304 Australian Dental Journal, October, I959

Clinical isolation of the bruxogenic syndrome Eric Francis, B.A., M.D.Sc. (Q’land), B.D.S. (Syd.)

Introduction Florey(l) stated that “a great deal of the

most important medical research of today is performed by workers who have no medi- cal qualifications whatever”. The present investigation, which has mainly medical im- plications, has been carried out during daily dental practice on patients who have been referred for treatment by qualified medical practitioners. The results obtained indicate that the findings have significance to at least some branches of clinical medicine.

The project commenced some twelve years ago with observation of the results obtained when temporomandibular joint disorders, as popularly termed, were treated on Costen’s premisedp) or on the various suggestions advanced, at that time by students of these conditions. A stage was reached when it was apparent that the results obtained by the insertion of splints, onlays and such like devices to correct lost vertical relation, or by other methods such as restoration of centric occlusion were little more than Costen achieved when he inserted his cork discs originally. It appeared that each method was merely achieving the same end-result, in that they restored a more balanced occlusion and thereby removed abnormal function of one or other of the temporomandibular joints. The successful results were about sixty per cent. The treatment was thus not specific, with the basic cause probably still hidden.

Consequent on a simple observation in 1950, it was decided to discard completely all consideration of the action of the condylar head within the temporomandibular joint, and in fact of the joint itself, as well as any theory that had been built on Costen’s premises. Since temporomandibular joint dis-

Received for publication July, 1959. (I) Florey, H.-Address, Aust. Broadcasting Com-

mission, 1954. (*) Costen, J. B.-Neuralgias and ear symptoms

associated with disturbee function of the temporomandibular joint. J.A.M.A., 107 : 253, 1936.

order had become, and still is, a major sub- ject of research in almost every dental school of note, this step was a drastic one. How- ever, i t is only recently that investigators have tended towards the same course and have tentatively advanced the suggestion that the solution of these disorders might lie in muscle and certain types of malocclusion.

The simple observation made by the writer was that all patients presented evidence of attrition of particular teeth. Moreover, their teeth and surrounding structures were sup- remely healthy. Treatment was then directed to the reduction of the points of excessive contact which caused the attrition, and amazing results followed. Not only did aural symptoms respond immediately to treatment, but also symptoms of headache and facial pain. It was postulated that the attrition was caused by the forceful and repetitive friction from opposing teeth, and that this caused some form of trigeminal insult.

The extension of this principle of treat- ment led to the observation that the patients took advantage of any type of dental im- balance that may be present in order to obtain these satisfying contacts. If no im- balance was present they produced their own imbalance, often by fantastic protruso- lateral positioning of the mandible, in order to rub or grind together opposing teeth of the upper and lower jaw. Restoration of balanced function to the mouth removed the symptoms, provided that at the same time it terminated the use of the selected contacts. This suggested that the unsucccssful 40 per cent were those cases in which the self- selected contacts could still be made, despite balanced occlusion.

The investigation proceeded by the integra- tion of clinical facts until i t became apparent that the rubbing together of teeth during periods of stress gave rise to a syndrome which was a clinical entity possessing its own aetiology, differentiating criteria and specific treatment. The diagnosis of the

Australian Dental Journal, October, I959

syndrome was the responsibility of the doctor, but the treatment was solely dental, and conservative medical treatment was of little avail in the relief of the symptoms.

The investigation was hampered by lack of literature, medical or dental, to which the writer could relate his clinical evidence. Healthy teeth have little significance in clini- cal medicine. In a wide survey of medical journals, no evidence could be found that the effects of the rubbing together of healthy teeth had previously been considered, except where it produced pathological conditions. The results indicate that a new field of medical and dental research may have been opened. They also strengthen the belief of Wienerc3) that “the most fruitful areas for the growth of the sciences were those which had been neglected as a no-man’s land between the various established fields”.

The writer has recognized the syndrome in its various guises since 1954 and in that time has collected a large number of cases of what he now terms the bruxogenic syndrome. The symptoms of the syndrome, which are com- mon daily problems of the medical surgery and the out-patients department of hospitals, are frequently ascribed incorrectly to other causes. Accordingly, the syndrome is herein described in the hope that these doubts of diagnosis might be removed. It can be readily diagnosed by its differentiating criteria.

