Bruxism and the Airway – PDP149

Jaz’s Introduction:
It’s underdiagnosed because every time I see a patient, right, and I say to them, ‘Hey, did you know that you’ve got the signs of teeth grinding and clenching? Look at this wear, look at this crack or whatever.’

And they all turn around and say to me, ‘wow, no dentist has ever told me that before.’ So in that regard, we can argue that bruxism is underdiagnosed because dentists are often sharing cases online and suggesting that the etiology of the wear that we see was bruxism.

Whereas when I look at it, I see erosion and I see a restricted envelope or an envelope of function issue and perhaps there’s a little bit of bruxism, but I don’t think that’s the primary reason of the failure. Or even sometimes people say that, ‘oh, this patient keeps chipping away their class four composite or this crown has broken.

I think the patients are bruxist, but really the crown fracture because the patients are bruxist or perhaps there wasn’t enough occlusal reduction, right? So it’s both underdiagnosed as also overdiagnosed, and it’s an area that I love to read about. So I am a bruxist. Okay, confirmed bruxist. And there’s three levels of diagnoses you can make in bruxism, and we cover that in this episode today called Bruxism and the Airway were Dr. Aditi Desai. She also featured, if you remember, on PDP139 on Sleep Disordered Breathing and Sleep Apnea and that kind of stuff. So talking about that, it’s relevance to bruxism and for you, welcome. I just want to share with you my story and how I got into splints and TMD.

It was through bruxism, like I am a massive bruxist and I rely very heavily on my occlusal appliance. Now get this, my occlusal appliance doesn’t stop my bruxism. I still brux. How do I know that? Because I color in my occlusal appliance with a black Sharpie marker time to time again, and the next morning I’ve got a pattern on it, and not only me, but hundreds of patients.

Every time I give a patient an appliance, they’ll always be a mark on it. And I’m going to show you some photos. If you’re watching right now, I’ll show some photos on the screen of all the different types of marks that you see. So does that mean every single patient has been a bruxist? Now it’s all about definitions again, because if you go by the definition that bruxism is any sort of movement of the jaw, any oro-motor movement, for example, if I just wiggle my jaw side to side without my teeth touching, that’s technically bruxism.

Did you know that? Whereas other people claim that bruxism is when you have to have a series of physiological events, your heart rate has to elevate, you have to be in a certain stage of sleep, and then teeth come together and you grind left and right. And so that is a type of bruxism. And so my favorite way to classify bruxism is normal bruxist and patho bruxist.

So one thing I’m going to do is I’m going to put in the show notes. So protrusive.co.ukshownotes for this episode /149. I’m going to put this paper by G Levine, okay, Levine is fantastic and all the literature he posts about bruxism, and I’ve learned a lot from G Levine’s literature and his studies.

So his suggestion of a classification and let’s classify patients as either Norma Bruxist or Patho Bruxist. So what that means is that most of us, all of us, do something called ‘rhythmic masticatory muscle activity’ at nighttime, meaning every night we do a little bit of bruxism, right? A jaw wiggle side side.

Sometimes a teeth are touching, sometimes they’re not, and that’s completely okay. The difference between a Norma Bruxist and a Patho Bruxist, It’s a Patho Bruxist will be doing it at much higher forces, much more muscle recruitment, and they are the ones that are more destructive. So we’ll be talking more about that with Aditi on the show.

The theme of this episode is very much bruxism and the airway. So could the airway be the cause of your patient’s bruxism and why perhaps a bruxist is not best managed with any older occlusal appliance if they have an airway issue. So we’ll talk about screening the airway before you give an occlusal appliance.

Now, if you’re looking for restorative management of bruxist and how to make your dentistry survive in these hostile environments, then this episode doesn’t really cover that. For that, I’d love to welcome you to OBAB, Occlusion Basics and Beyond. We cover this theme. We show you how we did some full mouth rehabs on some bruxist, but as you know, it’s called Occlusion Basics and Beyond.

80% of this course is very much the basics of occlusion, and it’s to make you no longer confused about this big grand topic of occlusion. We break it down, we make it tangible. So if you’re ready to learn occlusion online, head to occlusion.online, and then we talk about, yes, we talk about occlusal appliances, we talk about the restorative management of bruxist, how to identify that and how to build that into your restorations so that your restorations become unchippable.

Hello Protruserati. I’m Jaz Gulati and welcome back to the Protrusive Dental Podcast. Slightly longish intro there, and if you’re watching the video, I’m in a different place. Yet again, I’m in a funny phase of my life at the moment. If you are looking carefully, you can see on my hoodie over here, I’ve got milk, breast milk vomit on my hoodie, right?

