treatment of bruxism and TMJ dysfunction

1. The differential diagnosis of temporomandibular disorders.

2. The role of occlusion in temporomandibular disorders.

3. The role of bruxism in temporomandibular disorders.

4. Managing Masticatory Muscle Pain disorders.

5. Managing Intracapsular TMJ Pain disorders.

6. The use of occlusal appliances in temporomandibular disorders.

7. When an occlusal appliance reduces the TMD symptoms, what do you do next?

8. When are permanent occlusal changes indicated for TMD.

About the lecturer:

Dr. Okeson is Professor, Division Chief and Director of the Orofacial Pain Program, which he established in 1977.

Dr. Okeson has more than 240 publications in the area of TM disorders and orofacial pain in various national and international journals.

He has authored two textbooks on TM disorders and orofacial pain, which have been translated into eleven different languages.

Dr. Okeson is a very sought after lecturer on the subject of TMD and orofacial pain and has presented more than 1300 invited lectures on the subject of TMD and orofacial pain in all 50 states and in 58 different countries.

- Understanding bruxism…which is not just grinding the teeth
- Comprehending the assessment strategies
- Changing old paradigms focused on dental occlusion - neither bruxism nor Temporomandibular disorders must be treated by occlusal corrections
- Evaluating the clinical impact of different bruxism activities, from tooth wear to Temporomandibular Disorders
- Managing bruxism, bearing in mind that bruxism is a masticatory muscles activity that is a sign of some underlying conditions

In 2013, consensus was obtained on a definition of bruxism as repetitive masticatory muscle activity characterized by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible, and specified as either sleep bruxism or awake bruxism. In addition, a grading system was proposed to determine the likelihood that a certain assessment of bruxism actually yields a valid outcome. Recently, a need for an update and upgrade of such consensus emerged, with specific focus on the following aims: 1. to further clarify the 2013 definition and to develop separate definitions for sleep and awake bruxism; 2. to determine whether bruxism is a disorder rather than a behavior that can be a risk factor for certain clinical conditions; 3. to reexamine the 2013 grading system; and 4. to develop a research agenda.

Based on that, a panel of experts prepared a new consensus document, specifying that: 1. sleep and awake bruxism are masticatory muscle activities that occur during sleep (characterized as rhythmic or non-rhythmic) and wakefulness (characterized by repetitive or sustained tooth contact and/or by bracing or thrusting of the mandible), respectively; 2. in otherwise healthy individuals, bruxism should not be considered as a disorder, but rather as a behavior that can be a risk (and/or protective) factor for certain clinical consequences; 3. both non-instrumental approaches (notably self-report) and instrumental approaches (notably electromyography) can be employed to assess bruxism; and 4. standard cut-off points for establishing the presence or absence of bruxism should not be used in otherwise healthy individuals; rather, bruxism-related masticatory muscle activities should be assessed in the behavior’s continuum.

Approaches for assessing bruxism can be distinguished as non-instrumental or instrumental. Noninstrumental approaches for assessing bruxism include self-report (questionnaires, oral history) and clinical inspection, both for sleep and awake bruxism. Instrumental approaches for assessment are currently available for both forms of bruxism. Measurement of jaw muscle activity via polysomnography (PSG) or electromyography (EMG) is the standard of reference for sleep bruxism. Ecological momentary assessment (experience sampling methodology [EMA/ESM]) app-based assessments for real time subjective information about masticatory muscle activities at certain time points during the awake phase can also provide evidence of awake bruxism.

