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American Family Physician
Treatment A ppro ach es to Bruxism
BENJAMIN A. THOMPSON, CPT, MC, USA, Womack Army Medical Center, Fort Bragg, North Carolina
B.
WAYNE BLOUNT, LTC, MC, USA, Eisenhower Army Medical Center, Fort Gordon, Georgia
THOMAS
S
KRUM HOLZ, LCDR, MC, USN, Fallon Naval Air Station, N evada
Bruxism
or the grinding and clenching of
teeth occurs in approximately 15 percent of
chiidren and in as many as 96 percent of
aduits. The etioiogy of bruxism is unciear
but the condition has been associated with
stress occlusal disorders allergies and
sleep positioning. Because of its nonspecific
pathoiogy bruxism may be difficult to
diag-
nose. In addition to complaints from sleep
partners signs of teeth grinding inciude
masticatory pain or fatigue headaches too th
sensitivity and attrition oral infection and
temporomandibular joint disorders. Signs of
bruxism include tooth wear and mobility as
weil as tender or hypertrophied masticatory
muscies and joints. Chiidren with bruxism
are usually managed with observation and
reassurance. Adults may be managed with
stress reduction therapy a lteration of sleep
pos itioning dru g therapy biofeedback
train-
ing physical therapy and dentai evaluation if
significant tooth attrition mob ility or fracture
occurs dentai referral is mandatory.
Bruxismthe grinding and clenching of
teethis common in persons of all ages.
Early detection of this condition can pre-
vent sequelae such as headaches, muscle
pain, temporoniandibular joint dysfunc-
tion and permanent tooth damage.
The reported incidence of bruxism varies,
depending on the population that is stud-
ied, the definition that is used and the diag-
nostic criteria that are applied. The inci-
dence of this condition in adults ranges
from 5 to 96 percent and is approximately
15 percent in children, with equal distribu-
tion between the sexes.^
Elements of bruxisni have been ob-
served in infants, but the condition occurs
more often in children, particularly those
with primary dentition. The prevalence in
childhood increases up to the age of seven
to 10 years. In children, bruxism is usually
transient and resolves with eruption of the
secondary dentition.-^-^
Since bruxism most frequently occurs
during sleep, only 5 to 20 percent of per-
sons with this condition are aware of their
behavior.^
Etiology
The etiology of bruxism is not well im-
derstood, although the condition has been
associated with many factors, most no-
tably stress and occlusal discrepancies.
STRESS
Ahmad^ has suggested that bruxism is
the subconscious outlet for the stress of
unexpressed emotions, such as anxiety,
hate and aggression. Teeth grinding may
occur in children w ho are just beginning to
vocalize but are restrained from expressing
their feelings. The incidence of bruxism is
higher in adults who are under stress or
who have personalities characterized by
time urgency and achievement compul-
sio n/ Clinically, bruxism com monly accom-
panies the stress of marital strife, school
examinations or difficult work situations,
and it may resolve as these stresses lessen.**
OCCLUSAL DISCREPANCIES
The l ink be tween bruxism and occ lusa l
dis cre pan cies is controversial** b ut is still
a c c e p t e d b y m a n y h e a l t h c a r e p r o f e s -
s iona l s , inc luding dent i s t s , o ra l su rgeon s
May 15,1994
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American Family Physician
Brux i sm
TABLE 1
Common
Oin ica l
Manifestations of
ruxism
and physicians. Occlusal discrepancies
linked to bruxism include malocclusion,'
premature contact between the teeth,**
faulty dentition in children,^ faulty restora-
tions^ and den tal trauma. *
It has been hypothesized that as a person
attempts to reduce improper contact be-
tween the teeth, reflex receptors elicit con-
traction of the jaw muscles.'^ However, a
number of investigators ^ '- believe that the
link between bruxism and occlusal discrep-
ancies is unclear. In experimental studies
by Rugh and colleagues, occlusal deflec-
tions did not incite teetln grinding, even in
patients with previous bnixism. Kardachi
and associates ' - studied the effects of
occlusal adjustment on bruxism and found
that the results were u npredictable.
