Dental Tribune Untited Kingdom Edition

26 Clinical April 16-22, 2012United Kingdom Edition I f ever there was an ap- propriate time for raising awareness of bruxism, the parafunctional grinding and clenching of teeth, and the problems it causes, this could be it. As a dentist with a special interest in migraine and pain management, Pav Khaira of the Migraine Care Institute says the condition is becom- ing increasingly common as the economic crisis takes its toll on the nation’s health. “I think bruxism is definite- ly becoming more common,” says Pav. “The symptoms and fallout of bruxism that we see are more common too, such as frequent headaches and mi- graines, and increased facial pains.” Dozens of new cases arrive in his practice every month and between 80 and 90 per cent of patients show some signs of at least some historic bruxism, he adds. Many of the new patients presenting with these issues may have always suffered from bruxism to some extent, but found that their symptoms are increasing as their stress levels rise along with debt or job security worries. “From my point of view stress is a modifier to brux- ism, not a driving force,” adds Pav. “And it is a complex sub- ject that highlights biodiver- sity. It’s like a threshold. For some people, as their stress drops below the threshold, their symptoms will resolve. But other people always seem to be above their thresh- old, even if their stress levels are low.” For many patients, arrival in a migraine and pain man- agement practice might follow months or years of shuttling between different medical practitioners in search of help. A lack of knowledge about bruxism throughout the medi- cal education system is to blame for that, suggests Pav. “It’s not about a lack of empa- thy, it’s about a lack of knowl- edge,” he adds. In general practice there can be gaps in knowledge about bruxism, or where to send sufferers, according to Pav. “If I see somebody who has really crooked teeth, I send them to my orthodontist. If I’ve got somebody with rag- ing toothache and I can’t do the root treatment I send them to my endodontist. Where do you send patients who’ve got these types of problems? There is no set speciality,” he says. “I’m not one of those people who say you can cure bruxism. But you can manage it; you can manage the signs and the symptoms, and often you can get the patient com- pletely comfortable. There are some patients who are ab- solute monster clenchers and grinders, and somebody has to help them. You can’t just leave them.” As well as substantially improving quality of life for patients, successful manage- ment of bruxism can also save them from future dental prob- lems that might necessitate invasive and expensive treat- ment. “Bruxism can cause extensive damage in the long term,” says Pav. To treat the condition ef- fectively and efficiently, prac- titioners must take the time to make the fullest diagnosis possible, Pav believes: “We do a very in-depth history, a very in-depth analysis. I talk to the patient about wheth- er they have ever had jaw popping and clicking, lock- ing jaw joints, any sinus pain, any ear pain, any joint pains elsewhere. I also do a full muscular examination, a full ligament insertion exami- nation.” This process is used to tease as much information from the patient as possible. “Quite often people say, ‘I’ve had a clicking jaw joint for several years, and it was re- ally painful for four or five months. But then it settled down by itself.’ But of course it didn’t settle down by itself. Something happened and you have to try to get to the bottom of it.” Sometimes, asking the right questions can open the floodgates of medical history. If a patient feels they are final- ly being listened to after years of migraines or jaw pain, they may have a lot to say. “Some- times it turns out that the problems stem back to an old whiplash injury from five, ten, 15 or even 20 years earlier,” says Pav. “You need to understand that a problem won’t just cause immediate pain in a particular place, it can also give referred pain in anoth- er area – perhaps causing a headache. Often I see people who have seen other dentists and found it helped a bit. Oth- er practitioners have done the right thing, but part of the di- agnosis has been missed and that is why there is still a re- sidual problem. You need to be very thorough if you are going to give the patients the treatment they deserve.” To make sense of all the in- formation gleaned without be- ing overloaded, it is important for practitioners to change their mind set, says Pav: “You have to take off your dental shoes and put on your pain management ones.” This means assessing all of the body’s systems inde- pendently of each other, and accepting that patients can appreciate, and benefit from, alternative treatments. Pav is licensed to practise acupuncture, and often re- fers patients to a chiroprac- tor. “People often say to me, ‘Isn’t that just placebo effect?’ Well, it might be. But if the pa- tient gets pain free, does that matter?” It is vital to remember that being pain free and having an improved quality of life is the ultimate goal for most pa- tients. Pav relates a story of two recent female patients, both of whom had been suf- Pav Khaira discusses treatments for bruxism Seeking release from the daily grind Fig 1 Fig 2 Fig 3 ‘If I see somebody who has really crooked teeth, I send them to my orthodontist. If I’ve got somebody with raging toothache and I can’t do the root treatment I send them to my endodontist. Where do you send pa- tients who’ve got these types of problems? There is no set speciality’ NTI side NTI front Effects of bruxism