Sleep Bruxism: Myths, Misconceptions and Management Strategies
Video: Sleep Bruxism

Course Author(s): Warden H. Noble, DDS, MS, MSEd

Video: Sleep Bruxism

Ward Noble: Hello, everyone and this is new for me too. So we'll have fun together I hope. Our copy today is going to be sleep bruxism and you'll see, as I get into it, there's a lot more to it, and a lot of different ideas and perhaps you've learned before. But I just want to say a couple of things before I move on. This is not advancing is it?

Speaker 1: That next button should just advance you there, where it says next on the bottom.

Ward Noble: Oh, next. You want me to click on that? Okay. I got it.

Speaker 1: Yep. There you go.

Ward Noble: So I don't know where you are, but I'm so lucky to be in San Francisco as I have to survive this crisis we're going through now. So if I look at my office door right here at my home, this is what I see. And this is actually two days ago. It's just been beautiful here. And if I go for a walk, which I do every day, I walk down through the Presidio, and some of you have been there. And then I can continue around and back up the hill, as you see here. That dome I just showed you, that little dome with the bottom of these stairs, this is actually a street that they turned into the stairs because it's too steep for a street. And then I walked two blocks and then I got back to my house. So it's not all bad. And you know, we're surviving like you are by taking lots of walks and trying to get by.

So back to the basics now. Sleep bruxism has been fraught with lots of problems over the years. And I have to tell you that I went around the country 20 years or so ago or more, talking about bruxism and occlusion. And it's difficult to reflect back on the fact that a lot of what I was talking about then is really no longer true. And so I'm hoping that you can approach this with an open mind and accept the fact that there will be some things that are different than what you've learned.

So we're going to talk about, is tooth wear related to bruxism? What the cause of bruxism is. And then about, are all bruxisms alike? For example, sleep versus awake bruxism, which they are not alike. And also at the end about occlusal splint therapy, does that actually result in less bruxism? And then I'm going to talk about some restorative management philosophies at that point.

So the objectives now are, think of bruxism as a tooth wear problem, not just tooth grinding. That's the whole key to what I'm talking about today. This is a wear problem, not a tooth grinding problem. And if it's a rare problem, then you can look at the causes of the tooth loss, such as acid erosion, corrosion, attrition, bruxism, abrasion, abfraction. And then we can begin to relate that to sleep bruxism, awake bruxism, and then how to manage these problems. So that's where we're headed today. And enough of that, we'll get into some teeth.

To frame this discussion, and I'll tell you now and beat it like a dead horse, I want you to think more globally about bruxism. Because only by thinking more globally, in other words, more regionally or in a larger context than just grinding, can we even relate this to management and control problems. And so, look right quickly at these four different cases I have here. And think for a second, are any of these, in any of these, the main cause of where bruxism, based on your point of view right now. And I'll help you, we'll start with the upper left. And of course, there is some wear on the incisal of these teeth, but no, this is not directly related to bruxism. This problem, and by the way, we're going to look at each of these cases in more detail, is more of a non-carious lesion type problem. A class five cervical erosion/abfraction problem. This other one is bulimia, on the upper right. Lower left is more grinding, as you can see by the facets on those teeth. And finally, the lower right is a combination of all these different processes. So let's look at each one individually.

Let me go back a second here. Here are just a few more to get you thinking about it. Upper left again, is this really just grinding? Well, obviously it's not. Those potholes are related to erosion. The case on the upper right, even though there's extensive tooth wear ... by the way, that's not carious anywhere there, those black areas are hard as can be. This is all acid erosion, but it's wear, and it's not related at all, hardly, to tooth grinding. Lower left, again, possibly to tooth grinding. But all this tooth loss is acid. But yet you might look at that and say, "Oh, that's bruxism." Well, I'm afraid it's not, very much.

And finally, lower right, this also is tooth grinding. And this was the one that is more related to tooth grinding, as you can see the flat surfaces. But then where I have that little red arrow there, you'll notice that there's an upper partial denture, and you don't see this, but it's a free end saddle, there's no tooth support. And so as a patient chews, and he probably doesn't wear it a lot of the time anyway, all his pressures on the front teeth because he doesn't have any posterior occlusal support. And consequently, we are seeing a lot more wear on those teeth.

And so, as I ask you now, what is your concept of tooth wear? And again, you see it's a lot more than you maybe have before. Upper left, you see here again, I mean the left picture again, you see that, yes, on the incised ledges of these lower incisor teeth, where the light's reflecting around there, there are sharp edges. That person has been grinding. But how about the lingual? The teeth never touch the lingual. What about these little potholes that you see, these cupped out areas in the bicuspids where the dentin is exposed? Those teeth never touch in occlusion. How can they have anything to do whatsoever with bruxism? Well, they might ... and we'll talk about that.

And then of course, this was another one over here, most likely a bulimic type patient, but some kind of a gastric acid problem that we will discuss in more detail. But again, you can begin to see that it's not grinding the teeth, do not touch in these areas.

So going back to those cases I showed you in the first place. If this were a case in your practice, whether you're a hygienist or dentist, and the patient didn't like it. She came in complaining about, "Gee, these are ugly teeth." She has kind of a high smile line. She's very, "I am a wealthy patient," and you know the type I think, and has sort of unrealistic goals. Like a giant red flag when she walks in the door. How would you handle this case?

She didn't like the black triangle. She didn't like her long teeth. Receded gums. So, what would you do? Would you put veneers on here maybe? Well, they'd close the spaces perhaps, but they'd be long, ugly teeth still, and probably white and discolored badly. I mean, ugly veneers. And then secondly, you can put composites up there, but it wouldn't really solve her problems. So, what would you do? And I'll show you what we did just to get thinking a little differently.

So as you can see on the upper right picture, we decided to do a repositioned palatal graft where we would simply move the tissues from where they are right now, and like a curtain, take and pull the whole curtain down and cover the cervical areas and consequently solve the problem. So, this is a free gingival graft off the pallet. You can see the flap is tucked in under the lip up there on the upper right picture. And then that's placed, the tissues are simply brought down and over and sutured. And so on the lower right, you see, we solved the problem of this possible bruxism problem, by only having you do two composites. You see on the two cuspids there, I replaced two composites, class five composites, and that's all I had to do to solve her problem. She was a very happy camper. So you see, again, I'm just trying to look at these things a little differently.

The second one I showed you, if you remember there, was a bulimia case, and this is a very sad case to me. This is a young girl who in 2007 had finished her orthodontics, as you can see here. And she had no wear on her teeth. And in 2015, she looked like this and pictures that I just showed you. Well, the really horrifying part of this is that, she had her teeth cleaned by probably a couple different dentists or a couple offices at any rate, every six months during this period. So how in the world could those healthcare practitioners go through all those treatments and never do anything about it? But worse than that, never make a diagnosis. But bulimia's the problem, they're in denial.

What bulimia is by the way, in case you don't know, it is vomiting. And so, they eat and then they gag themselves, so they vomit back up to food for obesity-type image problems. But these patients are usually in denial, even to themselves about their problem, to their parents and to their health practitioner. So, my point here is again, by thinking more globally about this, it gives us an opportunity to increase our awareness about how to take care of these patients.

