A Wider Perspective On Bruxism
Bruxism is the result of a broader disharmony, as also are headache, neck , and teeth pain, and all possible symptoms associated with bruxism. This disharmony covers five main subsystems: the Soft Tissues (skin, subcutaneous), the jaw joint (Temporomandibular Joint , TMJ), the Masticatory Muscles , the Dental Occlusion (how the teeth touch between them) and the neck (Cervical Spine) .
The disharmony generated between these five subsystems have a generic name: Cervico- Cranio- Mandibular Disorders or DCCM, which encompass the neck, the head, and the jaw . These three areas of the body contain the five fundamental subsystems that we have mentioned formerly.
INFORMATION ON CERVICO-CRANIO-MANDIBULAR DISORDERS (DCCM)
Cervico-Cranio-Mandibular Disorders (DCCM) or Masticatory Disorders are a number of disharmonies that affect the normal functions of this system, such as chewing, opening the mouth, eating, speaking, swallowing, and even breathing. The masticatory system consists of several elements: the teeth, the masticatory muscles, soft tissues, and the joint of the mandible with the skull (Temporomandibular Joint or TMJ ) .
It was long thought that CCMD were caused solely by the way the teeth touched each other (dental occlusion). Many treatments were first conceived and directed toward teeth protection with interocclusal appliances (plates) which also sought to relax the masticatory muscles. In parallel, there was a tendency to organize the teeth so all they be able to touch evenly when closing the mouth. This organization was based on orthodontic procedures (movement of teeth with fixed or removable appliances) and/or oral rehabilitation (crowns, bridges, etc.).
Nowadays, we know that the causes of DCCM are MULTIPLE and although the teeth play a very important role, they should be evaluated in a broader health context. We also know that the masticatory system is not isolated from the neck, but forms an inseparable unity with it: the Cervico- Cranio- Mandibular Unit.
The CCMD are precisely functional abnormalities mainly involving the cranio-mandibular complex and the cervical spine. They are characterized by PAIN and DYSFUNCTION in the jaw area, face, skull (head) and cervical spine. PAIN can be spontaneous (it hurts by itself) or caused by moderate palpation of certain structures in these areas. The DYSFUNCTION, meanwhile, is an alteration of the normal function and is closely associated with pain. For example, if a muscle of the face hurts, one will probably have trouble exercising proper function of the masticatory system and would not be able to chew a piece of meat or to open the mouth wide.
The characteristic CCMD pain and dysfunction can occur in the named five basic subsystems of these disorders: the Soft Tissue (ST), the jaw joint or Temporomandibular Joint (TMJ), the Masticatory Muscles (MM), the Dental Occlusion (DO), and the Cervical Spine (CC).
When we talk about CCMD and bruxism is essential to think these five structures as neuro-functional UNITY, i.e., what happens to one of them affects necessarily what happens with the remaining four. Probably, one of them presents the sharpest pain or dysfunction, but this does not mean that the other four subsystems are not affected. That is why an initial deep diagnosis of these structures is essential to indicate, to monitor and to perform a CCMD treatment.
Pain in CCMD Pain in CCMD is usually chronic, extended for a variable period of time. It greatly affects people´s quality of life, beginning with a less effective night’s sleep. This type of pain is described in many different ways: headache (anywhere in the head), migraine, generalized head pain, pain on the sides of the jaw , pain in the TMJ (which may or may not be associated with noise in this joint); toothache (which does not have a justifying dental pathology); sore gums; sinusitis pain type (without sinusitis); pain behind the eyes , pain in various areas of the skull, in the muscles of the face, and varied neck pain. These pains may occur individually or together and its configuration changes over time, depending on multiple and varied factors. Among other distinguishing features, this type of pain sometimes CHANGES OF LOCATION, it moves. This has a neurological justification that is explained to the patient in the first appointment and according to his or her specific case.
