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Bruxism has been a perennial problem for dentists to treat. Innumerable bruxism guards save the teeth but not the surrounding structures like the muscles or the TMJ. By providing a guard, we dentists do not actually solve the cause of the problem. Hence, most bruxers end up with TMD or other myofascial disorders. Diagnosis is of prime importance in any treatment protocol. And diagnosis should also involve finding all the causes of any problem. Bruxism, too, can be caused due to a few factors; but mainly psychological stress and OSA (Obstructive Sleep Apnoea). Up until lately, bruxism was always seen as a product of psychological stress. And, thus, the widespread use of bruxism splints. Some of these patients recover from the bruxing after successful counselling sessions and sometimes drugs. But most of them dont and due to the ineffective treatment protocol provided, they end up stressed quantifying the problem. Thanks to newer technologies available, bruxism has now been proven to be caused majorly due to airway obstruction pathologies like OSA and UARS (Upper Airway Resistance Syndrome). Bruxism is now shown to be a physiological response to an oxygen desaturation event. Since the tongue position plays a huge role in an airway obstruction and since the tongue is attached to the mandible, the role of the dentist gains importance in treatment of OSA. The common symptoms are morning headaches (muscle hypertonicity caused due to continuous clenching), snoring (tongue hitting the uvula in a negative pressure tube - Bernoulli's principle), disturbed sleep (breakage in sleep pattern-NREM not going into REM), excessive daytime sleepiness (due to lack of quality sleep), generalised lethargy and tiredness, restless leg syndrome, etc. It would be unfair on my side to try and explain the physiology of sleep in a couple of paragraphs. But a dentist treating bruxism should know that if the cause is OSA, then only a sleep appliance would help and not a bruxism splint. OSA is caused due to an obstruction in the airway passage like nasal polyps, deviated nasa septum, bullous conchae, posterior displacement of tongue, large neck circumference (fat deposits on the neck pushing into the airway), etc. Every OSA patient has to be referred to an ENT to confirm all other obstructions are removed or absent. The absolute diagnosis can then be confirmed with a sleep study (home study is more convenient than the polysomnograph-PSG). The sleep study report among other parameters show us the AHI (Apnoea-Hypopnea Index) and the number of Oxygen Desaturation events. In the event of a retruded genioglossus(tongue) during sleep (supine position), the oxygen content in the body reduces and the carbon di oxide increases as the airway gets blocked. This creates an ANS/CNS response wherein the brain virtually tells the tongue to move upward and forward. This ends up as the clench/grind that we term as bruxism. This whole process lasts only less than a second but the forces applied are so massive that the teeth wear away drastically. Hence, every Oxygen Desaturation event ends up in a clench/brux. The sleep report would show the number of Desaturation events. Ideally, it has to be less than 5. What the sleep appliance does is maintain the forward position of the Mandible with support from the maxillary teeth ensuring that the tongue remains forward in the supine sleep position and hence keeping the airway open. This is something that the bruxism splint would not do. However, the sleep appliance will normally be helpful only if the AHI is below 30-35. If more, a CPAP (continuous positive air pressure) is required. This is a ventilator-like device which pushes positive air pressure by a mask through you nose to keep the tongue forward. Some serious cases would need both to keep the airway open. The CPAP is cumbersome and not easy to travel with. Patient non-compliance is another disadvantage with the CPAP. The bite registration technique is the most important protocol in the treatment process. Firstly, we need to recognise the muscle tonicity in these disorders. Hence, a proper bite registration should be performed only after relaxing the muscles with a bilaterally simultaneous anti-dromic pulsing ULF TENS device. Once we confirm the isotonicity of the muscles using a portable EMG device, we follow the ICCMO NM (International College Of Cranio Mandibular Orthopaedics - Neuro Muscular) protocol to register the bite. This bite can then be transferred to an articulator for construction of the sleep appliance. Most chronic bruxers end up with TMD, which will also have to be treated neuromuscularly or else the whole deterioration will cascade into a MPDS (myofascial pain dysfunction syndrome) condition. Recognition of the importance of muscle physiology can only ensure scientific and ethical treatment of OSA and bruxism. Why depend on arbitrary and assumed Mandibular position when you should actually provide precise treatment? The technology is there to measure and prove. Use it. "If it has been measured, its a fact; if it has not been measured, its just an opinion." Thanks Dr. Rajesh Raveendranathan Neuromuscular TMJ/Sleep Consultant Managing Director, Indra Craniofacial Pain Relief India LLP. Admin Off - 63/538B, FA Tower, Kaloor - Kadavanthara Road, Kaloor, Cochin - 682017, Kerala, India Ph - 0484 4050002 HO - 30/9, 80 Feet Road, Indiranagar, Bengaluru - 38, Karnataka, India. M – +91-9061033468


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Mrs. Shani

I used to have constant headaches for nearly 20 years. I've met lots of ENT surgeons and neurologists and have been consuming their medicines until I heard about Dr. Raj's NMD therapy from a friend of mine who got cured by him. I am really thankful to him for freeing me from my aches. I never realized my tiredness during any physical activity could in any way be related to my snoring.

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