So this is the kind of stage I’m in. I’m the most commonly said phrase in my household right now is, ‘Did he burp? Has he burped yet?’ So, as you know, we welcome the baby boy recently. And yeah, things are a bit funny at the moment. I’m not in my usual home. I’m going between Redding and West London, and so things are a little bit crazy and you see the bags under my eyes.

But hey ho, this is the beauty, the magic of parenting. But I will always make time for Protrusive Dental podcasts, don’t you worry. And team Protrusive always hard at work to make content ready for you few week by week.

Protrusive Dental Pearl
And of course, The Protrusive Dental Pearl. The Protrusive Dental Pearl is my Bruxism Screening Sheet, so this is a simple little PDF I made. It’s actually for my splint course online delegates. I’m happy to share it with you, is that one of the things that you can look for in terms of your extra-oral examination and your intra oral examination and the history to give you a clue that this patient might be a bruxist as well as some communication strategies that we’re going to discuss in the main episode today.

The way you can download that, if you head to protrusive.app, make a free account, and then in the episode 149 freemium version, you’ll see it’s there in the pdf. If you’re a Protrusive Premium member, it’ll be there in the Protrusive Vault and in the premium version of the episode, we can get the full CE or CPD certificate by answering a few questions.

So I’ll remind you again at the end of the episode. So download the Protrusive Dental Pearl, which is my Bruxism Screening Sheet. I wrote it myself inspired by all the literature I read about bruxism and the diagnosis of bruxism. And I’ll catch you in the outro. Let’s join the main interview.

Main Episode:
Dr. Aditi Desai, welcome back to Protrusive Dental Podcast. Great to have you after that brilliant episode on Airway, everything Airway, and now a close cousin of Airway. It is Bruxism. So for those who haven’t listened to that episode yet, and they must go back and listen to it, please, Dr. Desai, introduce yourself. What are you doing at the moment? What is your mission statement? And how did you fall into place with Airway? And then bruxism as well.

[Aditi]
Thank you very much for the invitation, Jaz. Real pleasure to be here. So my name is Aditi Desai. I’m president of British Society and the Academy of Dental Sleep Medicine. I’m president of the odontology section of the Royal Society of Medicine, and I’ve just been appointed a fellow of the College of General Dentistry.

So that is what I am. I’ve been practicing dental sleep medicine for about 15 years now, but predominantly my practice is now limited to sleep medicine in the last maybe five to seven years. So my focus is all to do with airway. Cause over the years having provided being a dinosaur, really having provided Michigans and Tanners and all kinds of other appliances, I found myself wondering how effective my treatment was and just delving into it a little bit more.

And then, looking at the other side of the pond with the Americans, I realized actually we may be doing some disservice to our patients by not looking at the airway. Not only from a sort of bruxism point of view or from any other point of view, but just generally. Because my mission is to make sure that we all carry on practicing dentistry in whatever field that inspires and excites us, really, whether implants, orthodontics, whatever.

But whatever you do, do it well. Keep in mind that whatever you may be doing without looking at the airway, you might be doing a disservice not only to the patient but to yourself. Cause you have patients that come back saying, ‘oh, this feeling is broken again’. The implant has failed again. Or the crown is structured again.

And that is what I am trying, my mission is really to get dentists to just open their mind. There has to be that paradigm shift where they have to open their mind and say, when I ask the patient to open their mouth, what is the first thing I see? Are we looking at just the teeth? Are we looking at the palate?

Are we looking at the tongue or are we looking at the gums? But why are we not looking at the airway? Because that is the most important part of everything that we do. And if I can achieve that only, I will thank myself a very successful person.

[Jaz]
I’m loving the conviction, your voice. I love your messages. I love your enthusiasm for it. And you’re a great figurehead to educate the masses in terms of the public and the dentist. Because let’s be honest, we don’t get told much about this at dental school. It’s something that we saw for stumble upon accidentally by just falling to the correct lecture at the right time.

And as we alluded to in the previous episode, some other countries are really accelerated in being clued up about the airway. But I feel as though we have a bit of work to do, to catch up and those around the world. Listen to this podcast. Wherever you are. I think there’s something really valuable to gain and holistic care of the patient at the end of the chair in terms of looking at the airway.

Now, some people may not have understood, like listening to the first few things you said. You mentioned about a failed implant. You mentioned about a crown breaking. So a dentist might be thinking. What has that got anything to the airway? So please explain the link and where that comes from.

