Management of bruxism,lip biting and

masochistic HABITSby:SNEHA SURAPALLI.

Final year BDSPEDODONTIC PRESENTATION

Definition:RAMFJORD(1966):Bruxism is the habitual

grinding of teeth when the individual is not chewing or swallowing.

Rubina(1986):Bruxism is the term used to indicate non-function contact of teeth which may include clenching,gnashing and tapping of teeth

BRUXISM

bruxism

Etiology:• The etiology of bruxomania could be from certain

definite cortical lesions.• A tendency to gnash and grind the teeth has been

seen associated with the feelings of anger and aggression.

• Occlusal discrepancies-Improper interdigitation of teeth may lead to bruxism.

• Mg++ deficiency has been reported as an etiological cause for bruxism and has treated several cases with therapeutic doses.

• Allergies have also been related to noctural bruxism.

• An overenthusiastic student over achievers may also develop the habit.

Management:1. Occlusal adjustment-• This would result in immediate disappearance of habitual

grinding of teeth.• Any prematurities or occlusal interference in restorations

should be able to withstand the forces of bruxism.• Cronoplasty plays an important role in occlusal treatment.• However extensive occlusal adjustments are

contraindicated.• Before any occlusal adjustments are done the muscles

should be brought back to a relaxed position to allow the jaw to resume its normal physiologic movements

2.Occlusal splints: • Vulcantic splints have been recommended to cover

the occlusal surfaces of all the teeth as a treatment for bruxism.

• A reduction in the increase muscle tone is observed with its use.

• In the case of children the use of a soft splint is advisable.

• The splint is made on the mandibular models using dental bioplast material.

• Little adjustment is required in children where intercuspation is less.

OCCLUSAL SPLINTS

THE TMJ APPLIANCE

It is a prefabricated intraoral appliance designed mainly for the treatment of TMJ disorders habits such as bruxism are prevented by the patented aerofoil shaped base and a double mouth guard design

Tmj appliance.

3.Restorative treatment:• If the abrasion is so severe that penetration into

the pulp chamber is imminent,pulpal therapy with full coverage stainless steel crowns is indicated.

4.Psychotherapy:• Counselling the patient can lead to a decrease in

tension and also create a habit awareness.• This may result in an increase in voluntary

control that can lead to reduced tooth para functions.

• Behavioral modality is initiated by the dentist through explanation and arousal of the patient’s awareness of the habit.

5.Relaxation training:• In this technique,the patient is instructed to

tense the muscle group in consideration and relax ,thereby training the patient to relax the muscle group voluntarily.

• Hypnosis,conditioning,etc.,are also indicated for subjects in whom bruxism is due to central cause.

Physical training

RESTORATIVE treatment

6.Physical therapy:• If musculoskeletal pain and stiffness are associated

with bruxism,a brief course of physical therapy is appropriate.

7.Drugs:• Vapo coolants such as ethylchloride for pain within

the TMJ area,local anaesthetic injections directly into the TMJ or into the muscles,tranquilizers,sedatives and muscle relaxants are used

• Placebo may be used to rule out the psychological etiology

• Medications can be prescribed for few days to alter the sleep arousal and anxiety level,eg.,diazepam.

• Low doses of tricyclic antidepressants may be used to inhibit the amount of REM sleep.

8.Biofeedback:• This is a technique that utilizes postive feeback to

enable the patient to learn tension reduction.• It is accomplished by allowing the patient to view

an EMG monitor, while the mandible is postured with a minium of activity.

9.Electrical method:• Electrogalvanic stimulation for muscle relaxation is

currently being utilized for treatment of bruxism.

10.Acupuncture technique for muscle relaxation :• They are under evaluation

11.Orthodontic corrections:• Malocclusions such as classII and classIII

relation,frontal open bite and crossbite when associated with functional malocclusion may create a predisposition to bruxism.

DRUGS

ACUPUNCTUREORTHODONTIC

TREATMENT

LIP BITINGDEFINITION:Lip biting:Habits that involves manipulation of the

lips and peri-oral structures are termed as lip habits.

CLASSIFICATION:Wetting the lip with the tongue.Pulling the lips into the mouth between the

teeth(Schneider,1982)

LIP BITING

ETIOLOGY:1) Malocclusion2) Habits 3) Emotional stress

Management of lip biting:Lip habit is non-self correcting and may become more deleterious with age,because of muscular forces interacting with the child’s grown.Treatment of a lip habits should be directed initially towards the etiology of the habit.

