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El Dolor de Myofacial y TMJ

El Uso de Retroalimentacin biolgica de Electromyographic para el Tratamiento de Dolor Facial


LEONARD G. Hudzinski, Ph.D. Director, la Retroalimentacin biolgica Repara, Seccin de Psiquiatra, Clnica de Ochsner y Alton Ochsner la Fundacin Mdica Nuevo Orleans, Lousiana, P.J. Walters, Presidente de DDS, la Seccin de Ciruga de Maxillofacial, Ochsner Orleans Clnico, Nuevo, Louisiana,

La introduccin
Se estima que aproximadamente 70 a 90% de pacientes con el dolor facial tienen un primero o desorden del msculo secundario y ese dolor en estos pacientes puede aliviarse con el biofeedback(1). El dolor facial normalmente es el resultado del overstretching agudo de msculos, tralla, fatiga del msculo, ciruga oral o inmovilizacin de msculo o como consecuencia de un hbito oral msculo-tnico, como fijar y/o moler y malocclusion. Se describe el dolor experimentado el ms a menudo como un dolor profundo embotado que es normalmente constante y activo durante meses, a veces durante aos. El dolor es normalmente ms intenso en despertar, y es frecuentemente unilateral o unilateral. A menudo, pulsando el botn o haciendo estallar sonidos que originan de la juntura del temporomandibular (TMJ) el rea se informa. Los movimientos de

Mandibular estn limitados porque los pacientes tienen dificultad que abre su boca. La mandbula se desva a menudo al lado afectado y doloroso de la cara. El dolor puede radiar en los msculos de templo y abajo en el msculo del sternocleidomastoid y msculos de capitis de splenius as como al proceso del zygomatic.

La retroalimentacin biolgica de los msculos de TMJ ha demostrado ser muy eficaz en pacientes fuera para quien se han gobernado artritis y otros etiology non-msculo-relacionados. La retroalimentacin biolgica es importante en el tratamiento de trastorno de TMJ porque alerta a los pacientes a la actividad del msculo excesiva e impropia, y ensea TMJ apropiado que funciona ayudando que los pacientes desarrollaran las habilidades de relajacin de msculo. La estrechez del msculo reduciendo y la reduccin generalmente reduce o elimina el dolor. El atestamiento y Steger(2), Schneider y Wilson(3), y Hudzinski y Lawrence(4,5) ha contribuido a los adelantos en el myofacial duela supervisando y terapia con el electromyographic convencional (EMG) el equipo. Los procedimientos siguientes se disean ayudar el amonestador msculo reduccin trastorno, establecer o confirmar su diagnstico, y por eso para dirigir al mdico a una estrategia del tratamiento.

La Retroalimentacin biolgica de EMG y Tratamiento

Empiece el tratamiento con una explicacin bsica de las relaciones entre la reduccin del msculo, tensin y percibi el dolor facial. En el informe, la tensin puede causar los msculos para acortar, y prolong o reduccin frecuente de causas de los msculos y puede sostener el dolor facial. La explicacin es crtica al tratamiento y puede ser especialmente til en la direccin del paciente de tensin. Explicando cmo el proceso e instrumentacin de retroalimentacin biolgica pueden reducir que la actividad del msculo elevada le proporciona una comprensin de dolor y un sentido mejorado de mando que a su vez ayuda relevar tensin, ansiedad y depresin al paciente. El EMG Examinando activo Hasta recientemente, el proceso de msculo examinar ha estado abierto al artefacto de la medida significante. El MyoTrac(TM) la unidad de EMG elimina muchas limitaciones de la medida a travs del uso de MyoScan(TM), un sensor examinando miniatura adelant as que generalmente ninguna preparacin superficial se requiere, mientras permitiendo examinar una vista o supervis en segundos. MyoScan(TM) se disea para incluso ser usado en las reas elctricamente ruidosas dnde otro EMG tpicamente la falta, y ofertas una opcin de bandwidth supervisar ancho o estrecho.

Usando el MyoTrac(TM) el Sistema de EMG


Ponga el MyoScan(TM) el sensor encima del sitio de msculo de masseter (Figura 1) usando un electrodo del trodo disponible. Pdale al paciente que se relaje los msculos faciales, mientras guardando los labios cerrados (los dientes no necesitan el toque) y graba la media actividad de EMG nivela durante aproximadamente 3 a 5 minutos. Documente el medio EMG en el lado izquierdo o el lado correcto o preferentemente ambos, usando un segundos MyoTrac(TM) o uno del dual-cauce de Tecnologa del Pensamiento EMG, como el MyoTrac2(TM), MyoDac2(TM), ProComp(TM), o FlexComp/DSP(TM). Examinando una vez del msculo del masseter est completo, el MyoTrac(TM) el amonestador de retroalimentacin biolgica ayuda el tren paciente los masseter y los msculos relacionados reforzando la actividad de relajacin apropiada y supervisando la reduccin. Para acelerar la proporcin de aprender, se restablecen la lectura de la balanza y escenas del umbral para levantar el nivel de dificultad. La regeneracin visual del bargraph LLEVADO, o variando el sonido proporcional, premios el paciente para la consistencia y calidad de esfuerzo.

La tcnica para el Entrenamiento de Masseter

En la primera sesin del tratamiento, entere al paciente con el equipo de EMG, repase los datos del myofacial, y explique las metas del tratamiento de relajarse los msculos faciales que mueven el TMJ. Entrene al paciente en el conocimiento del msculo y retroalimentacin biolgica mientras instruyendo el him/her para disminuir estrechez del msculo o tensin o ambos. Repase el material en las Mesas 1 y 2 en las indirectas tiles y hbitos para los pacientes de dolor faciales.

Figure 2. Mesa 1

Figure 3. Mesa 2

Las escenas en el nuevo MyoTracTM:


Ponga el interruptor de ganancia a x10 Puesto umbral que pone a 5uV on/cont/thr del Juego cambie al umbral Ponga los interruptores interiores al off/off/abv/wide Si las luces rojas son adelante que cuando los masseter y sus msculos relacionados estn relajados, el dial del umbral se ha vuelto en sentido contrario a las agujas del reloj hacia los nmeros ms altos hasta que las luces verdes vengan. Semejantemente, la ausencia (la desaparicin) del signo de la regeneracin audio puede proporcionarse como el refuerzo al paciente en el entrenamiento de relajacin. Cuando el paciente se ha relajado al nivel pre-seleccionado determinado por el seleccionador del umbral, la regeneracin audia apagar. En este caso, los esfuerzos pacientes por guardar el signo de la regeneracin audio fuera de para como largo un tiempo como posible. Cuando el aprendiz tiene el xito mantenindose lejos el signo de la regeneracin para por lo menos 80% del tiempo, el seleccionador del umbral ha bajado una cantidad pequea, mientras estableciendo un ms bajo nivel de tensin de msculo como el criterio para la desaparicin de la regeneracin audia (si el signo est menos de 10 uV, cambie el interruptor de ganancia al x1). El paciente entrena entonces para la desaparicin del signo de la regeneracin audio a la nueva escena del umbral. A travs del uso diario de regeneracin, el paciente aprende a identificar la reduccin en los msculos del masseter y podr en aumento relajarse esos msculos como necesitado. Un acercamiento del tratamiento particularmente eficaz que un mdico puede usar por cada sesin involucra formando conocimiento del msculo y relajacin. Despus de aplicar el electrodo encima del msculo del masseter, permtale un 30-segundo periodo del resto o periodo de eliminacin de artefacto al paciente en que tragando, el cambio de posicin, etc., se anima. Se dan diez ensayos de controlar la reduccin en los msculos del myofacial durante cada sesin (Mesa 3). Slo d el refuerzo verbal cuando el paciente baja el potencial del msculo. Si la actividad de EMG se baja significativamente, refuerce la conducta correspondientemente. Si la actividad de EMG slo se disminuye ligeramente, premie al paciente comparablemente con el refuerzo verbal apacible y las tcnicas formando. (Formar es el desarrollo gradual de una contestacin correcta por medio de los esfuerzos iniciales pequeos, los primeros pasos provisionales alojados la direccin correcta hacia una meta particular). Usando el umbral de EMG que pone y refuerzo, una conducta particular puede formarse a un nivel del microvolt deseado. Puede ser til demostrar al paciente la asimetra inicial entre la izquierda y masseter del derecho. El MyoTrac2TM es un dual-cauce autnomo EMG que supervisa el sistema similar al MyoTrac(TM) pero con la memorizacin de EMG y computadora que unen las capacidades. Estos

