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How to Manage Grinding in Children & Is Grinding a Symptom of Other Problems?

I’d like to sincerely thank Dr. Michael Sigal, Professor in the Faculty of Dentistry at the University of Toronto, who provided a response to two questions that we received following our call for questions in pediatric dentistry. 

Dr. Sigal has kindly agreed to respond to other questions, so please email those to us at oasisdiscussions@cda-adc.ca 

Chiraz Guessaier, CDA Oasis Manager

Questions

  1. My question is about grinding in children. I see a good number of kids that grind their teeth and sometimes their dentition is really worn down. How do we treat this and at what age is a night guard recommended?
  2. Discuss maintenance of the leeway space in the mixed dentition. Effectiveness of nance vs TPA.  Indications. 

 

 

8 comments

  1. While I disagree with much of what Dr Sigal has discussed, especially in regard to the use of the Nance arch, I would suggest that the photo of the dentition that he displayed during the video showed clear signs of acid erosion, likely indicative of GERD. While the youngster may be a bruxer, the level of the erosion on the incisors so close to the gingival margins, with very clear and distinct delineations at the mesial and distal of each incisor, and the enamel pitting on the primary molars, are unlikely a result of bruxing. Mis-identifying acid erosion as a consequence of bruxism is a very common diagnostic error made not just for paediatric patients but for adults as well. GERD is often “silent” with no other obvious signs or symptoms initially with the enamel erosion often being the 1st sign of the condition. GERD can have serious health consequences, not just for the teeth but for soft tissues as well, and has been suggested as a link to some forms of esophageal cancers. A good place to start in terms of learning about GERD is http://www.aboutgerd.org/

  2. For anyone interested in this topic, I encourage you to dedicate a good portion of time to researching/studying nocturnal bruxism (in children, and all ages for that matter) in addition to sleep disordered breathing (SDB). In 2017 we have an incredible ability to be able to learn from research around the world. The relationship between grinding and sleep disordered breathing has been thoroughly investigated and proven around the world, over and over again. We no longer can go by what we learned when we were in school, or in our prior textbooks, as with the amount of incredible research that is being published (especially in this domain) – we know more today than we did yesterday, and will know more tomorrow than we do today. To further elaborate on the topic – we must go back to anatomy and physiology…

    If you recall the stages of sleep, deep sleep (beginning in phase 3 and then into phase 4) – is when the body is completely relaxed, muscle paralysis, and because after 6 months of age, humans have the maturational decent of the epiglottis- thereby the posterior tongue (base) occupies the anterior border/wall of the oropharynx, leaves us susceptible to airway obstruction, compromise and the spectrum of sleep apnea. For those that are at risk for this to occur, the body – caring MOST about the airway to keep us alive, will activate the sympathetic nervous system, to therefore keep the body lightly stimulated and aroused, one of these microarousals is nocturnal bruxism (grinding). If you see or hear someone grinding, you can guarantee they are NOT having good quality sleep, and that the body is on alert in its attempt to maintain an open, patent airway.
    Now this issue becomes very worrisome for children, especially those under the age of 6 years old. Under 6 is when the bulk of neurocognitive development happens, and if our children are consistently not able to achieve deep, quality sleep (which is phase 3 and 4), they will not reach their full genetic potential, they will be chronically overtired, and during the daytime- most children (unlike older teens and adults who may nap and fall asleep), will be hyperactive, agitated and unable to focus/concentrate. There is enough research in this domain to spend an entire year investigating, and again for anyone that is caring for children – I urge you to take the time to really understand the full story. We have the ability to catch this, provide information – and with enough learning and additional education – we do have the ability to improve our patient’s airways, breathing, sleep and overall function.

    The first step however, is realizing that there is more to the story. If anyone has any further questions or ideas, the great part about Oasis is that is promotes discussion and collaboration.

    I am always more than happy to extrapolate on everything I have mentioned. For anyone in Ontario, the tip of the iceberg was published in the March issue of Ontario Dentist – that was dedicated to airway centric dentistry. This is a good starting point, to have an introduction to this topic.

