This is a continuation of the discussion of extensive tooth wear from part I, caused by three underlying interconnected conditions, Sleep Bruxism (SB), Gastroesophageal reflux disease (GERD) and Obstructive Sleep Apnea (OSA). The following is a checklist of signs, as well as, a questionnaire.

Evaluate the following [1]:

  1. Tooth wear. Asymmetric wear on areas other than occlusal surfaces will suggest the presence of an erosive process. Compare:
    • Maxillary vs. Mandibular
    • Left vs. Right
    • Buccal vs. Lingual
    • Anterior vs. Posterior
  2. Hypersensitive teeth
  3. Tongue indentation; linea alba on cheek along the occlusal plane
  4. Gingival recession
  5. Presence of tori [2]
  6. Hypertrophy of masseter muscles
  7. Criteria that would increase the risk for sleep apnea:
    • BMI more than 35.
    • Age more than 50.
    • Neck size more than 40 cm.
    • Gender is male.
    • Malampatti score Class 3 or 4 [3]. Assessed by asking the patient (in sitting posture) to open his/her mouth and protrude the tongue as much as possible.

Symptoms Questionnaire [4][5]:

For Sleep Bruxism:

  1. Are you aware of clenching your teeth while you are asleep?
  2. Has anyone ever told you that you grind your teeth while you're asleep?
  3. When you wake up, have you noticed:
    • Tension or fatigue in your facial muscles;
    • headache;
    • upper shoulder or back pain;
    • pain in the back of your neck?


  1. Are you taking prescription medication for acid reflux?
  2. Do you often get a burning feeling behind your breastbone (heartburn)?
  3. Do you often feel stomach contents (liquid or food) moving upwards to your throat or mouth (regurgitation)?
  4. Do you often have a pain in the center of the stomach?
  5. Do you often have difficulty getting a good night's sleep because of your heartburn and/or regurgitation?
  6. Do you often take OTC medication for your heartburn and/or regurgitation?

For Sleep Apnea:

  1. Do you snore loudly?
  2. Do you feel tired, fatigued or sleepy during the day?
  3. Has anyone noticed that you stopped breathing during sleep?
  4. Are you being treated for high blood pressure?

Resources: la Hoz-Aizpurua, José-Luis, et al. "Sleep bruxism. Conceptual review and update." Med Oral Patol Oral Cir Bucal 16.2 (2011): e231-e238.

2. Morrison, Matthew Daniel, and Faleh Tamimi. "Oral Tori Are Associated With Local Mechanical and Systemic Factors: A Case-Control Study." Journal of Oral and Maxillofacial Surgery (2012).

3. Nuckton, Thomas J., et al. "Physical examination: Mallampati score as an independent predictor of obstructive sleep apnea." Sleep New York then Westchester- 29.7 (2006): 903.

4. Jones, R., et al. "Development of the GerdQ, a tool for the diagnosis and management of gastro‐oesophageal reflux disease in primary care." Alimentary pharmacology & therapeutics 30.10 (2009): 1030-1038.

5. Chung, Frances, and Hisham Elsaid. "Screening for obstructive sleep apnea before surgery: why is it important?." Current Opinion in Anesthesiology 22.3 (2009): 405-411.

Vivek Mehta DMD, FAGD, Visiting Faculty, Spear Education. Follow him on Twitter @Mehta_DMD.


Commenter's Profile Image Suraj
July 21st, 2013
Nice introduction can we have some more in depth information like diagnosis and treatment
Commenter's Profile Image CARLOS MAS BERMEJO
August 8th, 2013
Very useful in diagnosis. Thank's so much
Commenter's Profile Image Chandanpreet Jaspal
August 22nd, 2013
Thank you so much for this knowledge. Where can i get detailed information or videos on these lectures?