When Costen,(‘) an otolaryngologist, described the symptoms of the syndrome which bears his name, he passed the responsibility of treatment to the dentist. It now seems that these symptoms are part of the general bruxo- genic syndrome and appear in the region of the ear mainly because of the proximity of the muscles of mastication to that organ, and not because of traumatic function of the condylar head within the temporomandibular joint. When the symptoms of the bruxogenic syndrome appear elsewhere in the head and neck, other medical specialties become in- volved. The responsibility of diagnosis lies in the medical surgery, where the symptoms are first presented, and much unnecessary investigation may be avoided by recognition of the bruxogenic syndrome. The ancillary aid of the dentist should in these cases be

305

(3) Wiener, N.-Cyhernelirs New York, John

( I ) Costen, J. B.-On. rit. Wiley & Sons, 1 9 5 2 (Introduction).

the first enlisted, when the general examina- tion reveals no obvious organic cause.

The clinical findings have led to three main conclusions as follows:

1. That bruxism gives rise to trigeminal insult.

2. That there are a number of unrecognized sequelae of dental imbalance.

3. That the bruxogenic syndrome is a clinical entity.

These findings resulted from the observa- tion and interpretation of the clinical facts recorded during treatment. The mechanisms can only be postulated a t present. The neuro- physiological aspect of bruxism, as a sug- gested hypothesis for the clinical results, has been considered and will be published sepa- rately. This is the first occasion on which the bruxogenic syndrome has been described. The purpose of this particular article is to enable the dentist to diagnose the bruxogenic syndrome and to undertake the treatment of it in any form in which i t may be referred by the medical practitioner.

Et io logy Three factors operate in the development of

1. Stress. 2. Increased muscular activity. 3. Bruxism (G. Bruchein: to gnash the

1. Stress arises from emotional stimuli and all individuals are subject to it. The degree of reaction to stress appears to depend upon the personality profile of each individual. The treatment of symptoms arising purely from stress are not the responsibility of the dentist. Stress is, however. the “trigger” which fires off the bruxogenic syndrome. I t is the essential factor which precipitates the bruxism. It causes increased activity of the masticatory muscles as a defence reaction. Reaction to stress may proceed for many years without painful symptoms. In the susceptible patient the stage is thus set by previous minor stress common to all indi- viduals. An increased emotional disturbance may then, in these cases, suddenly “trigger off’ one or .more of the bruxogenic symptoms.

,2. Increased muscular activity. During nor- mal mastication muscular effort does not give rise to muscular spasm or pain nor are teeth brought into actual contact except as an

the bruxogenic syndrome. They are:

teeth).

306 Australian Dental Journal, October, I959

“overshoot”.(6) During bruxism, however, the full power of the masticatory muscles is applied and, when performed during sleep, the grinding of the teeth is maximal. Prolonged contraction of muscle gives rise to painful symptoms.(8)(’)(8,(s) Furthermore, anxious or tense patients display increased muscular activity.(lo)(ll)

Not only the masticatory muscles of anxi- ous people go into contraction during emo- tional stress, but also muscles in other parts of the head and neck. Pain may occur in any of these areas as a result of this con- traction in the form of frontal, temporal or occipital headache, pain in the throat or tongue or in the neck and shoulder girdle. It is postulated that the pain threshold is reached only when there is increased emo- tional stress and resulting excessive bruxism.

The pain which occurs in and about the ear is due to the forceful and sustained contraction of whatever muscles and ligaments are called upon to implement the repetitive and forceful friction of the particular teeth chosen by the patient during emotional ten- sion. For example, if bruxism is applied to the cuspid area the pain will be felt in the contralateral external pterygoid muscle which is held in continuous contraction during the grinding process. The temporomandibular ligament and the stylomandibular ligament may be similarly called upon in their func- tion as restricting agents. They become taut in their effort to prevent the abnormal mandibular movement and pain occurs as a result of the prolonged tension. If there is a shearing action of the teeth in achieving flnal occlusion, the particular musculature

called into forceful action to achieve th i s objective will give a painful reaction. Sicher,(‘z’ in considering damage to the temporomandibular joint through occlusal disturbance, states that “The pain radiating in all directions from the damaged and pain- ful capsule of the joint is in many a patient simply a case of referred pain. But more often it is muscular pain . . . The pre- dominant role of the mandibular muscles in producing the painful symptoms cannot be exaggerated”. The latter contention is well supported by the clinical results obtained by the writer and, in most cases, the pain is of a dull aching type with tenderness to palpation.

