When is Bruxism Bad?

Patient Presentation
An 11-year-old female came to clinic for her junior high health examination. She was well and had no concerns. She noted that she was going to get braces soon. Her mother said, “Yeah the dentist also started her wearing a mouth guard at night because she was grinding her teeth and was wearing away her teeth. The orthodontist thinks that some of it will be better with aligning her teeth better.” She denied any problems otherwise with sleeping including no snoring, and no headache, mouth or neck pain. She and others did not notice the bruxism during the day. The past medical history revealed a broken arm from a playground fall.

The pertinent physical exam revealed a healthy female with normal growth parameters, who did have noticeable wearing on her molars and many malpositioned teeth. The diagnosis of a healthy female with bruxism was made. “I don’t have anything else to offer you. It looks like you are otherwise healthy so keep wearing the mouthguard and do what your dentist and orthodontist say to do,” the pediatrician recommended.

Discussion
Bruxism “is a masticatory muscle activity that may occur during sleep ([sleep bruxism, SB] characterized as rhythmic or non-rhythmic) and/or wakefulness ([awake bruxism, AB] characterized as repetitive or sustained tooth contact and/or by bracing or thrusting the mandible.)” Bruxism was first described in 1907. Bruxism studies are quite variable in their results given the lack of standardized diagnostic methods.

Patients or family members will often report tooth grinding noises, and on physical examination there will be abnormal tooth wear, tooth mobility, hypertrophy of the masseter muscles and other problems such as fatigue, pain or discomfort in the mouth/jaw and/or headache. Tooth grinding noises by themselves is not necessarily a problem. Usually minimal criteria for SB include “…tooth grinding or clenching while asleep and one or more of the following: abnormally worn teeth, bruxism-related sounds, and mandible muscle discomfort.” Prevalence in adults for AB = 22-30%, SB = 1-15%, and in the pediatric population is 3-49%. Peak age is 10-14 years.

Factors that seem to be associated with SB include second-hand smoke, caffeine, tobacco and alcohol use, gastroesophageal acidification and some psychotropic medications (including serotonin reupdate inhibitors, antipsychotics, norepinephrine reuptake inhibitors, amphetamines, and Ecstasy).

Bruxism can also be considered a sleep-related movement disorder and can be associated with sleep disturbances such as obstructive sleep apnea, restless leg syndrome, rapid-eye movement disorders and mandibular myoclonus. Bruxism can have direct problems such as pathological tooth destruction, dental procedure failure, temporomandibular joint dysfunction [commonly in teens], mandibular joint movement problems and headaches.

Etiology is probably multifactorial but some data suggest potential risk factors including anxiety and stress, personality traits, genetic predisposition, socioeconomic and sleep problems. SB may offer some benefit by protecting the airway or stimulating saliva production. Gastroesophageal reflux may also stimulate saliva production and therefore SB may be partially protective as well.

Learning Point
Bruxism is probably a continuation from no bruxism to some that is not clinically significant and thus not needing treatment to some that is clinically significant and/or severe and needs treatment. Treatment also has a range of options, from patient and family education to occlusal appliances to more substantive treatments. Those can include physiotherapy, psychotherapy including biofeedback, medications such as benzodiazepines, and surgical treatment. Good sleep hygiene is good for any patient. In addition to dentistry, other consultants may be necessary such as sleep medicine, psychology and otorhinolaryngology. Per one study their decision making included the following questions:

  • Is the bruxism frequent and is the tooth wear severe? Needs dental evaluation
  • Is the patient anxious? Needs psychology and psychiatry expertise
  • Does the patient show signs of ventilatory disorders (snoring, oral ventilation, dark circles, daytime sleepiness, etc.)? Needs otolaryngology and pulmonary expertise. Sleep medicine is also a consideration.
  • Does the patient present with associated sleep disorders such as night terrors or agitation? Needs primary care and developmental expertise

Questions for Further Discussion
1. What are common parasomnias? A review can be found here
2. What causes temporomandidibular pain? A review can be found here
3. What causes jaw pain? A review can be found here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Tooth Disorders and Sleep Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Melo G, Duarte J, Pauletto P, et al. Bruxism: An umbrella review of systematic reviews. J Oral Rehabil. 2019;46(7):666-690. doi:10.1111/joor.12801