OTHER POSSIBLE ETIOLOGIES
Since teeth grinding often occurs in more
than one m ember of a family, a genetic pre-
dispos ition for the cond ition m ay exist. -^'
Bruxism has also been found to occur
three times more frequently in children
with allergies tlian in those without aller-
gies.' * Teeth gr indin g ap pe ars to relieve
the itching, sneezing and coughing asso-
ciated with allergies. The pathophysiology
The Authors
BENJAMIN A. THOMPSON, err,MC, USA
is a third-yea r residen t in family practice at Wom ack
Army Medical C enter, Fort Bragg, N.C . He received his
medica l degree from the U n ivers i ty o f C a l i fo rn ia ,
Irvine, C oilege of M edicine and served an internship in
family practice at Fort Ord,
Calif
B.
WAYNE BLOU NT,
i.TC,MC, USA
i s c h a i r ma n of th e D e p a r t me n t o f F a mi ly a n d
C omm unity M edic ine a t E isenhower Army M edica l
C en te r , Fort C ordon , C a . After g radu a t ing from the
U niversity of Miami School of Medicine, he completed
a family practice residency at Fort Belvoir, Va., a two-
year faculty development fellowship at Madigan Army
Medical C enter, Seattle, and a maste r's degree in pub lic
health at the U niversity of Washington Schooi of Public
Health, Seattle.
THOMASS.KRUMHOLZ,
LCDR, MC,
USN
is a staff dentist at Fallon Naval Air Station, Nev. He is a
grad uate of the U niversity of Califom ia, Los Angeles,
School of Dentistry.
Grinding noise notedbysleep partner
Abnormal tooth attrition, especially
of the
maxillary canines
Tender temporoman dibular jointan dassociated
musculature
Headaches
Decreased jaw-opening range
Excessive tooth mobility
Sensitive teeth
Masseter muscle h j'pertrophy
is postulated to be stimulation of the tri-
geminal nuclei by increased negati\'e pres-
sure from mucosal edema of the eustachi-
an tubes.'-''
Ano ther hypo thes i s i s t ha t b rux i sm
relates to a dysfunctional central nervous
system.*^ Sup por ting the C NS etiology is
the finding that various dru gs, such as am-
phetamines, phenothiazines, levodopa and
alcohol, precipitate bruxism.'* Further evi-
dence for a C NS etiology is the occurrence
of bruxism in brain-damag ed children, co-
matose patients and persons with cerebral
palsy. * How ever, the C NS s tructure s a sso-
ciated with teeth grinding have not yet
been identified.
Bruxism also occurs more frequently iii
persons with sleep disturbances. ' ' '^ The
condition h as been found to occur in every
sleep stage, except the first . The most
destructive teeth grinding occurs in rapid-
eye-movement (REM) sleep.
Clinical Manifestations
T h e a v e r a g e p e r s o n w i t h b r u x i s m h a s
f ive eight-second episodes
of
teeth gr inding
per n ight , wi th these episodes generat i i ig
substantial force on theteeth. ' T h e average
max imum b i t ing fo r ce is 162 p o u n d s p e r
square inch (psi) , while th e highest record-
ed bit ing force durmg teeth grinding is 975
psi. '^
T h u s , if teeth gr inding persis ts , var i -
o u s p r o b l e m s c a n occur, often before t h e
pa t i en t isa w a r eof thecondi t ion Table I ) .
A pa t i en t m a y p resen t fo r med ica l he lp
b e c a u s e a n o t h e r p e r s o n , s u c h a s a s l e e p
par tner , h a s heard th e g r ind ing o r g ra t ing
s o u n d s . S u c h s o u n d s
a r e
near ly impo ssible
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American Family Physician
FIGURE
1.
Tooth a t tr i t ion, with w orn incisors
and cu spids w ith flat occlusal surfaces.
FIGURE
2.