[Aditi]
So one of the main things is if you’re not looking at the airway, and I’m not saying that every patient who has a failed implant or a failed restoration has a problem with the sleep. But I think that if you look at a person who keeps coming back with the same problem, unless you deep dive to look and see, well why is this happening? My restorations are well done. But the materials I use are superior quality. I’ve checked the occlusion, it’s fine.

So what is it that they’re doing that I’m not aware of? It could be something they’re doing in the day. It could be something they’re doing at night. Are they clenching? Are they biting their nails? Are they holding a pen? Are they crunching on bone every day? And there are lots of communities in the world that actually thrive on biting on bone and chewing bone.

[Jaz]
African communities that I see. I used to work at Guy’s hospital lots of my colleagues. Yeah.

[Aditi]
And there’s nothing wrong with that. But then whatever we provide to the patient has to withstand all those practices. Now, if you are going to see a patient again and again for the same problem, then you look and say, ‘well, maybe they are grinding, maybe they’re clenching, maybe they’re bruxing. But what does that mean? What does bruxing mean?’

I mean, the word la bruxomania was introduced in 1907 by Lady called Marie Pietkiewicz Excuse my pronunciation of it, but since then it’s been sort of changed into bruxism. But you know that the terminology itself is so broad that it now has to be, it has been reclassified several times now.

So we now sort of divided it into awake bruxism and sleep bruxism. And the etiology is quite different for both of them. And one of the reasons we don’t have sort of exact figures of how many people are bruxing, what is happening when they’re bruxing, what type of bruxing is because people don’t know the difference.

I didn’t know the difference. Until I actually was teaching on the Oxford Masters’s sleep course and I suddenly thought, you know what? I need to do a bit more research on this. And I spoke to a very good friend of mine called Maria Clotilde Carra and if anybody’s interested in this, they should listen to her and read her articles because they’re fantastic.

They explain the whole etiology the presentation of bruxism. And I think, if we are able to distinguish between the two, then we will be able to manage them differently. So awake bruxism is very connected with familiar problems. Stress, anxiety, kids waking you up in the middle of the day.

And stress, I mean, we’ve got the pandemic, we’ve just recently come out of. Now we’ve got this cost of living crisis. Everyone is worried and everyone is concerned and everyone’s bruxing in the day, so that’s fine. And then in at night it’s a completely different phenomenon.

And this link between a person is grinding at night because they are stressed or they’re anxious. That’s just not true anymore. They may do somewhat, but that is not etiology anymore.

[Jaz]
It’s always been Aditi like stress has been the easy thing to blame bruxism on. And it’s been, I mean awake bruxism as I’ve read the same things you have that we feel as though as a community at the moment, that it is to do with, it’s like social stress and people clenching during the day out of that.

But sleep bruxism, there may be an element, but there’s so many other factors involved, which obviously going to allude to now. The problem with studying these factors which I’m sure you’ll get to as well, is Awake Bruxism is based on questionnaires and people are often not aware. And so they’re giving, they don’t know themselves, so how can they actually give you a true representation?

And with sleep bruxism, the best highest quality will be from a sleep study. And that’s very expensive to run. And that’s why as a profession, we really lack these clinical trials. So I’m not saying we’re making it up, but there’s a lot of information, data, we’d still like to collect as a profession. Would you agree with that?

[Aditi]
So, absolutely. So I think with sleep bruxism for example, or bruxing or clenching, okay. So there are three ways in which you can probably identify, or when a patient comes in and says, ‘I think I’m grinding my teeth, or my partner tells me I’m grinding my teeth’, and that is the possible presence of grinding or clenching.

Then the next one is when you look in the mouth, so dentist doesn’t look in the mouth. The patient has no idea. And you look in and you may see facets, wear facets. You may see anything that’s got to do with abfraction’s, whatever, and you look at them and you say, ‘well, you know, I think you’re grinding your teeth. Do you think you’re grinding your teeth? That is a probable diagnosis’.

Now, the third, which is the most comprehensive, is by using an instrument, instrumental diagnosis. That is the use of EMG recordings, polysomnography, which is quite not an invasive, but a very involved procedure. Either you can have it in a hospital or you can have it at home as well.

But we are now trying to look at other ways of making that diagnosis. Cause we have got multi-channel polygraphy, for example, which may have a sensor that you can put on the chin or on the masseters. And that will also give us some idea. And that is the most comprehensive way of diagnosing.

