therapy of bruxism

7/24/2019 Therapy of Bruxism

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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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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

volume 49, num ber7


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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 .

9


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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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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

May 15, 994

62


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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.

REFERENCES

1. Pavon e BW. Bmxism

and its

effect

on the

natura

teeth. J Pro sthet Dent 198S;53:692-6,

2.

Schneider

PE

Peterson

J.

Oral habits : considera

t ions in ma n a g e m e n t . P e d ia t r C l in N o r th Am

1982;29:523-46.

3. L e u n g AK Robson WL.Brux ism. How to s to

t o o t h g r i n d i n g and c l e n c h in g . P o s tg ra d Me

99 ;89(8):

167-8,171.

4.

Cash RC. Bruxism inchiidren: reviewof thelitera

ture.

J Pedodont 1988;12:107-27.

5. .Attanaaio R. Noc turna l h rux ism and its ciinica

management. Dent Ciin North Am 1991;35:245-52,

6 . A h ma d R. B ru x i s m in c h i l d r e n . J P e d o d o n

1986; 10:105-26.

7 HicksRA Chancellor C. Noc turna l b rux isman

type A-B behavior

in

coilege students- Psycho

Re

1987;fi0(3Pt2):1211-4.

8. Rugh JD, Hartan J. Noct urnal bruxism

and

temporo

man dibu lar disord ers, A dv N eurot 1988;49:32'>-41,

9. Savers P. The bruxer,Ann RoyAust Coll D ent Sur

986;9:158-66.

10.

ClarkeNC Townsend GC.Distribution of ntKtur

n a l b r u x i n g p a t t e r n s in man. J O ra l R e h a b i

1984;10:529-54.

i l -

R u g h

JD

Barghi

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D r a g o

CJ.

E x p e r i m e n t a

occlusal discrepancies and noc turna l b rux ism.

Prosthet Dent ]984;51:548-53.

12. Kardachi BJ Bailey JO,Ash MM Acomparisono

biofeedback

and

occlusai adjustment

in

bruxism-

Periodont 1978;49:367-72-

13.

M a r k s

MB.

Brux ism

in

a l le rg ic ch i ld ren .

Am

Orthod iy80;77(l):48-59.

14.

Reding

GR

Zepeiin

H

Robinson

JE

Smith

VH

Zimm erman SO. Sleep patternsofbruxism:arevi

sion. Psychophysiology 1968;4(3):396,

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Ware JC, Rugh JD. Destructive bruxism: sleep stag

relationship, Slt-ep ]98 8;ll:]72- 8i-

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Boero RP,Thephysiologyofspiint th erapy:alitera

u v review- An gle Or Hw d 198^:59(3): 165-80-

17 Colquitt T Thes leep-wear syndrom e.J Prosthe

Dent 1987:57:33-41.

18, Nasedkin JN Occlusal dysfunction: screeningpro

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1978;26:52-7

19- McLoughlin PJ.Ciinicai strateg ies to help patient

reduce

ja\v

clenching

and

bruxing behaviors.

Int

Orofacial Myoiogy 19qO;16(l):13-7

20 .

Cherasia

M

Parks L. Suggestions

for use of

behav

ioral measures in treating bruxism- PsycholRep

1986;58:719-22,

21 .

Mo s s RA H a m m e r D A d a m s HE J e n k in sJO

ThompsonK Hab er J. A more efficient biofeedback

procedure

for

tJie treatment

of

nocturnal bnixism-

Oral RehabU 1982,-9:125-31-

22. Aycr WA- Massed practice exercises for theelimi

na t ion of tooth-grinding habits . Behav ResThe

1976;14:163-4-

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Ware JC- TrL-yclic anti dep ress ants

in the

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of insomnia,

J

Clin P sychiatry 1983;44:25-8.

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Van Zandi jcke M Ma rc h a u MM.T re a tme n t o

bruxism with botulinum toxin injection.s [Letter],

Neurol Nemosurg Psychiatry 1990;53:530-

25 .

Kent JM- Comm onstinsc management

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TMJ trou

bles. Pa tient Car e 1984; 18:129-64,

1622

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therapy of bruxism

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