Now, the other one I showed you in the lower left corner of that previous slide, was one that really is grinding. When you see, like you see in the upper left image and the lower image right below it there on the left side, this type of sharp edges, defined areas, they are definitely grinding on this, by definition is not bruxism, if you eliminate your bruxism definition to tooth-to-tooth grinding. It is tooth-to-tooth, but the wear is caused by the opposing crowns. And you see on top, there's a lot of wear on these crowns, which in turn, a lot of adjustment on these porcelain crowns and the rough surface wears the teeth.

Now, the dynamics here, if you look at the lower left image where I put that yellow bar, the dynamic is that as the teeth erode, they don't just get shorter. They get shorter physically, but the whole jawbone and the whole alveolus extrudes upward, and this creates a problem restoratively. And what we have to often do in these cases, as you see on the right hand side, is actually do a full mouth reconstruction, open the vertical dimension to achieve restorative space. Not because the patient's over closed, but to achieve restorative space and restore the case. But again, this is more of a case of real bruxism.

So again, just to summarize these. Again, maybe now you changed your concept of bruxism. And what did all these cases have in common? So I'm hoping I'm beginning to paint the picture now that dental wear is an acid disease. It's not grinding alone, but this whole area of bruxism and wear is an acid disease. And if you think in these terms, then we can think about management strategies. Now we can think about, well, what can we do to change the environment? What can we do to protect the tooth surface itself from an acid attack, which is going to soften it and relate more erosion? So that's where I'm going now with our conversation to a large extent.

And I hope you get this, but look what happens when you cut down too many trees? What I'm saying here is, look what happens when you focus only on grinding and not the rest. And the dogs all use the same tree. So, I think that will help you understand where I'm headed with this whole thing. This is weird by the way, trying to talk to my silly computer and not see if people are smiling and grinning or laughing or something. So bear with me on the whole thing.

Anyway, if you can think now in terms of dental wear involving attrition, and that would relate to bruxism. Abrasion, and that relates to grinding as well. And acid erosion. And actually the correct name for acid erosion is corrosion. That's the chemical process that it goes through. But the dental community has endorsed acid erosion, and it fits in better with our whole therapies in terms of treatment, and that's why we're going to use the word here.

But, wear mechanisms involve, first of all, chemical softening of the surfaces. In other words, the enamel and dentin, by acids, by dietary acids and intrinsic acids. Intrinsic acids are the ones that come from your stomach, like a gastric reflux or vomitus. As opposed to the dietary acids that come from some of the foods that you eat and all your soft drinks and things like that. We'll talk about that.

And they also, the other mechanism, is mechanical. And that relates to tooth surface loss, TSL, relating it to attrition, abrasion, bruxing and abfraction. And those things you know about. And then finally there is a tooth surface loss related to behavioral problems that we'll talk about, related to tapping, nail biting, various things like that. And that also is going to cause problems.

So there are two distinct processes here. First is acid erosion, which involves some actual disillusion of the tooth surface. In other words, with an animal for example, if you have acid in your mouth, the lower pH actually demineralizes, just like carious, it's the same chemical process as carious in a way, except we'll talk about the source of the acid in the second. But, the teeth are softened first. Some actually, the calcium goes out of the tooth, demineralizes into the saliva and is gone. And that is related in this lower left picture here. If you look at the green arrow there, that's where the tooth is normally. Then there's a void in the tooth surface where it actually dissolved. And then beneath that there's a softened layer, and this is related to a softening. And you see that in the B diagram there with the purple arrow. And that relieves these little pieces of enamel that are softened and demilitarized. And that's how the wear occurs.

Every time even your tongue, or eating abrasive food, passes over, there's certainly toothbrushing, certainly grinding, it rubs those little demineralized enamel rods away, and I'll show you more about it, micron by micron over time. And this is the process by which the tooth surface loss occurs. So to continue to explain this, between attrition and bruxing we'll call it, and wear, the upper left picture here shows the patient with their jaw in lateral movement. In other words, they drop their jaw way, and the lower [inaudible] along these angles. So this is going to wear. And in the presence of acid, these softened areas like I just showed you, will be rubbed off at a much faster rate.

But if you look at the patient now in maximum intercuspation, in other words, where they're fully closed, you get a little more complete picture. And that is, where the arrows are, you notice that under there, yes, there's some wear. But there's also some cupping and additional tooth loss, especially in the dentin, from the acid. And so that's why I have to paint this different type of picture for you to get a context of the whole thing.

Now despite what you learned, in the absence of acid, when there is no acid, you can grind your teeth and grind your teeth for the most part under normal conditions, and you don't get wear. What I'm telling you now, is that no acid, minimal wear. Little, if any, wear. However, once the teeth are softened by any kind of acid attack, then the wear goes up substantially, up to a certain point. So if you look at the left side of this diagram in this study, under normal loads, the gray bar versus a striped bar is when you have acid, as opposed to saliva in the other one. So you see there's a lot more wear. And, the left side really represents more normal chewing loads. When you get heavier loads, it still is much worse, twice as much as you can see here with the acid, but obviously if you load your teeth more and put more force on them, you're going to get more wear.

Under very heavy loads, and these are artificial conditions done in a laboratory. Actually done by bioscientists, not even dentists in this case, you now get the heavy forces actually override other factors and you do get wear. But you actually never, almost never, maybe with some awake bruxism, do you ever load your teeth to the extent that it's showing in that last graph. But I'm doing this just to make a really important point about the fact that without acid, you don't have wear.

But it is multifactorial, and this was a case in my office, way back in, my gosh, 30 years ago now. I can't believe it. And you see, this is when we started doing ... these are all PFMs obviously, but patients at that time felt that the silver material on PFMs might be just cheaper materials. Some of them still demanded gold on these things, but the gold they use to bond the porcelain to was very soft and consequently it wore. And indeed this was mechanical wear against this adjusted lower bicuspid against the upper bi there. But if you look at the teeth right next to it on the lower, it's related to the wear from the upper, actually porcelain crowns that have been adjusted and left rough, and erosion. So again, it's a multifactorial case. There's a lot more going on.

Toothbrush abrasion is another real big cause of wear. We can talk about this a lot and don't have time. But the interesting thing here is that the toothbrush itself doesn't affect the wear, it's the toothpaste or any kind of abrasive material between the teeth. And as long as you're using toothpastes that are within the ADA recommended value for the abrasiveness, these are safe for a lifetime with brushing and all the main commercial toothpastes on the market are safe in that extent. If you get to the whitening toothpastes, if you get to some of the natural food type toothpaste, and I won't name names, some of those are more abrasive because you can't take off stains very well without having some abrasive particles in there. And you can't really achieve what some of these whitening pastes like to achieve.

Again, be careful with those. The other thing is that you should not use a stiff brush. But a stiffer brush versus a soft brush does not cause more wear, believe it or not. It causes more gum recession and it's very bad to use a stiff brush. But when you have more gum recession, you expose more root surface, and that is softer because of the cement of indention and it's more likely to wear. So, you see, there are many wear interactions that are going on in the mouth sort of simultaneously.