Tooth attrition, with scoop ing
out of
teeth, gingival erosionsandspacing betweenthe
teeth.
to produce consciously, imless the person
has organic brain disease.^
Signs of teeth grinding include hypertro-
phy and tenderness of the masseter and
temporal muscles, limited jaw opening,
inflammation of the gingiva, temperature-
sensitive teeth, broken restorations, frac-
tured cusps and abnormal wear of the
^Tooth abrasion is the most com-
TABLE
Screening Questions for ruxism
Do you denchorgrind your teeth,orhas anyon e ever told you that you do ?
Do you ever have headaches
or
pain
in
your neck
or
shoulders?
Do you haveaclicking jaw ?
Do your teeth
or
jaws ever feel tired whe n you wak e up ?
Do you have sensitive teeth?
Do you have,
or
have you ever had, pain
in
your jaw
or in
the sides
of
your
faceinthe areaofyour ears?
On which sideofyour mouthdoyou chew?
Adapted from Nasedkin /M .Occlusal dysfunction: screening proceduresand initial
treatment planning. GenDent 1978;26:52-7. Used with permission.
m o n l y r e p o r t e d s i g n ,
and is
p e r h a p s
the
bes t gu ide
for the
d i a g n o s i s
in
a d u l t s .
In
chi ldren , howeve r , some wea r
on the pri-
mary tee thisnorma l .
Attrition occursinboth pr im aryand per-
m a n e n t d e n t i t i o n
and can
affect
one or
mo re tee th Figures 1 and2).^Teeth g r indin g
can des troy mostof the thin enam elin pri-
m a r y d e n t i t i o n , s o m e t i m e s e x p o s i n gthe
p u l p and re su l t ing in abscess formation.-
For tunate ly, these abras ive forces ini t ia te
dent in produc t ion
and the
p u l p
is
protect-
ed.^ In p e r m a n e n t t ee t h , d a m a g e o c c u r s
slowly,but it is ir revers ibleand the tee th
are difficult
to
restore.
T h e m a x i l l a r y c a n i n e s are u s u a l l y the
first teeth to s h o w s i g n sof wea r ,but the
p o s t e r i o r t e e t h are al s o c o m m o n l y af-
fected.**'*'^ The wear
may be so
grea t tha t
it
diminishes vertical facial height.'* Withper-
s is tent bruxism, per iodonta l l igamentscan
be injured, thereby increasing tooth mobili-
ty. *Thepressi-u on theteethcan interfere
with loca l blood supply and lead toa lveo-
la r bone loss . '^ Other e ffec ts
of
b r u x i s m
i n c l u d e m a s t i c a t o r y m u s c l e p a i n
and
fa t igue ,
and locking and c r a c k i n gof the
jaws.
B r u x i s m can i n c i t e a m y o f a s c i a l p a i n
s y n d r o m e and cont rac t ion headachesdue
to fa t igue of the masse te r , t empora l ,and
lateral and medial pterygoid muscles.**In
t i m e ,
the
co ns t an t force
of
b r u x i s m
can
cause musc le hype r t rophy.If them asse ter
m u s c l e h y p e r t r o p h i e s , it can b l o c k the
parot id duct , resul t ing in a condi t ion tha t
imita tes parot i t isorsialolithiasis.
For
the
detec t ion
of
bruxism , Nasedkin^^
r e c o m m e n d sthe use of a s imple , 30-sec-
o n d s c r e e n i n g e x a m i n a t i o n t h a t is de-
s igned to eva lua te mos t types of occ lusa l
disease.
In
addi t ion
to the
seven ques t ions
l i s t e d
in Table2,' the
s c r e e n i n g e x a m -
ina t ion inc ludes measurementof the max-
i m a l jawo p e n i n g (theave rag e in te rc i sa l
dis tanceis 40 to 60 mm) and pa lpa t ionof
the t emporomandibula r jo in t sand the lat-
era l pte rygoid muscles .