[Jaz]
Hey guys, this is chance interfering here with a lovely testimonial that’ve been sent by one of dentist. Her name is Sabna. So Sabna message as she said that, ‘I just wanted to say that I’m doing your OBAB course at the moment. It’s mind blowing. Never thought I did enjoy occlusion so much. I love the short burst of videos into bite-size pieces where each video builds on the previous video’s knowledge. Amazing stuff. Well done to you both’.

So thank you so much Sabna for going out. We wait to message that kind feedback without even being asked. So I just want to share those kinds with you guys. So if you’re stuck on occlusion, please let us help you head to occlusion.online. Let’s get back to the main episode.

The ones in the hospital, when they do it properly, it’s very sophisticated because they actually have a camera on you as well. So they’re looking at that as well as does it actually coincide with the muscle activity, which is really fascinating.

That’s why that kind of data is you said is the best, but it’s also the most elusive. It’s the most difficult to obtain for all these reasons. But I like that breakdown of a possible probable. And then the definite is only when you use an instrument.

[Aditi]
Yeah, that’s correct. And you know when it’s linked to a sleep disorder example, and if you had a PSG, polysomnography in a hospital, a sleep test in a hospital, then you wide up with EMG and then you have the respiratory sensor, the snoring sensor, you have all, you are wide up top to bottom. And that will also give us an idea whether you are bruxing episodes are linked to you trying to open up that airway. Are they pre or post episodes of apnea? And that’s also very powerful. So we’re trying to establish if there’s a link.

[Jaz]
And with your knowledge in sleep medicine as well. From what I’ve read, most of the bruxism activities happen in non-REM sleep and also in the changes of the phases of sleep.

[Aditi]
Yes.

[Jaz]
In terms of actually making it tangible for the dentist. A dentist, when we have a patient in front of us, the restorative dentist sees the bruxism, all of this stuff is so far from, it’s all literature, but how can we actually help our patient? And the biggest problem that we have in, it’s all fair and well, knowing how to diagnose when you say to a patient, do you think you’re grinding?

And then the patient says no, and then that’s usually the end of the conversation and we just move on and do the BPE. So, the problem is the communication as well. So, if we feel that there are probable bruxist because we’ve seen the wear facets and pleas. If we just cover what other signs we’re looking for.

And then I’d love you to come onto to how do you communicate with patients in a way that’s a not too confrontational, not too accusatory. Because sometimes patients feel like, ‘this dentist is accusing me’. And I’ve had in my earlier years almost like, ‘no, you are grinding’. Like, ‘no, no I’m not. My husband would tell me if I was’, ‘no, no, you definitely are’. And that’s sort of conflict. So please tell us more about that.

[Aditi]
So you need to have a very comprehensive clinical consultation. Now, if you don’t have that, then you’re not going to win anything. You have to be able to correlate things together and make sure, so if you look in the patient’s mouth and you say, ‘ do you grind your teeth?’

They said, ‘no, I don’t think so’. Then that’s it. That’s where you stop. At that point, you then look in the mouth. Look at signs and symptoms of anyone who may have a sleep disorder, breathing disorder. If they have a large tongue, if the tongue is scalloped for example. One of the most significant telltale signs of sleep bruxism is a scalloped because when they’re grinding, it takes the imprint of the lingual and palatal surfaces of the teeth, and that in itself is enough for you to suspect.

We can’t say to the patient, ‘you are definitely grinding’. You just have to communicate it in a gentle way saying, ‘you know what? You may be grinding. Let’s have a look and let’s see whether you may be’, and then you look at the airway. You look at whether they’ve got a abfraction’s that is another very significant indicator.

And you look at the size of the tongue, the scalloping. Are there any Tori, is there anything about the patient that tells you that he may not be sleeping as well? So another question you may want to ask the patient is, ‘ when you sleep, does anybody tell you that you make some odd sounds?’

Because sounds is another very important symptom. It is literally the gnashing and the patient may not be aware and the bed partner doesn’t necessarily always tell the wife or the husband that ‘ you are making sounds’ because they just love a happy life. If you then say to the husband or the wife, do I make any sounds at night?

And the husband say, ‘well, actually yes you do. It doesn’t bother me’. And that’s how we do that deep dive, a gentle deep dive in order to get as much information as possible. And then from there I said to them, ‘okay, well how do you feel when you wake up in the morning? Do you feel refreshed?’

