Circuit 4, station 1

Bruxomania is a condition that is similar to Bruxism (involuntary tooth grinding when the patient is sleeping) but it occurs while the patient is awake. Bruxomania is thus defined as the uncontrollable nervous grinding of teeth while a patient is awake. It is typically caused by emotional tensions such as repressed anger, aggressiveness, or fear.
Cognitive-behavioural therapy (CBT) is considered the most effective treatment option for bruxism as it addresses the psychological and emotional factors that contribute to the condition. CBT techniques, such as stress management and relaxation, can help reduce the anxiety and tension that trigger bruxism.
Splint therapy can provide symptomatic relief by reducing the frequency and duration of grinding phases, but it does not necessarily end the bruxism activity. Reducing the loading vector may help with premature occlusal contacts, but it is not effective in stopping bruxomania and bruxism activity.
Medication and surgery are not commonly recommended as first-line treatments for bruxomania, as they only address symptoms and do not address the underlying causes.

Therapeutic exercises are a good tool to relieve and prevent recurrence of TMJ pain. Among the best known routines are 6×6 Rocabado exercises and the therapeutic exercises of the Kraus program.
The 6×6 Rocabado therapy includes six exercises to be performed six times a day:
1. Rest position of the tongue: Place the tip of the tongue on the palate exerting slight pressure.
2. Control of TMJ rotation: Open and close the jaw repeatedly while exerting gentle pressure on the palate.
3. Rhythmic stabilisation technique: In a resting position, the mandible is opened and closed with lateral movements to contribute to muscle relaxation.
4. Axial extension of the neck: Cervical flexion movement by raising and lowering the chin.
5. Shoulder posture: Raise the chest to mobilise the shoulder girdle.
6. Stabilised head flexion: Interlace the fingers behind the neck to stabilise the head, bring the chin towards the neck and then outwards.
There are proposed a series of exercises to inhibit excessive chewing muscle activity.
1. Tongue position at rest: Place the tip of the tongue on the palate just behind the upper incisors.
2. Teeth apart: Keep the upper and lower teeth apart to relax the jaw.
3. Diaphragmatic nasal breathing: Breathing through the nose to strengthen the position of the tongue and teeth.
4. Tongue up and wiggle: In the resting position move the jaw from side to side. If a click or popping occurs, the intensity of the movement should be decreased.
5. Strengthening: Close the jaw with manual resistance with contractions of 5 to 10 seconds.
6. Touch and bite: Touch the upper canine with the index finger and try to bite it.
7. Neuro-muscular control: Place the tip of the tongue on the palate, fingers palpating the chin and mandibular condyle, repeatedly open and close the mouth.
8. Isometric exercises: They are performed before the closing click in any position.

Temporomandibular Disorders
Temporomandibular disorders (TMDs) are a group of clinical conditions that affect the temporomandibular joints and/or masticatory musculature that control jaw movement. They are commonly observed in individuals aged 20-40, with a higher incidence in women than men.
The TMJ is a complex joint that connects the mandible to the cranium by muscles, ligaments, and tendons, and its uniqueness in structure and function makes it more susceptible to disorders. These disorders can cause pain and discomfort in the jaw, face, neck, and ears, as well as headaches and difficulty chewing or speaking.
Classification of TMDs
The latest revised version of the Research Diagnostic Criteria for Temporomandibular Disorders (TMDs) was published in 2010. The revised criteria employ a dual-axis classification system that encompasses physical diagnoses on the first axis and pain-related disabilities and psychological status on the second axis. TMDs are categorised into distinct subtypes, including masticatory muscle disorders, temporomandibular joint (TMJ) disorders, chronic mandibular hypermobility, and growth disorders. Within each subtype, further classifications exist to differentiate specific conditions and manifestations. Masticatory muscle disorders encompass protective co-contraction, local muscle soreness, myofascial pain, myospasm, and centrally mediated myalgia. TMJ disorders include derangement of the condyle-disc complex, structural incompatibility of the articular surfaces, and inflammatory disorders of the TMJ and associated structures. Chronic mandibular hypermobility subtypes consist of ankylosis, muscle contracture, and coronoid impedance. Lastly, growth disorders encompass congenital and developmental bone disorders as well as congenital and developmental muscle disorders.
Aetiology of TMDs
The exact cause of TMDs is not fully understood, but it is believed that a combination of factors can contribute to their development. These factors can be grouped into three categories: predisposing, initiating/precipitating, and perpetuating.
• Predisposing factors: Predisposing factors increase the risk of developing TMD and can include anatomic factors, pathophysiologic conditions, genetic factors, psychological (stress), and behavioural factors (teeth grinding or clenching).
• Initiating factors: Initiating factors cause the onset of TMD and can include micro-trauma and macro-trauma.
• Perpetuating factors: Perpetuating factors interfere with the healing process or enhance the progression of TMD and can include behavioural, social, emotional, and cognitive factors.
Signs and Symptoms of TMDs
The signs and symptoms of TMDs can vary widely, but some of the most common include:
• Jaw pain or tenderness
• Headaches or migraines
• Earaches or tinnitus (ringing in the ears)
• Popping, Clicking, or grinding sounds when opening or closing the mouth
• Difficulty opening or closing the mouth
• Neck or shoulder pain
Diagnosis of TMDs
The patient’s history and examination are crucial for diagnosing and treating functional disturbances. The patient’s chief complaint should be carefully examined, including the location, onset, characteristics, aggravating, and alleviating factors of the pain, past consultations, and treatments. The patient’s past medical history, review of systems, and psychological assessment should also be considered.
The physical examination should include a neurologic screening, general inspection of the ears, nose, and oropharynx, TMJ, palpation of masticatory and cervical muscles, cervical spine evaluation, and a detailed intraoral evaluation. Diagnostic imaging is essential in cases of TMD and orofacial pain patients to confirm the suspected disease, rule out the disease, and gather additional information when the clinical diagnosis is equivocal or unclear. There are various imaging modalities available, such as two-dimensional and three-dimensional imaging.
Management of TMDs
Treating patients with temporomandibular disorders (TMD) requires achieving normal jaw function, reducing or eliminating pain, encouraging a return to normal activities of daily living, and reducing long-term healthcare use. It is also important to improve the patient’s understanding and management of their condition, eliminate unhelpful thinking about it, and increase their confidence in coping with it while reducing or eliminating powerful medications.
Many therapies have been proposed for TMD treatment, but practitioners should select the most cost-effective and evidence-based options that provide long-term symptom relief. Self-management therapies are generally the most cost-effective when continuously used.
The treatments for TMDs can be divided into two types: supportive therapy and definitive treatment. Definitive therapy directly targets the underlying causes of the disorder, and the treatment options depend on the aetiology. Supportive therapy is often used to reduce or eliminate pain and can include pharmacologic and physical therapies.
Conclusion
Temporomandibular joint disorders (TMDs) remain a complex challenge for clinicians, even with the current advances in biomedical research and technology. This is mainly due to the multifactorial nature of these disorders, which involves the interplay of various etiologic factors. Therefore, accurate diagnosis is crucial before any treatment plan can be initiated. A systematic interdisciplinary approach is necessary, particularly for patients with severe temporomandibular disorders and orofacial pain syndromes. It is essential to have ample evidence that treatment will benefit the patient before any intervention is implemented.