Tooth Wear and Bruxism Triad

Question 1

What is tribology and what are three sources in sleep bruxism?

Answer 1

Study of interacting surfaces in motion and associated issues of lubrication, friction, and wear

1. Reduced lubrication (saliva lower at night)
2. Erosive friction (tooth on tooth contact)
3. Contact time (clenching and at swallowing)

Question 2

What are the three categories of respiratory disturbances during sleep?

Answer 2

1. Snoring
2. Upper airway resistance syndrome (UARS)
3. Sleep apnea-hypopnea syndrome

Question 3

What are the STOP BANG items?

What’s the score breakdown?

Answer 3

Ask patient:
Snoring
Tired often?
Observed apnea?
Pressure (high blood pressure)

Objective findings:
BMI (35 kg/m2)
Age (50 years)
Neck circumference (40 cm)
Gender

2 or less is low, 3-4 moderate, and 5+ is high risk for moderate or severe OSA.

Question 4

A sleep burner has how many episodes of bruxing per hour, bruxing bursts/hour, and how many episodes must make noise?

Answer 4

1. 4+ bruxing episodes/hour
2. 25+ Bruxing bursts/hour
3. 1 episode must make noise

Question 5

Apnea is the repeated absence of ___ with cessation of breathing for ___ seconds and oxygen desaturation exceeding __%.

Upper airway resistance syndrome is an increased inspiratory effort creating increased __ and narrowing of the ___ without oxygen desaturation below __%.

Answer 5

1. Ventilation
2. 10 seconds
3. 4%
4. Microarousals
5. Pharynx
6. 4%

Question 6

What are the three components to the Bruxism Triad?

Answer 6

1. Sleep bruxism
2. Sleep disturbance
3. Sleep-related GERD

Question 7

The bruxism triad coupled with nocturnal ___ appreciably increase the risk of __ and __ toothwear.

Answer 7

1. Hypo salivation/xerostomia
2. Erosive
3. Frictional

Question 8

Niswonger stated how many mm is present for closest speaking space?

Answer 8

3

Question 9

Turner/Missirlian Classification
Category 1?

Answer 9

Excessive wear with loss of VDO (with room to restore)

Question 10

Turner/Missirlian Classification
Category 2?

Answer 10

Excessive wear without loss of OVD (with room to restore)

Question 11

Turner/Missirlian Classification
Category 3?

Answer 11

Excessive wear without loss of OVD and without room to restore

Question 12

Turner/Missirlian Classification Cat 2 patients seemingly have insufficient interocclusal restorative space. But why is this not the case?

Answer 12

Manipulation into CR reveals a significant anterior slide from CR to MI. Equilibration or restoration at CR should provide enough restorative room.

Question 13

Turner/Missirlian Classification Cat 3 patients do not have sufficient restorative space. How can space be gained? (4)

Answer 13

1. Orthodontics
2. Restorative repositioning
3. Surgical repositioning of segments
4. Programmed VDO modification

Question 14

Verrett’s 2001: Four types of tooth structure loss

Answer 14

1. Attrition
2. Abrasion
3. Erosion
4. Abfraction

Question 15

Verrett’s 2001: What are the four patterns of mechanical wear?

Answer 15

1. Anterior wear greater than posterior
2. Anterior wear progressively greater than posterior
3. Wear on facial surfaces of cuspids and premolars
4. Variable location and distribution of wear

Question 16

Verrett’s 2001: M1: Anterior wear greater than posterior - Etiology (3)

Answer 16

1. Inadequate posterior wear
2. Posterior occlusal prematurity
3. Loss of posterior teeth (overuse of anteriors)

Question 17

Verrett’s 2001: M2: Progressively greater wear on anteriors - Etiology (1)

Answer 17

Chronic bruxism

Question 18

Verrett’s 2001: M3: Wear on facial surfaces of cuspids and premolars - Etiology?

Answer 18

Toothbrushing

Question 19

Verrett’s 2001: M4: Wear in variable locations, primarily occlusal and incisal - Etiology?

Answer 19

Parafunctional habit

Question 20

Verrett’s 2001: Chemical erosion - 3 types?

