio buccarum,** developmental disabilities, other sleep disturbances, REM behaviour disorder, endocrine disorders. | | 2. Risk factor: associated with 1 or more negative health outcomes | | | | | 3. Protective factor: associated with 1 or more positive health outcomes | | | | **Some Relevant Medical History** **Medications, Alcohol, Cigarette smoking, Caffeine, Recreational drug use,** Sleep disordered breathing, Gastrooesophageal reflux, Sleep related movement and other sleep disorders, Psychosocial factors and Psychiatric disorders. | Consider investigations targeted towards the medical history or differential diagnosis, or referral if indicated. | Sleep: OSA 50, STOP BANG, Epworth Sleepiness Score |  #### Diagnostic Considerations Bruxism is often not the complete diagnosis. Clinicians should evaluate the following: 1. **Classification:** Determine if it is Awake Bruxism (AB) or Sleep Bruxism (SB), and whether it is Primary or Secondary. 2. **Behavioral Impact:** - Harmless behavior (not a risk or protective factor). - Risk factor (associated with negative health outcomes). - Protective factor (associated with positive health outcomes). #### Differential Diagnoses Consider the following conditions that may mimic or coexist with bruxism: - **Movement Disorders:** Parkinson’s disease, Oromandibular dystonia, Tardive dyskinesia, Oromandibular myoclonus. - **Neurological/Neurodegenerative:** Epilepsy, Traumatic Brain Injury (TBI), Huntington’s disease. - **Other:** Morsicatio buccarum, developmental disabilities, REM behavior disorder, endocrine disorders, and various sleep disturbances. #### Medical History and Risk Factors Evaluate the influence of: - **Substances:** Alcohol, Cigarette smoking, Caffeine, Recreational drug use. - **Systemic Health:** Gastrooesophageal reflux, Sleep-disordered breathing (e.g., OSA), endocrine disorders. - **Psychosocial:** Psychiatric disorders and psychosocial factors. #### Investigations and Referrals Targeted investigations or referrals should be considered based on medical history: - **Sleep Assessment Tools:** OSA 50, STOP-BANG, Epworth Sleepiness Score. A clinical flowchart titled 'Bruxism is not the complete diagnosis!' that guides the diagnostic process. The chart branches into four initial decision points: 'Is it Bruxism?', 'What type of bruxism is prevalent?', 'Consider the definition of bruxism and classify', and 'AB or SB Primary or Secondary?'. A yellow highlighted box under 'Is it Bruxism?' lists differential diagnoses such as Epilepsy, Parkinson's, TBI, and Morsicatio buccarum. A grey box details 'Some Relevant Medical History' including medications, sleep disordered breathing, and psychiatric disorders. The bottom section directs the user to 'Consider investigations targeted towards the medical history...' which leads to specific tools like OSA 50, STOP BANG, and Epworth Sleepiness Score. <table> <thead> <tr> <th>Risk Factor</th> <th></th> <th>Notes</th> </tr> </thead> <tbody> <tr> <td>Alcohol</td> <td>Increases risk for SB</td> <td>Consuming more than 4 standard drinks</td> </tr> <tr> <td>Cigarettes</td> <td>Increases risk for SB, stimulates central dopaminergic activity</td> <td>Needs further study</td> </tr> <tr> <td>Caffeine</td> <td>Stimulant</td> <td>Some studies report: More than 600mg/day (withdrawal) or 6 cups of coffee</td> </tr> </tbody> </table> ```mermaid graph TD A["Some Relevant Medical History<br>Medications, Alcohol, Cigarette smoking, Caffeine, Recreational drug use, Sleep disordered breathing,<br>Gastroesophageal reflux, Sleep related movement and other sleep disorders, Psychosocial factors and<br>Psychiatric disorders."] --> B["Consider investigations targeted towards<br>the medical history or differential<br>diagnosis, or referral if indicated."] B --> C["Sleep: OSA 50, STOP BANG, Epworth Sleepiness Score"] ```   #### Lifestyle and Substance-Related Risk Factors - **Alcohol** - Consuming more than 4 standard drinks increases the risk for Sleep Bruxism (SB). - **Cigarettes** - Smoking increases the risk for SB and stimulates central dopaminergic activity. Further study is required to fully understand this relationship. - **Caffeine** - Acts as a stimulant. Some studies report increased risk with consumption exceeding 600mg per day (or 6 cups of coffee) or during withdrawal. #### Clinical Assessment and Diagnostic Pathways When evaluating a patient's medical history, consider the following factors that may influence or coexist with Sleep Bruxism: - **Medical and Lifestyle History** - Medications and recreational drug use - Alcohol, cigarette, and caffeine consumption - Sleep-disordered breathing and other sleep-related movement disorders - Gastroesophageal reflux - Psychosocial factors and psychiatric disorders - **Diagnostic Investigations** - Targeted investigations should be directed toward the medical history or differential diagnosis. - Referrals should be made if clinically indicated. - **Sleep Quality Screening Tools** - OSA 50 - STOP-BANG - Epworth Sleepiness Score A table listing risk factors for sleep disorders. Columns include 'Risk Factor', an unlabeled middle column describing effects (e.g., 'Increases risk for SB'), and 'Notes' with specific details like drink counts or caffeine amounts. A flowchart diagram illustrating a clinical workflow. It starts with a grey box titled 'Some Relevant Medical History', flows to a yellow decision box about investigations, and ends with a white box detailing sleep assessment tools: OSA 50, STOP BANG, Epworth Sleepiness Score.   