Bulanda S, Ilczuk-Ryputa D, Nitecka-Buchta A, Nowak Z, Baron S, Postek-Stefanska L. Sleep Bruxism in Children: Etiology, Diagnosis, and Treatment – A Literature Review. Int J Environ Res Public Health. 2021;18(18):9544. doi:10.3390/ijerph18189544

Casazza E, Giraudeau A, Payet A, Orthlieb JD, Camoin A. Management of idiopathic sleep bruxism in children and adolescents: A systematic review of the literature. Arch Pediatr. 2022;29(1):12-20. doi:10.1016/j.arcped.2021.11.014

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

How Long Does A Cephalohematoma Take to Resolve?

Patient Presentation
A 14-day-old female came to clinic for her routine infant followup. Her experienced parents had no questions other than when her small cephalohematoma should resolve. The past medical history showed a term infant at 3280 grams birthweight born by vaginal delivery, who was breastfeeding and had no significant jaundice.

The pertinent physical exam revealed a vigorous infant with a weight of 3340 grams, head circumference and length were 50%. She had an approximately 2 cm elevated firm mass on her right parietal skull that did not cross any suture line. The rest of her examination was normal.

The diagnosis of a healthy infant with a small cephalohematoma was made. The resident reassured the family that it should resolve in a few weeks, but when staffing said she didn’t know the exact answer. The attending said he didn’t know exactly either but in his experience it was just a few weeks but they could ossify which then takes longer to resolve. He said he had never seen any intervention done for them. The patient’s clinical course at followup at 2 months of age, showed the cephalohematoma to be resolved.

Discussion
Cephalomatomas occur relatively commonly in 0.2-3% of newborn infants. They are blood collections in the subperiosteal skull bones, usually in the parietal area. They are usually unilateral but can be bilateral. They do not transilluminate. They are felt to be caused by pressure or other trauma and occur in vaginal and cesarean deliveries, with presumed periosteal disruption leading to externally located bleeding (not on the brain side of the bone). The blood fills the space with some pressure building up and the blood acts to tamponade itself. The blood coagulates, slowly organizes and is reabsorbed. If reabsorption is delayed then ossification can occur but these also usually reabsorb but more slowly.

Increased risks include prolonged overall or second stage of labor, macrosomia, abnormal fetal position, multiple gestation, weak uterine contractions and instrumented delivery such as vacuum extractor or forceps. Larger cephalohematomas are more likely to have ossification. The differential diagnosis includes caput succedaneum, vacuum caput, subgaleal hematoma, congenital abnormalities such as leptomingeal cyst or meningocoeles. Persistent bleeding could also be an indication of a hemophilia. Underlying skull fracture can occur but is unlikely. If there is more significant bleeding, then hyperbilirubinemia may be accentuated.

Treatment is usually reassurance for families and watchful waiting. Compressive dressings can be applied around birth. Aspiration or other surgical techniques are usually not necessary and have risks of infection, anesthesia, potential surgical complications and necessary followup care. Usual indications for surgery include cosmetic deformities, craniosynostosis or confirmed restricted brain growth. Monitoring of infants is always recommended.

Learning Point
Reports of resolution timing usually say something like “a few weeks.” One case series of 94 infants with large (> 50 mm) cephalohematomas found 76.6% had resolved at 4 week examination and 12.7% more (total = 89.4%) had resolved by 8 week examination. The additional 9.6% became ossified but again resolved completely or partially by 1 year.

Another study of ossified cephalohematomas in their discussion state that “After ossification, cephalohematoma may still get absorbed slowly and most often disappears over 3-6 months.”

Questions for Further Discussion
1. What causes macrocephaly? A review can be found here

2. How is caput different than cephalohematoma?
3. What are indications for neonatology consultations?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Child Birth Problems

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Guclu B, Yalcinkaya U, Kazanci B, Adilay U, Ekici MA. Diagnosis and treatment of ossified cephalohematoma. J Craniofac Surg. 2012;23(5):e505-507. doi:10.1097/SCS.0b013e318266893c

Ucer M, Tacyildiz AE, Aydin I, Akkoyun Kayran N, Isok S. Observational Case Analysis of Neonates With Large Cephalohematoma. Cureus. 13(4):e14415. doi:10.7759/cureus.14415

Raines DA, Krawiec C, Jain S. Cephalohematoma. In: StatPearls. StatPearls Publishing; 2022. Accessed June 27, 2022. http://www.ncbi.nlm.nih.gov/books/NBK470192/

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Causes Sudden Vision Loss?