  3. This is a great discussion.

    Paul is right on with his comments about GERD. It is something that gets misdiagnosed all the time. GERD is often part of the spectrum of issues that accompany Sleep Disordered Breathing (SDB). One of the challenges of addressing GERD is getting the MD to do something about it. I’ve found that unless there are frank symptoms they do nothing. On the other hand, there is not much they can do. It ends up being left to the knowledgeable dentist to identify potential SDB problems.

    Alison’s summary of SDB is very good, although there are clinicians and studies that would suggest that the “point of no return” age is around 3 – or even 1/5 years! The line, “There is no such thing as benign snoring in children” is an appropriate one.

    Part of the challenge is diagnosis. Ensuring that a child is a nasal breather isn’t exactly an easy thing to do in more subtle cases. Airway measurements even with CBCT mean little or nothing. First of all, the soft tissues of the airway are variable and dynamic. I have seen absolutely NO data that suggests that you can accurately determine volume in any one patient at two different time points i.e. reproducibility is not there, which makes the static measurements of no value. Second, my “anecdotal” observations having used a CBCT routinely for almost 10 years reinforce the significant variability in the same patient at different time points. Yes, you can identify enlarged lymphoid tissues with a CBCT, but as they say size isn’t everything. I’ve seen plenty of children with enlarged TAs that exhibit no associated signs or symptoms.

    So what do you do? I think the starting point is to ask the question, “Are there signs and symptoms that make you suspect SDB in this child?” In my practice we’ve been doing routine Paediatric Sleep Questionnaire surveys on all new patients and for specific recalls for about 7 or 8 years. I’ve found this to be an excellent starting point. The PSQ has some decent science behind it, and alerts you in situations where you need to look more closely. It is also a wonderful teaching tool for parents – it stimulates awareness, and I can’t tell you the number of times that I’ve heard, “Johnny doesn’t have any of these, but little Suzy who isn’t here today has ALL of these!”

    Further to diagnosis, some of the medical tests and invalid and/or impractical. Noturnal pulse oximetry has been shown in the literature to be invalid except for obese children (who you suspect have an issue already). Polysomnography is the gold standard, but expensive, difficult to administer in non-hospital settings, and resources for administering these are limited at best in our health care system. This is a tough one for physicians. You have to also look at the physician’s perspective – their standard for treatment is surgical removal of TAs. They’re looking for something that can justify doing the surgery in a child, which is not without its own risks. So they’re rather hamstrung.

    Furthermore, TA surgery is NOT necessarily the ideal choice. There are crossover studies that demonstrate that maxillary expansion is more effective, and a summary Pediatrics article which finds that TA surgery has not been as effective as expected.

    In my own practice I’ve pretty much set a protocol. PSQ screening and clinical assessment. Maxillary expansion first level of treatment when there is a problem (I’ll widen a primary dentition into a buccal xbite; doesn’t create negative occlusion consequences later). This alone can be VERY effective and I’ve seen numerous times where we haven’t needed an ENT referral. IF ineffective, then consider ENT referral (or naturopathic approach although I’ve found this to be a bit hi-and-miss). This has proven to be an effective and logical protocol.

    My disagreement with Mike would be around expecting a maxilla to expand with a Nance. I don’t see that. If I need expansion, I make an expander. Any age, even 2 or 3 for the right kids. Easy now with intraoral scanners vs. impressions. Positive, definitive, leaves nothing to chance. These kids, as Alison suggests, need intervention NOW or they don’t catch up.

    Oh, and to close, don’t do serial extractions. In my opinion, EVER. The problem is almost never the size of the teeth, it’s the size of the arches. We can change those if you know good interceptive ortho techniques. But serial xos just diminish the room for the tongue – then you have to wonder if you’re creating OSA now or in the future…?

  4. Lawrence Jones

    I struggle with what Alison Sigal wrote” In 2017 we have an incredible ability to be able to learn from research around the world. The relationship between grinding and sleep disordered breathing has been thoroughly investigated and proven around the world, over and over again.”