dispositivos proporcionan una visualizacin grfica ms clara de los efectos de entrenar, y puede grabar la sesin al progreso de la sesin. As como el MyoTrac2(TM), el MyoDac2(TM), ProComp(TM) y FlexComp/DSP(TM) los instrumentos pueden unir con IBM las computadoras compatibles.

Figure 4. Mesa 3 Un procedimiento supervisando particularmente eficaz involucra comparando el non-tensin a los estmulos tensin-relacionados. Mientras el paciente se sienta, evale la actividad del msculo facial durante e inmediatamente despus de una discusin sobre un problema nonemocional, como actividades que pueden usarse para promover la relajacin. Compare los datos de non-tensin a actividad del msculo medida despus de una 3-5 discusin del minuto de un problema emocional, como el dolor facial del paciente y su impacto en funcionar diariamente. Note las diferencias entre el material emocional y nonemocional como reflejado en los niveles del microvolt relacionados al EMG supervisar. Consagre una porcin de cada sesin del tratamiento a corregir los modelos de myofacial de dysponetic del paciente como documentado a travs de la evaluacin del myofacial. Conductas que evolucionan en impropio msculo-tnico estn a menudo llamado ser el dysponetic. Los Dysponetic myofacial modelos pueden incluir fijando, mientras moliendo, rechinando, rechinando, y pulsando el botn de dientes. Ellos tambin pueden incluir el contacto de dientes durante masticar de mejillas o labios, lpices, las caeras, o incluso la enca. Los modelos de Dysponetic tambin podran incluir la actividad menos obvia, como imbalanced que respira o postura, reduccin de msculos en el cuello,

hombro o trax - todos de los cuales es diagnosable y treatable a travs de EMG que examina mtodos o procedimientos de la multi-medida. Los ejemplos de modelos del dysponetic pueden ser tiles. Muchos pacientes con la TMJ trastorno experiencia asimetras del msculo graduales y crecientes que producen el dolor. Mantener un estado dolorlibre o reducir el dolor, el paciente puede alterar muy ligeramente a la posicin de la mandbula en un esfuerzo. Aunque este posicionamiento puede relevar el dolor inicialmente, lleva a menudo a la amargura en otros msculos de la cara y mandbula debido a la tensin y tirando de msculo, particularmente en el lado opuesto de la cara. Msculos no slo se puestos penoso porque ellos son contrados pero tambin porque ellos se acortan. stos los desequilibrios del msculo son dondequiera que frecuentemente responsables para el dolor del tejido suave la tensin del msculo es experimentada, en las reas del cuello, cabeza, la parte de atrs, e incluso el pecho.

Casa que Entrena con MyoTrac(TM)


Reforzar el tratamiento efecta, EMG que supervisa en el lugar de trabajo del paciente y casa es muy til. MyoTrac(TM) y MyoTrac2(TM) el rasgo un rasgo de la alarma tardado que permite la actividad del msculo para exceder el lmite del umbral durante 4 segundos antes de que una alarma audible se oiga. El paciente puede llevar a cabo el normal hablando, mientras bostezando y otros movimientos, y slo se advierta por un tono continuo cuando la actividad del msculo ha sido el umbral anterior para mayor que 4 segundos. Para poner el nuevo MyoTrac(TM) en este modo:
1. los off/cont/thr del juego cambian al umbral 2. ponga los interruptores interiores al off/alarm/above/wide 3. Dgale al paciente que ponga un "trodo" el electrodo encima del rea del masseter, reljese la mandbula y ponga los bargraph despliegan para ser 2 o 3 LEDs verdes a la izquierda del amarillo LLEV, y entonces para hacer sobre la actividad diaria. Este proceso proporcionar la regeneracin incesante y entrenando en un ambiente de real-vida.

Hay tambin alguna evidencia que el supervisando nocturno y un umbral activaron la alarma pueden aliviar o pueden disminuir el bruxism nocturno. Para poner MyoTrac(TM) para el uso nocturno, siga el procedimiento anterior, sin embargo ponga el interruptor a la "cerradura" en el compartimiento de la batera a EN. Esto cerrar con llave el tono, mientras despertndose al paciente cuando la actividad de TMJ excede el umbral para ms de 4 segundos. El paciente se obliga a apagar la unidad y entonces EN de nuevo. Si el retiro es deseable, el audfono puede usarse.

La conclusin
La actividad del msculo facial puede formarse a un microvolt deseado nivele usando la retroalimentacin biolgica de EMG con las funciones del umbral y refuerzo. Documentos de la evidencia clnicos que los msculos del masseter pueden entrenarse para soltar y relax.6 los entrenamientos Continuados y regulares producirn los efectos beneficiosos a largo plazo, mientras permitindole al paciente permanecer dolor-libre, incluso bajo condiciones que despiertan la tensin. Usando el MyoTrac(TM) EMG para supervisar y evaluar el progreso paciente es bsico a un paciente est logrando la meta de xito del tratamiento.