Now, this is an important concept I'm just introducing too ... and that is that nothing happens on the tooth until it happens in the saliva. This is sort of true for ... Not sort of true. It's very true for caries and certainly for the erosive process. Let's say you drink a Coke or some type of acidic drink. At that point, the pH, the acid level immediately drops in your saliva. Then you all know about the acquired pellicle or the biofilm on the teeth. It's called plaque as well, but the teeth are covered ... even the smooth surfaces by a pellicle or biofilm. Then the acid has to permeate through that before it even gets to the tooth surface. When you look at a lot of this research, they'll take a tooth and put it in Coke, for example ... and drop my tooth in some acidic solution, it'll dissolve. That's not quite what happens in the mouth. There are many other processes, including the effect of saliva, which becomes very, very important as we'll talk about.

It's the most important biologic factor with erosive tooth wear. I think most of you are aware of this, but the saliva is really important from caries and a lot of other things, including erosion. Because first of all, if you have healthy saliva, meaning lots of saliva as opposed to a dry mouth ... when you take these things that are immediately clear ... you're swallowing, you're getting rid of them, you're diluting them with the saliva. It might be a strong acid when it gets there, but it's already diluted. Then saliva contains buffering agents: bicarbonates, among other things, that help to neutralize the acid before it even gets to your teeth. And then the calcium phosphate is there to help to combine with the acid to make it less strong. It builds up a healthy biofilm. That's really important. It's really important to think about that.

We can expand our conversation now ... prevention beyond just looking at the wear of teeth. But how about people who have dry mouth? What about their medications? I'll get into that later. This is another really important thing I want you to take home with you. That the severity of the attack from the acid, it doesn't just depend on the pH and all that. But it really depends on how you drink your drinks or eat your food. If you sip or swish a drink as opposed to swallowing it or gulping it, the swishing part obviously is really bad. Talk to your patients about how they drink their drinks. If you're going to sit and sip a Coke or energy drink next to your computer when you're working all day, at least swallow it. Don't hold it in your mouth. Because contact time is what allows the saliva to undergo all those changes I just talked about, meaning for the acid to drop their pH, get more acidic ... I mean for the saliva to drop the pH and get more acidic to infiltrate through the biofilm and get to the surface.

We're seeing a huge problem in California in Silicon Valley. My [inaudible] friends in that area are getting a lot of referrals for these young patients in 25 of 40 that never had extensive wear in their mouth before. But what they're doing is that they're sitting next to their computers all day long sipping on Red Bull or some type of energy drink, and they're literally coating their teeth with acid all day long. They're doing all the bad things that I just have been talking about to predispose their teeth, plus probably their stress, and clenching, and grinding to cause wear. We're seeing some real, real serious problems. Talk to your patients about how they consume their drinks. It's not what they consume.

The other thing that's very effective for me is to monitor the acidity. And this is a really good thing for hygienists to do if you test for pH and get the patient involved. Because if the patient gets involved in this, they sort of begin to own their problem. I give them these little pH tabs that you see in the lower right there to take home, and this little card on the upper left. I say, "Take a drink at home, take this and hold it in your mouth. Dip the little piece of paper, the pH paper in your mouth, and check it. It'll come out acidic." Then I say, "Rinse it out with water and do it again, or show them this in your office." It's a very, very powerful motivator to make them aware of what they're eating.

Just to wrap this part up, we're talking here about interactions between an attrition, an abrasion, and the net result is tooth wear. I want you to remember that. We're trying to not just think about the wear from bruxism. I have to mention just briefly ... the difference between caries and erosion. They both involve acid, but it's much different. I'm sure a lot of dentists and hygienists don't differentiate between these two, but it'll really help you a lot with your diagnosis and understanding. Excuse me.

As you know, caries involves bacteria and caries is actually reversible. You can remineralize caries, as you know, and harden it. The interesting thing is caries is really effective down to a pH of about 4.5. I'll explain that in a second. As opposed to erosion and caries, no bacteria is involved. Your source of the acid which causes caries is from bacteria, as you know. The source of acid from erosion is not from bacteria. It's from your intrinsic and extrinsic acids that you consume or that come up in your stomach. That's a very important part.

The other thing about erosion that's kind of scary is that it's irreversible. Once you lose the tooth surface, it's gone. It's also scary because unlike caries, it's subject to additional loss from abrasion and wear. What happens ... if you look at this chart on the left is that once the pH gets below about 4, actually the caries process shuts down. Because below a pH of 4, or 4.2, or the acidogenic bacteria stop producing acid. Then you get the erosive problems below that. Again, it's just a little insight into the problem to help you understand it.

Quick pause here. What do you think? Now, this is oral health. Not just your teeth, but oral health. And not just erosion, oral health. Which of these three drinks do you think is the worst? Raise your hands. What do you think is the worst? I don't know. When I do this in front of a live audience, a lot of people say Coke and a lot of people say Red Bull. I'll tell you a little bit about each one. They're all bad, but in different ways.

Red Bull or energy drinks and to some extent ... energy drinks are bad in a lot of ways for your health in general because of the caffeine in there. But we won't go there right now. They are high in acid, and many of them are high in sugar. Some are less high in sugar than others, but most of them are very acidic. They're bad potentially for both caries and erosion. Now, Diet Coke doesn't have the sugar. You might think, "Well, that's great." And it is great, and it probably is better for caries, but because it's the sugar that's promoting the bacterial nutrition that relates to the acid. However, it's very bad for erosion just like all the other acidic drinks. That's maybe somewhat better for your health. I question that in some ways. But certainly, it doesn't have the sugar.

Now, you might think chocolate milk is really good. But chocolate milk is not so good either because it has a lot of sugar in it. It's viscous, and sticky, and it sticks to your teeth. Again, it is probably bad for your health because of all the extra calories. Pick your poison, I guess, is what it comes down to.

This is a more spot on question here for you. Now, which of these drinks is the least erosive? They're all erosive, but which one's the least? If I had you raise your hands, I think that most of you ... at least the audiences I've talked to would say Red Bull is the ... I'm sorry. Yes. Maybe one of the energy drinks is least erosive, like Red Bull or Monster. The fact is that the least erosive one here is Coke. This will surprise you. I'll show you a slide in a second. A 5-hour Energy is probably very erosive because it's viscous and it sticks to your teeth. Red Bull, of course, has a lot of acid and sugar, as does Monster drinks.

But this was kind of a fun thing to think about here ... that acid attacks from soft drinks, sports drinks, energy drinks, et cetera, all of course cause problems. Remember in grammar school when you had ... many of us dropped a tooth in Coke and it dissolved after a while. Indeed it did. But actually, Coke is not very erosive. It's on this scale here at the low end, even though it has the lowest pH. What I'm saying is pH doesn't necessarily result in more erosion. It's how strong the acid is. The difference is a Coke has phosphoric acid. All the other drinks have citric acid. And it's a citric acid, even like orange juice and things, that's much worse.

In this study ... This is a lab study in vitro. It doesn't relate to the mouth because of saliva and whatnot. But the energy drinks and sports drinks were 10 times worse than a Coke. That's pretty shocking, isn't it? Anyway, I'm not proposing you drink a lot more Coke, but I'm just pointing out to you how scary it can be. Because of course Coke and things like orange juice are not only erosive, but they contain a lot of sugar, and this is bad for many, many other things. I think to give your kids orange juice in the morning, in fact, is a terrible thing to do. All you're doing is giving them sugar water and that is all. There's nothing else in it because there's no fiber. But I won't get carried away with that like I often do.

