Louis Malcmacher, DDS, MAGD, tells the story of a patient with severe bruxism and explains the importance of using a home bruxism/sleep monitor test to determine a patient's bruxism episodes index (BEI).
Let me share with you the tale of a young patient I first met at an American Academy of Facial Esthetics (AAFE) live-patient training course who presented for Botox treatment of her masseters. Her story is very instructive as to a universal challenge that plagues every single dentist on a daily basis.
This patient complained, "I grind my teeth, and my implant is beginning to get loose." The interesting thing about this patient is that she was only 22 years old and already had a dental implant. After a complete dental, head, and neck examination, I found that many of her teeth had restorations, but she had a very low caries index. She reported that many of her restorations were a result of teeth that were chipped or broken and not from "cavities."
She went on to explain why she had the dental implant, and the scenario she described was a common one. Her tooth suffered a fracture when she was approximately 19 years old, and the tooth was restored with a tooth-colored filling. A year later, the tooth and filling broke, and the tooth was restored again. A year later, it broke again, and the patient needed a root canal, post, core, and full crown. Three months later, the patient woke up one morning with no crown or post in her mouth. She returned to the treating dentist, who, for the first time, mentioned that she must have sleep bruxism. As the tooth was nonrestorable, a dental implant was necessary. The dental implant was placed, the patient waited six months, and a crown was fabricated. When it felt as though the crown was coming loose (after she had spent thousands of dollars), she sought out another opinion.
Just looking at this patient, it was obvious she had significant masseter hypertrophy. Using AAFE protocols that we teach, I had her take a STATDDS home bruxism/sleep monitor test and soon found that her bruxism episodes index (BEI) was well over 8.0, indicating that she was a significantly destructive bruxer. We treated her masseter muscles with 20 units of botulinum toxin (Xeomin, STATDDS). Two weeks later, she was tested again and had a BEI of only 0.6. Her bruxism is resolved as long as she maintains this botulinum toxin treatment.
With the new objective data about this patient's bruxism, I was able to properly formulate a treatment plan involving very strong restorative materials that can withstand very high occlusal forces for the time after the patient regains full contraction of her masseter muscles until she returns for botulinum toxin treatment. In this patient's case, based on her BEI numbers, I would use a fracture-resistant universal nanohybrid composite resin, such as G-aenial Sculpt (GC America) or Reflectys (Itena USA) for any restorative treatment necessary. In her case, I had to drill through the crown to unscrew the abutment. I replaced the implant crown with a full monolithic zirconia crown (BruxZir, Glidewell Laboratories) cemented with a temporary cement (DentoTemp, Itena). Should any other full crowns become necessary due to her other large restorations failing, I would use either BruxZir with conventional cementation or e.max (Ivoclar Vivadent) with full resin-bonding cementation. By making these restorative choices based on the objective bruxism data, I can ensure a good long-term prognosis.
It would have been nice if the first treating dentist had an objective bruxism number to use for guidance in treating this patient, but it wasn't available then. With one of three patients suffering from bruxism, and with our capability to obtain specific, evidence-based, and objective data on patients who will allow us to plan treatment properly, it is no wonder that Dr. Gordon Christensen says, "Bruxism monitoring is one of the most important concepts we have today."
This technology is cost-effective, also tests for sleep disorders, and is easy to administer. This testing can help you finally measure bruxism so you can formulate a treatment plan with an excellent long-term prognosis and not have to guess if the patient has bruxism. The AAFE can teach you how to implement this in your office-get trained today!
Louis Malcmacher, DDS, MAGD, is a practicing general dentist, an internationally known lecturer and author, and the president of the AAFE. You can contact him at (800) 952-0521 or e-mail [email protected]. Visit FacialEsthetics.org, where you can find information about live-patient, frontline TMJ/orofacial pain training, Botox and dermal fillers training, dental implant training, frontline bruxism therapy, dental sleep medicine, and medical insurance. You can also download his resource list and sign up for a free monthly e-newsletter.
Disclosure: Dr. Malcmacher is the president of the AAFE and is a consultant for STATDDS.