And they say, ‘well, actually I wake up and I’m so tight. I feel so tight here. Or I get a headache here.’ And that is again, another sign. Look at the patient. If they’ve got a very square masseteric profile, then you know that they may be clenching, not necessarily grinding, but clenching. So that is where you end up doing that gentle dive to then say to them, ‘look, you may be, and this may be the reason why you’re feeling tired, unrefreshed’.

And then explain the etiology explain the the problem and tell them what happens when they grind. If you say to the patient, ‘you know what? Do you know that when you grind, sometimes it may be that you’re trying to open up your airway. It may be that you are not breathing as well as you could do. But if you are doing that, you may not be awake, but your brain is getting those micro arousal’.

And explain the micro arousals to them and tell them what the significance of those are. And then that’s when they’re set up and they listen. At that point, when you involve the brain, I mean, this is a great connect between medicine and dentistry. Getting them to connect the dots and say, oh, really? So then you explain what happens, the micro arousals maybe there’s hypoxia, maybe there isn’t any hypoxia, but this whole sort of the burden of a patient, the cardiovascular risks, their neurocognitive risks wake up in the morning feeling unrefreshed.

The lack of drive to do anything. The apathy that may set in, they may not, I mean, you’re never going to win every patient over, by the way, some people will (say). Oh, you’re only doing it because you want to make me a splint because you want to make the money. Trust me. It’s happen to me. It happens to me.

[Jaz]
Yes.

[Aditi]
And you know what? It’s okay. They’re entitled, their feelings and their thoughts, it’s fine, but, If you then are gentle with them and you explain it to them, then let them go away and they will come back. They may not come back to you necessarily, but they may go and seek another second opinion.

And we hope that your colleague that they go to will also have this knowledge where they’ll be able to say, ‘well, actually, you know what? I think we need to do this. Let’s have another look at this.’ And then if a patient, if a dentist is already aware of airway, then he will also connect the dots.

And if a patient has an airway problem and sleep bruxism, you know that the management is different. If, on the other hand, sleep bruxism and awake bruxism are just there, but there are no linked comorbidities. There’s no underlying disease. They’re not on SSRIs, for example, then, it’s not considered a disorder at all. Sleep bruxism and awake bruxism is just a being. You don’t treat it, it just happens. And if you’re making them-

[Jaz]
It’s a behavior. It’s a behavior. And we only classify as pathological if we suffer with the negative consequences of it.

[Aditi]
Yes.

[Jaz]
Which for me, when I was reading the works of Lavine and Manfredini on it, it was really enlightening because it’s almost like a dirty word, bruxism. And it shouldn’t be because it’s just a lot of our patients brux a little bit, some of the studies are read is at three minutes a night, the whole rhythmic masticatory muscle activity. Right.

And so this is normal RMMA. And, but the funny thing, Aditi when I read is that in the studies bruxism diagnosis, a definite bruxism diagnosis is even made if a patient is moving their jaw side to side without the teeth even touching together, that is still bruxism. Which is fascinating.

[Aditi]
But do you know that RMMA as is called in short, is enough to give a patient a very poor night’s sleep? They don’t have to grind and clench their teeth to be awoken. RMMA is probably the cause of a lot of poor sleep quality, really a lot. And in Gilles Levine in Montreal, he’s fantastic. He’s such a wonderful man. He’s so humble. And he said to me the other day, he said,’ look, we all were talking about the airway. The Americans are talking about the airway. We are talking about the airway. You are now beginning to talk about the airway’.

Fine, but it’s when the airway assessment is not taken seriously enough and then you start treating people with your splints. You’re doing them a disservice because by putting a splint in a patient, okay, I’m just going to go back a little bit, okay?

If you have a patient that comes in and you see that they may be clenching, grinding, and you say, you know what, I’m just going to do a make you a splint. What is a splint for? I have patients who come in and say, I was given this splint by my dentist to help me control my bruxing. And I never know whether to say your dentist is not talking sense.

But you have to be politically correct of course. And you have to say to them, okay, well let’s have a look and see whether this splint is doing its job. Now, if it’s linked to a poor airway, then I have to tell them that I’m really sorry, but this may not be helping your situation. If anything, it may be making it slightly worse.

And then look at me and say, why? Because I say to them that this splint was made to protect your teeth and your joint from further damage. It’s not there to help you stop bruxing because you can’t stop bruxing unless it’s linked to a sleep disorder. If you have a sleep disorder, airway, airway problem, and then the patient is bruxing, it’s thought that 40% of people do that because they’re trying to open up that airway. And that’s called that type of sleep bruxism. So if you want to make them a splint, make them a splint, which is protrusive.