Answer 20

1. Anterior surface loss greater than posterior surface loss
2. Posterior surface loss greater than anterior
3. Variable location and distribution of wear

Question 21

Verrett’s 2001: Chem 1: Anterior tooth wear etiology
A. Lingual surface?
B. Facial surface?

Answer 21

A. Chronic regurgitation (vomit, GERD, alcoholism)

B. Fruit sucking

Question 22

Verrett’s 2001: Chem 2: Posterior tooth surface loss
A. Occl surface of all posteriors
B. Occl surface of mand first molar

Answer 22

A. Fruit mulling
B. Soda swishing

Question 23

Verrett’s 2001: Chem 3: Variable location and distribution of wear

Answer 23

A. Environmental
B. Medication, drugs (vitamin C, illicit drugs, saliva)

Question 24

What’s estimated “normal” enamel wear for an adult?

If enamel thickness for an adult is 2 mm, how many years would it take to wear through to dentin?

Answer 24

20-40 microns/year

Therefore, if enamel thickness is 2 mm, it takes 66 years to wear through to dentin (age 72 for the permanent first molar that erupts at age 6)

Question 25

How long are teeth actual in contact during mastication? In total during the entire day?

Answer 25

1. 100 milliseconds 2. 17.5 minutes of contact/day

Question 26

In addition to the three Turner/Missirlian wear classifications, what is the fourth Wiens/Priebe occlusal wear classification? What is the etiology?

Answer 26

4. Excessive posterior wear with excessive OVD 5a. Iatrogenic dental treatment 5b. Result of malocclusion (VME, eruption of posterior teeth associated with chronic respiratory obstruction or apertognathia)

Question 27

What are four ways to measure GERD? Which is the gold standard?

Answer 27

1. Esophagram (pt swallows barium and fluoroscopy) 2. Upper endoscopy (direct visualization) 3. Esophageal manometry (small diameter tube to measure pressure during swallowing) 4. Ambulatory 24-hour pH probe (gold standard) (tube for 24 hours to measure pH levels)

Question 28

How many apnea events for OSA normal, mild, moderate, severe per the Apnea Hypopnea Index?

Answer 28

0 to 4: Normal 5 to 14: Mild 15 to 29 Moderate 30+ Severe

Question 29

How does Epworth Sleepiness Scale work? What are the point breakouts?

Answer 29

Answer how likely to nod off to categories like: Sitting and reading, watching tv, sitting/inactive, as a passenger in a car, lying down to rest, sitting and talking with someone, sitting quietly after a meal, in a car while stopped. 0-7: Unlikely to be abnormally sleepy 8-9: Average daytime sleepiness 10-15: May. be excessively sleepy 16-24: Excessively sleepy and should consider medical attention

Question 30

What Turner Category is your patient? How did you determine this? What did Goldstein say in his Best Evidence Consensus Statement about Turner?

Answer 30

Turner Category 1. Interocclusal distance from rest to closure was about 5 mm, closest speaking space about 3 mm. Both slightly larger than normal. You could argue that she doesn’t have excessive amount of wear yet, but given another decade or so without an occlusal device I believe she would continue to progress. 2. Without knowing what OVD/RVD was before Bruxism, you can't make a determination. Not evidence based.

Question 31

1-2. Difference between awake and sleep bruxism? 3. Sleep bruxism is secondary to what:

Answer 31

1. Awake bruxism: Semi-voluntary. Associated with anxiety/stress. Common in 20% of adult population and 18% of children. More common in females. 2. Sleep bruxism: Involuntary. 8-10% of population. Occurs during REM sleep (Stage 3-4) when micro-arousals occur (Stage 3). 3. Secondary to micro-arousals during stage 3, when there are 3-10 second rises in brain activity, heart rate and muscle tone. Micro-arousals occur 8-15 times an hour.

Question 32

Anything in her medical history increase her risk of bruxism?

Answer 32

Alcoholism (doubles risk), ADHD, depression (SSRI's)

Question 33

What are examples of SSRI's?

Answer 33

Bupropion (Wellbutrin), Fluoxetine (Prozac), Sertraline (Zoloft)