Patient Presentation
A 16-year-old female was admitted for evaluation of sudden visual loss in her right eye. She had gone to sleep and awoken without being able to see in her right eye including no light or movement. Her vision in her left eye was normal. She denied any pain or floaters in either eye. She had been well without fever, nausea, emesis, rhinorrhea, or cough. She also denied any head or neck trauma or neurological problems including slower mentation, speaking, difficulty with movements or gait.

The past medical history was positive for migraine with and without visual auras that begin 2 years before and occurred 3-4 times/year, and a generalized anxiety disorder that was treated with medication and therapy. The maternal family history was positive for Factor V Leiden and also Protein C deficiency, a maternal aunt who was being evaluated for an unknown neurological problem where she was having a problem with her hands and some walking, and a paternal cousin who had survived a brain tumor. The social history revealed that she was under a great deal of stress because of school, and peer interactions that had including physical fighting 3 days before.

The pertinent physical exam showed a scared teenager who had been crying. Her vital signs and growth parameters were normal. HEENT was normal and atraumatic. Her eyes appeared normal but looked like she had been crying. Her pupils were PERRLA. She had normal extra-ocular movements. Her visual acuity was 20/30 on the left and with both eyes. She denied being able to see with the right eye. Bilaterally, she did close her eyes appropriately with movement of a hand toward the eye. Corneal reflexes were normally bilaterally. She had a normal neurological examination including cranial nerves, rapid alternating movements, gait and balance. Her mini-mental status examination was normal except she was very anxious about her vision, and also talked about all the stress she felt she was currently under.

The diagnosis of sudden vision loss without pain and a normal neurological examination was made. She had been admitted from the emergency room where a radiologic evaluation of a computed tomogram of the head showed no space occupying lesion or intracranial bleeding. Ophthalmology had been called. The residents discussed the differential diagnosis including a globe problem itself, potential thrombus because of the maternal history of thrombophilias, neurological disease such as multiple sclerosis was considered much less likely, migraine and acute anxiety with conversion disorder or potentially factitious disorder was considered more likely given the negative workup and physical examination at the time. The planned work-up was to include testing for thrombophilias and after ophthalmology had seen her, the plan was to be re-evaluated their input and possibly would include more imaging and neurological and/or psychiatric consultations.

Discussion
Vision loss, whether chronic or acute, is distressing at any time for patients and families. Prompt evaluation and treatment are important as maintenance of any acuity and light or movement is considered paramount. Most vision loss is due to chronic problems and aging issues but the differential diagnosis is broad. For any age, but especially children, uncorrected refractive errors can cause problems in not only in childhood but throughout someone’s lifetime.

Visual impairment for distance vision is considered mild if worse than 6/12 in meters = 20/40 in feet or 0.3 LogMAR and for moderate impairment is 6/18 meters = ~20/60 = ~0.6 LogMAR. LogMAR stands for the Logarithm of the Minimum Angle of Resolution and is considered more accurate than other charts. Near vision is considered impaired if acuity is worse than N6 or N8 at 40 cm with existing correction. N numbers are the size of the letters on the handheld card.

Examples of some visual acuity scale equivalents

Foot 20/16 20/20 20/32 20/40 20/63 20/80 20/100
Meter 6/4.8 6/6 6/9.5 6/12 6/19 6/24 5/30
LogMAR -0.1 0.0 0.2 0.3 0.5 0.6 0.7

Learning Point
Sudden vision loss is most commonly due to an acute event that has an obvious cause such as trauma, stroke, or seizure. Others can be less obvious such as a migraine or slow-growing tumor. Psychiatric causes can be more difficult to evaluate and tease out from other causes. Common presentations of factitious disorder can be found here.

