Home - Clenching & Grinding (Bruxism)

Put simply, bruxism is teeth grinding. More accurately, bruxism describes a range of related behaviours including teeth grinding, gnashing and clenching of the jaw. Bruxism is usually a subconscious behaviour performed whilst one is asleep.

What Is Bruxism?

Bruxism affects around 8-10% of the population. It is broadly characterised by grinding of the teeth and clenching of the jaw that causes tooth wear and breakage, disorders of the jaw (pain and limited movement) and headache. Bruxism is most common in 25-44 year olds, however, most people grind and/or clench their teeth occasionally to a certain degree.

Bruxism is classified into awake bruxism and sleep bruxism. Awake bruxism is characterised by involuntary clenching of the teeth and jaw bracing in reaction to certain stimuli. There is generally no tooth grinding with awake bruxism. Sleep bruxism is characterised by automatic teeth grinding with rhythmic and sustained jaw muscle contractions.

Bruxism is further divided into primary, (that occurs without any prior medical condition) and secondary bruxism, where a medical or psychiatric condition is known. The teeth grinding observed during wakefulness and secondary bruxism can be associated with certain medications such as antidepressants or recreational drugs such as cocaine and ecstasy, and disorders such as Parkinson's disease, depression and major anxiety.

Many studies have found that there are other characteristics associated with sleep bruxism because it rarely occurs alone. Sleep bruxism occurs as a response to arousals during sleep (periods of awakening), indicating that it may also be a sign of a sleep disorder. Nearly 80% of bruxism episodes occur in clusters during sleep and are associated with these arousals. The strongest association has been found between sleep bruxism and Obstructive Sleep Apnoea (periods of stopping breathing during sleep), which is a condition that is often accompanied by daytime sleepiness and non-restorative sleep. Individuals with OSA have many arousals during the night due to their breathing difficulties. The termination of the apnoea event is often accompanied by a variety of other events such as snoring, gasping, mumbling and teeth grinding. OSA has been found to have the highest risk factor for tooth grinding during sleep than any other sleep disorder.

Significant associations with sleep bruxism have also been found with other sleep conditions such as sleep talking, hypnagogic (state of consciousness between sleep and wakefulness) hallucinations, violent or injurious behaviours during sleep and REM sleep disorders. Psychological disorders such as stress and anxiety are also known to exacerbate teeth grinding during sleep. In one study, around 70% of sleep bruxists related their nocturnal teeth grinding to stress and anxiety. Bruxism is also more prevalent in individuals who regularly use alcohol, tobacco and caffeine (6 cups or more per day).

There is no specific cure for bruxism and it is important to manage the consequences of the disorder. Various preventative measures including mandibular advancement devices, drugs, stress management and occlusal splints have been used. However all but occlusal splints have demonstrated adverse effects which reduces their appropriateness.

Causes Of Bruxism

Why bruxism occurs is not always clear. However, possible causes range from psychosocial factors (stress and anxiety) to excessive response to arousals during sleep.

Sleep Disorders

It is known that bruxism rarely occurs alone. Research has consistently found that bruxism is found more frequently in those individuals who have an existing sleep disorder such as snoring, breathing pauses during sleep and Obstructive Sleep Apnoea (OSA). Other parasomnias such as sleep talking, violent or injurious behaviours during sleep, sleep paralysis, hypnagogic/hypnopompic hallucinations (semi-consciousness between sleep and wake) are also more frequently reported by bruxists and tooth grinding individuals. Of these, OSA appears to be the highest risk factor as it is associated with an arousal response. The termination of the apnoea event is often accompanied by a variety of mouth phenomena such as snoring, gasps, mumbling and tooth grinding.

Lifestyle Factors

Demographic and lifestyle factors such as young age, higher educational status, smoking, caffeine intake and heavy alcohol consumption are associated co-factors of bruxism. The use of psychoactive substances (tobacco, alcohol, caffeine, or medications for sleep, depression, and anxiety) increases arousal and leads to problems falling asleep, staying asleep and daytime sleepiness. Bruxism is significantly higher in individuals whose lifestyle includes the use of these psychoactive substances.

Stress, Anxiety & other Psychological Components

Mental disorders, anxiety, stress and adverse psychosocial factors are significantly related to tooth grinding during sleep and it has been found that nearly 70% of bruxism occurs as a result of stress or anxiety. It is well documented that job related stress is detrimental to good sleep and as a consequence can be responsible for daytime sleepiness. But, it is also the most significant factor associated with bruxism. One study found that shift workers who suffered stress due to dissatisfaction with their shift-work schedule were more susceptible to bruxism than those who were satisfied and not stressed. Interestingly, the men in this study demonstrated high levels of job stress, depressive symptoms and bruxism whereas none of these symptoms were significant for the women. These adverse symptoms were particularly evident in male workers who experienced low social support from supervisors or colleagues.

Many physical ailments have psychological components that may influence a person's vulnerability to illness as well as their ability to recover. Stress levels and personality characteristics are often considered as initiating, predisposing and perpetuating factors for several diseases. The workplace offers a unique environment where stress and personality play a major role in performance. Personality variables include the individual's coping style both in perception and coping techniques. Some people are less resilient to stress and therefore suffer more from the physical and psychological consequences. Previous research findings point to the possibility of a link between bruxism and the work environment, especially the coping strategies for work related stressful demands. Some people of course, may be exposed to high levels of stress unrelated to their job, but still affect bruxism.

Symptoms Of Bruxism

Physical symptoms: headache, temporomandibular joint (TMJ) discomfort and muscle aches, facial myalgia (muscle pain), ear ache, tightness and stiffness of the shoulders, limitation of mouth opening and sleep disruption of the individual as well as the bed partner.