Just to sort of review now where we've been and where we're going is that ... again, I'm asking you to look more globally at these things that it's more than just one item like bruxism. Now, we'll talk about bruxism. Maybe that's why you tuned in. The definition of bruxism from the American Academy of Sleep Medicine is ... as you see here, it's repetitive jaw muscle activity. And then awake bruxism is differentiated ... and it's very important. I'll get into a little bit more about that. But it involves nonfunctional activities such as clenching, grinding, tapping, biting objects, et cetera, and it's related to stress. Sleep bruxism is not really directly related to stress.

In terms of making a diagnosis for bruxism, one of the main signs, there's no question, is tooth wear. I'll go over these things in the subsequent slides here. But I want to talk a little bit more about the symptoms with you now. Self-reported bruxism is not reliable, and I'll show you that in a moment. I used to ask my patients, "Are your teeth sore in the morning?" That, I thought, was a really neat question. Sometimes they are. Sometimes they're not. It's not a good indicator of bruxism, and headaches are not, and TMJ pain is not a good indicator.

These things are helpful, and they may be related, but they're not the primary cause in most cases. Again, the signs of wear ... we talked about quite a bit already. This was a useful one for me. If you look at the patient's tongue and they have a large tongue ... this is lower left. You see little scalped areas where I've got the areas there? That's usually very, very indicative of bruxer. The reason is that the large tongue, and I'll get to this later as well, is interfering with your sleep. It's causing interruptions of their breathing.

Again, it's interruptions with the sleep that cause the tooth grinding. If you just look at someone's mouth and you see a large tongue, especially with a narrow arch, and these scallops, it's a really good sign that they may be actively a bruxer. Then the gold standard for it is to put sensors on the side of the face and actually look at their muscle movement. The RMMA stands for rapid masticatory muscle activity, and that will tell you exactly what's going on. That's often a part of a sleep study, and that's where we've done a lot of our research on bruxism.

Again, sleep versus awake bruxism, they're two distinctly different matters infestations of different processes. Sleep bruxism is under central nervous control, central nervous system control, and it's related to sleep cycles. I'll get to that. Awake bruxism is under peripheral control related to stress, psychological, and environmental impacts. This is why these two things, sleep bruxism and on the right side awake bruxism, should be thought of differently. When we talk about management, we'll talk about that in that sense.

The way I want you to look at this now, if you look at this triad ... by the way, the bruxism triad was first introduced to me by Jeff Rouse. He's a prosthodontist down in San Antonio, Texas, and he's done a lot of work in this area. He talked about this notion, and we've sort of been running with it. The end result here is erosive tooth wear. It's modulated in many ways by the saliva and the pH. I told you that. Lower pH, teeth are softened, and they're more likely to wear. But in terms of actually triggering off now focusing on sleep bruxism, it involves these three things: the actual act of bruxism itself, sleep apnea or sleep-disturbed breathing, and GERD. Gastric reflux fluids coming up in your stomach. We'll talk about each of these separately.

Again, just to tell you sleep bruxism is centrally mediated and it's related to changes in your respiration and heart rate while you're asleep. It therefore is related to sleep cycles. Now, it gets more involved when you look at the bruxism studies. I will tell you right now that I don't fully believe ... I mean, I can't [assess] all these results personally. I do think they provide a structure for us to help to understand, and help the management.

Most of the bruxism ... the highest prevalence of bruxism is among children. Then, the older you get, the less your bruxism. It seems counterintuitive to me, honestly. But if you accept the fact that perhaps only 3% of adults over 65, even grind their teeth, why are we doing all this focus on bruxism and talking about it so much? I think this is something to really consider that kids brux the most. As you get older, you brux less and less. That concept ... I think it's more than 3%. The [inaudible] is 8% or 9%. It doesn't matter. I think this concept needs to be built into our treatment philosophies and management philosophies. I just put this here. Tooth wear in a 70 year-old patient is probably not from bruxism if it's active wear. It may have happened 40 years ago, and what we're seeing in 70 year-old is wear, but it's probably not accurate bruxism at that moment. We'll talk about that.

I think ... if you can imagine these things, smoking, caffeine, type A personality. But what do all these have in common? Well, the answer surprises you. But it's not about acid. It's not about anything else. I mean, it's maybe a little bit about those things, but it mainly is that they all, in terms of bruxism, disturb normal sleep patterns. It's the sleep arousals, the disruptions in the sleep, that cause the problems.

Herein lies the problem. Pardon me. You all give your patients these health tests, health questionnaires when they walk in the door. And oftentimes it's the hygienist who reviews it with them, whatever. You all have a question on there saying, "Do you brush your teeth at night," or something like that. Don't you? I mean, I just know you do. You may have some additional questions about grinding your teeth. But this will kind of upset your little safe haven. Of all the self-reported bruxers, only half of them actually bruxed. In other words, when they put these EMG recordings like I talked about ... sensors on these people who said they bruxed, in fact, half of them did. And you know why half of them said they bruxed? Because they were wearing their teeth, and their dentist probably told them at sometime in their life that they ground their teeth. Half of them who say they're not bruxers actually brux per these EMG recordings.

What does that leave the poor dentist or hygienist to do, and how do you make your decisions? My point is that they're very poor correlations between any of the other factors, like morning pain wear, and that correlations don't mean causation. That correlations don't mean that that's what caused the problem. Based on that, how do we make a diagnosis? I've done this many times. I show pictures like this to an audience, and I say, "What do you do?" And they say, "That's bruxism." And then I say, "What's your diagnosis?" "That's bruxism."

Well, I want you to begin to think differently if you can. These should be called erosive tooth wear. It's not just bruxism. Bruxism might be one of the least important parts of the whole factor, at least as far as what's going on. And if you limit your thinking to bruxism only, you're going to really miss out on the whole treatment opportunity. He could be a bruxer, your patient, yes. But it's not a diagnosis for the problem. He wrote. That's why, again, we're moving toward this more global diagnosis.

Believe it or not, brux wear is not a good indicator between active bruxism. I keep saying active, because bruxism is ... it could have happened 40 years on the person that hasn't around their teeth for 40 years. Yet they could be in a situation where they're grinding them more at that time, or they could be in a situation where they're having exacerbated amounts of tooth loss because of some other things like increased acid intake, dry mouth at night, and GERD that are affecting these problems. Again, self reports are not very reliable. The other thing that may upset you a

We had, that the cause is not related in general to occlusion. I taught, and I lectured on this years ago, that it was related, but it's not. It's related to these microarousals, RMMAs, which are related to changes in your sleep, like heart rate and respiration.

And the way this works, if you look at sleep cycles, is that every night we go through four or five cycles of sleep. The earlier ones are the deep sleep ones, and we go down to stage four sleep. And that's a really important part of our night's sleep. And we do our memory consolidation and lots of those types of really important things, that our body basically is anesthetized. Our heart rate goes down, our breathing slows down, our temperature actually maybe drops up to half a degree. So we're sort of paralyzed during that, and that's a very regenerative stage of our sleep. And these two are important.

And then as we pass through the hours of sleep at night, as you see on this graph, those deep stage sleep periods get less and less. We move up to REM sleep, which is rapid eye movement sleep. And by the time we're getting near morning, this is when you have your more vivid dreams, and you're thinking about a lot of other things. Your brain is kind of waking up again. Well, it turns out that the bruxism cycles happen during these periods of REM sleep, actually between stage one and stage two. And so, this is when the bruxism happens during the night. And again, it's not related to occlusion. It's not necessarily related to stress, but other things.