For various reasons, it must be remarked that using standard cut-off points for everyone for the ‘gold-standard’ assessment of sleep bruxism or non-sleep bruxism should not be considered optimal for clinical use in otherwise healthy individuals. This issue is best exemplified by the still inconclusive literature on the polysomnographic assessment of sleep bruxism and its clinical consequences. Indeed, bruxism has always been considered a detrimental factor for the stomatognathic structures. This lecture will provide a brief overview on its role as a risk factor for the following clinical consequences:
1. Tooth wear;
2. Biological (i.e., implant failure, implant mobility, and marginal bone loss) or mechanical (i.e., complications or failures of either prefabricated components or laboratory-fabricated suprastructures) complications on dental implant-supported rehabilitations;
3. Temporomandibular disorders (TMD). In particular, the proposed mechanism for the bruxism-TMD relationship within a biopsychosocial framework at the individual level is that stress sensitivity and anxious personality traits may be responsible for those bruxism activities that may lead to TMD pain, which, in turn, is modulated by psychosocial factors (e.g., depression, anxiety, treatment-seeking behavior).

As for bruxism management, based on available knowledge drawn from a recent systematic literature review by Manfredini and colleagues (J Oral Rehabil 2015), it can be suggested that: 1. almost every type of oral appliance (OA) (seven papers) is somehow effective to reduce SB activity, with a potentially higher decrease for devices providing large extent of mandibular advancement; 2. all tested pharmacological approaches (i.e., botulinum toxin [two papers], clonazepam [one paper], and clonidine [one paper]) may reduce SB with respect to placebo; 3. the potential benefit of biofeedback (BF) and cognitive behavioral (CB) approaches to SB management is not fully supported (two papers); and 4. the only investigation providing an electrical stimulus to the masseter muscle supports its effectiveness to reduce SB. It can be concluded that there is not enough evidence to define a standard of reference approach for SB treatment, except for the use of OA. Future studies on the indications for SB treatment are recommended. Until that, a so-called “Multiple-P” approach including Pep Talk (i.e., counseling), Plates (i.e., oral appliances), Psychology, Physiotherapy, and Pharmacology, is the best available, good-sense, option to manage bruxism and its consequences in the clinical setting.

About the lecturer:

Daniele Manfredini received his DDS from the University of Pisa, Italy in 1999, a MSc in Occlusion and Craniomandibular Disorders in 2001 from the same University, a PhD in Dentistry from the ACTA Amsterdam, The Netherlands, in 2011, and a Post-Graduation Specialty in Orthodontics from the University of Ferrara, Italy, in 2017.
He was a clinical fellow at the Section of Prosthetic Dentistry, Department of Neuroscience, University of Pisa, Italy until 2005.
Since 2006, Daniele Manfredini has been Assistant Professor and coordinator of the research projects at the TMD Clinic, Department of Maxillofacial Surgery, University of Padova, Italy, and he held teachings in Prosthodontics and TMJ Physiopathology, and in Bruxism and Parafunctions at the School of Dentistry, University of Padova until 2016.
Currently, Daniele Manfredini holds teaching in Oral Physiology and in Clinical Gnathology at the School of Dentistry, University of Siena, Italy.
On January 2017, the Italian Ministry of University and Research (MIUR) appointed him as a Full Professor by scientific merit at the age of 41.
Daniele Manfredini authored more than 180 papers in the field of bruxism and temporomandibular disorders in journals indexed in the Medline database (Scopus H-index=34). He also edited, among the others, the book “Current concepts on temporomandibular disorders” (Quintessence Publishing, 2010), including contributions from 45 world-renowned experts, and co-authored several textbooks on the same topics.
Based on publication ratings, since November 2013, the US agency Expertscape has been ranking Prof. Manfredini as world № 1 expert in the field of temporomandibular joint disorders, and among the top three experts in the field of bruxism.

- The mechanisms responsible for pain referral in the orofacial structures.
- Recognition and differentiation of orofacial pain disorders that may clinically present as toothache.
- Differentiation of toothache of non-odontogenic from true odontogenic toothache.
- Seven different types of non-odontogenic toothaches and their management considerations.