Infographic chart titled 'DRUG-INDUCED BRUXISM' featuring a blue color scheme. The chart categorizes drugs into three sections: 'ANTIDEPRESSANTS' (listing Citalopram, Escitalopram, Duloxetine, Fluoxetine*, Fluvoxamine, Paroxetine, Sertraline*, Venlafaxine*), 'ANTIPSYCHOTICS' (listing Chlorpromazine, Fluphenazine, Haloperidol), and 'DRUGS FOR ADHD' (listing Atomoxetine, Methylphenidate). A footnote at the bottom clarifies that an asterisk (*) denotes the most commonly reported causes. Infographic chart titled 'DRUG INDUCED BRUXISM (PART 2)' featuring a red color scheme. This chart lists stimulant drugs associated with bruxism in four categories: 'AMPHETAMINES (SPEED)', 'METHAMPHETAMINE (ICE)', '3,4-METHYLENEDI OXYMETHAMPHETAMINE (MDMA; ECSTASY)', and 'COCAINE'. **Title:** Are OSA patients always sleepy? <table> <thead> <tr> <th></th> <th>In Sleep Clinics</th> <th>In the general population</th> </tr> </thead> <tbody> <tr> <td>Sleepy</td> <td>45%</td> <td>30%</td> </tr> <tr> <td>Disturbed sleep</td> <td>20-30%</td> <td>14%</td> </tr> <tr> <td>Minimal-no symptoms</td> <td>20-25%</td> <td>56%</td> </tr> </tbody> </table>  #### Prevalence of Sleepiness in OSA Patients | Symptom Category | In Sleep Clinics | In the General Population | | :--- | :--- | :--- | | Sleepy | 45% | 30% | | Disturbed sleep | 20-30% | 14% | | Minimal-no symptoms | 20-25% | 56% | Table comparing OSA patient symptoms in 'In Sleep Clinics' versus 'In the general population'. Rows are categorized as 'Sleepy', 'Disturbed sleep', and 'Minimal-no symptoms', with corresponding percentage values for each group. Why do we care about OSA? • Accidents • Depression • Hypertension • Diabetes • Cardiovascular disease #### Comorbidities and Risks Associated with OSA - Accidents - Depression - Hypertension - Diabetes - Cardiovascular disease Head nodding = Microsleep Difficulty keeping eyes open / blurred vision = Earlier warning signs #### Warning Signs of Microsleep - **Head nodding:** Indicates microsleep. - **Earlier warning signs:** Difficulty keeping eyes open or blurred vision. | Factor | Risk | | --- | --- | | Alcohol 0.05%-0.08% | ↑2-3 | | Sleep apnoea | ↑2-7 | | <5 hours sleep | ↑3 | | Driving 2-5am | ↑5 |   #### Comparative Risk Factors for Accidents | Factor | Risk Increase | | :--- | :--- | | Alcohol (0.05%-0.08%) | ↑ 2-3 | | Sleep apnoea | ↑ 2-7 | | < 5 hours sleep | ↑ 3 | | Driving 2-5am | ↑ 5 | A data table titled 'Accidents' with a green header row containing columns for 'Factor' and 'Risk'. The rows list specific risk factors: Alcohol 0.05%-0.08%, Sleep apnoea, <5 hours sleep, and Driving 2-5am. Corresponding risk multipliers are displayed in the second column using an upward arrow symbol followed by numbers (↑2-3, ↑2-7, ↑3, ↑5). The table has alternating light green and white background shading. An illustration of a red warning flag on a black pole, positioned to the right of the main table content. <table> <tbody> <tr> <td><b>OSA 50 Screening Questionnaire</b></td> <td><b>If YES, score</b></td> </tr> <tr> <td>Waist circumference*:<br/>Male > 102cm<br/>Females > 88cm</td> <td>3</td> </tr> <tr> <td>Has your snoring ever bothered other people?</td> <td>3</td> </tr> <tr> <td>Has anyone noticed you stop breathing during your sleep?</td> <td>2</td> </tr> <tr> <td>Are you aged 50 years or over?</td> <td>2</td> </tr> <tr> <td><b>TOTAL SCORE</b></td> <td><b>OUT OF 10</b></td> </tr> </tbody> </table> *Waist measurement to be measured at the level of the umbilicus 5/10  #### Scoring Criteria | Question | If YES, score | | :--- | :--- | | **Waist circumference** (measured at umbilicus):<br>Male > 102cm; Female > 88cm | 3 | | Has your snoring ever bothered other people? | 3 | | Has anyone noticed you stop breathing during your sleep? | 2 | | Are you aged 50 years or over? | 2 | | **TOTAL SCORE** | **OUT OF 10** | **Threshold:** 5/10 OSA 50 Screening Questionnaire table listing criteria for obstructive sleep apnea. Rows include waist circumference thresholds (Male > 102cm, Females > 88cm), snoring impact on others, observed breathing cessation during sleep, and age ≥50 years. Each row corresponds to a score value (3, 3, 2, 2) if 'YES' is selected. Total score out of 10 is indicated at the bottom. # STOP BANG * **Snoring ?** Do you **Snore Loudly** (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)? * **Tired ?** Do you often feel **Tired, Fatigued, or Sleepy** during the daytime (such as falling asleep during driving or talking to someone)? * **Observed ?** Has anyone **Observed** you **Stop Breathing** or **Choking/Gasping** during your sleep * **Pressure ?** Do you have or are being treated for **High Blood Pressure** ? * **Body Mass Index** more than 35 kg/m²? * **Age older than 50** ? * **Neck size large** ? (Measured around **Adams** apple) For male, is your shirt collar 17 inches / 43cm or larger? For female, is your shirt collar 16 inches / 41cm or larger? * **Gender = Male ?** http://stopbang.ca/osa/screening.php #### Screening Criteria - **Snoring:** Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)? - **Tired:** Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)? - **Observed:** Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep? - **Pressure:** Do you have or are being treated for High Blood Pressure? - **Body Mass Index:** More than 35 kg/m²? - **Age:** Older than 50? - **Neck size large:** (Measured around Adam's apple) - Male: Shirt collar 17 inches / 43cm or larger? - Female: Shirt collar 16 inches / 41cm or larger? - **Gender:** Male? STOP BANG ctd - OSA - Low Risk : Yes to 0 - 2 questions - OSA - Intermediate Risk : Yes to 3 - 4 questions - OSA - High Risk : Yes to 5 - 8 questions or Yes to 2 or more of 4 STOP questions + male gender or Yes to 2 or more of 4 STOP questions + BMI > 35kg/m² or Yes to 2 or more of 4 STOP questions + neck circumference 17 inches / 43cm in male or 16 inches / 41cm in female - Different cut-off scores can be used to trade off sensitivity and specificity. #### Risk Stratification - **OSA - Low Risk:** Yes to 0 - 2 questions - **OSA - Intermediate Risk:** Yes to 3 - 4 questions - **OSA - High Risk:** Yes to 5 - 8 questions **Alternative High Risk Criteria:** - Yes to 2 or more of 4 STOP questions + male gender - Yes to 2 or more of 4 STOP questions + BMI > 35kg/m² - Yes to 2 or more of 4 STOP questions + neck circumference (17 inches / 43cm in male or 16 inches / 41cm in female) *Note: Different cut-off scores can be used to trade off sensitivity and specificity.