Having said that as a prosthodontist and a person who cares a lot about occlusion and manages it a lot, it's very important. Occlusion is very important with the effects of bruxism. So please don't for one second think I'm saying occlusions aren't important. Because the effects of bruxism are that you can fracture teeth. You can make teeth loose. If you grind on, you can make them sensitive. You all know that. And we can often adjust the occlusion and improve the occlusal function, improve the occlusal support, and solve these problems. But they are not related to sleep bruxism. Okay? So the management is really important. Don't say for a second, that Dr. [inaudible] said that occlusion isn't important, but it's not important significantly in relation to sleep bruxism.

Now I just want to go back and say a couple things about daytime bruxism. During daytime bruxism, you can put much greater forces on your teeth, much higher forces. And so that's why it's really important to make your patients aware of it, because they don't wear a splint during the day, obviously. They're not protecting their teeth from high forces. And there's some really good studies out now, some recent studies that show that during awake bruxism, daytime bruxism, patients put two to five times more stress on their teeth, force on their teeth, than they do during night time. And much to what you learned, people probably don't put a whole lot of stress on their teeth during nighttime bruxism. Many of you will disagree with me on that, but I'm just talking about what the studies are showing now.

But daytime stress, they can do a lot of damage. Daytime stress and bruxism can be managed by an increase in patients' self awareness. And so talk to them about it. If you catch yourself grinding your teeth, and you're stuck in traffic, and your kids are late for school, and all those terrible things we go through all the time... Are stuck in your house right now, you're trying to teach your kids school while you're watching this, I think that you can understand that. So, decrease the stress, be aware of it, catch yourself, and then stop yourself. That's about the best advice I can give you.

The second part of this is the GERD, the acid intake part from your stomach. And I'm just going to go through those quickly. But reflux is related to the lower esophageal sphincter here, this little like backflow valve between your esophagus, where the food drops in, and your stomach. And the acid comes up through that, and comes up, potentially... It usually doesn't get that far, according to what the gastroenterology people tell me, but it gets into your mouth. It can get into your nasal pharynx. It can cause a lot of problems in addition to erosion, but mouth pain, sinusitis, esophagitis... A lot of the problems like this can be related to that.

So one of the main points about GERD, and you can recognize it as a dentist, because you will see teeth that have extreme wear, is that it leads to other medical problems. So this is your opportunity to network with your physicians, to refer your patients to people for help. And believe me, these are great relationships. I had relationships with ENT people, with gastroenterologists, and they're a really good referral source for you, but it's just great to sort of raise the bar and talk about other things, and they enjoy it as well as you do.

But GERD is related to... Gastric reflux is related to a lot of changeable behaviors, like eating before bed time. Ideally, you shouldn't have a heavy meal less than three hours before bedtime. And spicy foods, smoking, obesity is one of the main factors, and stress. So there are changeable things you can do to manage the GERD. And I won't go into this, except to say that there is compelling research now to relate GERD problems to dental erosion. To relate GERD problems to dental erosion. So we know that's a factor.

And what I did with my patients, where I saw these... if you ask patients about what are your symptoms, like heartburn. That's one of the main ones. That's a problem, too, because nearly 40% of GERD is so-called silent GERD, where they don't have symptoms, yet the acid will still get up into the mouth and up into the esophagus. So you have to be careful with that. But there's nothing wrong with having people use anti-acids, symptomatically, and you can have him try some of these proton pump inhibitors, PPIs. They're over the counter, Prilosec, Nexium, you know a lot about that.

What I do, sometimes, if they complain about this and I see a lot of symptoms, I say, try this for a short period of time. The boxes come in, I think, about a six week sample, is what it would come in a box with 42 tablets, and see if your symptoms get better. If they don't, then for sure, go to your doctor. Okay? That's a key point. Have them talk to their physician about it. But this is a huge problem for us. And we're seeing more and more of it.

So a little bit now about sleep apnea. You're going to hear more about it, by the way. Dr. Santucci is giving his talk tomorrow. He's a colleague of mine at University of Pacific. And he'll elaborate a lot more than I'm going to on this, but this was an interesting patient to look at real fast. What do you see with this guy? Well, number one, he has a narrow arch. Number two, he has a next size over 17. He's class two. He's overweight. And if we look at a few more things, you see again, narrow arch, et cetera.

So he is sort of a poster child for the type of person you'd expect to have maybe a lot of erosion. Now, he doesn't have it, interesting... I think he's getting some back here in these posterior teeth, it looks like here. But he is... An indicator of a lot of these other problems, like probably GERD and probably sleep apnea. And these are signs, by which you can begin to understand these things.

So to talk very briefly about sleep disturbed breathing and how it relates to bruxism, it relates to bruxism because any upper airway restriction problem means that your patient is going to have it... If their throat is restricted, their breathing is restricted, they have to breathe harder. If they increase their respiratory effort, their heart rate goes up, as well as their respiration, and it increases their sleep arousal. So they don't sleep. They're awake. They pop up on that graph, remember, up to the REM sleep? They pop out of those deep sleep, sleep cycles, 14, 15, 20 times during the night. And they ended up being exhausted in the morning, among other things.

And even with your kids, there is a high, high, high incidents of breathing problems with children. And it's often related, as you can see here, to these large adenoids and tonsils in the back, that obstruct it. And more and more, some of the pediatricians are looking at this. I don't think that they're paying enough attention to this. This study right here is a really good study. It's out of England. This pediatrician looked at children from the age of three through seven, starting, followed him for seven years, which is remarkable. Approximately 10,000 kids. They found the ones that have diagnosed sleep apnea problems at that age, seven years later, were an inch and a half shorter, their IQs are 30% lower, 20 points lower. Their incidence of ADHD and those types of things were higher. They're acting out in school because they weren't sleeping, and consequently, they were irritable. Terrible, terrible problems. And I think the dentist can play a role in working with that.

So again, I just said just before, with an adult, big tongue, lying back in bed, their tongue falls back, blocks the airway, and their heart rate goes up. They can't breathe. This is a sleep apnea episode. Some of you have probably slept with people who have sleep apnea. It's very scary. They stop breathing for 14 seconds. Their breathing actually stops because their airway is blocked. And then all of a sudden, they wake up and cough, and these are the factors that set off the bruxism episodes.

And one thing that bruxism might do, oddly enough, is when you clench your teeth, and you bring your jaw forward to grind your teeth, to actually open your airway. So it's not even a big stretch to me, actually. You can almost say the bruxism is helpful for people that have sleep apnea because it helps them move their jaw, open their airway, and get some oxygen in their lungs.

I'm not going to talk about oral appliance therapy, but that's exactly what it does. It opens the airway up and allows breathing. And again, this is what triggers off this sleep bruxism. Some people are using the CPAP machines, and this is good. By the way, I put this slide in here, not to show you and talk about CPAP machines. These are the machines that are being converted into respirators, now that all these hospitals with the COVID virus problems are in such short supply of them. So now they've been able to modify these CPAP machines that are widely unused, and turn them into a ventilator that they can use to ventilate these patients with the respiratory problems from the virus. So it's kind of an interesting change on how people are managing.