    I question that there is very little in the literature regarding SBD and Bruxism that is proven over and over. Sleep Breathing Disorders are extremely complex in both children and adults. Palatal expansion procedures which works successfully in a significant percentage of cases is an intervention procedure unfortunately, that does not work in all bruxung cases. That is also true in adults who have been treated with cpap who have their bruxism activities drop but not for all cpap patients.

    Lastly I question that every child and adult who bruxes their teeth have apnoeic events.

  5. I got sidetracked in the SDB discussion. I believe that Lawrence is correct. While I’ve seen a few situations with SDB where there seems to be a causal relationship with parafunction, I don’t think by any stretch it’s universal.

    In children, as with adults, occlusal disease (let’s set aside the misleading term of TMD for something more all encompassing) is primarily the result of malocclusion. Most typically it’s the avoidance response to posterior interferences, and the occlusions once in a stable centric reveal themselves to be open bites, often with a Class II-ish appearance (whether that be true skeletal or the result of CW rotation of the mandible). For me, in adults as well as children, this seems to be the most prevalent. There are some out there who call these problems such monikers as “biopsychosocial” and the like, but in my experience with thousands of treated TMD cases they truly are biomechanical problems and any of the psychological issues tend to be more the consequence of being in chronic pain and misdiagnosis leading to all sorts of ineffective treatment (incredibly still including valium which I thought went out with the 80s for TMD tx).

    The other wear pattern you’ll see is the “restricted envelope of function” situation – the deep overbite with retroclined upper incisors, wherein they keep crashing into the anterior teeth during normal function and wear them down.

    Back to the kids. In the true excessive wear situation in a healthy child (setting GERD aside for the moment as that has its own diagnosis and treatment challenges, and various other definite medical issues like CP, etc.), what do you do? Personally, if I see no other complicating factors in the primary dentition (no SDB, no pain problems, etc.) then I tend to monitor and observe the situation. I find that parafunction in the primary dentition does not necessarily translate to the same in the mixed and even permanent dentitions. If it’s truly related to a developing malocclusion, there is not a lot you’re going to be able to do about it in the primary dentition anyway. The only things that you can really manage well in the primary dentition are posterior crossbites/ asymmetries and Class IIIs. So if it’s a Class II or camouflaged open bite situation it’s an impetus to start treatment as soon as you can in the mixed dentition.

    There are rare situations where a child will indeed present with TMD symptoms; chronic headaches, etc. Parents have had their eyes tested, sometimes even MRIs to no avail. This is where you have the opportunity to use some of your knowledge from back in dental school. Janet Travel’s seminal work on trigger points decades ago provides you some clues. For example, if they’re complaining about frontal headaches, palpate trapezius. If they jump out of the chair, then you have a spinal-cervical problem. Lay them completely flat on the chair and look at their leg lengths at the heels. Is one leg longer than the other? If so, you have a spinal-cervical problem – the hips are out of alignment, which means the spine is out of alignment. Which means the neck is out, and the head is out, and so is the occlusion. Occlusal disease/parafunction and spinal-cervical issues are a two-way street. One can very much affect the other.

    What do you do in these cases? I’ve found that upper cervical (NUCCA) chiropractic care can be life-changing for some children with these specific issues (more so than physiotherapy). Very non-invasive, gentle, no high-speed manipulations. Sometimes it can be the greatest gift for children – to get them aligned and straight, not compensating – and then they don’t end up as wrecks in adults. NUCCA practitioners are relatively rare but it is an area of chiropractic study and care that is growing because of its effectiveness.

    Even more rare are the one who are refractory to intervention like NUCCA. It might indeed be the result of the malocclusion (the kids with the more temporal headache pattern would be a clue). To test this, I make a soft lower splint (2mm thick) for wear several hours during the day and at night (night alone never works because you reflexively just take whatever it is out – you need the daytime wear). Make sure it’s balance on the posterior with articulating paper and send them away for a week. Check the balance next visit and see if they’re feeling better. If over the course of a few weeks they are, then try cutting back the wear. This goes back to the old trick – if a person has TMD problems, anything you put between their teeth will make them feel better (for a while) because you break up the brain stem-level reflex patterns. Hopefully you can wean the primary dentition child off of it (but if they need it continue night wear) and when the mixed dentition child is feeling better then you can address interceptive treatment of the malocclusion.