* Berlin ### **Berlin Questionnaire©** **Sleep Apnea** Height (m) _____ Weight (kg) _____ Age _____ Male / Female Please choose the correct response to each question. **Category 1** 1. Do you snore? ☐ a. Yes ☐ b. No ☐ c. Don’t know *If you answered ‘yes’:* 2. You snoring is: ☐ a. Slightly louder than breathing ☐ b. As loud as talking ☐ c. Louder than talking **Category 2** 6. How often do you feel tired or fatigued after your sleep? ☐ a. Almost every day ☐ b. 3-4 times per week ☐ c. 1-2 times per week ☐ d. 1-2 times per month ☐ e. Rarely or never 7. During your waking time, do you feel tired, fatigued or not up to par? ☐ a. Almost every day ☐ b. 3-4 times per week ☐ c. 1-2 times per week ☐ d. 1-2 times per month ☐ e. Rarely or never #### Patient Information Height (m) _____ Weight (kg) _____ Age _____ Male / Female #### Category 1: Snoring 1. Do you snore? - a. Yes - b. No - c. Don’t know *If you answered ‘yes’:* 2. Your snoring is: - a. Slightly louder than breathing - b. As loud as talking - c. Louder than talking #### Category 2: Daytime Sleepiness 6. How often do you feel tired or fatigued after your sleep? - a. Almost every day - b. 3-4 times per week - c. 1-2 times per week - d. 1-2 times per month - e. Rarely or never 7. During your waking time, do you feel tired, fatigued or not up to par? - a. Almost every day - b. 3-4 times per week - c. 1-2 times per week - d. 1-2 times per month - e. Rarely or never ```html <table border='1'> <thead> <tr> <th colspan="5">Table 2. Diagnostic utility of obstructive sleep apnoea screening questionnaires for detecting moderate-to-severe obstructive sleep apnoea</th> </tr> <tr> <th></th> <th>Berlin Questionnaire<sup>13</sup></th> <th>STOP-BANG cut-off $\ge$3<sup>16</sup></th> <th>STOP-BANG cut-off $\ge$4<sup>16</sup></th> <th>OSA50<sup>14</sup></th> </tr> </thead> <tbody> <tr> <td>Sensitivity* %</td> <td>82</td> <td>94</td> <td>81</td> <td>94</td> </tr> <tr> <td>Specificity$^+$ %</td> <td>39</td> <td>32</td> <td>51</td> <td>31</td> </tr> </tbody> <tfoot> <tr> <td colspan="5"><i>Data taken from validation studies<sup>14</sup> and meta-analyses<sup>13,16</sup><br/> *Sensitivity refers to the proportion of subjects with OSA who have a positive questionnaire. (Note: for a highly sensitive test, a negative result is good at ruling out disease.)<br/> +Specificity refers to the proportion of subjects without OSA who have a negative questionnaire. (Note: for a highly specific test, a positive result is good at ruling in disease.)<br/> In general, OSA screening questionnaires have good but not optimal sensitivity, and poor specificity for detecting AHI $\ge$15 events/hour.<br/> <i>OSA, obstructive sleep apnoea; AHI, Apnoea Hypopnoea Index</i></td> </tr> </tfoot> </table> ```  #### Diagnostic Utility for Moderate-to-Severe OSA | Metric | Berlin Questionnaire | STOP-BANG (≥3) | STOP-BANG (≥4) | OSA50 | | :--- | :---: | :---: | :---: | :---: | | Sensitivity % | 82 | 94 | 81 | 94 | | Specificity % | 39 | 32 | 51 | 31 | **Definitions and Notes:** - **Sensitivity:** Proportion of subjects with OSA who have a positive questionnaire. (A highly sensitive test is good at ruling out disease with a negative result). - **Specificity:** Proportion of subjects without OSA who have a negative questionnaire. (A highly specific test is good at ruling in disease with a positive result). - **General Finding:** Screening questionnaires have good but not optimal sensitivity, and poor specificity for detecting AHI ≥15 events/hour. *Abbreviations: OSA, obstructive sleep apnoea; AHI, Apnoea Hypopnoea Index.* Table 2. Diagnostic utility of obstructive sleep apnoea screening questionnaires for detecting moderate-to-severe obstructive sleep apnoea. Columns: Berlin Questionnaire (Sensitivity 82%, Specificity 39%), STOP-BANG cut-off ≥3 (Sensitivity 94%, Specificity 32%), STOP-BANG cut-off ≥4 (Sensitivity 81%, Specificity 51%), OSA50 (Sensitivity 94%, Specificity 31%). Footnotes explain sensitivity and specificity definitions and note general performance characteristics of these questionnaires. # Epworth Sleepiness Scale ```html <table style="text-align: left"> <tr> <td colspan="3"><b>Feeling sleepy?</b></td> </tr> <tr> <td colspan="3">How likely are you to doze off or fall asleep<br>in the following situations, in contrast to<br>feeling just tired?</td> </tr> <tr> <th>Situation</th> <th><b>Never</b></th> <th><b>Very frequently</b></th> </tr> <tr> <td>While sitting and reading (not too challenging)</td> <td></td> <td><b>Doze off</b></td> </tr> <tr> <td>As a passenger in a motor vehicle when not feeling tired</td> <td></td> <td><b>Fall asleep</b></td> </tr> <tr> <td>Later in the afternoon as you are not doing something active (e.g., sitting in a lecture theatre, watching TV, in a movie theatre, meeting friends at lunch)</td> <td></td> <td><b>Fall asleep</b></td> </tr> <tr> <td>When sitting and talking to the other person (during business meetings, meetings, etc.)