So again, to wrap this up, your perfect storm here is a patient who's a bruxer, has sleep apnea, GERD, medicine-induced hypo-salivation, meaning they have less saliva, less protection from the saliva. They're over age 55, they're obese, their neck size is over 17, they drink and they smoke. This patient is a tough patient, but if you can be aware of these things, it really helps you, I think, in sort of, again, framing your attitude toward these problems, framing how you are going to manage them.

It's time for a sip of water, excuse me. Having said all that, dental wear is an acidic disease. And to manage this problem of where we need to, I've been saying all morning, control the acid, control, protect, and minimize the forces. So bruxism plays a role down here, but the most help we can give those patients is to control the acid contact to the teeth and protect the teeth from acid contact. And this means that we need to modify the environment. And if we modify the environment, then we have a chance to identify problems early on like this, and start to talk to the patient about how they can change their behaviors, what they can do to help out. And we can modify the environment, as I told you, by counseling them about acidic drinks, about GERD, about bruxism, the things I've been talking about.

Those are really important, but one of the few things that we can do to really change people's behavior, because I think you've all experienced... It's really hard to get them to stop drinking energy drinks and whatnot. But at least we can talk about how they can protect their tooth surface [inaudible] mass of challenges. And quite frankly, the only way we can do that is with some type of stannous fluoride application, be it topically or with toothbrush, et cetera.

And this is very compelling research, that in the presence... If you use a stannous fluoride toothpaste, rather, now, it provides 60% more protection from sodium fluoride toothpaste. Well, that's a simple change for people to make, to stop using fluoride toothpaste. You get the same fluoride benefit with both toothpastes, but you also get the stannous, and I'll explain how this is working in a second.

But just to show you, here's another study showing that Crest Pro-Health, compared to Crest Cavity Protection, so Crest Pro-Health has stannous fluoride. Crest Cavity Protection is sodium fluoride. Colgate Total, at this point, was sodium fluoride only. Sensodyne, Arm-in-Hammer. So you had two and a half to three times more protection from erosion, using the stannous fluoride products, than you did with the sodium fluoride products. And even when you go to the [inaudible] the 5000 part per million one, you get three times or more protection from erosion with the stannous fluoride products, such as Crest Pro-Health, compared to the sodium fluoride products.

So it's a simple thing to do, just get your patients to change. And this is why it works. It works because it coats the teeth with a tin covering. That's the stannous part. And these, starting from the right hand side here now, you see this is enamel that's been subjected to an acid challenge. Here is after brushing it... This is brushing before the acid challenge, with sodium, and here's brushing before the acid challenge with a stannous fluoride product. This is Pro-Health.

And you can see that this is why I want you to advise your patients. This is so counterintuitive for you, I know, to brush before a meal and not after a meal. That's the key, because if you brush before a meal, you coat your teeth with the protection that you see on the left hand side of this picture, and the acid doesn't attack it. If you brush it after a meal, right after an acid attack, you're doing exactly the wrong thing because you're brushing it... When it looks like over here on the right side, where all these little things are brushed away easily by your toothbrush, the demineralized enamel that's been acid attacked. So you see again, it's a compelling thing, and something that you can do very easily, to get your patients to change to.

Now in terms of treating bruxism, as far as the bruxism, per se, the standard treatment has been using an occlusal splint. And I did many hundreds of these things, and many of you do, but just remember, the splint only treats the effects and not the cause. It doesn't stop the patient from grinding their teeth. The grinding is related to the sleep arousals. And it also is related to the sleep arousals, as a result of sleep apnea and GERD. Because those problems, again, cause the breathing change. The breathing causes the muscles to contract, the masticatory muscles.

But I want you to think about why you use an occlusal splint. I think the main reason I use an occlusal splint is to protect the teeth, not to protect the patient from bruxing. But you have to be careful because one thing the standard occlusal splint will do, is that it actually makes sleep apnea worse. You wear a night guard at night, you lie back in your sleep, and what happens? Your teeth aren't in contact. You have no more occlusal support. And your jaw drops back, and as a consequence of that, your throat closes up, and it triggers off more bruxing. So it actually makes the bruxing worse, potentially.

And again, you might hear you hear more about this from Dr. Santucci, but I just want to give you that notion, that we make appliances to treat wear, to maybe help out with active verified bruxism. Verified is the magic word because we don't even know it, as I just told you earlier, that most of your patients don't even know if they brux, or if they say they didn't do it, they don't. And again, awake bruxism would be great. That's when we probably need it most, but patients don't wear their splints during the day. But we do care about preventing damage to restorations, and possibly it helps with TMJ problems. I think I helped some, over my years, with that.

But here are a couple of questions before you. Should occlusal splints be used as routine prescriptions for diagnosed bruxers undergoing implant therapy? Some people are saying you should. I'm saying that not necessarily. The studies are not positive either way. Some say it's more likely to be a problem with or without it, related to overload of your implants, but it's not certain. There's a brand new study that just came out a couple months ago that points out that if you have full mouth implants, complete implant dentistry, it may be a good idea. Not because the implants are at risk. It makes little difference whether the implants fail from overload, the problems are the technical problems with the porcelain on top, the porcelain chipping, related to grinding. And it may be a good idea there to do that. Is placing implants in diagnosed bruxers contra-indicated? The answer is no, as far as I'm concerned, and that's backed up by some pretty good studies now.

I'm going to pass over this because I want to get to the next part here. I'm going to talk to you just briefly about minimally invasive restorative treatment for erosive wear. The main thing I'm telling you here is don't watch and wait. When you see this type of wear, little potholes like this, you should be proactive and going after those things. Certainly, you can use fluoride varnishes and sealants. They will definitely help. And from a hygiene standpoint, these are things that the hygienists could and should suggest doing. And they don't last, in terms of the protection from the acid, for long periods. But if you have somebody on a three or six month or four month recall, you could even freshen them up. So I would encourage you to talk to your [inaudible] about that. I think that in cases of a lot of wear, like I'm showing you, this would be a big help.

The other thing you can do is to do some minimal restorative care. And this is a guy... this doesn't look too bad, but actually, I'll show you a closeup in a second... Who has some problems, as you can see here. And looking at these seats closer, yes, he has a lot of erosive type wear. Now, you could put veneers on these patients, but otherwise, there are no problems, really, with caries in these cases, oftentimes. And so what I'm suggesting is that by doing some simple composites, and this involves no grinding, no anesthesia, and you can fill these little potholes, you can fill out some of these areas that are eroded around the teeth. We've even added some... Back here, as you remember, a second ago, had some erosion in these areas. And this is great treatment.

Even flowable works really well, especially in these areas where they're not under occlusal contact or forces. The newer volt flowables are really good on these pothole areas that we filled in here. And you've done a huge service. And quite frankly, it's a way to up your production too, if you want to. But it's a terrific service with patients. It's minimally invasive and it's useful.

So we were able to take this guy. He's a really happy camper. He loved it. He loved the fact that we took his picture, and we didn't have to charge a lot of money. We didn't have to grind his teeth down. We protected his teeth. And, in combination with the fluoride, the stannous dentifrice, is that we'd been a really good service for him. And this is what I'm talking about.