If
there
are
mul t i -
p le pos i t ive r e sponses , fur the r inves t iga -
tion
of
bruxism i s wa r ra n ted .
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American Family Physician
Bruxism
Treatment
While
the
s y m p t o m s
of
b rux i sm
in
adults can
be
treated, the condition usually
cannotbe cured. Treatment focuseson re-
lieving acute symptoms
and
limiting
per-
man ent sequelae. Treatment should be pro-
vided jo in t ly
by the
p a t i e n t s family
physician and dentist. Because bruxism
may have
a
number
of
causes,
a
variety
of
treatmentshasbeen proposed Figure3 .
The success
of
treatment
is
determined
by
symptom resolutionand improvedman-
dibular range of motion.
The possible etiologies
in the
individual
patient must
be
investigated,
and
treat-
ment must
be
targeted
at the
suspected
causes. This approach can be frustratingto
both the physician and the patient, and
the
physician should explain
why it may be
necessary
to try
several different treat-
ments. Patient compliance may be im-
proved
if the
patient
is
shown pictures,
d iag rams or models that i l lustrate the
pathology of bruxism.
Treatment approaches include biofeed-
back exercises, massed negative practice,
changes
in
sleep positioning, drug therapy,
psychotherapy, hypnotherapy, occlusal
orthotics,
and
stress reduction
and
coping
techniques.
Stress must
be
considered as
a
causative
factor
in
bruxism.
A
thorough evaluation
of financial, marital
and
familial relation-
Obvious signsofbruxismor positive screening
exam ination see text and Table2
Yes
If appropriate, refertoa dentist
1 . Stress present
1
Education
Counseling
Visual imagery
Autosuggestion
Aversive condit ioning
Massed negative practice
Biofeedback training
Unsuccessful
Trialof an
mlidepressant
2. Malocclusion
Refer to a dentist
Unsuccessful
Psychotherapy
3. Muscle pain
and fatigue
NSAID Iherapy
Soft diet
Biofeedback training
Isotonic exercises
Changes insitiep
posit ioning
Unsuccessful
Physical therapyor trial
Ota muscle relaxant
4.
Primary dentition
vfithout attrition
Observation
FIGURE 3. An approach to the treatment of buixism. Note that items 1 through 4 are not mutually exclu-
sive. NSAID nonsteroidal anti-inflammatory drug.)
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American Family Physician
ships should be mad e. Coimseling in these
areas can lead to an awareness of stressful
situations, and long-term management
should be directed at helping the patient
make comprehensive l ifestyle changes.
Stress reduction can be achieved using a
num ber of techniques.
VISUAL IMAGERY AND AUTOSUGGESTION
One approach to stress reduction uses
visual imagery and autosuggestion. The
patient is counseled to periodically relax
his or her jaws while the lips are closed
and the teeth are apart.''' A beginning goal
is for the patient to practice the relaxation
exercise 50 times a day. When the patient
is comfortable performing the exercise, he
or she is then instructed to visualize sleep-
ing while the m outh is in this relaxed posi-
tion. This method of jaw relaxation is easi-
ly taught and, in conjunction with other
modalities, may be helpful.
AVERSIVE CONDITIONING
Moderate success has been achieved
using aversive conditioning, such as awak-
ening the patient during episodes of teeth
grind ing. ' ' W hen practiced consistently,
aversive conditioning can at least tem-
porarily decrease the episodes of teeth
grinding. The combination of aversive
conditioning and another modality, such
as biofeedback or overcorrection, has been
found to improve treatment efficacy.^*
MASSED NEGATIVE PRACTICE
In massed negative practice, the patient
voluntarily clenches the teeth for five sec-
onds and then relaxes the jaws for five sec-
onds.^ The patient repeats this exercise
five times in succession, six different times
a day, for two weeks. This simple treat-
ment is cost-effective in that it requires lit-
tle trairung time.