LAS REFERENCIAS
1. Dohrman RS, Laskin DM: Una evaluacin de retroalimentacin biolgica del electromyographic en el tratamiento de sndrome de dolor-trastorno de myofacial. J Es la Mella Assoc, 96:656-662, 1978. 2. Empolle JR, Steger JC: EMG que examina en el diagnstico de dolor crnico. La retroalimentacin biolgica y Autorregulacin, 8:229-242, 1983. 3. Schneider CJ, Wilson ES: la Consideracin Especial para el EMG Retroalimentacin biolgica Entrenamiento. El Espinazo del trigo, CO: la Fundacin de Prctica de Retroalimentacin biolgica, la Sociedad de Retroalimentacin biolgica de Amrica, 1985. 4. Hudzinski LG, Lawrence GS: la Importancia de EMG superficie electrodo colocacin planea y resultados del dolor de cabeza. El dolor de cabeza, 28:30-35, 1988. 5. Hudzinski LG, Lawrence GS: Myofacial Pain y la Juntura de Temporomandibular. En el Atestamiento JR (el ed): EMG Clnico para las Grabaciones de la Superficie, 2 ed. La Ciudad de Nevada, CA los Recursos Clnicos, pp 329-351, 1990. 6. Budzinski TH, Stoyva S: Una tcnica de regeneracin de electromyographic para la relajacin voluntaria instruccin de msculo del masseter. J Dent Res, 52:116, 1973. 7. Chaco J: Electromyograph de los msculos del masseter en el sndrome de Costen. J de Med Oral. 28: 45-46, 1973. 8. Clark GT, Beemsterboer PL, Rugh JD: la actividad de msculo de masseter Nocturna y sntomas de trastorno del masticatory. J. de Rehabilitacin., 8: 279-285, 1981. 9. Gessel AH: la retroalimentacin biolgica de Electromyographic y antidepresivos del tricyclic en el myofacial duelen el sndrome del trastorno: el predictors psicolgico de resultado. J AMER. Assoc dental., 91: 1048-1057, 1975. 10. Vidrio AG, Rao SM: Bruxism: una revisin crtica. Psych. El boletn, 84: 767-781, 1977. 11. Malamed BG, Mealiea WL, Hijo,: Behavioral intervention in pain related problems in dentistry. El Manual Comprensivo de Medicina Conductual, Vol 2 (el pp. 241-259). La Ciudad de Culver, CA, el Espectro Int., Inc, 1981. 12. Scott DS, Lundeen TF: Myofacial duelen involucrando los msculos del masticatory: modelo experimental. Duela 8: 207-241, 1980.

Registre la propiedad literaria de, 1997 La Fundacin de Retroalimentacin biolgica de Europa


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Unrecommended Bruxism Treatments This section briefly describes widely used--but, for the most part ineffective--bruxism treatment modalities. In each of the cases below, my recommendation is simple: DON'T USE IT. Psychotherapy
The belief that bruxism is traceable to stress and other emotional and psychological factors gives rise to a variety of psychotherapeutic approaches (Murray, 1998). For instance, calmness and self-confidence may be fostered by listening to progressive relaxation, visual imagery, or autosuggestion tapes just before going to sleep (Horowitz, 1989).

Wakeful EMG Feedback


Another psychological approach to stress reduction resorts to instrumentation. During bruxing, the relevant muscles are active, and this increased activity or tenseness can in turn be measured with the electromyograph (EMG: electro = electric; myo = muscle; graph = record). During treatment sessions at home or the laboratory, the patient sits or reclines comfortably. One or more pairs of recording electrodes are then attached to the surface of the skin, in close contact to appropriate muscles (e.g., masseter muscles). These electrodes transmit information about the level of muscle activity to a computer monitor. The patient is instructed to consciously lower that level below a threshold line (also visible on the screen). Gradually, by becoming alert to the presence of

muscle tension, patients may develop techniques for reducing that tension, and hence, bruxism. One problem with this approach is expense--of the machinery and of expert guidance. Another problem is that muscles can be tense for a variety of reasons, and not simply because patients grind or clench. An unpleasant recollection, for instance, may result in a high reading, although it has nothing to do with bruxing. Moreover, as in the case of many other psychotherapeutic approaches, the training takes place in the daytime, when the patient is awake and when his behavior is under conscious control. It is not at all clear that such learning is transferable to the unconscious, sleeping, brain. The main problem, though, is lack of evidence that EMG feedback does the patient any good. In one study, for example, subjects undergoing this treatment for two weeks, along with a program of listening to relaxation tapes, seemed to brux no less than control subjects (who received no treatment whatsoever) while they were receiving this treatment or six months after treatment ceased (Pierce and Gale, 1988).

Massed Negative Practice


Another controversial approach is the so-called massed negative practice, a scholarly variation of the folk principle of reverse psychology. Here the patient is told to voluntarily clench the jaw for five seconds, relax it for five seconds, and repeat this procedure five times in succession, six different times a day, for two weeks (Thompson, Blount, and Krumholtz, 1994). Alternatively, the duration of the clenching period may be individually tailored to each patient, with each clench continuing to the point of discomfort (Pierce and Gale, 1988). This technique involves little or no cost and it does not interfere with the patient's sleep. But, by itself, this approach damages the teeth and may aggravate other bruxism symptoms (Feehan and Marsh, 1989, p. 181). Notwithstanding early enthusiastic clinical reports, at the moment the evidence for the effectiveness of this approach is meager at best. In one study, for example, subjects undergoing this treatment performed no better than controls while they were receiving this treatment or six months after treatment ceased (Pierce and Gale, 1988).

Exercise
Quinn (1995) and many others suggest isokinetic and stretching exercises of the mandible. Such exercises may or may not help alleviate bruxism, and they may perhaps be used to complement other approaches, but it seems unlikely that they could ever be used as the sole therapeutic approach.

Drugs
Both the stress and the brain malfunction theories give at times rise to the use of anti-anxiety agents, muscle relaxers, and other drugs. Most authorities, however, feel that, at best, drugs in use now are of limited value in the treatment of the great majority of chronic bruxers, and that they often involve, moreover, untoward side effects.

Equilibration Therapy
The malocclusion theory focuses correcting the malocclusion through orthodontic adjustment (=occlusal adjustment or equilibration). According to Ramfjord (1961), such adjustment was first used by Karolyi in 1901. But, as we have seen, the role of malocclusion in causing bruxism is in doubt. Also, this technique is irreversible, for it involves grinding down of some teeth (and artificially restoring others). Moreover, even if malocclusion triggered the bruxing habit, there are no guarantees that its removal will eliminate or ameliorate bruxing, for by now the habit may have become entrenched and self-sustaining. In view of these difficulties, and despite some spectacular claims in the older bruxism literature, it is perhaps safe to say that the majority of practitioners agree by now that "occlusal equilibration is costly and relatively ineffective" (Shatkin, 1992). Needless to say though, in severe and borderline cases of malocclusion, when equilibration would have been considered anyway, equilibration will continue to be used, and may constitute a part of a bruxism treatment program. But even then, this approach will need to be supplemented by other therapies aimed at eliminating what by now is probably an ingrained behavioral pattern.