[Jaz]
Yes. Mandibular advancement to some degree.

[Aditi]
So that will solve two birds with one stone. You open up that airway. Control their sleep bruxism. And the third one is that, you’re killing the third bird, is that you’re stopping the damage.

[Jaz]
And I’m going to add a fourth one in there, which is you’re helping their sleeping partner because it might help their snoring as well.

[Aditi]
Well, when I’m treating my patients, I always say them, listen. You’ll think that whatever I’m going to do for you is going to be expensive. You give them 50, 100 thousand, doesn’t matter. I said, but remember that I’m treating two for the price of one cause not only am I treating your sleep, but I’m treating your bed partner’s sleep

[Jaz]

I love that so much. I’m going to use that one.

[Aditi]
And honestly, and then I always say, does your wife love me now or does your husband love me? And they said, yeah, he’s in love with you. And I think myself, that’s fine. You can keep him though. And it’s funny, so I tell you, I find it so wonderful when a patient comes in, it’s like when somebody’s had a root canal or they’ve come in with acute pain and you relieve them of the pain and they burst into tears because they’re so relieved.

You know that feeling that you have that. It’s just wonderful. That’s exactly how I feel when patients say, I can’t sleep. I can’t function in the day you treat them and they come back with a, they never come back with chocolates or flowers for me, trust me. I wish they did.

But you know, when they write a really nice review, you think yourself, you’ve done your job, you’ve done your job well.

[Jaz]
Very good now, and I just wanted to add to that, a term I’ve heard is, as you said, the sleep disorder breathing, being a driver for the sleep bruxism and some educators call it, not parafunction, but protective function, because they feel as though that bruxism or the muscle activity in that patient is having a protective mechanism for the body.

The other two protective, or the other protective mechanisms I’m aware of is a theory that actually someone with a reflux disease. That bruxism actually gets more saliva production, which may be helping as well. So those are two main sort of benefits claimed in literature.

[Aditi]
Yeah. So the sort of nomenclature of sleep bruxism in that, it’s quite different. So for the medical community, it used to be a movement, parasomnia or things in when you odd things in the night.

[Jaz]
Sleepless leg syndrome and restless leg syndrome. Yeah.

[Aditi]
Periodically movement, all of that. Then they sort of changed it to a parafunction and now it’s actually now a sleep movement disorder. So it’s sleep bruxism is now a movement disorder. That’s how it’s been classified. And in the terminology of the sort of glossary of prosthodontic terms, we actually term it a parafunction, but it’s not a parafunction. And now therefore what they’ve done, they’ve brought out a standardized terminology. And I’m actually going to read it because it’s quite long and I’m going to just read it for you. It’s easier for me to do that.

[Jaz]
Sure.

[Aditi]
If I can find it, I’ll read it for you.

[Jaz]
While you find that, I’m just going to say a little summary. So far, I think the main take home and tell me if you agree with this. The main take home of our conversation is before you dive into, like okay, we covered some communication tips. And I’m just going to add a few more of those in the intro, outro as well to get the most time from you. We covered that, which is good. We know about diagnosis in terms of management.

A splint may be involved, but you’ll be doing a massive disservice if you don’t screen the airway. I think the biggest take home here is airway, airway, airway, because a lot of our patients who have ‘tempomandibular disorders’ are actually sleep disorder breathing patients, and bruxism is very finely intertwined with that discipline.

[Aditi]
Yeah, absolutely. You’re absolutely right there. So I’m going to read this. So this is the glossary of terms, prosthodontic terms, right? So it says it’s a parafunction grinding of teeth. It is rhythmic or spasmodic. So it’s tonic or phasic and depends on how long that episode is. That’s what determines whether it’s tonic or phasic.

And then in 2013, there was an international consensus that brought it all together, the medics and the dentist where they said that the definition of bruxism as a repetitive muscle masticatory muscle RMMA which is characterized by clenching or grinding of the teeth or bracing or trusting of the mandible, and this is specified as either sleep bruxism or awake bruxism, depending on his circadian. So whether you do it in the day or the night.

Now, the fourth edition of the guidelines of assessment for the American academy of Orofacial Pain and also the International Classification of Sleep Disorder, ICSD three have actually adopted this classification. So it’s now becoming more cohesive as a terminology and we should be doing exactly the same.