3. Bruxism. The observations that pro- longed muscular contraction gives rise to pain and that emotional tension gives rise to increased muscular activity a re signiflcant facts in the study of the bruxogenic syn- drome. It must be borne in mind, however, that bruxism is the basic cause. The symp- toms do not occur unless the teeth are clenched or ground together.

A distinction should be made between mal- occlusion in its accepted sense and bruxistic occlusion. The former is considered to be an abnormal contact of teeth as the mandible moves to final occlusion. Bruxistic occlusion, on the other hand, is a particular contact of teeth adopted by each individual in res- ponse to emotional tension. It might be direct, as occurs in the clenching of teeth, or i t may be of a shearing type as one tooth is forcibly ground back and forwards on the opposing tooth. These bruxistic contacts are assumed during brief periods of emotional tension. Just as the chewing mechanism, by

J. A.-The physiology of the stomatognathic ~eUrOm~SCUlar adaptability, can be condi- system. J.A.D.A., 46 : 375-386 (ADr.), 1953. tioned to overcome an unbalanced dentition,

(4) Simons, D. J., Emerson, D., Goodell, H., and Wolff, H. ~ . - ~ ~ ~ ~ ~ i ~ ~ ~ ~ ~ l studies of head- SO may the mandible be conditioned always ache : muscles of the scalp and neck as to assume a particular bruxistic occlusion in sources of pain. Proc. Ass. Res. in N. & M. Disease. 23: 228, 1943. response to the individual’s mental conflict.

(6) Jankalson, B., Hoffman, G. M., and Hendron,

( 7 ) Perry, H. T.-Muscular changes associated with temporomandibular joint dysfunction. J.A.D.A., 54: 644-653 (May), 1957.

(8) Schwartz, L. L.-Pain associated with the temporomandibular joint. J.A.D.A., 51 : 394-397 (Oct.), 1955.

(D) Holmes, T. H., and Wolff, H. G.-Life situa- tions, emotion and backache. Psychosom. Me&, 14: 18, 1952.

(lo) Sainsbury, P., and Gibson, J. G.-SymptOmS of anxiety and tension and the accompanying physiological changes in the muscular system. J. Neurol. Neurosura. and Psychiat., 17: 216, 1954.

(11) Wolff, H. G.-Headache and other head pain. New York, Oxford Univ. Press, 2nd ed., 1950 (P. 5 0 7 ) .

Patients, distressed by their pain problems, often during interviews in the surgery, slide their mandible into such a conditioned posi- tion without being aware of the fact. Indi- viduals, conflicting in opinion with others, will often contain their irritation by clench- ing their teeth forcibly together in small rapid vibrations, as is clearly evidenced by the lively functioning of their temporal

(11) Sichzr, H.-Problems of pain in dentistry. Oral Surg., Oral Med. & Oral Path., 7: 149, 1954 .

Australian Dental Journal, October, 1959 307

muscles. The noise caused by the grinding of teeth together during sleep, both by chil- dren and by adults, is a common occurrence. Bruxism is a physical act unconsciously per- formed during sleep, and by day when the mind is employed with problems far removed from tooth function.

Bruxism has received little attention in dental research or in dental literature, except i n regard to i ts disintegrating effect on periodontal structures. Negligible considera- tion is given to its neurological effects. Nadler,(I3) after discussing various aspects of bruxism, attributes it variously to local, systemic, psychological and occupational causes. “The major cause of bruxism”, he says, “seems to be on a psychological basis and concerned with the personality of the individual”. Later he states that ‘it would appear that the act of bruxism affords the individual an opportunity to take out on his own body the frustrations and tensions which beset his personality”. He considered that bruxism was almost universal, that it appeared to have a psychological bgsis and was “concerned with the personality of the individual.” He says “The role of physical and mental stress as causation to bruxism in daily life is highly significant.”