Splints
By far the most common treatment regime for bruxism relies on the timehonored procedure of splint therapy. (e.g., Karolyi, 1906, cited in Ramfjord, 1961, p. 23; Matthews, 1942). In the United States alone, some 3.6 million splints (aka nightguards, biteguards, occlusal splints, biteplates, removable appliances, or interocclusal orthopedic appliances ) are annually prescribed by dentists in an effort to combat bruxism (1.6 million splints), myofacial pain (.9 million), and TMJ pain (1.1 million)--a $1 billion industry (Pierce et al., 1995). Much current research on the treatment of bruxism has been centered on the use of such dental appliances. Many patent applications describe splints for the treatment of bruxism (e.g., U.S. Pat. Nos. 5,666,973 and 5,823,193). A Hard Splint

There are many variations of this appliance. The most common is the customized, hard acrylic variety. Some dentists prefer a customized appliance made of soft, rubber-like, elastomeric material. One can also purchase prefabricated soft splints at a pharmacy. They cost much less than the custommade ones, but they dont provide as close a fit. Another, far less popular, variation is the hydrostatic splint, a water-bearing pressure-equalizing appliance sold under the commercial name "Aqualizer" and manufactured by Jumar Corp., Arizona (see also U.S. Pat. No. 4,211,008). This prefabricated splint does not require dental impressions or the manufacture of customized appliances. Instead, this disposable splint can be purchased through a dentist, ready-made for use, and is claimed to fit the mouths of most users. In practice, however, the pads often slip from under the teeth, the appliance wanders in the mouth, or is even expelled during sleep. These shortcomings could be readily overcome by combining the idea of a hydrostatic splint with the witch's brew biteplate design. The pads would be attached to the sleeves, and could be connected to each other either along the contours of the appliance, as they do now, or directly. The central question about all splints is: Just how effective are they? Like other therapies, the splint has its fair share of aficionados. For example, in one study (which, however, lacked controls and hence could not rule out a placebo effect, and which, moreover, relied for the most part on subjective measures of improvement), long-term reductions in symptoms of bruxism were noted even in patients who wore the splint for six months (Sheikholeslam, Holmgren, and Riise, 1986). However, even in this highly favorable report of splint therapy, "the signs and symptoms recurred to the pre-treatment level within 1-4 weeks in about 80% of the patients." Many other researchers feel that the splint does not diminish bruxing behavior, in the long term, nor alleviates most symptoms and consequences. They insist, in fact, that the splint only provides a measure of protection for

the teeth, and, in the case of grinders, a moderation of the sound. And even this is purchased at a price: the splint is uncomfortable to wear, some patients remove it during sleep, and it may negatively affect one's bite, cause decay, and lead to degenerative joint disease (Messing, 1992, p. 438). The splints popularity can probably be ascribed to the gap between dental research and practice--most dentists are simply too overworked to keep up with the dental literature. Also, the splint provides some protection for the teeth, and most dentists are naturally more interested in protecting teeth than in such things as appearance or the temporomandibular joint. For a short while, too, the splint is often effective in treating the closely related TMDs (Messing, 1992, p. 395), and there is a tendency often, in both lay and professional circles, to think of these two conditions as more closely related than they actually are. Moreover, for a short while, the splint may be truly successful in stopping bruxism, a temporary effect that may lull patients and dentists alike to its limited value over the long term. Then there is the placebo effect: any kind of treatment seems better than no treatment at all. In one study of TMD patients, for instance, 64% reported a striking improvement of their condition following two mock equilibration sessions (cited in Biondi and Picardi, 1993, p. 90). In two other studies, the artificial temporary creation of gross biting abnormalities led to reductions of masseter EMG activity during sleep in 90% (Rugh, Barghi, and Drago, 1984) and 44% (Shiau and Syu, 1995) of the subjects. Because all positive views of splint therapies merely claim improvement, not cure or cessation of bruxing, the use of a double-blind design and control groups seems essential. Yet, this essential experimental design feature is lacking in most studies of splint therapy. Lastly, there is the belief that nothing can really be done to treat the condition, or, if something can be done, that it's not easy to achieve, so one might as well lower one's sights and settle for a device with a proven, if temporary, track record. Given the popularity of the splint, and some of the claims that have been made about its effectiveness, it may be worth while to cite what appears to be, at this point, the emerging majority view in the research community: "The most common treatment is a rubber device, worn over the teeth at night, called a mouthguard. This does not actually prevent or cure the bruxism, but it will prevent damage to the teeth when bruxism occurs" (Hartmann, 1994, p. 601). "Occlusal splints worn at night did not significantly reduce bruxing-clenching activity in bruxing subjects" (Kydd and Daly, 1985). Pierce and Gale (1988) found that bruxing decreased by about 50% during two weeks of splint therapy, but that, following withdrawal of treatment, it returned to baseline levels. Klineberg (1994) concludes that occlusal splints "will protect the teeth, but will not alter the habit in the long term." Splints, he says, become "worn when in use and wear and tear on the splint indicates continuation of the habit, even though patient[s] might report that they were no longer aware of clenching their teeth. The longer term effects of splint therapy indicate that

clenching returns after the splint has been removed, or with continued use of it." (p. 15). According to Rugh et al. (1989), splint therapy is effective at first, but "the usual trend with longer treatment is to lose its effects. In other words, one usually sees a dramatic decrease or increase in EMG activity the first few nights of splint usage, followed by a gradual return to pretreatment EMG values." Perl (1994) says that "there is no way of preventing the clencher or bruxer from engaging in such parafunctional habits. Regardless, the clinician may be able to decrease the potential for destruction adding a nightguard to the treatment protocol." Sheikholeslam, Holmgren, and Riise (1982) conclude that "when patients stopped wearing the splint, "signs and symptoms of nocturnal bruxism returned to the pre-treatment level within a period of 1-4 weeks in 80% of the patients. . . . Thus, the splint therapy in most cases must be regarded as a symptomatic treatment" (p. 142). The comparative ineffectiveness of the traditional splint is also "borne out by the common clinical finding that patients may bite large teeth marks into night bite guards and frequently fracture appliances" (Trenouth, 1979). Moreover, the use of such splints may sometimes adversely affect the patient's occlusion, e.g., cause an open bite (cf. Ahlin, 1991; Wiygul, 1991): "As with any technique, splint therapy has both positive and negative effects. If the complications are known and understood, they can be included in the treatment planning process and discussed with the patient before treatment begins. The most common complication of splint therapy is the creation of changes in the patient's occlusion." (Messing, 1991, p. 437). Another complication of splint therapy is decay under the splint, which may in turn cause caries and gum inflammation. Still another problem is severe degenerative joint disease (Messing, 438).
After wearing a splint for a year, a patient can no longer Severe open bite. Source: Kaplan & Assael, 1992, p. bring his front teeth together 48

To sum up, the splint may help slow down the destruction of teeth and it may moderate the sounds of grinding. In some patients, it may bring about a

temporary reduction in bruxing, lowering it to about 50% of its former value. This effect, though real, may be nothing more than the well-known placebo effect, or it could be ascribable to the fact that the nighttime introduction of just about anything into the mouth temporarily alleviates bruxism symptoms. In a few patients, the splint may produce long-lasting improvement, although we are far from being sure about this more moderate claim. In other cases, it may intensify bruxism. Thus, the splint may or not stop bruxism for a while, it partially protects the teeth, and it moderates grinding sounds. For most patients, it accomplished little else. A patient may wear this uncomfortable appliance for years and years, perhaps risking an open bite where none existed before (a minor inconvenience, to be sure, but still annoying--try to eat artichoke leaves, a hard salami slice, or sunflower seeds with lower and upper front teeth that cannot come together), and still destroy her teeth, still develop headaches, still change her appearance for the worse, still develop TMD. Given these shortcomings, even the most enthusiastic advocates of splint therapy would have to concede that, at the very least, something else is required to treat the millions of chronic bruxers whose condition is getting worse despite faithfully wearing this appliance for years.