The differential diagnosis of sudden vision loss includes:

  • Trauma
    • Globe injury
    • Hyphema
    • Corneal injury
    • Retinal detachment
  • Tumor
    • Brain
    • Eye
    • Adjacent structures such as sinuses
  • Infectious
    • Optic neuritis
    • Septal cellulitis
    • Sinusitis
  • Neurovascular
    • Cerebrovascular accident
    • Thrombus
    • Increased intracerebral pressure
    • Multiple sclerosis
    • Transient
      • Concussion
      • Seizure
      • Migraine
  • Psychiatric
    • Conversion disorder
    • Factitious disorder or malingering

Questions for Further Discussion
1. What is the difference between factitious disorder, conversion disorder and malingering?
2. What are some inherited thrombophilias? A review can be found here

3. How are septal and preseptal cellulitis managed?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Vision Impairment and Blindness.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Solebo AL, Teoh L, Rahi J. Epidemiology of blindness in children. Arch Dis Child. 2017;102(9):853-857. doi:10.1136/archdischild-2016-310532

Irwin W, Kienstra A, Vezzetti R. Sudden Unilateral Vision Loss in a Teenage Girl. Pediatrics In Review. 2021;42(Supplement_1):S112-S116. doi:10.1542/pir.2019-0110

Flaxman AD, Wittenborn JS, Robalik T, et al. Prevalence of Visual Acuity Loss or Blindness in the US. JAMA Ophthalmol. 2021;139(7):717-723. doi:10.1001/jamaophthalmol.2021.0527

Karlica Utrobicic D, Karlica H, Ljubic Z, Kusevic Z. Visual Evoked Potentials in Evaluating Sudden Visual Loss in Adolescents: A Psychosomatic Perspective. Psychiatr Danub. 2021;33(Suppl 4):674-675.

The Lancet Child Adolescent Health. Vision for the future. Lancet Child Adolesc Health. 2021;5(3):155. doi:10.1016/S2352-4642(21)00029-8

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

How Common is Tongue-Tie?

Patient Presentation
A pediatrician asked her partner if she had also been seeing an increase in parents being told their newborn had a lingual tongue-tie. “This is the third family today,” she said, “They can’t all have one.” Her partner replied that she had noted the increase too, and was concerned about unnecessary procedures being performed, their potential complications and their cost. “I agree that some babies and Moms would benefit from cutting the tongue-tie, but probably not at this rate,” she remarked.

Discussion
The anterior 2/3s of the tongue is formed from the 2 lateral lingual swellings fusing with the tuberculum impar and then separating from the mouth’s floor to form the lingual sulcus. Separation failure can result in anchoring of the tongue to varying degrees. Frenula are soft tissue structures which attach and support other oral structures. The lingual frenula attaches the tongue to base of mouth. Labial frenula are located centrally and attach the lips to the alveolar ridges. Often less prominent are the buccal frenula which are on the labial side and are smaller and more lateral to the labial frenula, usually being located around the canine and premolar areas.

Ankyloglossia or “tongue tie” is a “…condition of limited tongue mobility caused by a restrictive lingual frenulum.” The term “anterior” ankyloglossia refers “…to a lingual frenulum that extends to the tip of the tongue or near the tip of the tongue and restrict tongue mobility.” Posterior ankyloglossia for some professionals refers to the frenulum inserting into a posterior position on the tongue, with some people meaning it to insert submucosally. Other professionals do not feel it exists. In a recent consensus statement, the group could not reach actual consensus on this term. Buccal ankyloglossia “…has been used to describe a perceived tightness in the maxillary and/or mandibular buccal frenula.” Tight labial frenula are sometimes referred to as “lip ties.” While there are some classifications for lingual ankyloglossia, the professionals writing a recent consensus article could not recommend a preferred system.

Learning Point
The incidence of tongue-tie ranges from 2.8-10.7% depending on the study, and even up to 59% in healthy newborns in another. “There has been an increase in diagnosis of tongue-tie by 834% from 1997-2012 with a similar increase in the number of frenotomy procedures performed over the same time period.”