Moore(14) viewed bruxism as “one of the most important etiological factors in the production of periodontal disease and in the loss of teeth”. He also considered tension to be the commonest cause of bruxism. His group of patients, numbering 606, showed strongly developed masticatory muscles, festooning at the gingival margin, facets on teeth other than in the chewing contact and disturbances in the temporomandibular joint. He found that the patients who were mostly susceptible included “mothers with young children” or ‘single women in their late thirties, with marital intent”, or, again “the perfectionist or overly-conscientious females”. These same individuals he found ‘complain of tension headache and tense muscles in the neck”.

Bruxism may occur in all types of denti- tion, either full natural dentition, partial natural teeth without or with artificial resto- ration, full upper restoration with partial

(m) Nadler, S. C.-Bruxism, a classification : critical review. J.A.D.A., 54 : 615-622 (May), 1957.

(14) Moore, D. S.-Bruxism, diagnosis and treat- ment. J. Canad. D. A,, 2 2 : 583-590 (Oct.). 1956.

or full natural teeth on the lower jaw or the reverse, or complete artificial dentures. The patient makes his own selection of satisfying bruxistic contacts from t4e teeth available. Individuals who have at lqast one jaw fully edentulous, that is without natural teeth or artificial restoration, do not experi- ence the symptoms because they cannot exercise bruxism.

Differentiating Criteria There, are a number of signs and symptoms

u.hich identify the bruxogenic syndrome. The symptoms which fall within the syndrome are, in general terms, those of headache, facial pain, non-articular pain i n the neck and shoulder girdle and, of interest to dentists, the numerous symptoms described by Costen. The main features of the syndrome are: 1. The patients present a distinctive per-

sonality profile, for which the writer can find no medical term which is definite. The patients often remark that they are of a nervy type, highly strung or worriers. Their mental profile is often hereditary, as are many Physical likenesses of height or facial features. Susceptibility appears to vary according to the degree of apprehension in the personality of the patient.

Patients presenting the bruxogenic syn- drome, although at times distressed and apparently overacting their ills, revert to normal practical individuals on removal of the symptoms. They are anxious to help in order to be freed of their discomforts, they rarely exaggerate their symptoms and they describe them consistently. To the patient the symptoms are real, but to the clinician they may appear at times to be overacted because of the otherwise healthy physical state of the patient and the absence of an organic cause.

2 . There is no pathological evidence in the dental structures to suggest an infective pro- cess. The teeth are hard and firmly estab- lished in the bone, and the gums give the appearance of rude health, regardless of whether the whole force of the bruxism has fallen on one or on more than one tooth. There is thus no evidence of alevolar loss, calculus or pyorrhea pockets. If there is any inflammatory condition in the periodontal tissue, the syndrome is contraindicated. Radiological evidence may, in cases where

3 08 Australian Dental Journal, October, I959

becomes major, where even more powerful drugs give only tentative relief.

Summary o f the Diagnostic Signs and Symptoms of the Bruxogenic Syndrome

1. Subjective ( a ) Painful or non-painful symptoms in

various areas of the head and neck, appear- ing singly, or in combination, without any demonstrable organic cause.

( b ) Symptoms are associated with a period of stress.

( c ) Otherwise good medical history, both mental and physical.

( d ) History of . difficult extractions. ( e ) Symptoms are most prevalent on awak-

ing, but rarely cause the patient to awake. ( f ) Poor sustained response to drug

therapy. ( 9 ) Recent increase in the intensity and

frequency of the attacks. ( h ) A characteristic personality profile.

( a ) Healthy appearance of gum tissue, and

( b ) Radiographical evidence of a resistance

(c ) Signs of attrition of teeth a t the

( d ) Hyperaesthesia of affected areas to pal-

2. Objective

teeth strongly set in alveolus.

to the forces of bruxism.

bruxistic contacts.

pation or light touch.

bruxism has long been practised, show that a resistance has been established in and about the teeth, in response to the bruxism, either in the form of a condensing osteitis, and enostosis, an increase of cementum or calcification of the pulp. The structures are thereby reinforced to resist the bruxism. This reaction to mechanical stress is the possible explanation for another collateral diagnostic feature that the bruxist frequently has a history of dimcult extractions. Where there is a breakdown in periodontal tissue as a result of malocclusion, as in pyorrhea alveo- laris, the patient rarely suffers the bruxogenic symptoms. Conversely, those who fall within the bruxogenic syndrome experience no periodontitis-an important diagnostic fact.