Sleep Feedback: An Introduction


We have already discussed wakeful biofeedback, which involves giving an awake patient information about the state of his facial muscles. There is yet another form of feedback therapy which holds perhaps the greatest promise in the development of effective treatment modalities for teeth grinding and clenching. As we have seen, this biofeedback variant is based on the belief that the habit of bruxism was likely to develop in the first place only because it has not been accompanied by immediate sensations of pain. When it comes to the habits of teeth grinding or clenching, nature failed to provide the pain or awareness signal which often blocks or minimizes self-destructive behavior. Sleep feedback approaches attempt to artificially reintroduce this missing signal. Such approaches often successfully treat other sleep disorders. For instance, idiopathic primary enuresis (bedwetting) can sometimes be cured by sounding an alarm at the moment urine is released (Broughton, 1994, p. 395; cf. U.S. Pat. No. 1,772,232). This alerts a sleeper to the bedwetting at the moment in which it is taken place, as opposed to finding out that it happened upon waking, hours later, as a bedwetter would in the absence of such an alarm

system. The sleeping brain, apparently, is capable of responding to signals and modifying ingrained patterns of behavior.

Sleep Feedback: Sound Alarms


In the treatment of bruxism, sleep feedback may involve electromyographic (EMG)-activated alarms (Cassisi, McGlynn, and Belles, 1987; U.S. Pat. No. 4,934,378). Bruxism, as we saw, requires tensing of certain facial muscles. This tensing involves an increase in electrical activity of the muscles, which can in turn be recorded by an electromyograph. The electrodes of this instrument are placed on the facial area where these muscles are located. When the tenseness exceeds a certain, predetermined, level, the alarm goes off. The loudspeaker can be free standing, or, to prevent waking others, connected to earphones which the patient wears during sleep. Most clinicians recommend overcorrection right after the alarm sounds. The patient is advised to fully wake up after each bruxing episode and to stay awake for a few minutes, usually by performing such meaningless, harmless tasks as hand washing or recording time in a bruxism log (Cassisi, McGlynn, and Belles, 1987). In either case, the alarm can be turned off manually by the awake bruxer or be turned off automatically when the sleeper's facial muscles relax. This approach is fairly unintrusive--one need not insert anything into the mouth, but need only attach electrodes externally, to the face. On the other hand, this procedure may fail to correct any bruxing behavior which is associated with muscle tension lower than the predetermined intensity or duration threshold. Another obvious problem is that muscle tension may occur in the absence of bruxism: "numerous other types of orofacial movements unrelated to bruxism . . . can easily be confused with bruxism if only EMG criteria are used for scoring" (Miguel et al., 1992). So a patient may sometimes not receive a signal when a signal is needed, while at other times a patient may be jolted out of deep sleep for nothing. To bypass this problem, many United States patents rely on an alarm system, but take the more reliable bruxing activity itself (instead of enhanced muscle activity) as their point of departure (U.S. Pat. Nos. 4,220,142; 4,976,618; 4,979,516; 4,989,616; 4,995,404; 5,078,153; 5,190,051; 5,586,562). The extra pressure may be registered, for example, by securely inserting a strain gauge between the teeth. When the pressure exceeds a predetermined level, the alarm goes off. A commercially available device, the OralSensor, manufactured by Cycura Corp. of Rocklin, CA, similarly produces an audible tone when bruxism occurs.

The OralSensor

A typical sound alarm setup for the treatment of bruxism. Source: U.S. Patent #5,078, 153, Jan. 7, 1992

Feedback approaches employing sound alarms share some of the drawbacks of EMG-activated alarms. They also suffer from machine breakdowns and are often unsightly, invasive, intimidating, and expensive; they thus do not lend themselves readily to wide use, and especially not to long-term use. As well, they are only partially effective. In evaluating EMG-activated studies, Pierce and Gale (1988) found that bruxing only decreased by about 50% during two weeks of biofeedback therapy, but that, following withdrawal of treatment, the

condition returned to baseline levels. Piccione et al. (1982), to cite another example, found that "biofeedback does not appear to be effective in reducing nocturnal bruxing," probably because, over time, "subjects learned to ignore the tone and to maintain sleep."

Sleep Feedback: Electrical Stimulation


In another biofeedback embodiment, bruxism is followed by electrical stimulation to the jaw (U.S. Pat. No 4,669,477), neck (U.S. Pat. No. 4,715,367), lip (Clark et al., 1993), mouth (U.S. Pat. Nos. 4,995,404; 6,490,520), or tooth (U.S. Pat. No. 5,553,626). These approaches share many of the strengths and weaknesses of sound alarms. In all such cases, an optimal stimulus level must be found which is strong enough to discontinue bruxing, but not to cause undue pain, hurt, or unduly startle the patient. The effectiveness of these approaches has yet to be studied and evaluated in a large-scale, controlled, study.
References Ahlin J. H. (1991). Clinical application of remoldable appliances for craniomandibular disorder. Cranio Clinics International, 1, 65-79. Biondi, M., & Picardi, A. (993). Temporomandibular joint pain-dysfunction syndrome and bruxism: etiopathogenesis and treatment from a psychosomatic integrative viewpoint. Psycother Psychosom, 59, 84-98. Blount, R. L., Drabman, N. W., Wilson, W., & Stewart, D. (1982). Reducing severe diurnal bruxism in two profoundly retarded females. Journal of Applied Behavior Analysis, 15, 565-71. Broughton, R. J. (1994). Parasomnias. In S. Chokroverty (Ed.). Sleep Disorders Medicine (pp. 381-99). Boston: Butterworth-Heinemann. Cassisi, J. E., Mcglynn, F. D., & Belles, D. R. (1987). EMG-activated feedback alarms for the treatment of nocturnal bruxism: current status and future directions. Biofeedback & Self Regulation, 12, 13-30. Clark, G. T., Koyano, M. S., & Browne, P. A. (1993). Oral motor disorders in humans. CDA Journal 21, 19-30. Clarke, J. H. and Reynolds, P. J. Suggestive hypnotherapy for nocturnal bruxism: a pilot study. 1991. American Journal of Clinical Hypnosis 33(4): 248-53. Ellison, J. M. , and Stanziani P. (1993). SSRI-associated nocturnal bruxism in four patients. Journal of Clinical Psychiatry, 54, 432-434.

