jeffrey prall sleep bruxism final

Sleep Bruxism for the Sleep Professional

Jeffrey PrallSenior Sales ConsultantRespiratory [email protected]

Sleep Bruxism

© 2015 CareFusion Corporation or one of its subsidiaries. All rights reserved.

• Sleep Bruxism is no longer considered a parasomnia

• Bruxism is considered to be primarily a sleep related movement disorder with yet to be determined multifactorial etiology involving multisystem physiological processes

Classification of Bruxism


Bruxism can be divided into two distinct entities◦Awake ◦Sleep bruxism


Sleep Bruxism

• Sleep Bruxism is no longer simply related to mechanistic factors such as occlusal discrepancies, or psychological issues such as stress, anxiety or depression

• Sleep Bruxism is considered to be primarily a sleep related movement disorder with a yet to be discerned multifactorial etiology


Sleep Bruxism Definitions (AASM)• 1990 (ICSD) “Sleep Bruxism is a stereotyped

movement disorder characterized by grinding and clenching of the teeth.

• 2005 (ICSD) “Sleep Bruxism is defined as oral para functional activity characterized by tooth grinding or jaw clenching during sleep usually associated with sleep arousals.

• Third Edition (ICSD) “Sleep Bruxism a repetitive jaw muscle activity characterized by clenching and grinding of the teeth and/or by bracing and thrusting of the mandible.”• Sleep related bruxism. In: International classification of sleep disorders. 3rd ed. Darien, IL.: American Academy of Sleep

Medicine; 2014.

http://www.aasmnet.org/library/default.aspx?id=9


Bruxism Classification

• Primary Bruxism• Idiopathic Bruxism (no known cause) • Secondary Bruxism which is related to socio-

psychological or medical condition (movement or sleep disorder including PLMS, rhythmic moving disorders such as head banging, sleep disordered breathing due to upper airway resistance or apnea hypopnea events)


Diagnostic Grading System for Sleep and Wake BruxismPossible – Based on self report using a questionnaire and/or the anamnestic part of clinical exam.Probable – Based on self report plus the inspection report of the clinical examination.Definite – Based on self report, a clinical examination, a polysomnographic recording preferably containing audio/visual recordings or a medical grade sleep bruxism monitor.


Diagnostic Criteria for Sleep Related Bruxism (ICSD third edition)

• Presence of regular or frequent tooth grinding sounds occurring during sleep

• Presence of one or more of the following clinical signs◦ Abnormal tooth wear consistent with above reports of

tooth grinding during sleep◦ Transient morning jaw muscle pain or fatigue; and/or

temporal headache; and/or jaw locking on awakening consistent with the above reports of tooth grinding during sleep


Tooth Wear as a Diagnosis of Sleep Bruxism• Causes of tooth wear

◦ Oral habits◦ Food consistency◦ Acid Reflux

• Occlusal attrition does not reliably confirm sleep bruxism without report of tooth grinding as witnessed by a bed partner.

• Tooth wear is present in 100% of sleep Bruxism patients it also occurred in 40% of asymptomatic individuals.


Scoring Rules for Sleep Bruxism• EMG, 10-100 Hz band-pass filtered, AASM 2007

criteria◦ Bruxism may consist if the chin EMG activities are at least

twice the amplitude of the background EMG.◦ Calculation of Bruxism Episodes Index or BEI calculates all

bruxism events per hour of sleep◦ Types of bruxism episodes: • PHASIC: at least 3 EMG bursts lasting ≥ 0.25 seconds and < 2

seconds • TONIC: 1 EMG burst lasting > 2 seconds • MIXED : phasic and tonic bursts

Note: EMG bursts must not be separated by > 3 seconds to be considered part of the same episode.


Medical Grade Sleep Bruxism Monitor Nox T3 by CareFusion


• Sounds ◦ Teeth grinding and exclusion of other oro-facial activities

by listening. ◦ Additionally autonomic arousals can be marked in the

following manner: • Mark spontaneous arousals if the pulse wave amplitude (PWA)

drops by 30% or more in a 20 second period before Rhythmic Masticatory Muscle Activity (RMMA).

Scoring Rules for Sleep Bruxism


Bruxism Episodes Index - BEI

• Bruxism episode index: number of episodes per hour of sleep (phasic, tonic and mixed)

• Bruxism burst index: number of EMG bursts per hour of sleep

• Apnea to bruxism index: number of episodes per hour of sleep (phasic, tonic and mixed) where apnea is scored after each episode of bruxism.

• Arousal to bruxism index: number of episodes per hour of sleep (phasic, tonic and mixed) where arousal is scored after each episode of bruxism.


Placing the EMG Leads on a patientOption 1


Examples of Nox T3 EMG


Bruxism Report from Nox T3


Stress and Psychological Factors

• Sleep Bruxism cases are more likely to deny the impact of life events because of coping style or personality.

• EMG activity increased during sleep following days with emotional or physical stressors.

• PSG studies report no association between sleep bruxism and anxiety or depression however the link with insomnia exists.


Current Hypotheses• Bruxism-RMMA episodes occur during transient (3-10s)

arousal associated with brain and cardiac activity as shown by a rapid increase in heart rate at the onset of RMMA during frequent micro arousal episodes.

• Micro arousals are natural activities during sleep that consist of a repetitive rise in heart rate, muscle tone and brain activity 8-15 times/hr of sleep.

• Most sleep bruxism episodes are observed during light non REM sleep

• 10% of episodes occur during REM sleep in association with sleep arousal


Role of Respiration in Sleep Bruxism• Respiration in Sleep Bruxism is not well

understood however it may play a role in some patients.

• RMMA tends to occur with large breaths and oral appliances used to improve airway patency help to reduce bruxism-RMMA frequency.

• Direct cause and effect relationship between breathing disorders and sleep bruxism cannot be assumed.


Treatment• Sleep Bruxism can be managed through behavioral

strategies including risk factor avoidance (smoking, alcohol and drugs).

• Patient education, relaxation and sleep hygiene.• Biofeedback aimed at reducing EMG activity in the

temporalis without disrupting sleep shows promise.• Occlusal appliances to remove occlusal interference,

protect dentition and relax masticatory muscles are in routine clinical use however no evidence supports their role in stopping sleep bruxism.◦ 20% of patients report an increase in EMG activity during sleep

when they wear an occlusal appliance especially the soft mouth guard type.


References

• Journal of Canadian Dental Association 2015;81f2◦ http://

www.jcda.ca.php5-9.dfw1-2.websitetestlink.com/article/f2

• Sleep Bruxism Customer Support Document – Nox Medical◦ 22-Sleep Bruxism.pdf

http://www.jcda.ca.php5-9.dfw1-2.websitetestlink.com/article/f2

http://www.jcda.ca.php5-9.dfw1-2.websitetestlink.com/article/f2

Questions

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jeffrey prall sleep bruxism final

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