3. There is objective evidence of a degree of wear of the occlllsal surfaces of the teeth involved in the bruxistic function. In arti- ficial dentures polished surfaces mark the area of excessive contact. The clinician may check the bruxistic origin of this attrition by asking the patient to slide the mandible into a position in which the attruded surfaces of the opposing upper and lower teeth fit snugly into one another. In many cases fantastic protruso-lateral movements of the mandible are necessary in order to achieve this result. In some instances, as much as half of the crowns of the bruxized teeth have been reduced, but the perfect fit in these cases is readily obtained.

4. The symptoms do not prevent the patient from going to sleep, rarely disturbs him during sleep and, as a general rule, are most apparent on awaking. The symptoms might increase as the day proceeds, especially if postural or emotional factors induce addi- tional bruxistic contact of the already attruded teeth. They may, in cases not of long standing, subside as the morning advances because of the absence during the day of intense bruxism, which is again resumed during the next sleeping period, if the stress factor is still present.

5 . Response to drug therapy is not sus- tained. Aspirin may relieve the symptoms at their earliest appearance, but later is ineffec- tive even in increased quantity. As the pain condition increases, through neglect of the dental cause, codeine, at first effective, later loses its therapeutic potency. A stage is ultimately reached, when the complaint

Treatment The diagnosis and the treatment of the

bruxogenic syndrome are clear cut and specific.

The syndrome is characterized by differen- tiating criteria, which clearly confine it, and the treatment requires no more than standard dental techniques. A tentative diagnosis should be possible a t the first appointment. This should be verifiable a t the next appoint- ment after evaluation of the clinical data has been completed.

First appointment 1. ColIection of clinical data. 2. Dental examination. 3. Preliminary test. 4. Study models.

Recond appointment 5. Evaluation of clinical data. 6. Diagnosis. 7. Commencement of reduction of bruxfstic

contacts.

Australian Dental Journal, October, I959 3 09

1. Collection of clinical data. I t is essen- tial that an accurate recording be made of the associated symptoms as well as of the chief complaint. Symptoms should be investi- gated as to:

( a ) Type. (a) Description.

1. Location. 2. Intensity. 3. Continuous or intermittent. 4. Frequency. 5. First appearance. 6. Time of day when most apparent. 7. Do they wake the patient or are

they first felt after awaking? (c) Provocation, e.g., chewing, yawning,

( a ) Any recent injury or disease. (e) History of previous medical investiga-

tion of the symptoms. ( f ) Estimation of the personality proflle

of the patient. (9) History of increased emotional dis-

turbance at time of onset of symp- toms.

2. Dental examination: This should record: (a) State of health of the teeth and gums

under clinical and X-ray examination. ( b ) Evidence in X-rays of resistance to the

force of bruxism in the teeth and surround- ing bone.

( c ) Whether there has been a history of difacult extraction when any teeth have been removed.

emotional tension.

( d ) Signs of bruxistic attrition. (e ) Whether these areas correspond to the

location of the symptoms. ( f ) Whether, in the case of symptoms in

and about the ear, the mandibular movement necessary to obtain and hold the particular bruxistic contacts involves sustained contrac- tion of one or more muscles in the area of the symptoms.

(8) Whether, in the case of facial symp- toms, the location of the symptom bears the anticipated relation to the bruxistic contact.

3. Preliminary test. If the bruxism is diagnosed as the probable cause of the chief complaint the contact point responsible should be eased as an immediate treatment. In complete restorations, the non-wearing of the lower denture at night should lessen the symptoms as bruxism is not then possible.

4. Htudy models. These are necessary for treatment planning and for future reference.

They also assist in conflrming the clinical facts.