Differential diagnosis of orofacial pain is an extremely challenging aspect of the dental practice. The complexity of neural network involving the craniocervical region establishes an environment for much diagnostic confusion. Many conditions exist which may mimic odontogenic or masticatory pain. Appropriate treatment and/or referral are predicated upon accurate identification of these diseases, syndromes, and clinical conditions. This presentation will provide a review of current basic concepts of pain mechanisms, pathways, and referral pattern in the head and neck. The clinical characteristics of 7 different non-odontogenic toothaches will be presented

About the lecturer:

Dr. Okeson is Professor, Division Chief and Director of the Orofacial Pain Program, which he established in 1977.

Dr. Okeson has more than 240 publications in the area of TM disorders and orofacial pain in various national and international journals.

He has authored two textbooks on TM disorders and orofacial pain, which have been translated into eleven different languages.

Dr. Okeson is a very sought after lecturer on the subject of TMD and orofacial pain and has presented more than 1300 invited lectures on the subject of TMD and orofacial pain in all 50 states and in 58 different countries.

More and more patients are showing up in the office, where not only aesthetic wishes needs to be met, but also functional problems play a significant role and needs to be solved. The lecture presents a new concept to analyze such cases, carried out jointly by dentist and dental technician, based on the patient request, the functional analysis and the treatment prognosis. Attendees will learn a predictable way to solve such cases, also the importance of different growth patterns, Angle classes and their causes, the functional treatment by using the Plane system according to MDT Udo Plaster based on the Ala-Tragus line and the NHP (Natural Head Position) and finally the prosthetic restauration.

About the lecturer:

1987 - 1989:​​​Dentist at a dental office, Bad Zwischenahn, Germany

1987:​​​​ Graduation in Dentistry, University of Goettingen, Germany

1993:​​​​ DMD, University of Muenster, Germany

1989 - actual:​​Owner of „Dr. Wahlmann & Associates“, Edewecht, Germany

2004: ​​​​Master in Aesthetics, Rosenthal Institute at New York University, ​​​​United States of America

2005:​​​​Goldmedal, American Academy of Cosmetic Dentistry, Indirect ​​​​​Restaurations Category

2006 - 2015:​​​Head of Dentistry, Estetica Clinic, private clinic for plastic ​​​​​​​surgery and esthetic dentistry, Hamburg, Germany

2008:​​​​Chairman, International Membership Committee, AACD

2010:​​​​Appreciation Award, International Academy of Laser Education, ​​​​​Vienna, Austria

2010 - 2015:​​​Owner, White Lounge, Hamburg, Germany

2011 - actual: ​​Chairman, Give back a Smile Germany

2015:​​​​Fellow, IADFE, International Academy for Dental/Facial ​​​​​​​Esthetics

2015:​​​​Member Science Advisory Board

2017:​​​​President, German Society of Cosmetic Dentistry

More than 200 lectures and Hands-on workshops in Germany, Austria, Switzerland, England, USA, Dubai, Russia, India, China, Thailand, Vietnam, Australia and more

2011 - 2013: ​​​Guest lecturer, University of Manchester, England, ​​​​​​​​Master Program „Restorative and Aesthetic Dentistry“

since 2013:​​​Professor invitado for Aesthetic Dentistry at State University ​​​​​​of Seville, Spain

Abstract:
Dental caries remains a global public health burden as 44% of all people worldwide is suffering from untreated caries in primary and permanent teeth. Caries is today regarded as a preventable non-communicable disease (NCD), sharing similar biological, behavioral, socioeconomic and lifestyle risk factors with other NCD’s within the metabolic syndrome. Therefore, caries should be subjected to a similar model of chronic disease management. Caries prevention has traditionally relied on fluoride exposure, diet control, proper oral hygiene and antibacterial agents. Prevention of caries as a NCD does certainly not disqualify these methods but bring them into a new context. The lecture will give a brief overview on how these preventive measures can interfere with the drivers of dysbiosis and promote the growth of health-associated clusters in the oral microbiome. Besides the established routines of regular tooth brushing with fluoride products and fluoride varnish applications, there is an opportunity for additional technologies based on ecological principles to address and modify the oral biofilm. Methods to reduce dietary sugar, slow down plaque metabolism and support saliva functions should be further developed and investigated in terms of efficacy, compliance and cost-effectiveness.