</td> <td></td> <td><b>Doze off</b></td> </tr> <tr> <td>When you have to lie down to rest / snooze while you are awake but can close your eyes</td> <td></td> <td><b>Fall asleep</b></td> </tr> <tr> <td>Just before lunchtime of time immediately after</td> <td></td> <td><b>Doze off</b></td> </tr> <tr> <td>While sitting and inactively watching TV (e.g., watching a movie)</td> <td></td> <td><b>Fall asleep</b></td> </tr> <tr> <td>While sitting in a public place reading</td> <td></td> <td><b>Fall asleep</b></td> </tr> </table> ``` #### Assessment of Dozing Probability How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? - **While sitting and reading (not too challenging):** Doze off - **As a passenger in a motor vehicle when not feeling tired:** Fall asleep - **Later in the afternoon when not active (e.g., lecture, watching TV, movie, lunch with friends):** Fall asleep - **When sitting and talking to another person (business meetings, etc.):** Doze off - **When lying down to rest/snooze while awake but eyes closed:** Fall asleep - **Just before lunchtime or immediately after:** Doze off - **While sitting and inactively watching TV:** Fall asleep - **While sitting in a public place reading:** Fall asleep <table> <tr> <td>0</td> <td>Would NEVER dose</td> </tr> <tr> <td>1</td> <td>Slight chance of dozing</td> </tr> <tr> <td>2</td> <td>Moderate chance of dozing</td> </tr> <tr> <td>3</td> <td>High chance of dozing</td> </tr> </table>  #### Scoring Scale 1. **0:** Would NEVER doze 2. **1:** Slight chance of dozing 3. **2:** Moderate chance of dozing 4. **3:** High chance of dozing A table defining a 4-point scale for the likelihood of dozing. The rows are labeled 0 through 3, corresponding to: 'Would NEVER dose', 'Slight chance of dozing', 'Moderate chance of dozing', and 'High chance of dozing' respectively. # Epworth Sleepiness Scale * Sitting and reading * Watching TV * Sitting, inactive in a public place (e.g. a theatre or a meeting) * As a passenger in a car for an hour without a break * Lying down to rest in the afternoon when circumstances permit * Sitting and talking to someone * Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in the traffic #### Situations for Assessment - Sitting and reading - Watching TV - Sitting, inactive in a public place (e.g. a theatre or a meeting) - As a passenger in a car for an hour without a break - Lying down to rest in the afternoon when circumstances permit - Sitting and talking to someone - Sitting quietly after a lunch without alcohol - In a car, while stopped for a few minutes in the traffic **bold = bolded text** Website: http://epworthsleepinessscale.com/ Score interpretation: - 0–5: Lower Normal Daytime Sleepiness - 6–10: Higher Normal Daytime Sleepiness - 11–12: Mild Excessive Daytime Sleepiness - 13–15: Moderate Excessive Daytime Sleepiness - 16–24: Severe Excessive Daytime Sleepiness 8 or more may indicate need for Medicare  #### Score Interpretation - **0–5:** Lower Normal Daytime Sleepiness - **6–10:** Higher Normal Daytime Sleepiness - **11–12:** Mild Excessive Daytime Sleepiness - **13–15:** Moderate Excessive Daytime Sleepiness - **16–24:** Severe Excessive Daytime Sleepiness *Note: A score of 8 or more may indicate a need for Medicare.* Table representing the Epworth Sleepiness Scale questionnaire. Includes header fields for Name, Date, Age, and Sex. Contains instructions on how to rate the 'Chance of Dozing' (0-3) for eight specific situations: Sitting and reading, Watching TV, Sitting inactive in a public place, As a passenger in a car for an hour without a break, Lying down to rest in the afternoon when circumstances permit, Sitting and talking to someone, Sitting quietly after a lunch without alcohol, and In a car, while stopped for a few minutes in the traffic. **Epworth Sleepiness Scale** - ESS is not correlated with SDB at mild to moderate levels in women and has a smaller association than in men with severe SDB - Poor marker of OSA but does predict response to treatment when elevated Lipford et al. 2019 #### Clinical Considerations - ESS is not correlated with Sleep Disordered Breathing (SDB) at mild to moderate levels in women and has a smaller association than in men with severe SDB. - It is a poor marker of OSA but does predict response to treatment when elevated. *(Lipford et al. 2019)* Facets of Bruxism Clinical Signs and Symptoms Is it Bruxism? Is it Awake or Sleep Bruxism? Is it harmless, risk or protective behaviour? Is it primary or secondary? How bad is it? Are there modificable factors? Stress? Am I going to manage this? How? <hr> **Awake bruxism frequency and psychosocial factors in college preparatory students** Mariana Barbosa Câmara Souza DDS, MSC, PTR; Amanda Guimarães Carvalho DDS; Olívia Maria Costa Figueiredo DDS, MSC; Alessandro Bracchi DDS, Ph.D.; Daniele Manfredini DDS, MSC, PHD and Renatta Cunha Matheus Rodrigues Garcia DDS, MSC, PHD *Pracática Dental School, University of Campinas, Piracicaba, Brazil; School of Dentistry, University of Padua, Padua, Italy; School of Dentistry, University of Siena, Siena, Italy* <span style="font-style: italic;">CRANPR® THE JOURNAL OF CRANIOFACIALLY-GROWTH & SLEEP PRACTICE 2021, VOL. 31, NO. 2, 179–184</span> <span style="font-style: italic;">https://doi.org/10.1080/0901671/2020.1829089</span> <span style="border: 1px solid black; padding: 5px;"> <span style="font-weight: bold;">KEYWORDS</span> Bruxism; Bruxage; youth; quality of life; anxiety; stress </span> <span style="border: 1px solid black; padding: 5px;"> <span style="font-weight: bold;">ABSTRACT</span> <span style="font-style: italic;">Objective:</span> To assess the frequency of reported masticatory muscle activity during wakefulness (i.e., awake bruxism [AB]), levels of anxiety, depression, stress, and the oral health–related quality of life (OHRQoL) in college preparatory students. <span style="font-style: italic;">Methods</span>: Sixty-nine college preparatory students participated in the study. AB was evaluated by the Oral Behavioural Checklist (OBC) and a smartphone-based ecological momentary assessment (EMA). Anxiety and depression were measured by the Hospital Anxiety and Depression Scale, stress was evaluated by the Perceived Stress Scale, and OHRQoL was obtained by The Oral Health Impact Profile 14. Data were analyzed by Pearson's correlation coefficient (r < 0.65). <span style="font-style: italic;">Results</span>: The average EMA-reported frequency of AB behaviours was 38.4%. Significant correlations were found between AB and the OBC, anxiety, depression, stress, and OHRQoL (r < 0.05). <span style="font-style: italic;">Conclusion</span>: College preparatory students demonstrated moderate frequency of AB, which was significantly correlated