Feehan, M. & Marsh, N. (1989). The reduction of bruxism using contingent EMG audible biofeedback: A case study. Journal of Behavioural Therapy and Experimental Psychiatry, 20, 179-183. Golan, H. 1989. Temporomandibular joint disease treated with hypnosis. American Journal of Clinical Hypnosis, 31: 269-274. Hartmann, E. (1994). Bruxism. In M. H. Kryger, T. Roth, & W. C. Dement (Eds). Principles and Practice of Sleep Medicine (2nd ed., pp. 598-601). Philadelphia: W. B. Saunders. Horowitz, L. G. Freedom from Teeth Grinding and Night Clenching. Rockport: Tetrahedron, 1989. Kaplan, A. A., Goldman J. R. General Concepts of Treatment. In Kaplan, A. S. and Assael, L. A. 1992. Temporomandibular Disorders. Philadelphia: Saunders, pp. 388-394. Klineberg, I. Bruxism: aetiology, clinical signs and symptoms. 1994. Australian Prosthodontic Journal 8: 9-17. Kydd, W. L. and Daly, C. Duration of Nocturnal tooth contacts during bruxing. 1985. Journal of Prosthetic Dentistry, 53(5): 717-721. LaCrosse, M. B. Understanding change: Five-year follow-up of brief hypnotic treatment of chronic bruxism. 1994. American Journal of Clinical Hypnosis 36(4): 276-181. Lehvila, P. Bruxism and magnesium: Literature Review and Case Reports. Proc. Finn. Dent. Soc. 70: 217-224, 1994. Lerman, M. D. (1987). The hydrostatic splint: new muscle-directed TMJ-PDS treatment technique. CDS Review, 80, 30-34. Long, J, H., Jr. (1998). A device to prevent jaw clenching. Journal of Prosthetic Dentistry, 79, 353-4. Matthews, E. (1942). A treatment for the teeth-grinding habit. Dental Record, 62, 154-155. Messing, S. G. (1992). Splint Therapy. In A. S. Kaplan & L. A. Assael. Temporomandibular Disorders (pp. 395-454). Philadelphia: Saunders. Miguel, A. M. V, Montplaisir, J., Rompre, P. H., Lund, J. P., & Lavigne G. J. (1992). Bruxism and other orofacial movements during sleep. Journal of Craniomandibular Disorders, 6, 71-81. Murray, B. A psychologist investigates what sets peoples teeth on edge. 1998. APA Monitor Online, 29 (6).

Perel, M. L. (1994). Parafunctional habits, nightguards, and root form implants. Implant Dentistry, 3, 261-3. Piccione, A., Coates, T. J., George, J. M., Rosenthal, D. & Karzmark, P. (1982). Nocturnal biofeedback for nocturnal bruxism. Biofeedback and Self-Regulation, 7, 405-19. Pierce, C. J. & Gale, E. N. (1988). A comparison of different treatments for nocturnal bruxism. Journal of Dental Research, 67, 597-601. Ploceniak, C. Bruxism and magnesium, my clinical experiences since 1980. 1990. Revue de Stomatologie et de Chirurgie Maxillo-Faciale, (French; English abstract in Medline). 1990. 91 Suppl. 1:127 Quinn, J. H. Mandibular exercises to control bruxism and deviation problems. 1995. Cranio 13(1): 30-34. Ramfjord, S. P. (1961). Bruxism, a clinical and electromyographic study. Journal of the American Dental Association, 2, 21-44. Rijsdijk, B. A., Van Es R. J., Zonneveld, F. W., Steenks, M. H., & Koole, R. (1998). Botulinum toxin type A treatment of cosmetically disturbing masseteric hypertrophy. Nederlands Tijdschrift voor Geneeskunde, 142, 529-32. Rugh, J. D., Barghi, N. and H. Drago, C. J. Experimental occlusal discrepancies and nocturnal bruxism. 1984. Journal of Prosthetic Dentistry 51: 548-553. Rugh, J. D., Graham, G. S., Smith, J. C., & Ohrbach, R. K. (1989). Effects of canine versus molar occlusal splint guidance on nocturnal bruxism and craniomandibular symptomatology. Journal of Craniomandibular Disorders, 3, 203-210. Shatkin, A. J. Bruxism and Bruxomania. 1992. Rhode Island Dental Journal 25(4): 7-10. Sheikholeslam, A. Holmgren, K. and Riise, C. 1986. A clinical and electromyographic study of the long-term effects of an occlusal splint of the temporal and masseter muscles in patients with functional disorders and nocturnal bruxism. Journal of Oral Rehabilitation 13: 137-145. Shiau, Y. Y., Syu, J. Z. Effect of working side interferences on mandibular movement in bruxers and non-bruxers. Journal of Oral Rehabilitation, 1995, 22: 145-151. Thompson, B. H., Blount, B. W., & Krumholtz, T. S. (1994). Treatment approaches to bruxism. American Family Physician, 49, 1617-22. Trenouth, M. J. (1979). The relationship between bruxism and temporomandibular joint dysfunction as shown by computer analysis of nocturnal tooth contact patterns. Journal of Oral Rehabilitation, 6, 81-87.

Van Dongen, C. A. (1992). Update and literature review of bruxism. Rhode Island Dental Journal, 25, 11-16. Watson, T. S. (1993). Effectiveness of arousal and arousal plus overcorrection to reduce nocturnal bruxism. Journal of Behavior Therapy and Experimental Psychiatry 24, 181-185. Wiygul, J. P. (1991). Maxillary full-coverage appliance. Cranio Clinics International, 1, 39-53. Yustin, D., Neff, P., Rieger, M. R., and Hurst, T. Characterization of 86 bruxing patients and long-term study of their management with occlusal devices and other forms of therapy. 1993. Journal of Orofacial Pain 7: 54-60.
Back to Bruxism Menu

---------------------------------------------------------------------------------------------------------Biofeedback And Relaxation Therapy As Components In The Treatment Of Nocturnal Bruxism by PAUL W. GWOZDZ

prepared for the Behavioral Science Course Specialized Seminar Relaxation, Stress Management, and Behavioral Medicine Leader: Dr. Paul Lehrer, Ph.D. November 9, 1994

Copyright 1997 Paul W. Gwozdz All Rights Reserved

Nocturnal bruxism is the non-functional clenching, grinding or gnashing of the teeth during sleep[1], a disorder which significantly effects between 5% and 20% of the general population and is found in 20% of dental patients [2] . There are several approaches that are commonly used in treating nocturnal bruxism. There are dental approaches, which involve a plastic mouth guard designed to protect the teeth and/or change the bite. Dentists often provide what is called "occlusal adjustment", a controversial procedure, in

which the surfaces of some of the teeth are modified to fit together better. [3] An alternative to dental procedures, is therapy which may take the form of biofeedback, relaxation techniques or stress management through behavioral counseling. Biofeedback is the use of electronic instruments which allow one to measure and monitor muscle activity directly. There are three different forms of biofeedback for bruxism biofeedback equipment which must be used in the practitioner's office, portable biofeedback equipment that can be worn during the day in the patients own environment, and sleep-time biofeedback equipment that is designed specifically for nocturnal bruxism therapy. The biofeedback section of this paper will concern itself with only the sleep-time biofeedback equipment and its use as reported in the literature since this is appears to be the most popular technique for nocturnal bruxism. This type of biofeedback is also called "sleep interruption biofeedback" and has been shown in several studies to greatly reduce the amount of bruxing during sleep. [4] The therapy usually requires several weeks of use and will be described in detail later in the next section of this paper through the detailed review of a recent study. Relaxation therapies involve learning to relax muscles deeply and rapidly enough to be therapeutic, and long enough and often enough to be effective. It usually requires the individual to relax the whole body. This therapy may take several forms including the use of preprogrammed cassette tapes[5], hypnotism or self-hypnotism. Later in this paper, a case will be reviewed in which a 63 year old woman, who had been bruxing since the age of 3, was very quickly cured of nocturnal bruxing through the use of relaxation techniques including hypnotism. Stress management through behavioral counseling also appears to be an effective approach to the problem of nocturnal bruxism. Although this approach is outside of the main focus of this paper, one interesting study will be discussed which compared counseling to the use of biofeedback and to the combination of counseling and biofeedback.