5. Evaluation of clinical data. If the clini- cal evidence displays the differentiating criteria of the bruxistic syndrome and the preliminary test, applied a t the first appoint- ment, has caused a change in the character of the chief complaint, the diagnosis is definite.

6. The chief complaint should not be diagnosed as an individual symptom but should be treated as part of the total bruxo- genic syndrome. The chief complaint is merely the particular discomfort which caused the patient to seek treatment. Other symptoms are usually present, but are not, in the patient's mind, considered to be associated with the chief complaint. All the symptoms must therefore be considered to be of equal importance in the treatment of the syndrome.

7. Treatment should then be directed to- wards

( a ) Reduction of bruxistic contacts. ( b ) Mouth rehabilitation.

(a) The bruxistic contacts are registered by the patient biting on a wax shape, flrst in centric occlusion and again in grinding occlusion, which is the tension occlusion of bruxism. These can be verified and pin- pointed by again registering the centric and bruxistic occlusion on the teeth by use of articulating paper. Both registrations should coincide, since they indicate the prominent contacts which are being clenched together or ground one on the other during moments of emotional stress. The self-selected bruxistic contacts are recognized by the attrition of teeth outside of chewing contact and do not register in normal occlusion on the wax shape.

The pain sites bear a direct relation to the points of bruxism. They can be tabulated, as a general guide, as follows:

Headache and pain in the aural region

Patn aCte Location of hxis:snl Unilateral pre-auricular Contralateral cuspid Bilateral pre-aUrICular Incisors

1 Post-auricular Sub-auricular I

t Ipsolateral molars Styloid area DeeD in the ear I Temporal headache I Ipsolateral molars Frontal headache

and between eyes / Incisors. Occipital paln Contralateral cuspid area

310 Australian Dental Journal, October, 1959

The painful symptoms in the region of the ear mainly arise from the sustained contrac- tion of muscles. The particular muscles which bring the bruxistic teeth into contact become the site of the pain which is muscular pain and not referred pain. The ligaments, like- wise, as restricting agents, may become involved during excessive contraction of the muscles and the pain i n this event will be deep in the respective areas. The temporal headache is due to the contraction of the temporalis muscle. Why the occipital pain or the pain which occurs in the forehead and between the eyes should recede under the relief of specific bruxistic contacts is not yet clear.

Facial pain

Maxillary division Molars Zygomatico-temporal Molars or bicuspids Infraorbital Cuspids Supraorbital Supra and infra

trochlear

Pain stte Location of bruxiswi

Anterior teeth

Artificial restoration must be made when teeth are extracted; otherwise, if this is not done, the remaining teeth must be placed in balanced occlusion, so that the bruxism will be evenly shared by all teeth.

The significance of occlusal neglect will be more appreciated when the serious extensions of the syndrome are realised. This might be stressed by a n example of a common dental experience. Most dentists will recall the patient who insists that a particular tooth is aching severely. On examination, the dentist can find no apparent reason for the pain. X-rays are taken and fillings replaced by dressings to give relief, but the pain still continues and may spread to adjoining teeth. Simple reduction of the bruxistic contact, not necessarily a malocclusion, on the .tooth would have cleared the pain forthwith. Although the pain eventually ceases spontaneously, in some cases i t reappears at a later date as an intense burning sensation extending along

Non-painful symptoms the cheek towards the nose, apparently un- Symptom L~~~~~~~ of b,-uz&,, related to the tooth. The main division of

the maxillary nerve has thus become involved and the patient seeks medical aid. The doctor is baffled by the symptoms when full inves-

Clearance of the contact which is producing tigation proves negative and experimental treatment becomes necessary.