1.CORRECTION OF MALOCCLUSION:• If there is a classII division I malocclusion or an excessive

overjet problem,the abnormal lip activty may be adaptive to the dentoalveolar morphology.

• In such cases it is deemed wise to correct the malocclusion before onto break the habit.

• ClassI malocclusion with increased overjet fixed or removable appliance to tip the teeth back.

• ClassII growth modification procedures to treat the malocclusal.

• If the child has an uncrowded early mixed dentition and activator may be placed in an attempt to reposition the maxilla to the mandible in a favorable position and allow the child to effect a more normal lip seal.

2. Treating the primary habit:• The lip habit along with digit sucking can be corrected by

aligning the dental arch using hawley’s retainer with a labial bow,which can be used to retract the maxillary incisors and an acrylic plate can be used as a habit reminder.

3.Appliance therapy:• Oral shield is also an useful appliance classI malocclusion • It helps to stop the habit and also incisal alignment.

• The additional to a small loop to the labial oral shield improves the lip tonus by helping in lip exercise.

• Performed for 10 minutes , 3times a day.

Lip bumper• A lip bumper may be used as an adjunctive therapy

in both comprehensive and interceptive treatment regimens.

• The lip bumper is positioned in the vestibular of the mandibular arch and serves a prohibit the lip from exerting excessive force on the mandibular incisors and to reposition the lips away from the lingual aspect of the maxillary incisors

• This enables the distal repositioning of the maxillary incisor resulting in a decrease overjet and overbite.

• Either the second deciduous molars are the first permanent molars are banded and the buccal tuber and soldered to them

• The labial screen assembly may be either soldered to the band or crowns or slipped into the buccal tubes.

• The labial shield keeps the wire away from the lower incisor, preventing it from cushioning to the lingual of the maxillary incisor during posture functioning.

• With no labial restraining lip habit, the tongue will then stimulate the lower incisors to move labially,which increases the arch length, reduces crowding and excessive overjet.

LIP BUMPER

Masochistic habits

It is a self-injurious habits are those in which the patient enjoys inflicting damage to himself.It is rare in normal children but is mostly seen in mentally retarted children.(10-20%) and children with psychological abnormalities.

DEFINITION:Receptive acts that result in physical damage to the individual.This habits show an increased incidence in the mentally retarted population.

Etiology:The etiology may either be :-a. Organic:Syndromes and syndrome like maladies such as lesch-nyhan disease and de lang’s syndrome In which symptom such as repetitive lip,finger,tongue,knee and shoulder biting are commonb. Functional:This can be further divided into-• Type A-this are injuries superimposed on a pre-

existing lesion.eg.,a child with a finger nail finger habit is under treatment for a skin lesion.

• Type B:The self-injurious habit may exacerbate the feature existing due to a primary habit.eg.,rotation of the thumb while thumb sucking can harm the soft tissue.

• Type C:They may be injurious of unknown or complex etiology.This type of behavior has a greater psychological component.There may be multiplicity of symptoms of greater intensity.

Management :-They are initiated by=1) Pharmacological 2) Psychological3) Physical restraints4) Palliative treatment5) Mechano therapy

1) Pharmacological method• Most of the existing literature or pharmacological

treatment of SIB has adressed the postulaTed defects in the dopaminergic ,opiate or serotonin system.

• But there are disadvantages to pharmacologic treatment as it usually requires chronic use of drugs and this agents often places patience in a chronic stupor.

2)Psychological treatment• Some children experience a feeling of

neglect,abandonment and loneliness and through the use of self-injurious behavior attempt to solicit attention and love .

• Treatment of self-injurious behavior generally requires a multi-disciplinary approach.

• Care should be taken in dealing with this form of behavior because of the underlying emotional component.

• Continued concerned for the habit may support or reinforce the habit.

3)Physical restraints• Restraint may be reliable means of preventing

injury of the SIB-affected individual,physical restraints include mitten’s,arm,borders,facial masks,helmets and restrictive clothing,but requires constant wear if they are to be successful.

4)Palliative treatment

• Adjunctive therapy in the form of bandages for any oral ulcerations will help in healing of the wound as well as a habit reminder

5)Mechano therapy

• Oral shield will also determine the child from the unconcious continuation of the habit.

• Treatment for self-multilation may also include use of restraints protective padding.

Bobby pin opening• Usually seen in teenage girls where is opening

bobby pin with anterior incisors is done.• Clinically we see notched incisors and partly

denuded labial enamel.• At this age,calling attention to the harmful

habit is generally all that is necessary to stop the habit.

BOBBY PIN OPENING

THANK-YOU