A. BIOFEEDBACK
An early biofeedback study was reported in 1970 by DeRisi in which three bruxist subjects used a pressure transducer implanted in a silastic mouthpiece while sleeping in their own homes. The equipment presented a loud tone contingent upon rhythmic or lengthy pressure registration. Use of the alarm failed to produce enduring behavior change according to three experiments. More importantly, use of the mouthpiece posed an important methodological problem. It is now apparent that the transducer upset the normal relationships between the tooth surfaces and upset the masticatory system. Depending upon a variety of parameters, the modification of gliding contacts between upper and lower teeth can change the rate of bruxing activity. [6] The foundation for contemporary bruxing alarm systems was established in 1972 through the use of epidermal surface recordings of facial EMG activity to define bruxing. It was found that the EMG levels associated with bruxing were easy to identify compared to normal nocturnal behaviors such as swallowing. No incursion into the oral cavity was necessary and the EMG was able to record both audible grinding as well as clenching. [7] These "facial EMG-triggered alarms" appear to be the basis in most of the nocturnal bruxing alarm studies that have since been performed.

A good demonstrative example of the use of biofeedback is the following paper. In 1989, Feehan and Marsh [8] reported a single case in which EMG biofeedback behavior was utilized along with an accurately quantified brux core assessment. The subject was an 18 year old woman with mild depression, high anxiety (>95 %-tile), and sharp severe pain in her left TMJ. Assessment of the extent of the bruxing was conducted with the brux cores originally developed by Forgione (1974). The cores consisted of four differently colored plastic sheets laminated together to a total thickness of .02 inches with microdots printed on the upper most surface. The plastic was molded in a vacuum press into upper maxillary plates which were worn by the subject during sleep and during the day. To score the extent of the bruxing, each tooth surface on a plate was individually scored then totalled. A tooth that had two dots ground away received a score of 2. If the first layer under the two dots was exposed, the score would be 4, and so on, until all four layers were ground away and the score for the final are would be 10. [9] The authors used biofeedback at home with electrodes taped to her masseter. The threshold on the unit was set to sound on a moderate clenching force but not on swallowing. A different tone was used each night to avoid habituation. When the tone sounded, the subject was required to turn on the light and record the bruxing and the level of pain in her jaw. The purpose for recording the information, though, was to make sure that she was really aroused before returning to sleep. The progress that was reported showed a significant initial reduction followed by a spurt and then a more expected decline with zero awakenings by the 18th day. The initial decline could either be due to a reduction in the frequency of bruxing events or habituation. The threshold of the trigger was lowered during the second phase and the number of events rose significantly which would not be expected if habituation had occurred. Even at this lowered threshold the wakenings dropped off rapidly. Following the final phase, the brux cores were readministered and a dramatic reduction in the extent of abnormal wear was clear even to cursory visual examination of the cores. Overall, there was a 78% reduction in diurnal bruxing and a 66% reduction in nocturnal bruxing. Even though the patient was still occasionally bruxing after treatment, she reported much improvement in terms of pain and ability to open her mouth for eating. [10] Treatment was terminated after 3 weeks and during informal contact with the patient at six months, she reported no significant symptoms. [11] This study was significant since bruxing was reduced by two thirds after less than a month and the technique was more sophisticated than others since the attachment of the electrode to the jaw provides more accurate feedback and the multiple tone feedback prevents habituation which occurred in the Heller and Strang study (1973). [12] In a more recent (1993) and very interesting paper, Steuart Watson of Mississippi State University, combined arousal with overcorrection to completely eliminate bruxing in two married subjects. Since the subjects were married, Watson substituted a spouse for the EMG equipment, though, EMG equipment would probably have been better and appears to be easily resubstituted if available. The overcorrection on top of the arousal appeared to make a significant difference in the final results of this study.[13] The two subjects were Mark and Jenny. Mark was a 28 year old developmentally normal male with a 6 month history of nocturnal bruxism. Jenny was a 24 year old developmentally normal female with a 3 month history of nocturnal bruxism and had

begun bruxing just after graduating college. Both were reported by their spouses to brux the most during the first two hours of sleep. [14] As a baseline, their respective spouses recorded the number of time they were awakened by their spouses bruxing during the 2 hour period. These ranged between 4 and 9 times in two hours. During the next phase of the project, Mark and Jenny were awakened by their partners as soon as they were heard bruxing. They were required to sit up briefly (15 - 20 seconds) with their eyes open each time. After a week of steady improvement, a 5 day baseline was reestablished during which bruxing rose again. A second period of arousal followed by baselining was performed on each subject with the expected results improvement followed by some remission. Then came the interesting part of this study. For the next phase, the subjects were awakened and then were required to complete a 10 minute overcorrection procedure which consisted of face and hand washing, brushing and flossing teeth, rinsing the mouth with water and then mouthwash and repeating the procedure. The spouses were instructed not to provide any social interaction throughout implementation of the overcorrection procedure. After five successive nights with no bruxing, treatment was withdrawn and data was collected for five days. The average number of bruxes during the baseline for Mark and Jenny was 5.6 and 6.5 respectively. The initial phase of arousal resulted in a 40% decrease for Mark and a 33% decrease for Jenny. WIthdrawal of arousal resulted in increase of bruxing for both subjects. The second phase of arousal further reduced bruxing by an additional 20 % for Mark and 33% for Jenny. Another withdrawal of the arousal intervention resulted in minor escalations of bruxing. After the second return to baseline, the overcorrection procedure was added to arousal. Although the addition of overcorrection did not result in an immediate cessation of bruxing, it reduced bruxing to zero frequency. There was a return to baseline after five successive nights and no further instances of bruxing. Followup showed that Mark bruxed once at 3 months post treatment while Jenny had not bruxed at all. [15] Watson suggests that the most probable explanation for why arousal was ineffective in treating nocturnal bruxism is that the procedure was not of sufficient aversive strength in that the subject could almost immediately return to sleep following implementation of the procedure. He goes on to suggest that more research in this area is needed. [16] This author would like to know what would the result be if an electric shock was administered by the EMG device automatically!

B. RELAXATION THERAPY THROUGH HYPNOSIS


Clarke and Reynolds of the Oregon Health Sciences University School of Dentistry reported in 1991 a study of eight subjects who received hypnotherapy for their nocturnal bruxism. The authors used a compact, portable , integrating EMG detector (AL-200B Muscle Activity Integrator, Aaron Laboratories) to monitor levels of masseter muscle EMG activity. The study was setup as a one-group pretest-posttest design. The pretest was a 7 night series of EMG recording during natural sleep in each subject's own home. Treatment consisted of hypnotherapy and posttests consisted of a self-rating of change in symptoms and a repetition of the 7 night EMG recordings as done in the pretest. [17]