Oral symptoms: abnormal tooth wear, fracture of the teeth, inflammation and recession of the gums, excess tooth mobility and premature loss of teeth.

Headache seems to be the most commonly cited area of pain and it is estimated that bruxists are three times more likely to suffer headache than non-bruxists. Individuals with long-standing bruxism appear to be more likely to have craniofacial pain than non-bruxists.

It should be noted that these symptoms may not necessarily indicate a straight forward cause-effect relationship. For example, depression can conceivably be an effect of persistent TMJ discomfort rather than its cause.

In the case of children, bruxism often occurs with obstructive nasal and breathing symptoms due to overlarge tonsils and adenoids. They experience more arousals from sleep than adults but whether this is due to bruxism alone or their obstructive symptoms needs further investigation. However, it has been found that there is a greater incidence of behaviour and attention difficulties in children with bruxism. Similarly, it is unknown whether bruxism is the cause of increased arousals and behavioural problems or if children with behaviour and attention difficulties exhibit altered sleep along with bruxism. It is known that sleep fragmentation secondary to sleep-disordered breathing in children can lead to behaviour, attention and executive function problems.

Effects Of Bruxism

Bruxism affects sufferers in many ways. Some of the adverse effects are short-term and disappear when the bruxism ceases. Others sadly, are long-term or even permanent.

Short-term effects of bruxism

  • Headache - Bruxism sufferers are three times more likely to suffer from headaches.
  • Facial myalgia (aching jaw & facial muscles)
  • Ear ache
  • Tightness/stiffness of the shoulders
  • Limitation of mouth opening
  • Sleep disruption
  • Sleep disruption of bed partner due to noise
  • Excess tooth mobility
  • Inflamed & receding gums

Long-term effects of bruxism

  • Temporomandibular Joint Disorder (sometimes called TMJD or just TMJ)
  • Tooth wear & breakage

Who Is Most At Risk From Bruxism?

Some groups of people are more likely to suffer from bruxism than others. Those most at risk are:

  • People with another sleep disorder, such as:
    • Snoring
    • Obstructive sleep apnoea
    • Sleep talking
    • Violent behaviour during sleep
    • Sleep paralysis
    • Hypnogogic/hypnopompic hallucinations (semi-consciousness between sleep and wake)
  • People with a stressful lifestyle
  • Smokers
  • People with a high alcohol intake
  • People who drink 6 or more cups a day of tea or coffee
  • People who take medication for sleep, depression and/or anxiety

How Can I Stop Grinding My Teeth?

Bruxism - Treatments

  • Occlusal adjustment & orthodontic treatment
  • Mandibular Advancement Devices (MADs)
  • Behavioural approaches
  • Other Treatments

The only proven treatments for bruxism are mandibular advancement devices, hypnosis and occlusal splints. Although there have been many other treatments proposed over the years to decrease the level of bruxism.

Occlusal splints are small plastic mouth-guards that can be used immediately without specialist fitting.

Occlusal splints have been found to be the most successful as they protect the teeth from premature wear, reduce jaw muscle activity and the noise of teeth grinding. This means that the user need not worry about ruining their teeth (or any dental work they may have) and their bed partner will not be disturbed by the noise.

Occlusal Management (fit of the teeth as the two jaws meet)

There are two categories of occlusal management strategies: 'true' occlusal interventions and occlusal appliances.

Occlusal interventions usually involve occlusal equilibrium, rehabilitation and dental treatment. The treatment is aimed at achieving a 'harmonious' relationship between occluding surfaces. However, there is no high quality evidence to support the use of these irreversible techniques and therefore they are not generally recommended in the first instance.

The most common and effective treatment involves protecting the teeth with occlusal splints. These splints have different names (occlusal bite guard, bruxism appliance, bite plate, night guard), vary in appearances and properties, but in essence, they are all designed to prevent inadvertent tooth movement.

The occlusal splint is the treatment of choice as it reduces grinding noise and protects the teeth from premature wear without substantial adverse effects. Occlusal splints reduce muscle activity associated with sleep bruxism but it must be acknowledged that these devices, like MADs (See Below) for snoring and sleep apnoea, are only a control and will not cure the condition.

MADs (Mandibular Advancement Devices)

MADs are generally used for the management of snoring and sleep apnoea but researchers have investigated their use for the management of sleep bruxism. Many studies report highly effective outcomes in the reduction of sleep bruxism but with undesirable side effects. One study compared the effectiveness between a MAD and occlusal splint. A moderate reduction in sleep bruxism was found with the occlusal splint but a large reduction in bruxism activity with the MAD. This result was difficult to explain but it was hypothesized that because two thirds of the study sample reported pain when using the MAD it may be that with the presence of pain, bruxism activity was reduced.

Behavioural Approaches

Psychoanalysis, autosuggestion, hypnosis, progressive relaxation, meditation, self monitoring, sleep hygiene and habit reversal/habit retaining have been prescribed for the management of bruxism. Giving an autosuggestion before falling asleep such as 'I will wake up if I grind my teeth' is reported by psychoanalysts to help the bruxist become aware of the habit, even while asleep. Unfortunately, autosuggestion lacks scientific strength and is not recommended.

Hypnosis has long been under review and some bruxists have found profound relief from problems related to sleep bruxism. One study reviewed the long-terms effects of hypnosis and a positive outcome was still applicable even after 36 months. This treatment has promise, and for some it may be successful.

More general relaxation techniques including meditation are supposed to produce a sense of self-esteem and control over one's body. However, there is no current literature regarding the efficacy of this holistic approach to the management of bruxism.

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