Dysfunction in CCMD One of the most common symptoms of dysfunction in cases of CCMD is the noise in the TMJ when opening, closing or moving the jaw. This noise can vary in intensity and in quality. In addition, we may have difficulty chewing, yawning, swallowing saliva and food, kissing, talking and even breathing, if the contraction of the muscles of the area is too intense.
This muscle dysfunction often feels like a vague and constant tension and as a difficulty in opening the mouth or chewing food. Too often, downright mouth opening is decreased . Chewing is altered in quality, since we cannot grind food appropriately. This can cause stomach disorders such as heartburn and a heavy-feeling stomach (difficulty in digesting food). The neck, very often, is tense constantly, or even while doing normal movements.
A. DENTAL OCCLUSION (DO) This term refers to the way the upper and lower teeth “occlude”, i.e., the way they touch each other when we close the jaw. It is important that the teeth are intact, healthy, with correct anatomy and good spatial arrangement (architecture) so that there is a good dental occlusion and food can be properly grinded, facilitating further stomach digestion.
As mentioned above, the DO was long considered as the main cause of CCMD. If a person had a malocclusion, it was considered as the main cause of the problem of chronic pain and dysfunction and of bruxism. Today, the DO is considered a possible cause of the problem or one cause among others. It cannot be studied in isolation , but as one component in a particular universe of multiple and varied relationships between these five subsystems.
A person can have a good occlusion and at the same time, have an acute CCMD; or can have a malocclusion, and not have a CCMD. Although the evaluation of each of the five subsystems is essential, so is to identify the relationship that has been established between these subsystems in each person (individualized diagnosis).
B. MASTICATORY MUSCLES (MM) These muscles are needed in order to move the jaw in all possible directions. They allow grinding, swallowing, breathing and speaking. The muscles of the masticatory system are located in several places: on the sides and under the jaw; on the sides of the head (above and behind the ear) in the area of the temples; in the face; below the mandible and in the anterior part of the neck. Any muscle pain in these areas, either spontaneous or provoked by certain movements or moderate palpation, is a possible symptom of CCMD.
From a clinical standpoint, muscles are one of the most frequently responsible structures for a variety of symptoms of CCMD. It is in the muscles that bruxism is being produced and carried out. For this reason, much of the treatment of DCCM is directed particularly to the Masticatory Muscles and its intimate relationship with the Soft Tissues.
We cannot fail to mention the tongue as muscular component essential in determining the consequences of CCMD. In recent decades, oral bio-cybernetics has defined the functional space of the tongue as the fourth dimension of the mouth, emphasizing the importance of preserving it to ensure proper breathing. This is a particularly broad and complex topic. Suffice it to say here that depending on how the situation of the buccal space is, and its availability for tongue function, it can define, to some degree, the specific symptoms of a particular case of CCMD.
C. SOFT TISSUES (ST) The ST, that is, the skin, subcutaneous, muscle fascia (soft tissue overlying the muscles) and the periosteum (the soft tissue covering the bone), are rich in sensory and autonomic innervation. Nowadays, these structures are considered prone for metabolic congestion due to lack of blood, and also prone to suffer alterations in the removing of metabolic waste material (toxins). In a close relationship with Masticatory Muscles, these tissues are potential sources of pain and can produce all the effects associated with chronic pain that characterizes the CCMD. So considered they must be treated individually and using exclusive techniques. Quite often, a correct diagnosis and appropriate treatment for that diagnosis can determine the outcome of a DCCM treatment.
D. MANDIBLE JOINT (Temporomandibular Joint, TMJ) For muscles be able to move the jaw, we need a joint. The TMJs are located immediately in front of the ears, one on each side. They are formed by the “condyle”, a “ball” of bone, which articulates with a fossa in the skull specially prepared to receive it. You may feel the right and left condyles moving as you put your indicator fingers in front of the ear with a SLIGHT pressure, opening and closing the jaw GENTLY.