Now, there are cases where you have to go in and you have to do more aggressive care. And it's up to you as far as how much you want to carry this in your offices. You can do it with composites. You could fill in some of the areas like I just talked about here. But you sometimes have to work with the vertical dimension. You sometimes have to put complete restorations on these teeth. But if you do that, and I don't have time to talk about it here, we're taking a much more conservative approach. If we do decide to do crowns on a case like this, and we did for this lady, we are keeping our margins supragingival. You have no reason anymore with porcelain restorations, and especially bonded restorations like you're doing now with E-MAX and materials like that, to carry your margin subgingival, unless it's a cosmetic problem. Or unless it's an existing restoration.

But there's just no reason to, and you can make your life so much easier if you don't do that. And if you look up here, you see we didn't even go down over the buckle on this tooth up here. We just reduced the top a little bit. We opened the VDO a little bit. We tipped the other surface on the lingual a little bit, and bonded on a restoration. You can do this now without the old type of preparations we made. And It makes your life so much easier to think in terms of supragingival dentistry.

And this was a really nice way. We kept all this enamel here. For example, we can get a really good portion of bonding to that. So again, there are times when you have to, and choose to, for aesthetic reasons, for other reasons, to do extensive restorations. And in doing so, I just recommend and advocate that you do it as minimally as possible, as conservatively as possible. And I think we did a good service for this patient in doing so.

So, to wrap this thing up, the take-home lesson here is to, and I hope I didn't bore you to death with it, but think not just in terms of bruxism, but rather thinking in terms of tooth wear to surface loss. And if you adopt this worldview, it'll open up all these possibilities I've talked about. Possibilities, in terms of minimally invasive treatment. Possibilities, in terms of controlling the environment with your stannous fluoride toothpaste, with your sealants. And your ability to help these patients by giving them counseling and talking to them about their diet, talking to them about their health. And really thinking in a much more broad sense.

So again, I appreciate your being with me for this time, and I hope you're getting through this time and these times in good shape. And please, please stay well. Thank you very much.

Sarah: Great. Thank you for that today. Let me get those verification codes posted up here. Give me one second. Hey guys, code. The code for today is sleepnoble29. Sounded fun.

All right. We have got some really good questions for you. Okay. First of all, somebody asks, what was the name of the pH test that you showed?

Ward Noble: Oh, it's made by ... I'm sorry. Saliva-Check.

Sarah: Saliva-Check?

Ward Noble: Yes.

Sarah: Guys, we got Saliva-Check.

Ward Noble: It's from PC Dental. You can check their catalog.

Sarah: Okay. Have you found any help with bruxism and clenching using vibration devices like VPro that helps break the muscle cycle?

Ward Noble: No. And the reason is that, if you have an actual muscle spasm, I feel that these things ... It's no different than using a massager if you have a cramp in your leg. It's no different than stretching out your leg muscle if you have a cramp in your calf. I think that they can benefit certain people. But I think in terms of the actual symptoms, they don't occur while the person's awake and do it. That's my point, okay? So my opinion is of minimal benefit.

Sarah: Okay. Is there any connection to brutish and tori? I'm assuming they met bruxism.

Ward Noble: And what else? I didn't hear it.

Sarah: And tori.

Ward Noble: Yes, there could be. And I have seen that, and that may be related. The same way though that abfractions maybe related to bruxism, but not in a very strong way. But yes, it's possible. And you might think that by adjusting in the bite, you might do that. I wouldn't grind someone's teeth down for that reason, but possibly, yes.

Sarah: Okay. Can you hear me okay?

Ward Noble: Sure.

Sarah: Okay. As many of these cases are multifactorial with clenching and grinding as one component, how do you sequence treatment?

Ward Noble: Okay. I started out just as I went through the order. I try to figure out what's wrong. Then I talk to the patient about their diet. I make sure they get on a stannous fluoride toothpaste. And then I begin treatment. I make a decision if I'm going to do it totally conservatively, meaning just fill the little potholes and watch. And I see no reason for not doing that. I think that's really good treatment. I try to figure out whether the patient's actively grinding, or maybe the problem happened 20 years ago, and it's just now getting a little bit worse. I do some behavioral changes, first, some conservative treatment. And then finally, I may have to get into actual restorations.

Sarah:Okay. Thank you. In most of these cases, how many millimeters ... Sorry, they didn't type this out right. How many millimeters do you use to increase vertical dimension?

Ward Noble: Oh, God, that's a whole another talk. My quick answer is, as little as possible. The rest of the answer is, you can always do it two millimeters on the articulator pin or three millimeters on the articulator pin. Which means about one millimeter in the mouth without worrying about muscle problems or TMJ problems afterwards. And I do it only for enough room for restorative convenience, meaning enough room to get my restorations in, in the conservative way.

Sarah: Okay. Do you routinely check pH levels on these types of cases?

Ward Noble: I test the pH levels for a different reason, actually. I teach them as part of my patient education, to try and get them involved in their problem, to get them to own their problem. Because they will realize if you do what I told you about having them checking without acid and with an acidic drink, to begin to realize that those are the part of the problems. So that's the main reason. I don't think you can test it appointment by appointment with patients in a meaningful way because it changes hour by hour.

Sarah: Okay. How, how do you differentiate between abrasion and abfraction clinically?

Ward Noble: Good question. I think the question should be between abrasion and attrition, clinically. Although I know they said abfraction. But abfractions are not totally related to abrasion or tooth grinding. They're mostly related to acid wear and toothbrush abrasion. But I think the person is thinking that if I adjust the occlusion on a tooth that has an abfraction, is that going to make it stop? And it may help, and it may not. I do not routinely do that. So that's the best answer I can give.

Sarah: Okay. I was told the concept of abfraction was disproven. Is this true?

Ward Noble: Okay. That's a great question. I wish I had time to talk about them. No, it's not disproven, abfractions. What abfractions mean, very quickly, is that under grinding and when teeth are bent or torqued under tension, some of the tooth structure is weakened. And that predisposes it to structure loss from toothbrush abrasion, or whatever. That's the way it works, and it's a multifactorial thing.

I think the abfraction part, meaning the occlusion part and the tension on teeth is the least important of the other ones, meaning acid erosion and toothbrush abrasion. If you're brushing back and forth, like we all taught people like this. I mean, tell them not to do that's going to make those grooves more than they do if they brush it up and down. And if you have more acid there, it's going to be worse.

Sarah: Okay. That makes sense. What product do you recommend to reverse incipient caries?

Ward Noble: What product do I recommend?

Sarah: Uh-huh (affirmative).

Ward Noble: And in what caries?

Sarah: To reverse incipient caries.

Ward Noble: Oh, incipient caries. I like the anticaries products. And I'm sorry, I'm blanking on those names right now. I think just keep using regular fluoride toothpaste and brushing. And I think a big part of the caries, as far as I'm concerned ... Okay. I would use something like, the toothpastes that have more potassium and calcium in them, to remineralize that surface. That would be the way to go with that. But equally important is to modify your diet, so that you are taking in less processed food, less carbohydrates, less sugar, et cetera. The same old things. But the use of a different type of dentifrice might be helpful in that case.

Sarah: Okay. What do you think about Botox to limit bruxism?

Ward Noble: Botox?

Sarah: Mm-hmm (affirmative).

Ward Noble: I think it's ... Okay, I'll say it. I think it's bogus. And think it has little to do with it. It has something to do with maybe killing your lip so that muscles don't react in there and it doesn't go up if you show your front teeth and you're worried about that. It has little to do with stopping bruxism.