    But these symptomatic children are pretty rare. Mixed dentition bruxers with no major malocclusion problems that need interceptive treatment are also few and far between in my experience, but when I’ve seen them I’ve made a maxillary Hawley with an anterior bite plate to wear at night while we await the adult dentition. The premise here is that I’d rather have them wear down the acrylic (which they do!) than their own anteriors.

    As an side, there are some touting these removable plastic appliances in the primary and mixed dentition that the manufacturers claim as being the answer for everything. These are being marketed heavily in many centers right now. For the sake of brevity and staying on topic, these are a marketing scam, ineffective and merely a profit centre for the dentist/orthodontist with less discretion. In my opinion. The counter problem is that PREDICTABLE, EFFECTIVE interceptive orthodontics is becoming a bit of a lost art for a variety of reasons, and sometimes well-meaning dentists want to try to help their patients but have nowhere to turn.

  6. It is great to have this open forum for discussion and sharing of experiences.

    Lawrence, in regards to your comments, I would like to edit and extrapolate on my previous post…
    1) Firstly – I should start by saying that I am a kinesiologist, pediatric dentist, orofacial myofunctional therapist, so my expertise, experience, and dedicated research/world learnings from pediatric gurus in all of the relative and respective fields – is in the care of children from birth onwards. I am very happy to share with you the research and workshops I have created that tell the story with a focus on anatomy, physiology and everything being research based. Connecting all of the dots – but again the support I have is in pediatric health care. (I should also forewarn, that the literature searches are not as straight forward as you would think – requires many different key words, searches, and combinations)

    2) Secondly – I wanted to emphasize that nocturnal bruxism is ONE potential red flag of disordered sleep (during day and night). By no means, would I want anyone to think that this alone is something to make their sole diagnosis on. As we all are aware of – this is a complex diagnosis, and this is one piece of the puzzle. Unfortunately, many people have not been taught that it can be a sign, which is why this forum is great to create awareness. And if this sign is present – to have follow up questions, observations and investigations.

    3) I also did want to reply to your comment “Lastly I question that every child and adult who bruxes their teeth have apnoeic events”. As the sympathetic nervous system is being stimulated to cause the nocturnal bruxism – the child is staying within the light stages of sleep, and therefore is not obstructing. So you are right, there would Not be any hyponeas or apneas. Meaning if you were to see nocturnal bruxism and without any further investigation/questioning, etc, and send them for a sleep study, it could come back with a fairly normal AHI, and this could lead to missing the opportunity to help the patient.

    As such, I wanted to end this post – with more information relating to the examination that we complete on all of our new patients. Each receives what I call an orofacial myofunctional comprehensive assessment – focused on breathing (day and night), sleeping, swallowing, speaking, in addition to oral/dental health. Mark you are absolutely correct in that the earlier that we can educate all of this information the better – which is also why I am a BIG proponent of pre-natal education for the optimization of cranial-facial-respiratory growth, development and function. In addition to the assessment of baby’s – to ensure that all of these functions are optimized. Prevention and optimization. Beyond this, the earlier that we see kids, can identify signs/symptoms – and provide care the better. I loved your statement about when to treat.. NOW!

    To share a few pieces of what I feel should be in new patient exams (especially in pediatrics where we can set up that child for a future of optimized breathing, sleeping, function)… includes:

    1) Breathing – noisy while sleeping, mouth open (more than 5mm has shown to have negative impacts), difficulty breathing through nose, mouth open during day, amongst other questions.

