Sleep Bruxism_Final

Sleep Bruxism
for the Sleep Professional
Randy Clare
Respiratory Diagnostics
2015

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.

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 Bruxism
Possible – 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 patient
Option 1

Option 2

Option 3

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

Sleep Bruxism_Final

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