The treatment approach used was referred to as "suggestive hypnotherapy" to identify the use of hypnotic suggestion and to distinguish it from psychotherapeutic hypnosis. A number of inductions, deepening techniques, and hypnotic images were suggested. The phrase "lips together, teeth apart" was presented as a reminder of the relaxed jaw position. Images such as hot towels on the face were also suggested. An audiotape was made with the subject responding to the suggestions. The tape employed the induction and deepening suggestions he or she preferred along with images from the subjects earlier hypnosis. The subject was instructed to listen each night and then drift off to sleep. After a month, the subject returned for a progress check, reported results, asked questions and received a 10 minute hypnosis session for reinforcement. The number of treatment sessions ranged from four to eight and most subjects were completed in 2 to 4 months. [18] The author's believe that this study focused on bruxism as a habitual counterproductive response to psychological stress, and the treatment described is essentially a method of using hypnosis to alter the stress response. Nocturnal EMG activity of the bruxers upon completion of the study decreased from between 17% and 75%. Self rating by the subjects indicated most thought that they were much better immediately after the study but there was more variability in the self rating several months after the study. Responses ranged from slightly better to totally symptom free ( in 2 of 8 patients). [19] A recent article by Michael LaCrosse or Norfolk, Nebraska in the American Journal of Clinical Hypnosis recounts his experience as a therapist using hypnosis with a bruxer. The patient was a very highly motivated 63 year old woman who had nocturnally bruxed since the age of 3. Dental overlay splints were unsuccessful since she ground through them in her sleep! She worried a lot and often awakened 3 to 6 times per night "with something" on her mind (i.e. worries). His treatment strategy was in two parts which reduces the confidence that the hypnosis was "the" solution but the results were quite miraculous. LaCrosse first assigned the patient to do her worrying during a half hour interval in the least comfortable room in the house. If she started to worry outside of her interval she was to write the problem down but wait to worry about it until the half hour arrived. During the half hour she would write about all of her worries. For the second part of the therapy, she received hypnosis which suggested that there was nothing in life worth being too upset about. She was also instructed that she would sleep comfortably but awaken (without remembering) anytime she began to brux. Within three days, the patient was cured of her bruxing and in 1 month, 20 month, 37 month and 60 month followups, she and her husband reported separately that she was cured. [20]

C. RELAXATION THERAPY THROUGH BEHAVIORAL COUNSELING


In 1981, Casas, Beemsterboer and Clark, from the University of California at Santa Barbara and LA, performed a study which compared the efficacy of two treatment modalities on night time bruxism - stress reduction behavioral counseling and nocturnal EMG biofeedback. Sixteen subjects were assigned to one of four treatment groups: 1) stress reduction behavioral counseling, 2) sleep interruption biofeedback, 3) stress reduction behavioral counseling AND sleep interruption biofeedback and 4) "waiting list" control group. In the counseling group, the subjects of the study were taught to attribute bruxism to specific cognitions or self-statements rather than to external stimuli or complex inner dispositions. They were also instructed to use their internal speech to get themselves into a more relaxed state. [21]

The study demonstrated that the three treatments procedures were significantly superior to the no-treatment control group (i.e. greater reduction in EMG activity level). The outcome of the two treatments that made use of stress-reduction behavioral counseling was better than the treatment that solely made use of nocturnal contingent EMG feedback; however, the difference did not approach significance. Finally, the addition of nocturnal contingent EMG feedback to the stress-reduction behavioral counseling did not significantly increase its effectiveness. The authors of the study concluded that stress-reduction skills learned while awake can have a generalized effect on bruxing activity during sleep. [22] The author of this paper concluded that behavioral counseling is yet an additional approach that may have therapeutic value for nocturnal bruxism though not significantly better than sleep interrupted biofeedback.

SUMMARY
To summarize, there are several approaches to the problem of nocturnal bruxism. The most popular in the literature appears to be sleep interrupted biofeedback. The studies indicate that for the training to be effective, the subject must be sufficiently roused from their sleep when caught bruxing. The sensors should be external so as not to disturb the natural bite of the individual. The training needs to be performed for several weeks to avoid extinction and the feedback tone needs to change on a nightly basis in order to avoid habituation. There were not as many articles on hypnosis or self-hypnosis in the literature searched on MEDLINE. Both articles discussed though concluded that hypnosis was an effective treatment for nocturnal bruxism. The one article that was found about the 63 year old woman was just a single case report, although if based in fact, it certainly should be pursued by further research since the results were close to miraculous. Behavioral counseling provides an alternative to biofeedback but was not significantly better and would also require more individual attention of a trained instructor or counselor. The sleep interrupted biofeedback system requires much less training but does require the device being available. A personal comment after reading many of these studies is the noticeable lack of statistically significant study populations. This author has to agree with Cassisi, McGlynn, and Belles, when in 1987 they wrote that " A ... problem characterizing this literature is frequent failure to achieve the basic desiderata of the scientific paradigms that specific experiments represent. Group naturalistic trials, between-group comparisons of alternative treatments, and so forth, have routinely made use of fewer than 10 subjects within experimental conditions. In the absence of predictably robust effects, these sample sizes fall well short of actuarial acceptability (cf. Tversky & Kahneman, 1971)." [23] Despite this problem, though, it is clear that further study is warranted and the use of any of these aforementioned techniques should not be precluded in the therapy of nocturnal bruxism.

REFERENCES

[1]. Cassisi, Jeffrey E and McGlynn, F. Dudley (1988); Effects of EMG Activated Alarms on Nocturnal Bruxism; Behavior Therapy 19, 133-142. [2]. Feehan and Marsh (1989). The Reduction of Bruxism Using Contingent EMG Audible Biofeedback: A Case Study, Journal of Behavioral Therapy and Experimental Psychiatry, Vol 20, No. 2, p. 179. [3]. Schwartz, Mark Stephen (1987). BIOFEEDBACK A Practitioner's Guide, The Guilford Press, p. 298 [4]. Schwartz, pp. 299-300. [5]. Schwartz, p.298. [6]. Cassisi etal. p 14. [7]. Cassisi etal. p. 15. [8]. Feehan and Marsh, p. 180. [9]. Feehan and Marsh p. 181. [10]. Feehan and Marsh, p. 181. [11]. Feehan and Marsh, p. 182. [12]. Feehan and Marsh, p. 182. [13]. Watson, T. Steuart (1993). Effectiveness of Arousal and Arousal Plus Overcorrection to Reduce Nocturnal Bruxism, Journal of Behavioral Therapy and Experimental Psychiatry, Vol 24, No. 2, p. 181-182. [14]. Watson, p.182. [15]. Watson, p.183-184. [16]. Watson, p. 184. [17]. Clarke, J.H. and Reynolds, P.J. (1991). Suggestive Hypnotherapy for Nocturnal Bruxism: A Pilot Study, American Journal of Clinical Hypnosis, Vol 33, No. 4, p. 249. [18]. Clarke and Reynolds, p. 250.

[19]. Clarke and Reynolds, p. 252. [20]. LaCrosse, Michael B. (1994). Understanding Change: Five-Year Follow up of Brief Hypnotic Treatment of Chronic Bruxism, American Journal of Hypnosis , 36:4, pp. 277281. [21]. Casas, Jesus Manuel, Beemsterboer, Phyllis, and Clark, Glenn T. (1982). A Comparison of Stress-Reduction Behavioral Counseling and Contingent Nocturnal EMG Feedback for the Treatment of Bruxism, Behav Res. Ther, Vol 20, pp. 9-12. [22]. Casas et al., p. 13. [23]. Cassisi, McGlynn and Belles (1987). EMG-Activated Feedback Alarms for the Treatment of Nocturnal Bruxism: Current Status and Future Directions. Biofeedback and Self-Regulation, Vol. 12, No. 1, p. 26-27. Paul Gwozdz' Homepage