Sarah: It doesn't stop-

Ward Noble: There are no studies, let me put it this way. I shouldn't just say what I think. There are no studies that have an effect on that with Botox.

Sarah: All right. Can abfractions be caused by brushing too hard? I think you already answered that.


Ward Noble: Yeah. Yes, it can.

Sarah: Is gum chewing considered a type of bruxism?

Ward Noble: No. In fact, gum chewing is one of the best things you can do for this whole problem. Because when you chew gum in general, it creates more saliva. You put a stick of gum in your mouth and it just fills your mouth with saliva. Well, that's good. That does all the good things I was talking about, diluting the sugar, getting the acids out. I think chewing gum is a really good idea. If you chew it aggressively all day long, it may not be bad, but frankly, that probably doesn't wear your teeth down. If you have gum between your teeth and you're chewing it, you're not even chewing on your teeth. You're chewing on the gum.

Sarah: Right.

Ward Noble: And so I don't think it's a problem.

Sarah: Okay. If you brush your teeth while the pH is low, can it lead to more erosion of the teeth?

Ward Noble: Yup, absolutely, and that's why I say brush before an acid attack, as opposed to after. It's so counterintuitive, people can't get that. One of the worst times is after the kids play soccer and they're dehydrated and their mouth is dry. And then they go and they drink an energy drink or a Coke. Well, what a soccer mom should do is take some little cheese cubes with them and give the kids a cheese cube. And so after they have their Gatorade or whatever they have, as opposed to water, water's best, give them a little piece of cheese. And it'll pop their pH right back up. get rid of the acid in their mouth, and give their teeth a chance to remineralize after the acid attack. So that's the same reason why you don't want to brush after you have an acid attack.

Sarah: Got it. I have a friend who used to rinse her mouth out with Mountain Dew after she brushed her teeth.

Ward Noble: I hope you squared her away.

Sarah: I did. That's just made me think of that. What type of ulcers are seen with GERD? Where are they usually in the mouth?

Ward Noble: If you have GERD and you have a dry mouth, the acid ... In my experience, it just makes more generalized soreness in the mouth, as opposed to an [inaudible] type ulcer. But don't forget, what happens in your mouth also happens in your esophagus. In other words, if you have a dry mouth, you also may have a dry throat and a dry esophagus. And so that predisposes that entire channel that goes down into your stomach to more irritation from any acid problems.

Sarah: Okay. Is there a relationship with sleep bruxism and OSA?

Ward Noble: Yes, definitely. And that's where that triad I was talking about comes in. Because with the sleep bruxism, you're interrupting your sleep patterns, and consequently you're triggering off bruxism. And just to reiterate what I said about that, sometimes it ironically may help it because if you grind your teeth, you're moving your jaw forward and opening your airway up. So, it is definitely related and it definitely triggers it.

Sarah: I want to know how many people are sitting here, grinding their teeth while we're having this-

Ward Noble: [inaudible] right now.

Sarah: That's what I automatically do.

Ward Noble: That is so true.

Sarah: How long-

Ward Noble: Pardon me, that goes back to a good point, Sarah. That awake bruxism is what I think does a lot of the damage. You put much greater forces on right now when you're pushing on those teeth than you do at night. And like what most people have [inaudible 00:16:16].

Sarah: I feel like I need a massage or something. Okay.

Ward Noble: I know.

Sarah: Is it okay to use an anti-acid longterm?

Ward Noble: No. Well, that's a really good question. Some studies show that women, especially, can have vitamin B12 deficiencies and osteoporosis when they're taking them more than two years. That was my point. And I'm glad that question came up because if your patient has taken it more than a short term prescription, and they think they need them, they should be under the care of a physician.

I can tell you anecdotally in myself, that I use those and my physician monitors them, and we're aware of them. And if I have any symptoms like chronic sore throat, chronic cough, then I am taking them also, it may in fact, drop my bone hardness down, and you should be aware of that.

Sarah: Okay. How do you get a patient to admit to bulimia and accept serious conversation about treatment and prevention?

Ward Noble: Really good. That's probably the job for a psychiatrist, but this is where hygienists I think play a key role. I think patients open up to hygienists way more than they do their dentist. A dentist/patient relationship is much different than a hygienist/patient relationship. And I think all of you know that. You're gabbing, you're talking about their family, this and that. Though, the hygienist is the one who has a much greater chance for the patient, that demographic, that the teenage girls and things, to open up, I think.

Sarah: Right.

Ward Noble: Yeah. And so I think that's where the opportunity exists. Now, where do you go from there? I think once you start the conversation, then you have a chance to maybe engage a physician or maybe some type of mental health person in the problem. But that's a good place to start it, I think. It really is.

Sarah: Do you know if anti-reflux surgery helps?

Ward Noble: The answer is no, I don't. And I don't even know what anti-reflux surgery is ... I mean, I do know what it is. I do know that some of the other things such as ... Well, I think reflux is a problem for gastroenterologists. And there isn't much anti-reflux surgery done, I don't think, but that's not my area.

Sarah: Okay. How do you feel about xylitol?

Ward Noble: Xylitol helps. I can't say it doesn't help. I don't think it does anything for erosion. That's a quick answer.

Sarah: Yeah. Two more questions here. Well, three, do you know if there are more bruxism cases on the East Coast than the West?

Ward Noble: Okay. I think there are more bruxism cases on the East and West Coast and less in the middle? I don't know.

Sarah: Depending on the stress level?

Ward Noble: Yeah. That's what I was saying. Are we more stressed on the coasts? I don't think so. I think that it's a function of diet, more. And I think that there are plenty of people other than the computer people sucking on their energy drinks all day long. And all over the country, drinking a lot of Gatorades and things like that. And causing these problems.

And having dry mouth. I had a patient that was a golf pro. And the heat in the summer, and he had a dry mouth all the time. And he had severe [inaudible] and we had to rebuild his whole mouth, because of the drinking these things. So, no it's widespread.

Sarah: Do you recommend having a sleep study completed first before considering an appliance?

Ward Noble: Yes, in most cases. I'm not talking about an occlusal guard. I'm talking about an occlusal advancement appliance. And I think those should be done in conjunction with a sleep position. And that decision should be made jointly between the physician, not against.

Sarah: The last one here. Please review, why do you recommend stannous fluoride?

Ward Noble: Okay. Because it's the only dentifrice that adequately protects the teeth, and it does so in a safe way. It's not overly abrasive, despite what some people have been saying. It provides protection for erosion. It provides a lot of benefits, which I didn't even mention for periodontal disease. So you get a much more effective hit from that than you do a sodium fluoride toothpaste for periodontal problems. There's some really good recent studies on that, that you probably know about. There are many, many reasons, and as far as I'm concerned, it's a no-brainer. [inaudible 00:21:30].

Sarah: Okay. Well, thank you so much for your time today. We appreciate having you on here.

Ward Noble: My pleasure. It was more fun than I thought it was going to be.

Sarah: Good! We exceeded your expectations. This is good.

Ward Noble: Okay, I did.

Sarah: Thank you. And you exceeded the audience. Everybody, if you read, I don't know if you could see the comments at all. I'm assuming you didn't. Everybody loved this. It was new, and new ground breaking information, is what I kept reading. So thank you for that.

Ward Noble: I'm glad. My pleasure.

Sarah: Well, everyone have a good day. We'll see you tomorrow.

Ward Noble: You, too. Bye.