Tongue-ties are a hot topic that is very controversial. Consensus on the terminology and how to apply it to studies is lacking and makes it difficult to perform higher quality studies. Usually severe ankyloglossia is easily agreed upon, but moderate or mild causes more problems among professionals and in studies. Therefore studies may show associative effects but data for causal effects and treatment outcomes are often lacking.

Tongue-ties can have effects depending on the age and pattern. It is important to note that ankyloglossia may be present but does not cause any problems at all, and also if ankyloglossia is treated with frenotomy, it also may not fix the problem, as many of the problems listed below are multi-factorial.

  • Breastfeeding – this is probably the most common potential clinical problem and also a very common indication for potential frenotomy. Breastfeeding is a serious issue for the maternal-child dyad as well as for public health.Breastfeeding success or lack of is multifactorial with both maternal, infant and society playing multiple roles. Breastfeeding support along with time usually improves most breastfeeding problems. Positioning is one of the most important as significant percentages (70-90% in some studies) of maternal-child dyads with breastfeeding problems are found to have positioning problems. Frenotomy treatment is not a quick fix to breastfeeding problems.
    In a consensus statement, professionals said: “Breastfeeding difficulty can often improve with time and nonsurgical intervention by a lactation consultant or speech pathologist who specializes in breastfeeding issues.”
    Treatment with standardized clinical pathways for supporting breastfeeding and avoiding unnecessary surgery have shown a decrease from 11.3% to 3.5% without decreasing breastfeeding success.

  • Speech articulation – “…the quality of the evidence regarding speech outcomes is low and definite conclusions cannot be drawn.” Frenotomy in infancy is generally not considered an indication for this potential future risk but older aged children are sometimes considered for it.
  • Oral hygiene and caries prevention – as the tongue helps to clean the oral cavity, but many people even with ankyloglossia do not have any problems.
  • Dental occlusion and craniofacial development – data for causal effects is lacking
  • Functional/social – difficulties with daily activities such as kissing, licking foods, wearing dental appliance and playing an instrument are often not listed in the literature but can be concerns for older children, teens and families. These potentially can be reasons for frenotomy

Frenotomy or cutting of the frenulum is the most common procedure, being commonly performed in the outpatient setting. Frenuloplasty or cutting and re-alignment or tissues, or frenectomy or cutting and removal or tissues are other frenular procedures. Frenotomy complications commonly include pain, minor site bleeding, with risks to damaging the salivary ducts located near the lingual frenulum. Other potential complications include scaring, oral aversion, substantial bleeding including hypovolemia, hematoma, infection, oral edema, respiratory difficulty and problems handling oral secretions. Patients with underlying facial or genetic problems should be evaluated carefully before frenotomy is performed as it could cause additional problems. For example with Pierre Robin sequence, freeing the tongue may cause worsening glossoptosis.

Lingual frenula ties have been purported to be associated with “midline diastema between the teeth, increased caries and periodontal disease, gingival regression, difficulty in wearing denture or retainers, difficulty with lip mobility, and possible esthetic or psychological consequences.” Data on lingual frenula ties for breastfeeding is also controversial.

Questions for Further Discussion
1. What are your personal indications for frenotomy?
2. How do you support breastfeeding?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Tongue Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Walsh J, Links A, Boss E, Tunkel D. Ankyloglossia and Lingual Frenotomy: National Trends in Inpatient Diagnosis and Management in the United States, 1997-2012. Otolaryngol Head Neck Surg. 2017;156(4):735-740. doi:10.1177/0194599817690135

Messner AH, Walsh J, Rosenfeld RM, et al. Clinical Consensus Statement: Ankyloglossia in Children. Otolaryngol Head Neck Surg. 2020;162(5):597-611. doi:10.1177/0194599820915457

Colombari GC, Mariusso MR, Ercolin LT, Mazzoleni S, Stellini E, Ludovichetti FS. Relationship between Breastfeeding Difficulties, Ankyloglossia, and Frenotomy: A Literature Review. The Journal of Contemporary Dental Practice. 2021;22(4):452-461. doi:10.5005/jp-journals-10024-3073

Walsh J, McKenna Benoit M. Ankyloglossia and Other Oral Ties. Otolaryngol Clin North Am. 2019;52(5):795-811. doi:10.1016/j.otc.2019.06.008

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa