There are 2 primary causes of all dental deterioration: bacteria and force. Bacteria cause all those issues that we have traditionally dealt with in the past which include decay, infections and periodontal disease. Force however, is often an under diagnosed reason for dental destruction. Force cannot only cause the physical breakdown of the surfaces of the teeth, but can also serve as an accelerant in the progression of bacteria issues. Force can be “the gasoline on the fire”, if there is already an underlying infection. Clenching and grinding is a very common form of the abusive effects of force on teeth.
Clenching and grinding can take on many different personalities. In some cases patients are rubbing their teeth together by sliding them back and forth. In some cases patients are statically loading their teeth in increasing intensity. The end result essentially is the same: the deterioration of the surfaces of the teeth and the eventual catastrophic loss of teeth. Our goal is to identify those earliest signs of parafunctional activity and mitigate their effects before teeth are lost.
Once a patient has been identified as being at risk for clenching and grinding, it is important to assess the reasons for the activity. The predisposition for clenching and grinding can be boiled down to 2 groups: local and systemic. In local conditions the cause of the grinding may be due to some imbalance in the occlussal scheme of the teeth. A tooth or restoration may be out of alignment or hits in a way that is causing incoordination of the dental system. The solution for this type of parafunction is to identify the tooth or teeth that are causing this disharmony and make the appropriate corrections. These corrections may include the reshaping, the restoration, the repositioning or the removal of those teeth. In some cases, when balance has been re-established to the occlussal scheme, the parafunctional habit will be eliminated.
The second group of clenchers and grinders are those that parafunction, even though significant occlussal imbalances are addressed or eliminated. They will continue to clench or grind no matter what. In these cases, it is important to analyze and manage the complete balance of the occlussal design and then fabricate an appliance to protect the teeth when the patient is susceptible to this activity. The appliance is referred to as an occlussal guard or bruxism appliance.
There are many different types of appliances depending on a patient’s particular situation. Typically the appliances are designed to cover either the upper teeth or the lower teeth, but not both. Some appliances are designed to only to contact on the front teeth, such as the NTI appliance and other deprogrammers. However, there are two key points to remember in the design of appliances. First, any long-term use of an appliance requires full coverage of the entire arch and not just a segment. Second, the appliance needs to be hard and not soft. Soft appliances will often trigger more activity and possibly introduce additional complicating factors such as joint or muscle pain. Patients sometimes will attempt to “self treat” their parafunction by purchasing “over the counter” appliances that are the “boil and bite” type of appliance. The danger is that initially the patient may get a sense of well being, only to be surprised by the resurfacing of symptoms, often intensified, due to the trigger of the home made remedy. The professional fabrication of an appliance requires the proper diagnosis through meticulous analysis and then the fabrication and calibration in the laboratory and chair side by the dentist in an attempt to manage these damaging forces. Compliance with the appliance is essential, and needs to become a part of the patient’s nighttime daily wear.
The final consideration that is increasingly evident in today’s society is the impact of those factors that effect the frequency, intensity and extent of damage of teeth from this habit. Studies have shown that sleep is an important factor to our overall health. The lack of quality sleep may increase the propensity to clench and grind. Dietary considerations for caffeine and alcohol can effect these sleep patterns and reprogram muscle physiology and alter parafunctional habits. Some medications, such as Prozac and Wellbutrin, can increase the likelihood of parafunction. Lastly, certain acid based drinks or foods can potentially soften the surfaces of teeth and in the presence of clenching and grinding, increase significantly the damage from this activity.
Clenching and grinding is a common cause for the breakdown and deterioration of a person’s smile. It is an insidious factor that often causes very little discomfort initially. The thought of addressing this dilemma in the early stages is an inconvenience and expense that none of us find attractive. The reality is however, that failure to manage this sleeping enemy will only result in the continual destruction of teeth and the eventual catastrophic need for even more extensive and expensive dental rehabilitation.
Dr. Scott Finlay is restorative and cosmetic dentist in the Annapolis Area. He is an Accredited member dentist of the American Academy of Cosmetic Dentistry and an Examiner for the American Board of Cosmetic Dentistry. He is also a lead faculty member of the Dawson Academy and teaches dentists across the country and in Europe in postgraduate settings, the management of occlusal disease in relationship to the restoration of anterior teeth. Information about Dr. Finlay and his practice can be found at www.AnnapolisSmiles.com.