with psychosocial factors. </span> <span style="font-weight: bold;">Introduction</span> Bruxism is a behavior characterized by clenched and/or grinding of teeth, and/or by baring or thrusting of the jaw muscles. According to the most recent international expert consensus, bruxism may have two circadian manifestations: sleep and awake bruxism (AB). AB has a multifaceted etiology, with an interaction of biological and psychosocial factors. Genetics, environment, and lifestyle factors have been associated with increased susceptibility of AB occurrence in different age groups. Literature shows that reports of this behavior may appear in approximately 22-20% of the population, with higher prevalence in younger individuals. Moreover, it is associated with increased increased of pain and reduced quality of life. Some authors have demonstrated high prevalence of TMD signs and symptoms in college preparatory students, which were associated with emotional tension, anxiety, and oral parafunctions. For instance, around 55% of subjects aged between 16 and 19 years have shown at least a clinical diagnosis of TMDs. The college entrance exam is a highly competitive environment and is usually accompanied by social and/or family pressure, being considered an extremely stressful period. Consequently, anxiety, stress, and other emotional disorders are commonly found in this group. Frequent AB may lead to oralofacial pain, which could, cyclically, worsen psychological symptoms. Since it is relevant to assess such factors in this young population, a recent study has introduced the concept of smartphone-based ecological momentary assessment (EMA) to quantify AB frequency. This method has been used in several clinical fields, providing relevant real-time data collection during the day, based on the natural environment of each individual. Thus, such an approach has been successfully proposed for AB assessment. Although previous studies have tried to associate the presence of oral parafunctions with the academic stage (high school, undergraduates, graduates), this correlation between AB frequency and psychological factors has not been described. Therefore, this clinical study aimed to evaluate AB frequency in college preparatory students. <span style="font-weight: bold;">CONTACT</span>: Renatta Cunha Matheus Rodrigues Garcia, <span style="font-family: monospace;">rsp1728 Cardoso</span> — <span style="font-family: monospace;">Department of Prosthodontics and Periodontics</span>. <span style="font-family: monospace;">Pracática Dental School</span>. <span style="font-family: monospace;">University of Campinas</span>. <span style="font-family: monospace;">Brazil</span>. <span style="font-family: monospace;">2020 Taylor & Francis Group, LLC</span> #### Clinical Diagnostic Framework When evaluating the facets of bruxism, clinicians should address the following diagnostic questions: - Is it Bruxism? - Is it Awake or Sleep Bruxism? - Is it harmless, a risk, or a protective behavior? - Is it primary or secondary? - How bad is it? - Are there modifiable factors (e.g., stress)? - Am I going to manage this? - How? #### Research Case Study: Awake Bruxism in College Preparatory Students **Study Overview** - **Objective**: To assess the frequency of reported masticatory muscle activity during wakefulness (awake bruxism [AB]), levels of anxiety, depression, stress, and oral health–related quality of life (OHRQoL) in college preparatory students. - **Methods**: Sixty-nine students participated. AB was evaluated via the Oral Behavioural Checklist (OBC) and smartphone-based ecological momentary assessment (EMA). Psychosocial factors were measured using the Hospital Anxiety and Depression Scale, the Perceived Stress Scale, and the Oral Health Impact Profile 14. - **Results**: The average EMA-reported frequency of AB behaviors was 38.4%. Significant correlations were found between AB and the OBC, anxiety, depression, stress, and OHRQoL. - **Conclusion**: College preparatory students demonstrated a moderate frequency of AB, which was significantly correlated with psychosocial factors. **Introduction to Awake Bruxism (AB)** Bruxism is a behavior characterized by clenching and/or grinding of teeth, and/or by bracing or thrusting of the jaw muscles. It has two circadian manifestations: sleep and awake bruxism. AB has a multifaceted etiology involving biological and psychosocial factors. Genetics, environment, and lifestyle factors contribute to susceptibility across different age groups. Literature suggests a prevalence of approximately 22-30% in the population, with higher rates in younger individuals, often associated with increased pain and reduced quality of life. **Psychosocial Impact on Students** High prevalence of Temporomandibular Disorder (TMD) signs and symptoms has been observed in college preparatory students, linked to emotional tension and anxiety. The competitive nature of college entrance exams, accompanied by social and family pressure, creates an extremely stressful environment. Frequent AB in this group may lead to orofacial pain, which can cyclically worsen psychological symptoms. **Assessment Methodology** Smartphone-based ecological momentary assessment (EMA) has been introduced to quantify AB frequency. This method provides real-time data collection within an individual's natural environment. While previous studies associated oral parafunctions with academic stages, this research specifically highlights the correlation between AB frequency and psychological factors in the college preparatory demographic. | **If managing, consider assessment of Severity of Bruxism: Instrumental and Non-Instrumental Approaches** | | :--- | | - **_Non:_** Self report: time frame and presence | | - Bed partner report | | - Smartphone applications | | - **_Instrumental_** Electromyographic recordings, EMA, Polysomnography, | | **Principles of Management** | | - Referral if