It’s not a parafunction, it’s a movement disorder. Now, whether it’s a disorder or whether it is just one of those things that you do, it’s like people bite their nails, they just do it. And yes, it is linked to a class A personalities of course, but you know, so what? People pick their teeth, people grind their teeth and they bite their nails.

It’s just a habit. But when it’s linked to a another disorder, that’s when you have to take it a bit more seriously.

[Jaz]
In terms of this episode, the main three things I wanted to cover in this episode were, diagnosis, and we talked about that in terms of in the research and also in in practice. We talked a little bit about communication to the patient and make sure we’re not accusatory. And I’ve got a few more things to add in that regard. But last thing, management, the key lesson is make sure you don’t neglect the airway. Don’t go straight to your go-to splint in Michigan.

Tanner, the traditional. School thought because there’s a study by Gaignon and also the American, I think Board of Prosthodontics, they actually recommend that if you, before you give an appliance, screen airway first, which I was so happy to see that it’s a real, positive sort of suggestion made by the American Board of Prosthodontics.

What is the next step for a dentist to be able to gain the skills to actually look at the airway, because this is a new field other than going back a few episodes and listening to our episodes in the airway, which is critical, but what is a checklist that you can recommend? What is the next learning point so that our dentist can open their eyes to actually, before I give my stabilization splint, perhaps this patient needs a mandibular advancement to kill four birds with one stone, as we alluded to.

[Aditi]
So I think the only way you can actually learn about the airway is first thing, and this may seem a good point, but it’s actually quite important, is open your mind. You have to have that paradigm shift in your head that tells you that you’re just not just a dentist. You’re not there just to fix teeth and gums.

You’re actually a medical professional. You are dealing with a person’s health. Now, a person’s health doesn’t stop with teeth. It’s the whole thing, right? So that’s the paradigm shift. Number two, do a lot of reading. Just read, just read, pick up a pick pen article. Go into Google, go into any Google scholar, for example, if it’s too much for you.

The other, of course, protocol where I will always promote is a British Society of Dental Sleep Medicine that has their, so foundation course, which gives you a bit of an insight into what your role should be. Now from there, the Academy picks up the British Academy of Dental Sleep Medicine will pick it up and then there will be-

[Jaz]
I just want to add for you, tell us more about the academy. Like if you’re in America, you have a dental sleep medicine board there. If you’re in Australia, you have society there, wherever country you are in. If you are interested in this, which I think we should, we all really should be to take a step back and connect the head to the rest of the body and actually become integrated healthcare professionals.

Take an interest even if it’s just how every year we have a quota of learning on oral cancer and whatnot. Wouldn’t it be amazing if airway was like do at least an hour every couple of years? It would be really, really important. I think that’s your mission Aditi, isn’t it?

[Aditi]
Exactly, that’s exactly what I’ve been working towards for the last 10 years to try and get everyone to listen. And actually, I think, they are listening and yes, you’re right. I was talking about the British Society and the British Academy. I keep forgetting that we are actually talking to a global audience here.

So each one of you, whoever you is listening, will have in your own country will have a board or a society or an academy, whatever they’re called. They all do the same job, right? They’re raising awareness of the role of dentistry in sleep disorders. And I think if you can just get on with them and learn the basics.

There are so many online courses available now, but be a little bit more careful about which one you pick because you want to make sure they’re not industry led. These courses that you want to try and do, they should be free of industry bias.

[Jaz]
And what do you mean by that? Just make it tangible to a young dentist is like, they’re not promoting, they’re not aligned with one type of appliance. And that’s it. You want someone that’s going to give you a good data on, okay, this kind of patient might suit this kind of appliance, this kind of patient might suit that kind of appliance.

[Aditi]
My message has always been one appliance does not fit all. And now that I’m working with the NHS in this country, trying to get these NHS funding for all appliances. It’s been a hard task, but we’ve done it. We’re now going to get funding for NHS for appliances on the nhs, which has never been well funded so far. But, I think we’ve won that race now. So for every one of you, if you want to learn how to get involved, Just get involved with your local societies, and if you don’t have anyone, then find something online and just learn about it. And of course, they can always reach out to any one of us Jaz for the, for us.

[Jaz]
Absolutely.

[Aditi]
To make the connections wherever they are.

[Jaz]
And in the show notes, I’m going to put for the UK, for Australian, US, three main listeners of this podcast. Your main society to get in touch. So if again, if you’re in Australia, reach out us, reach out in UK, please reach out because Aditi is doing so much hard work to, she’s done so much in terms of helping the NHS recognize the role of dentists and wider medicine and the role of dentistry in sleep disorder breathing.