A serious stage has thus been reached in

Tinnitus Crepitus 1 Ipsolateral molars Clicking jaws J

the chief complaint is the prime objective in order to give immediate relief. In most instances there are present several associated

Removal of the contacts responsible for these by correct treatment at the symptoms should follow the clearance of the stage. Even at this stage Of the

bruxistic contact is the only conservative chief complaint. treatment which will give sustained relief. (a) Mouth rehabilitation. Any standard

dental technique which will restore the mouth In cases of direct anterior bruxistic contact to harmonious function may be used. This it is rare for the pain to occur initially in will depend upon the dentition of the indi- the bruxized tooth. The first indication is

infraorbital or supraorbital pain, which is vidual patient. The objectives should be: frequently paroxysmal. The medical practi-

1. To give smooth functfon to the tioner auite reasonablv seeks medical causes

symptoms are part of the syndrome. a problem which should have been avoided

muscles and ligaments used in mastication. 2. Restoration so that no tooth nor teeth

can be placed by the patient in unbalanced contact. The anxious patient will And any prominence of this type and will exercise bruxism on it and discard normal contacts. Free gliding movement on posterior teeth in all directions should be obtained.

I t is the responsibility of the dentist to counter the patient's susceptibility to the syndrome by keeping the mouth in balanced function. The vast majority of cases treated by the writer presented gross imbalance with extensive areas of the mouth edentulous.

and considers dental consultation only for a possible dental focus of infection. Since the pain is a component of the bruxogenic syn- drome, no dental sepsis will be found. Again, dental reduction of the bruxistic eontact will give sustained relief, whereas there is no conservative medical treatment which will ensure success.

The aim of this article has been to present the isolation of the bruxogenic syndrome in such a way that the practising dentist may efficiently treat any of the symptoms pre- sented by the patient. Successful treatment requires no more than simple dental tech-

Australian Dental Journal, October, 1959

niques. The clinical results obtained by the writer indicate that as a prophylactic require- ment, no mouth should be considered as dentally complete unless balanced function has been obtained.

Discussion The bruxogenic syndrome has been exposed

as the result of the integration of a number of clinical facts which have appeared during the treatment of over 400 cases in daily routine practice. During the past nine years treatment has centred around a theory, based on clinical observations, that the grinding together of teeth during periods of emotional stress was responsible for a type of insult that caused excitation of dental nerve endings. The intensity of the various symptoms depended upon the extent of the excitation, the degree of emotional stress and the period of time over which the combined effects had operated.

The same principle has been successfully applied to the treatment of many headache symptoms, both minor and major, and of types of facial pain of various intensities which have defied medical therapy but which rarely reach the dental surgery. The results show that these symptoms of no known organic origin are as much part of the bruxo- genic syndrome as are the so-called temporo- mandibular joint disorders. They are of dental origin and can only be conservatively treated by dental techniques. At the present time, no one is aware that such symptoms can arise from the bruxistic grinding of healthy teeth.

There is sufficient clinical evidence to show that the observation of trigeminal insult made by the writer may have opened up an extensive field of medico-dental research of which he has only scratched the surface. Since the approach to the problem is new, revolutionary, and a t Arst glance fantastic, it may be viewed by some readers as an

31 1

(lJ) Selye, €L-Stress and the general adaptation syndrome. B.M.J., 1 : 1383 , 1960.

unrealistic conception based on wishful think- ing or argument. The clinical facts are realistic indeed, and judgment of the work should be reserved until fully tested by practical test or clinical application.

Description of the syndrome is offered as a contribution to dental science and is herein published for the first time. In advancing this syndrome the writer has similar feelings to those expressed by Selye(=) when he pub- lished his general adaptation syndrome. Selye remarked “We realize that many lines in our sketch will have to be hesitant, some even incorrect, if we try to put on paper now what we still see vaguely. But a preliminary map-albeit largely incomplete and partly in- accurate-is needed now by those eager to exploit‘ this field which holds so much promise for all who suffer from stress. I hope that these pioneers in uncharted territories will accept my partial and distorted map in the spirit in which i t is offered, to complete and rectify it.”

1. 2.

3.

4.

6.

6. 7.

Summary The bruxogenic syndrome is described. The clinical symptoms are extensive but include headache, facial pain and the symptoms described by Costen. The intensity and range of the symptoms vary with the neglect of the causative factor in the presence of emotional stress. The basic cause is trigeminal insult resulting from bruxistic tooth contact. Excessive bruxism during increased emotional stress activates neurophysio- logical mechanisms which lead to pain and later, involvement of the sympathetic pathways. Differentiating criteria are detailed. A plan of treatment is described.

Ballow Chambers,

Brisbane. 121 Wickham Terrace,

C