On the other hand, in order for the TMJ to move appropriately, a “disk” of fibrocartilage, which functions between the two surfaces of the joint, is needed. This structure resembles, to some extent, to the one we have in the knee and that supports the internal pressure of that joint. When the TMJ is compressed for a long time and/or the ligamentous structure that fixes the fibrocartilage to the bone is permanently distended , the articular “disk” may deform, in the first case, and dislocate, in the second, resulting in a series of sounds that vary greatly from person to person. These are generically referred to as joint “clicks”, and they are a frequent complaint of patients with CCMD. Bruxism is one of the most critical sources of TMJ compression.
Clicks vary widely in their characteristics and in their causal relationships with other structures involved in CCMD. Their presence justifies a diagnostic appointment due to the high instability that may end up generating in the masticatory system. Many clicks are small and do not pose a future danger. In any case, it is very important to analyze how it is the functional environment of the TMJs in order to understand what were the possible causes that generated these joint sounds, and then find an informed solution for them.
E. NECK (Cervical Spine, CC)
The Upper Cervical Spine forms a neurological unit with the structures of the cranium, face and mandible. Anything that happens in the upper cervical spine affects the cranio-mandibular area and everything that happens in the latter area affects , in turn , the former. Initial diagnosis of the CC in terms of pain and dysfunction is essential to monitor the treatment, mainly in regard to symptom relief in the cervical spine and other areas of the spine in general. At the same time, it is essential to know which is the initial state of the CC in case there is need for further interdisciplinary treatment. This is thoroughly explained in the first diagnostic appointment, and in close relationship with the specific CCMD case under study. It is important to mention that the CC cannot be disregarded when making a treatment plan and neither can be during the monitoring of the effects of that treatment.
One of the most common causes of CCMD is bruxism or excessive tooth clenching. Studies in recent years have shown that there is a physiological bruxism that is related to a hormonal stress regulation (see article). Bruxism can happen during the day and, more frequently, overnight. The diurnal bruxism is more subject to consciousness, making it easier to control. Nocturnal bruxism consists of short episodes of intense tooth clenching, which may occur with the mandible in different positions of dental occlusion and may or may not be accompanied by the noise of teeth grinding. If someone has told you that you do not make noise with the teeth during sleep, it does not necessarily mean you are not clenching. During the night teeth can be clenched without making noise. This nocturnal bruxism is completely UNCONSCIOUS, it is not subjected to our voluntary control. On the other hand, daytime bruxism sometimes is performed CONSCIOUSLY and sometimes UNCONSCIOUSLY. It is very important to pay attention to the contraction of the jaw muscles to detect if you are clenching your teeth when you work or when under some kind of emotional pressure. Bringing to consciousness daytime bruxism opens the possibility to start controlling it.
However, when this clenching becomes very intense and repeated, exceeding the impact-absorption capacity of the body, a series of symptoms and signs do become evident. They are considered non-physiological and are responsible for much of the features of CCMD. In this sense, the goal of treatment with respect to bruxism is not to completely stop clenching at night, but stop clenching exaggeratedly, so that no harmful effects on the body occur.
Excessive teeth clenching causes muscle fatigue and then a chronic contraction of the muscles involved in it. This happens with any muscle of the body. For example, if you place a weight on your arms you will feel tired in a few minutes. Later, that fatigue will be transformed into a slight pain that will increase until you stop carrying the weight. If despite the pain you continue carrying that weight you will feel a progressive muscle spasm that will not let you move your arms, and then you will feel an increasingly intense and acute pain. This pain may compromise both the muscles involved in maintaining weight as well as the nearest joint. The same applies to the exaggerated and chronic teeth clenching. If you have any type of bruxism, your chewing muscles will be fatigued, their function will be affected and, in time, you might feel a great pain in that area along with a TMJ due to its repeated compression. Besides that, congestion in the Masticatory Muscles and Soft Tissue will emerge, probably compromising (through biomechanical and neurological pathways) the Cervical Spine as well.
Besides bruxism, there are other jaw movements that do not meet an essential, a vital function for the individual. For instance: repeatedly biting the tongue, cheeks and lips from inside; to move the jaw repeatedly in different directions (forward, backward, to the side); thumb sucking, nail biting, to chew gum, to chew pens, glasses etc. All of these movements that do not play a vital role and whose exercise is detrimental to the system are called parafunctions and should be avoided as much as possible.