It’d be a real shame not to continue this momentum going. With the new generation of dentists who we’ve fall into a trap of learning Invisalign and composite bonding and stuff. Let’s also look at the airway. Yeah. let’s be a little bit more holistic.

[Aditi]
Absolutely. I mean, you’ve just mentioned Invisalign, right? I mean, I’m not targeting Invisalign cause I don’t want to do that. But with any type of orthodontics, when you try and distalize, distalizing dentistry is the worst thing you can do for a patient. Try not to distalize you. The moment you distalize, you’re actually limiting that oral space.

The moment that all space is limited, you are blocking that airway and that is promoting, and I’ll just very quickly give you one example, which I think is very important. So in the last couple of months I’ve seen two medical legal cases and one of them was he has a class three occlusion. His lower jaw was okay, but his maxilla was underdeveloped.

About 27 year old man. Very, very bright, extreme. He’s a banker. He went off and saw a mix facial surgeon and he said, yeah, I think we’ll just move that upper jaw forward and make you look a bit better. And that’s all it was. He had no problem, no airway problem, nothing at all. He then came in and he saw me and he said, you know, I can’t sleep. I can’t breathe at night. I feel terrible. So I said to myself-

[Jaz]
Wait, this is after his surgery? This is after his maxilla being brought forward. Okay.

[Aditi]
So, well, that is what was going to be done. That’s what he tells me. Now remember, I’m just still in the midst of all this. So I said, okay, well what? Tell me exactly what happened. So he said, well, he went in to see this maxilla facial surgeon who told him his maxilla was underdeveloped. And then he had put him in touch with an orthodontist that he works with. So they did a little bit of orthodontic work. And again, I’m not sure what he did cause I haven’t seen the records yet. But apparently what they’ve done is they didn’t bring the maxilla forward.

They actually distalise the lower jaw, took a little bit off, pinned it all together. He’s got like six or seven screws and plates on each side and he’s made him an apnic. A severe apnic. And now and his bite is all over the place. And when I treated him, I said to him, I said, look, I’m going to treat you as best as I can.

I can’t promise the results, but I’ll do what I can. However, I had to get him to sign a disclaimer that if, when I treat you, if that bite changes somewhat, because I have to be very careful with all the pins and screws, I am not going to be liable. But, cause I don’t want orthodontist then to come back and say, you screwed up my bite.

So we have to now go ahead and keep some very comprehensive clinical records, scans, photographs, everything, everything. It’s, it’s quite a big case. And another case, exactly the same thing. Distalised all his teeth, took teeth out, an adult, took teeth out, straightened all up the lingual orthodontics.

He’s now become sleep apnic, that’s also going to go to court. And it’s happening. You see, the thing is, up to now, I don’t think it was on the actual radar, so nobody was really thinking about it. But it’s actually now in the forefront of everyone’s minds. And I’m trying to work with the indemnity insurer.

In fact, I’ve started working with them to see how we can make dentist take this seriously that distalize if you need to, but be careful about what you’re doing. Be careful about what you’re going to end up with because once you’ve taken those teeth out, there’s no putting them back.

[Jaz]
And like someone who may be on the borderline of an apnea hypopnea index. And then when you distalize everything, you tip ’em over the edge. It’s a bit like that, I guess. So that’s very thought provoking. So thank you for sharing those two examples. Because we can relate to examples.

We relate to these kind of information, so that’s very good of you. Aditi, I’ll put the links to the academy also for Australian, US. Thank you so much for giving us a tour about bruxism management. In terms of make sure, I guess what we can’t do in this episode is really go thoroughly into all the different types of splints and stuff, because that wasn’t the point.

The main message is don’t jump straight to the appliance without considering the airway. That’s the main thing, and there are a few gems in there in terms of diagnostics and communication. So thank you so much for coming on again, and it’s been absolute a pleasure as always.

[Aditi]
Thank you. Thanks very much for having me. Bye.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. If you head to the show notes, I’ll put some links on how can learn more from Dr. Aditi Desai and the airway program that she’s setting up in the UK. And if you’re gaining value from these episodes, please share ’em with a friend and do consider leaving some sort of a review on the App store or wherever you listen to your podcast, gimme some stars, throw some comments.

I love to read them. And so from Team Protrusive, thank you so much once again for listening all the way to the end. And if you can answer a few questions and get some CPD as a Protrusive Premium member, please do head to their web app protrusive.app, or on your Android or iOS.

Thanks so much now, catch you same time, same place, next week.