Learning objectives:
- To understand and embrace the 4D-loop (Determine, Detect, Decide and Do) for caries management and care in everyday practice.
- To practice evidence-based caries risk assessment, early caries detection, clinical decision-making followed by a personalized care plan for children.

About the lecturer:

Svante Twetman is a specialized pediatric dentist and professor of cariology at the Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
He holds the DDS, PhD and Odont Dr degree from Karolinska Institute, Stockholm, Sweden.
The research is focused on the role of oral biofilms in health and disease, risk assessment and caries prevention in children and young adults.
The most recent topics deal with biofilm control through the use of pre- and probiotic bacteria for maintenance of oral health in childhood.
The research has mainly been performed in clinical settings linked to explorative studies in the laboratory.
Dr. Twetman has authored and co-authored over 250 peer-reviewed papers and contributed in several textbooks.
He is a consultant of the Swedish Agency for Health Technology Assessment and Assessment of Social Services and thereby involved in systematic reviews and mapping of knowledge gaps.
Among several awards, he received the IADR Distinguished Scientist Award in 2010 and the IADR Borrow Award in 2011.

Prosthetic failure is often occlusal, orthodontic recurrence is often dysfunctional; the prognosis improvement of the treatments, is related to the optimization of the occlusal functions (stabilizing, centering, guiding). The occlusal requirement of the implant-supported prosthesis is greater than traditional fixed prosthesis. Optimal occlusion control does not necessarily always imply the use of a complex set of instruments. On the contrary, the methodology must be simple, but rigorous and fair; fair means to adapt the tool to the objectives. Therefore it is essential, prior to the therapeutic action, to precisely define objectives and occlusal architectural criteria. The principles must be very clear. The difficulty lies more in the decision process than in the action. Once the therapeutic decision is made, the choice of the protocols of realization becomes obvious: it falls under simple rules, intangible, reproducible. Using the same decision making process for both simple cases and complex situations can greatly increase the reliability and success.

• Introduction
• Determinants of the reconstructions and necessity of an architectural guideline
• Height occluso-architectural criteria of construction
1. Choose and record the reference plane
2. Choose and record the reference position
3. Choose and record the therapeutic position including vertical dimension of occlusion
4. Choose the situation (position and inclination) of the mandibular anterior teeth
5. Choose the situation (position and inclination) of the maxillary anterior teeth
6. Choose the radius of the curve of Spee and then the inclination of the occlusal plane
7. Choose the inclination of the cusp guiding slopes
8. Choose the guidance concept and radius of curves of Wilson
• Transfer wax-up into a second generation provisional reconstruction
• Conclusion

About the lecturer:

Received his doctorat in dentistry (DDS) in 1978 from the Faculty of Dentistry, Aix-Marseille University, France.
He was certified in Anthropology in 1979, in fixed prosthodontic and Occlusodontology in 1980.
He received his master (DSO) in 1983.
He became assistant in fixed prosthodontic department in 1985.
He received his "Doctorat d'Université " –University thesis- in 1990 (PhD).
In 1993 he was associated professor, Chairman of the Occlusion and Dysfunction department of Faculty of Dentistry of Marseille. In this university, he manages a postgraduate education program in occlusion and TMD and a postgraduate education program in fixed prosthetic.
From 2007, he is Full Professor of University.He is Visiting professor of Donau University.
He was President of the French National College of Occlusodontology in 1995-96.
He is member of the European Academy of Craniomandibular Disorders.
He was President of International Academy of Advanced Interdisciplinary Dentistry (iAAID).
He had published 6 books and more than 130 scientific papers about occlusion, TMD and prosthodontics.