    2) Feeding history/diet – breastfeeding (any difficulties, signs/symptoms of mom and baby), supplemental feeding, any products/devices training the tongue to have a low rest posture (therefore affecting whole CF growth/development), diet – with a focus on if child is utilizing their muscles (or having mainly processed/soft/refined foods). I can share studies and information relating to the need to have our kids be eating hard/semi-fibrous foods for at least 10 minutes a day, bilaterally for optimal symmetrical growth and development of the maxilla and mandible. Unfortunately, we know that 77% of our kids are eating unilaterally – mainly because their diet is soft, by not experiencing muscle fatigue, they are not moving the food to the other side. This as many know, is related to breathing. Mouth breathers will have their diets restricted or with great preference for soft foods (think of when we are sick, and cannot breathe through our noses – go for soups, soft foods, to simply swallow).
    *Many more items here, but I will resist posting an essay

    3) Sleep – This is huge, and needs to be included in every new patient exam. Everything from going to sleep, sleep hygiene (environment, routine prior to bed, avoidance of blue light 2-3 hours before bed, etc. – I can provide further details for anyone interested), During sleep ( restless leg/arms, moving around, heavy breathing, snoring, mouth open, sweaty/damp pajamas, bedwetting, bruxism, drool on bed, nightmares/night terrors (regular), etc.) When awake – dry lips, bed sheets a mess, morning headaches/sore eyes, venous pooling, etc. etc.
    The AAP (American Academy of Pediatrics) recently released new policy statements on the length of time that children should be sleeping for – and it must be quality (in regards to achieving deep sleep phases). Another policy statement was released regarding screen time, and saying that for children (newborns to 2 years of age) – they should have NO screen time – this is related to the blue light (and inverse dose dependent relationship with melatonin, that significantly affects their ability to fall asleep, and achieve deep needed sleep).

    The examination itself (extra and intra-oral) further needs to include assessment of posture, breathing, all the many s/s of chronically-overtired children, resting tongue posture, swallow function (rocker or piston), tongue needs to have a whole section to itself (as we know that a restricted lingual frenum – anterior or posterior, is a phenotype for future OSA in children), palatal dimension – if it is narrow with high palatal vault irregardless of a crossbite being present, this should be expanded – to achieve a wide, flat palate – maximal surface area to which the flipside, is a wide, optimized nasal airway. Myofunctional principles must be utilized- meaning we do not want to block the tongue from resting on the spot (5mm from incisive papilla), so however you perform your expansion, needs to allow for lip seal, tongue up at rest posture, and nasal breathing to be core goals. We must take a step back from the teeth, and look at the overall child, and airway.

    I will stop here – but the above is a drop in the bucket of some points that should be included in a new patient exam, and I hope I have demonstrated that I am in agreement with the above comments that bruxism (nocturnal) is one of the many possible signs/symptoms of sleep disordered breathing that needs to warrant further questions/observations.

    Happy Friday! And again – if there are any questions to what I have posted, I am more than happy to further extrapolate, provide references, or a phone call.

  7. Most of children w SDB – or more accurately Breathing Disordered Sleep – have restrictive lingual frenula/are tongue-tied. Assessing this soon after birth, and releasing the ties, allows the tongue to do its job – pushing the breast repeatedly up into the palate and creating a wide palate and open airway. Supporting breastfeeding also allows for optimal nutrition – breastmilk – vs bottlefeeding (causing narrow arches) of formula (keeps babies alive, but suboptimal nutrition, affecting lifelong health).

  8. Thank you for the opportunity to respond to the above posts.
    IMO. one of the most corrosive forces damaging our Profession is the propagation of dental myths.
    The perpetuation of these myths is truly unfortunate as it places hard working, well intentioned GPs in indefensible positions as they try to best serve their patients.

    Bluntly speaking, I do not believe the literature supports a causal relationship between sleep-disordered breathing and bruxism. Nocturnal bruxism is characterized as episodic in nature; breathing is more continuous in form. If bruxism was critical to a successful breathing event you would expect that patient’s would be grinding their teeth all night long. Not so!
    Secondly, bruxism events occur after an OSA event: not prior to the event. At best, grinding may have an associate relationship but IMO not a causal relationship.
    This posting is intended in no way meant to diminish how important airway management is in young children.

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