Night guards: A bad idea, or an idea badly done?

Dr. HalliganThe phone call this morning was typical. A local dentist wanted to talk about a patient he is referring to me. Several different dentists have done crowns for her and none of those crowns are in good occlusion. She has also had several night guards and all have been painful to wear for a time—until one after another they all broke. “So, I’m sending her to you. I hope you can figure out what’s wrong. She’s just miserable. And she can’t wear a night guard.”

And only a week ago I was giving a presentation to a prosthodontic study group and one of the dentists asked me about night guards. When do I recommend them? What to do when they don’t work? What do I think about them?

My answer was unpopular to say the least. “In general, I think night guards are a bad idea.” You would have thought I said I was in favor of repealing the Bill of Rights.

“Wait a minute, Doctor. How about protecting teeth from wear?”

“If your goal is protecting teeth from wear, then night guards may be fine. Or, use a night guard to protect your new veneers. But for TMJ pain or masticatory muscle pain, I generally see poor results with night guards.”

Boy, that ruffled some feathers. But let me explain.

Why did I say what I did? In part it was because of my experience with TMD patients over the last 10 years. My answer was also the result of reading and research both online and in various textbooks on TMD.

When I meet a new patient, one of the questions I ask during the intake interview is, “Has anyone tried a night guard or splint of some kind for your problem?” The answer is usually yes, and at that point the patient digs one or several night guards out of a purse or pocket. There is almost always at least one night guard in the patient’s past; often there are several. It’s not unusual for a new patient to show me a clear plastic bag containing as many as 5 night guards. The record so far is 13.

The patient explains it like this: “You see my first night guard didn’t help; in fact I think I clenched even harder on it. But the dentist insisted I keep wearing it anyway. So I left that dentist and when the next dentist also recommended a night guard, I said I already had one. But he said he would make a better one. The first one was on the upper teeth and he said if he made it on the lower teeth it would be much better. But it sure wasn’t any better, so I left that dentist too…” And so it goes.

Based on hearing that litany literally hundreds of times, my logical brain says, all these TMD patients have all these night guards and they have not relieved the patient’s pain. Sometimes the night guard even made the problem worse. So, a night guard must not have been the right approach.

If the patient brings a night guard to the exam appointment, I do a T-scan occlusal analysis with the night guard in place. The situation then starts to come into focus: a design and occlusion that are simply wrong.

Of course, I’m not seeing every patient who has a night guard. Maybe some people out there are getting relief from night guard wear. I just don’t see those people.

Online research hasn’t helped much. There certainly isn’t much definitive. The best one researcher can say is, sometimes a night guard helps with TMJ pain and sometimes it makes it worse. And which it will be is not predictable.

Next, I turned to books already on my shelf. Jeff Okeson’s text did not deliver an opinion. However, Dr. Peter Dawson, in Functional Occlusion from TMJ to Smile Design had quite a lot to say.

First, he says that routine use of a night time appliance should not be necessary if upon closing the patient’s teeth contact in verified centric relation and if lateral and protrusive movements cause disclusion of the posterior teeth.

But there are times, Dr. Dawson goes on to say, that a compromise is necessary. For example if there has been severe anterior attrition, then anterior guidance will not be ideal. In such cases anterior guidance may not be well established even with restorative dentistry. In that situation, a nighttime appliance will be appropriate for the clenching or bruxing patient.

Good, you may be thinking. Night guards are okay then. But consider Dr. Dawson’s description of a night appliance. First, whether it is an upper or lower appliance, when the patient closes on it, all teeth should contact the guard at the same time AND the mandibular condyles should be in verified centric relation. And furthermore, when the person shifts into right or left excursion, the posterior portion of the night guard should disclude immediately.

And also bear in mind that Dr. Dawson was writing about protecting teeth from wear as a result of bruxing and muscle pain due to clenching. Actual TMJ pathology with anterior disc displacement, requires full time repositioning of the condyles, not just a night time guard.

I am in total agreement with Dr. Dawson’s description of a proper night appliance. Unfortunately, not even one percent of the hundreds of night guards I have seen come close to meeting the criteria. In fact, whatever improper occlusal scheme is present in the dentition is usually carried out without change in the night guard.

Dr. Dawson goes on to say that an anterior deprogrammer is a useful appliance for clenching and that actual EMG studies show a decrease of anterior temporalis and masseter contraction by 80% when an anterior deprogrammer is used.

In my practice patients are treated in both day and night time appliances. And my night time appliance is either a deprogrammer or a special appliance that has cuspid rise ensuring no posterior contact during excursions.

Kois Deprogrammer
Kois Deprogrammer

Back to the question, what do I think of night guards? If we can agree that by “night guard” we are now talking about Dr. Dawson’s kind of night appliance with verified C.R. and with posterior disclusion upon lateral excursion, I will modify my answer and say they are fine for protecting the dentition including your recently placed porcelain veneers. That kind of night guard will also be useful to decrease muscle pain from parafunctional habits.

But if you are using a night guard to correct TMJ pathology, the appliance alone will not solve the problem of internal derangement.

A good question to always ask yourself before any treatment is What is the diagnosis, Doctor?

For example, a common reason for nighttime clenching is sleep apnea. If sleep disordered breathing is the diagnosis, you’re into entirely different territory and a simple night guard is definitely not indicated. See my article on screening for sleep apnea, but bear in mind that the diagnosis has to be made by an MD.

If the diagnosis is clenching or bruxing in the certain absence of TMJ pathology, a night appliance could be appropriate. But how will you make the night guard? Will you do upper and lower casts and a facebow mounting (or do a proper mounting on an Accu-liner articulator), and will you do a bite registration in verified C.R. (by now you know that for me, verified C.R. means verified radiographically)? And will you meticulously adjust that night guard and also be sure that there is posterior disclusion on lateral excursion?

Be honest. I think that for most, the answer is NO. And I don’t blame you. I don’t think you can charge the normal fee for a “night guard” and do all those things. The articulator mounting alone would require far too much time and expense. Therefore you are not likely to do it Dr. Dawson’s way. Or mine. And yet, that is exactly how the night guard should be done.

And then I’m back to the original question and the original answer: In general, I think night guards as they are most commonly made are a bad idea.

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