Bruxism is also considered a type of parafunction and may cause the following symptoms:
1. Muscle fatigue, preferably in the morning or at night, although it can also occur during the day. This fatigue occurs preferably in the muscles that are on the sides of the jaw or in the temple area. It can also be felt in the neck.
2. Muscle pain on the sides of the jaw, on the temples, behind the eyes, on the neck, on the sides of the head, below the jaw and on the front , the side and/or back of the neck. These pains can vary in intensity, from a feeling of mild discomfort to a sharp pain. Many people refer to these pains as “headache” or “migraine”.
It is common to find people who have had these pains for months or years and who are resigned to live with them. Although not all headaches can be treated by a specialist in CCMD, muscle , joint and soft tissue pain associated with CCMD (which are responsible for a large number of headache complaints) are treatable. These pains can be significantly reduced or may be eliminated.
3. Bruxism is often directly associated with pain and/or fatigue in the back, and in the side of the neck, with the possibility of compromising the shoulder. At the same time, any muscle or joint pain or any muscle contraction in the neck area will facilitate teeth clenching. This does not mean that if you have bruxism you will automatically have a cervical involvement. On the other hand, if you have cervical symptoms does not mean that you, necessarily, have bruxism. However, these situations are frequently associated. In such cases, the joint work of the specialized dentist with a kinesiologist or with a physiatrist, for example, will be crucial for obtaining stable results in the long run. In this sense, the Clinica Loyer offering consists in the Loyer Method combined with Global Postural Reeducation (RPG).
4. Some people feel pain or fatigue in the anterior area of the neck, under the jaw along this a swallowing difficulty. It is very important to know that in a situation like this, your masticatory muscles are already compromised (pain on the sides of the jaw, headache) and that they will not return to normal only with an effort to relax them. Once the muscle contraction is installed, it must be treated by a specialist in CCMD and often with the help of an interdisciplinary team.
The teeth are ready to receive certain types of forces produced during food grinding. When there is an exaggerated BRUXISM or other parafunction, they receive forces that are not normal neither in intensity, nor in direction. This type of abnormal forces can cause the following problems:
1. Excessive tooth wear.
It can cause enamel fracture. The tooth structure that has sensibility is below the enamel and is called dentin. When dentin is exposed to the environment, teeth hurt from eating sour things like lemon or orange and can also hurt with air, with cold and heat. Sometimes teeth can hurt just because they touch the opposing teeth.
Abnormal forces (horizontal) over teeth produce bending of it and generate, by alternating compression and decompression, a fracture of the enamel in the area between the enamel and the beginning of the root, that is , very close to the gum . This loss of enamel seems a cut of an ax in a trunk, a wedge-shaped cut. Besides producing gum recession, this “anfractuosity” can advance much within the tooth structure that can lead to pain and the need for a root canal (endodontics). Very often, these areas are quite sensitive to stimuli that normally would not produce sensitivity (food, cold water, etc.).
3. Problems in the tissue that supports the teeth (periodontium).
Many people who have some kind of DCCM can also develop inflammation of the periodontal ligament, the structure that receives and secures the tooth to the bone. This can be facilitated by excessive strain that this ligament is forced to endure. The pain is felt in the tooth, in the gum area, or in the teeth roots. This pain increases with chewing and tooth clenching. The adjustment of occlusal forces (between the teeth) is one of the key factors, among others, for the recovery of such problems in the periodontium.
5. THE TEMPOROMANDIBULAR JOINT (TMJ )
The TMJ is a rather complex structure. When there is bruxism or other parafunction, this joint receives forces that cannot always endure. That is why a sharp pain can be produced in the area that is immediately in front of the ear canal, in the area of the condyles, which we have described formerly.