indicated | | - Education and Reassurance of patient | | - Discussion of prognosis and expectations (can you “cure” bruxism? Is it a disorder?) | | - Lifestyle and risk/factor stress reduction | | **Proposed Grading** | | 1. **_Possible AB/SB_** based on **_self report_** | | 2. **_Probable AB/SB_** based on positive clinical inspection, with or without a positive **_self report_** | | 3. **_Definite AB/SB_** with positive instrumental assessment, with or without clinical inspection/**_self report_** |  #### Instrumental and Non-Instrumental Approaches If management is required, the severity of bruxism should be assessed using the following methods: - **Non-Instrumental:** - Self-report: evaluating time frame and presence - Bed partner report - Smartphone applications - **Instrumental:** - Electromyographic recordings - Ecological Momentary Assessment (EMA) - Polysomnography #### Principles of Management - Referral if indicated - Education and reassurance of the patient - Discussion of prognosis and expectations (e.g., addressing whether bruxism can be "cured" or if it is classified as a disorder) - Lifestyle modifications and reduction of risk factors/stress #### Proposed Diagnostic Grading 1. **Possible AB/SB**: Based on self-report alone. 2. **Probable AB/SB**: Based on positive clinical inspection, with or without a positive self-report. 3. **Definite AB/SB**: Confirmed with positive instrumental assessment, with or without clinical inspection or self-report. Flowchart illustrating the management and grading of Bruxism. The diagram consists of three main rectangular nodes connected by blue arrows indicating a process flow. The top node is titled 'If managing, consider assessment of Severity of Bruxism: Instrumental and Non-Instrumental Approaches' and lists specific methods such as self-report, bed partner report, smartphone apps, and instrumental recordings (EMG, EMA, Polysomnography). An arrow points from this node to the bottom-left node, labeled 'Principles of Management'. This green box contains a bulleted list of actions including referral, patient education, prognosis discussion, and lifestyle modifications. A second arrow connects the top node to the right-side node, labeled 'Proposed Grading'. This white box outlines a three-step classification system for AB/SB (Awake/Sleep Bruxism), ranging from 'Possible' based on self-report to 'Definite' with positive instrumental assessment. The assessment of bruxism severity is a critical step in determining the necessity and type of clinical intervention. Because bruxism is often considered a behavior rather than a disorder in otherwise healthy individuals, severity is judged based on the presence and extent of clinical consequences. #### Clinical Indicators of Severity - **Dental Damage**: Evaluation of tooth wear (attrition), fractured restorations, or cracked teeth that exceed what is expected for the patient's age. - **Musculoskeletal Symptoms**: Presence of morning jaw muscle stiffness, fatigue, or pain in the masticatory muscles. - **Temporomandibular Joint (TMJ) Status**: Assessment of joint sounds, locking, or pain associated with jaw movement. - **Hypertrophy**: Noticeable enlargement of the masseter or temporal muscles resulting from chronic overactivity. #### Diagnostic Grading System To standardize the assessment, a grading system is utilized to categorize the certainty of the bruxism diagnosis: 1. **Possible Bruxism**: Based solely on self-report via questionnaires or clinical history. 2. **Probable Bruxism**: Based on self-report plus a clinical examination confirming signs such as masseter hypertrophy or specific patterns of tooth wear. 3. **Definite Bruxism**: Based on self-report, clinical examination, and confirmed by instrumental assessment, such as polysomnography (for sleep bruxism) or electromyography (for awake bruxism). #### Impact on Management Severity assessment dictates the transition from observation to active management. While mild, non-symptomatic bruxism may only require monitoring, severe cases involving significant pain or rapid dental destruction necessitate immediate multi-modal intervention strategies. # Management * Education/reassurance * Psychosocial Management * Habit reversal * Ecological momentary assessment * Physiotherapy * Occlusal splint? ## Bruxism * Flat plane * Hard * Light even contacts * Not together with retainers!  #### Management Strategies - Education and reassurance - Psychosocial management - Habit reversal - Ecological momentary assessment - Physiotherapy - Occlusal splinting #### Bruxism Splint Specifications - Flat plane design - Hard material - Light, even contacts - Note: Do not use in conjunction with retainers Clinical photograph showing three transparent occlusal splints labeled A, B, and C arranged on a white surface. The splints demonstrate different designs: A is a flat plane hard splint, B appears to be a hard splint with light even contacts, and C shows a different configuration. In the background are dental models of mandibles and maxillae. The image illustrates the types of splints discussed under 'Occlusal splint?' in the management section for Bruxism. Don’t just “Splint and Split”! Don’t just “Splint and Split”! **Your Splint's Worst Enemy!