PEDIATRIC TREATMENTS
Since bruxism in children usually re-
solves spontaneously, observation and
reassurance, rather than intervention, are
wa rran ted in most cases.^ For the child
with bruxism, the home and school envi-
ronments should be kept as free of stress
as possible. Making expectations realistic
and supplying play opportunities that are
appropriate for the child's developmental
stage may relieve anxiety. Leung and
Robson^ suggest that parents and other
caregivers make the child's bedtime rituals
enjoyable and relaxed by, for example,
reviewing the day's activities and talking
about the fears and anxieties the child may
have experienced d uring the day.
PHARMACOLOGIC THERAPY
Pharmacologic therapies that suppress
REM sleep may be beneficial in severe
cases. Normaliz ing s leep pat terns and
eliminating depression with a REM-sup-
pressant antidepressant may also alleviate
bruxism.^ * Diazepam (Valium) can be an
effective muscle relaxant,^ but this drug
should not be taken chronically because of
its abuse potential. Methocarbamol (Ro-
baxin) and injections of botulinum toxin
have been anecdotally reported to be use-
ful in th e m anagem ent of bruxism.' ' ''
SLEEP POSITION
A change in sleep position may decrease
the frequency of bruxism.''' Lying supine
with neck and knee support allows the
lower jaw to rest. If unable to sleep on the
back, the patient should sleep on the side
with pillows beneath the head and sup-
porting the shoulder and arm. Sleeping in
this position removes strain from the neck
and decreases lateral forces on the teeth.^''
I t may also decrease pain and musc le
fatigue.
OTHER TREATMENTS
A soft food diet (to allow masticatory
res t ) ,
nons te ro ida l an t i - in f lammatory
drugs,
vapocoolant spray therapy, mus-
c le-s t re tching exerc ises , heat therapy,
and isotonic exercises of the masseter
and temporal muscles may be helpful if
the pr imary symptoms of bruxism are
muscle fatigue and pain.^'^ If symptoms
have not abated after one week, physical
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merican Family Physician
Bruxism
therapyor atrialof amuscle relaxant m ay
be considered."-^''
If the patient does
not
respond
to
initial
treatme nt after tu'o to three we eks, referral
to a dentistfor an intraoral applianceis
warran ted , if thishas not already been
done. Frequently,thedentistand the phy-
sician w ill already be w orking together.
The purposeof intraoral appliancesis to
correct muscle posture"and protectthe
teeth from further abrasion.^^ Intraoral
appliances have been effective in relieving
the symptomsof temporomandibultir joint
d isorder
and
myofascial pa in diso rder.
How ever, no agreement exists
on
the effec-
tiveness
of
these appliances
in
permanent-
ly decreasing teeth grinding."-^- Treatment
should
be
provided
by a
dentist
and is
usually continuedforonetothree months.
Techniques that
are
being investigated
for the treatmentofbruxism include trans-
cutaneous electrical nerve st imulation,
u l t rasound therapy , hypnotherapy and
acupressure.**-^
Final Comm ent
The family physician should approach
bruxism as a behavior with multipleeti-
ologies, with each cause having a variety
o f managemen t op t ions .The d i so rder
needsto beidentified, bec auseitcan cause
severe damage.Ifno dam age is visible,the
patient with bruxism may be treated with
stress reduction tecliniqucs, physical thera-
py and drug therapy.If fractured cusps,
teeth mobility and dental sensitivityare
p r e s e n t or if the family phy sician is
uncomfor tab le evaluat ing
the
teeth
for
dam age, the patient should be referred to a
dentist.
Figures 1 and 2from Smrickler H. Equilibration in the
natural and restored dentition. Carol Stream 111.:
Quintessence 1991:25 27. Used with permission.
The opinions contained herein
are
those
of the au-
thors and should not be construed asofficial or as
reflecting the views of the Department of the Army
the Department
of the
Navy
or the
Department
of
Defense.
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coilege students- Psycho
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Cherasia
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Parks L. Suggestions
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Ware JC- TrL-yclic anti dep ress ants
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of insomnia,
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Kent JM- Comm onstinsc management
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1622
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