This pain is punctual and poignant, as if a tough instrument was entering in the affected area. It makes eating enormously difficult, especially fruit or harder and fibrous foods (meat). Any food that makes the muscles and the TMJ function too much can cause pain when chewing. Sometimes it can hurt to open and close the mouth, and in the most severe cases, the pain is constant.
Besides the joint compressions produced by bruxism and by parafunctions in general, there is a different problem that arises from TMJ excess of mobility. This is known as joint hypermobility and translates clinically as the person opening his mouth too much. This is because, for varies reasons, the ligaments are distended and the elements of the TMJ are not subject to the constraints of normal movement. Joint hypermobility may or may not be painful and at the same time, may or may not be accompanied by a joint noise (clicking) produced by an articular disc that is not properly fixed by its ligaments.
People with TMJ pain may have the following symptoms:
1. Severe pain in the area of the condyles, pain that can be spontaneous, caused by mild or moderate palpation or even by the normal movement of the mandible.
2. Ear ache.
3. Sensation of ear ringing (tinnitus).
5. Headache or pain in muscles of the face and neck.
When the ligaments of the TMJ are distended, either by hypermobility or by parafunction, the articular disc is “loosen” and begins to move differently within the joint. This also happens when the disc is compressed and changes its shape (this can happen with exaggerated bruxism). When this is the case, even without pain, you should consult a dentist specialized in CCMD. Many of these joint disorders can be solved. However, certain types of noise, even if they cannot be completely eliminated, may decrease or be neutralized in its progression.
Depending on how this disc moves when you open or close the mouth, can occur any of the following conditions:
1. Feeling that the jaw is locked or that is going to dislocate.
2. The jaw “leaps” when you open or close the mouth.
3. Sandy feeling within the joint.
4. It might have happened that at some point you remained with your mouth open without being able to close it, or with your mouth closed or semi-close and unable to open it to its fullness.
In any case, you should consult a specialized dentist to assess your case and propose treatment alternatives.
6. COMMON SIGNS AND SYMPTOMS OF CCMD
It is important to know that, in order to understand the symptoms mentioned below and their relation to CCMD, a more specialized knowledge is needed, one that goes beyond the goals of this document. However, the relationship between the symptoms that you can recognize here and how this is explained in your specific, individual case will be evidenced clinically in the first appointment.
If you recognize yourself in some of these symptoms, we recommend you to see a specialist in CCMD. Besides the fact that the masticatory system is very complex from a biomechanical and also from neurological point of view (this explains the great consequences that CCMD can have on other parts of the body), the CCMD treatments that we perform are initially reversible and also, a very important fact, we do not use pharmacology. An early diagnosis can prevent unnecessary treatment with just a first appointment, in which we always perform relieving maneuvers of the most important symptoms.
To the set of signs and symptoms mentioned throughout this writing, we can add:
– Feeling of numbness ears.
– Recurrent external otitis.
– Feeling a light or a heavy head.
– Feeling of tiredness, tension and neck pain, spontaneous or provoked by moderate palpation, or by some functional movement.
– Daytime Sleepiness.
– Eye-burning sensation, dry or excessively watery eyes.
– Increased subcutaneous edema in the peri-ocular region (lower eyelid).
– Swelling in the face, no infection, no pain.
– Sensation of tension in the face.
– Face with a tense aspect.
– Feeling of maxillary sinusitis.
– Feeling of jaw tiredness.
– Teeth touch each other strangely or do not find a resting position
– The teeth vary their touch every day, there is no fixed mandibular position.
– Feeling of stiff tongue.
– Shortness of breath.
– Toothache that does not stop, even after root canal treatment.
– Sore gums associated with an exaggerated dental touching.
– Pain changing locations that might be associated with certain tooth and then do not seem to be associated with that tooth.
Most of these symptoms are due to the involvement of the central and autonomic nervous system in CCMD. The first appointment in Clinica Loyer, even if it does not entail a treatment, it will always be of tremendous help: a tool for knowledge and understanding of the combination of situations that have contributed to the problem, and an excellent guidance for future treatments, even in the purely dental field.