**   Your Splint's Worst Enemy! Composite figure showing dental anatomy and occlusion. Top panel displays a purple upper dental cast and a beige lower dental cast with visible wear facets on the molars. Bottom panel is an intraoral clinical photograph of a patient's teeth showing anterior crowding and misalignment. Photo collage illustrating a dog chewing on a clear plastic dental splint. The main image shows a small white dog sitting next to a hand holding the splint. A close-up inset on the right shows the dog biting the appliance. Text overlay reads 'Your Splint's Worst Enemy!' and includes social media handles for 'A Spoonful of Oral Medicine'. BruxApp BruxApp Others to consider? • Botox injections • Pharmacotherapy  #### Additional Considerations - Botulinum toxin (Botox) injections - Pharmacotherapy Product shot of Botox (Botulinum Toxin Type A) packaging including a box and vial labeled '100 Units', relevant to the slide topic on treatment options. Double blinded, randomised, placebo-controlled, cross-over study. N=35 Reviewed Bruxism Index (average bruxism events per hour of sleep using surface EMG) of 3 groups injected with BTX-A compared to a placebo group: i) bilateral masseter muscles (60U), ii) bilateral masseter and temporalis muscles (90U), iii) bilateral masseter, temporalis, and medial pterygoid muscles (120U). **Table 1** Baseline participant data | Variables | All participants | Group A | Group B | Group C | |----------------------------------|------------------|---------|---------|---------| | Age years (mean±SD) | 42.1±13.98 | 51.5±11.54 | 39±12.9 | 38.3±14.64 | | Sex (F, M) | 14,8 | 5,1 | 3,4 | 3,6 | | Baseline BI (mean±SD) | 8.29±2.88 | 7.04±2.44 | 10.14±3.71 | 7.69±1.77 | BI, Bruxism Index; F, female; M, male. 2 Crusent AL. BMJ Neurol Open 2022;4:e000328. doi:10.1136/bmjno-2022-000328 **DOI:** **10.1136/bmjno-2022-000328**  #### Clinical Study Overview This double-blinded, randomised, placebo-controlled, cross-over study (N=35) reviewed the Bruxism Index (average bruxism events per hour of sleep using surface EMG) across three groups injected with BTX-A compared to a placebo group: 1. Bilateral masseter muscles (60U) 2. Bilateral masseter and temporalis muscles (90U) 3. Bilateral masseter, temporalis, and medial pterygoid muscles (120U) #### Baseline Participant Data | Variables | All participants | Group A | Group B | Group C | | :--- | :--- | :--- | :--- | :--- | | Age years (mean±SD) | 42.1±13.98 | 51.5±11.54 | 39±12.9 | 38.3±14.64 | | Sex (F, M) | 14, 8 | 5, 1 | 3, 4 | 3, 6 | | Baseline BI (mean±SD) | 8.29±2.88 | 7.04±2.44 | 10.14±3.71 | 7.69±1.77 | *BI: Bruxism Index; F: female; M: male.* Table 1: Baseline participant data. The table presents demographic and baseline clinical characteristics for All participants, Group A (bilateral masseter muscles), Group B (bilateral masseter and temporalis muscles), and Group C (bilateral masseter, temporalis, and medial pterygoid muscles). Rows include Age years (mean±SD), Sex (F, M), and Baseline BI (Bruxism Index mean±SD). **Bruxism Index was significantly lower at 4 weeks after active treatment (compared with placebo) in all groups, but not sustained at 12 weeks.** **Improvement was greater with higher doses of BTX-A injected.** **In summary, BTX-A administered into more muscles (i.e masseter, temporalis, and medial pterygoid muscles) and at a higher dose in subject with higher Bruxism Index at baseline showed the greatest benefit.** **What happens at 3 months?** \begin{center} Open access Original research \\ BMJ Neurology Open \end{center} **Efficacy of botulinum toxin type a in the targeted treatment of sleep bruxism: a double-blind, randomised, placebo-controlled, cross-over study** Belinda Cruse\textsuperscript{1}, Thanuja Dharmadasa\textsuperscript{1,2}, Elise White\textsuperscript{1}, Callum Hollis\textsuperscript{1}, Andrew Evans\textsuperscript{1,2}, Sifat Sharmin\textsuperscript{3},\textcenterdot, Tomas Kalinicik\textsuperscript{1,2}, Lynnette Kiers\textsuperscript{1,2} \begin{tabular}{ll} \textbf{Title:} & Cruse B, Dharmadasa T, White E, et al. Efficacy of botulinum toxin type a in the targeted treatment of sleep bruxism: a double-blind, randomised, placebo-controlled, cross-over study. BMJ Neurology Open \\ \multicolumn{2}{l}{\textbf{ABSTRACT}} \\ \textbf{Background} & Intramuscular injections of botulinum toxin A (BTX-A) have been used in the treatment of sleep bruxism (SB) however controlled trials are limited and the optimal injection strategy and dose is not known. \\ \textbf{Methods} & This double-blind, randomised, placebo-controlled, cross-over study evaluated the efficacy and \\ \end{tabular} \begin{tabular}{l} \textbf{WHAT IS ALREADY KNOWN ON THIS TOPIC} \\ \textbullet{} Botulinum-toxin A (BTX-A) is used in the treatment of sleep bruxism (SB), with varying doses and muscles targeted. \\ \textbullet{} Controlled studies and objective evidence of efficacy is limited. \\ \end{tabular} <!-- Image (774, 586, 989, 838) -->  #### Study Results and Summary - The Bruxism Index was significantly lower at 4 weeks after active treatment compared with placebo in all groups, but this improvement was not sustained at 12 weeks. - Improvement was greater with higher doses of BTX-A injected. - Greatest benefit was observed when BTX-A was administered into more muscles (masseter, temporalis, and medial pterygoid) and at a higher dose in subjects with a higher baseline Bruxism Index. - Question for consideration: What happens at 3 months? #### Research Publication Details **Title:** Efficacy of botulinum toxin type a in the targeted treatment of sleep bruxism: a double-blind, randomised, placebo-controlled, cross-over study. **Authors:** Belinda Cruse, Thanuja Dharmadasa, Elise White, Callum Hollis, Andrew Evans, Sifat Sharmin, Tomas Kalinicik, Lynnette Kiers. **Journal:** BMJ Neurology Open #### Abstract Highlights - **Background:** Intramuscular injections of botulinum toxin A (BTX-A) have been used for sleep bruxism (SB), but controlled trials are limited, and optimal injection strategies/doses are unknown. - **Methods:** This double-blind, randomised, placebo-controlled, cross-over study evaluated efficacy. #### Current Knowledge - Botulinum-toxin A (BTX-A) is used in the treatment of sleep bruxism (SB), with varying doses and muscles targeted. - Controlled studies and objective evidence of efficacy are currently limited. Screenshot of a research article titled 'Efficacy of botulinum toxin type a in the targeted treatment of sleep bruxism: a double-blind, randomised, placebo-controlled, cross-over study' published in BMJ Neurology Open. The visual includes the title, author list (Belinda Cruse et al.), and an abstract section with headings for Background and Methods. ## Further Reading **Ref and Reading:** * Lobbezoo, F., Ahlberg, J., Raphael, K., Wetselaar, P., Glaros, A., Kato, T., Santiago, V., Winocur, E., De Laat, A., De Leeuw, R., Koyano, K., Lavigne, G., Svensson, P. and Manfredini, D., 2018. International consensus on the assessment of bruxism: Report of a work in progress. *Journal of Oral Rehabilitation*, 45(11), pp.837-844. * Manfredini, D., Ahlberg, J., Aarab, G., Bracchi, A., Durham, J., Ettlin, D., Gallo, L., Koutris, M., Wetselaar, P., Svensson, P. and Lobbezoo, F., 2020. Towards a Standardized Tool for the Assessment of Bruxism (STAB)—Overview and general remarks of a multidimensional bruxism evaluation system. *Journal of Oral Rehabilitation*, 47(5), pp.549-556.  #### Recommended Literature - Lobbezoo, F., Ahlberg, J., Raphael, K., Wetselaar, P., Glaros, A., Kato, T., Santiago, V., Winocur, E., De Laat, A., De Leeuw, R., Koyano, K., Lavigne, G., Svensson, P. and Manfredini, D., 2018. International consensus on the assessment of bruxism: Report of a work in progress. *Journal of Oral Rehabilitation*, 45(11), pp.837-844. - Manfredini, D., Ahlberg, J., Aarab, G., Bracchi, A., Durham, J., Ettlin, D., Gallo, L., Koutris, M., Wetselaar, P., Svensson, P. and Lobbezoo, F., 2020. Towards a Standardized Tool for the Assessment of Bruxism (STAB)—Overview and general remarks of a multidimensional bruxism evaluation system. *Journal of Oral Rehabilitation*, 47(5), pp.549-556. QR code: A square matrix barcode (Quick Response Code) intended for scanning to access the digital 'Further Reading' references listed in the text. The code is positioned on the right side of the slide next to the reference list. <img>A video call between a man and a woman, titled "Answering Commonly Asked Questions about Bruxism with Professor Daniele Manfredini," with hashtags #teethgrinding #ASpoonfulofMedicine #bruxism.<img>QR code.   Answering Commonly Asked Questions about Bruxism with Professor Daniele Manfredini. Topics include: - Teeth grinding - Bruxism - A Spoonful of Medicine Screenshot of a video call interface showing two participants. The left panel features a man with glasses in front of bookshelves; the right panel shows a woman wearing headphones and a scarf. OCR context identifies this as a session titled 'Answering Commonly Asked Questions about Bruxism with Professor Daniele Manfredini'. A QR code displayed on the right side of the image, likely linking to the video content mentioned in the title. - Yes. - Not well studied, but appears to have an association with parental grinding - Postulated as an autosomal dominant inheritance   #### Hereditary Patterns and Research - Evidence suggests a genetic component to bruxism. - While not yet extensively studied, there appears to be a significant association with parental grinding. - The condition is currently postulated to follow an autosomal dominant inheritance pattern. Text box containing the question 'Is there a genetic link?' highlighted in yellow background. This is part of a slide discussing parental grinding and its inheritance pattern. Bullet points summarizing research findings on genetic link to parental grinding: 'Yes.', 'Not well studied, but appears to have an association with parental grinding', and 'Postulated as an autosomal dominant inheritance'. Take Home Summary Tooth wear or other single clinical indicators are not pathognomonic for bruxism. Bruxism is common; think bigger picture. Bruxism is not a single entity. Bruxism is not a movement disorder or a sleep disorder in otherwise healthy individuals. Don’t have all the answers. Divergences in data collection and methods underscore the need for further research.       #### Clinical Considerations and Definitions - Tooth wear and other single clinical indicators are not pathognomonic for bruxism. - Bruxism is a common condition that requires looking at the bigger clinical picture. - Bruxism should not be viewed as a single entity. - In otherwise healthy individuals, bruxism is not classified as a movement disorder or a sleep disorder. #### Future Research Needs - Current knowledge is incomplete; divergences in data collection and methodologies underscore the critical need for further research. Header banner containing the text 'Take Home Summary' in a yellow background. Orange summary box stating: 'Tooth wear or other single clinical indicators are not pathognomonic for bruxism'. Orange-brown summary box stating: 'Bruxism is common; think bigger picture'. Brown summary box stating: 'Bruxism is not a single entity'. Darker brown summary box stating: 'Bruxism is not a movement disorder or a sleep disorder in otherwise healthy individuals'. Grey summary box stating: 'Don't have all the answers. Divergences in data collection and methods underscore the need for further research'. <img sign saying "THANK YOU" with a smiley face in the letter O</img> [^1]: Original PDF page 1: [[L36 bruxism dmd 2026.pdf#page=1|L36 bruxism dmd 2026, p.1]] [^2]: Original PDF page 2: [[L36 bruxism dmd 2026.pdf#page=2|L36 bruxism dmd 2026, p.2]] [^3]: Original PDF page 3: [[L36 bruxism dmd 2026.pdf#page=3|L36 bruxism dmd 2026, p.3]] [^4]: Original PDF page 4: [[L36 bruxism dmd 2026.pdf#page=4|L36 bruxism dmd 2026, p.4]] [^5]: Original PDF page 5: [[L36 bruxism dmd 2026.pdf#page=5|L36 bruxism dmd 2026, p.5]] [^6]: Original PDF page 6: [[L36 bruxism dmd 2026.pdf#page=6|L36 bruxism dmd 2026, p.6]] [^7]: Original PDF page 7: [[L36 bruxism dmd 2026.pdf#page=7|L36 bruxism dmd 2026, p.7]] [^8]: Original PDF page 8: [[L36 bruxism dmd 2026.pdf#page=8|L36 bruxism dmd 2026, p.8]] [^9]: Original PDF page 9: [[L36 bruxism dmd 2026.pdf#page=9|L36 bruxism dmd 2026, p.9]] [^10]: Original PDF page 10: [[L36 bruxism 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