A guide to bruxism/teeth grinding

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What is Bruxism (teeth grinding)?

It is not unusual for the majority of people to clench or grind their teeth on occasion. This phenomenon is medically termed bruxism and is non-harmful in most cases, although when teeth grinding becomes more frequent, teeth can get damaged and other problems may emerge. Bruxism affects approximately 9% of the UK and is the third most frequent sleep disorder after insomnia and snoring. It can be distinguished by teeth grinding and jaw clenching, that can lead to tooth wear and breakage, jaw disorders, including pain and limited movement. Bruxism is most common in adults aged between 25-44 years old, but can affect both adults and children. The disorder can be further classified into awake bruxism and sleep bruxism. The former is distinguished by the involuntary clenching of the teeth and bracing of the jaw as a reaction to certain stimuli. Awake bruxism rarely involves tooth grinding. Sleep bruxism, however, involves automatic tooth grinding with sustained, rhythmic muscle contractions of the jaw. Bruxism can be further categorised into primary and secondary bruxism. Primary Bruxism occurs without any prior medical condition, whereas for secondary bruxism a medical or psychiatric condition has already been identified. Certain medications are associated with awake and secondary bruxism, for example antidepressants or such recreational drugs as ecstasy and cocaine, and disorders such as Parkinson's disease and major anxiety and depression.

Causes of Bruxism (teeth grinding)

Research has shown that sleep bruxism rarely occurs in isolation, and so there are several other characteristics associated with the disorder. It occurs as a response to periods of awakening during sleep, suggesting that it may also be an indicator of a sleep disorder. Almost 80% of bruxism cases happen in clusters during sleep and are associated with the periods of awakening. Strong associations have been discovered between Obstructive Sleep Apnoea (OSA), which are episodes of breathing cessation during sleep, often with daytime sleepiness and non-restorative sleep, and sleep bruxism. OSA sufferers have many arousals during sleep as a result of their breathing difficulties. After an apnoea episode, snoring, gasping, mumbling, and indeed tooth grinding, commonly occur. OSA is the sleep disorder with the highest risk factor of tooth grinding. However, other sleep conditions, such as hypnagogic hallucinations, sleep talking, REM sleep disorders and violent or injurious behaviours during sleep have notable associations with sleep bruxism also. Bruxism is also more common in people who regularly consume alcohol, tobacco and large quantities of caffeine. The use of such psychoactive substances (also including medications for sleep, depression and anxiety) increase arousal and can result in problems getting to sleep, staying asleep and sleepiness during the day. One study stated that bruxism is more prevalent in men than women. This has much to do with the fact that smoking was more than two and a half times greater in men than women in the study. It is estimated that smokers are five times more likely to suffer from bruxism and grinding episodes than non-smokers. Nicotine is a neuro-chemically active substance and has been linked to motor activity during sleep. Furthermore, research has shown that smokers report higher levels of anxiety and are more likely to have personalities inclined towards tooth grinding.

Indeed, psychological problems, including stress and anxiety, mental disorders and adverse psychosocial issues can also worsen tooth grinding during sleep. A recent study has discovered that almost 70% of bruxism cases occur due to stress or anxiety. It is common knowledge that work-related stress has a negative impact on sleep quality, and consequently can cause daytime sleepiness, but it is less well known that it is also the most significant cause of bruxism. Research suggests a link between the work place and bruxism, especially in relation to coping strategies for job related stressful demands. Stress from other areas of life can, naturally, be of a high level also, which could equally affect bruxism. People of a higher educational status and young age are also more likely to be affected. Physically, an abnormal bite, or crooked or missing teeth may also cause bruxism.

Do I grind my teeth?

Tooth grinding commonly occurs during sleep. Therefore most people are unaware that they suffer from bruxism. However, an average of 1 in 10 people suffer from the disorder, and there are symptoms that you can look out for, including:

  • Your jaw muscles aching in the morning.

  • You experience difficulty eating upon waking.

  • Your teeth start to show signs of premature wear.

  • You experience frequent headaches and/or facial pain.

  • Others have noticed you making grinding noises in your sleep.

If you suspect that you suffer from tooth grinding, you can visit your dentist who will examine your mouth and jaw for signs of bruxism, for example jaw tenderness and abnormalities in your teeth.

Does Bruxism (tooth grinding) affect children?

Bruxism and teeth grinding affects both adults and children. Approximately 15% to 33% of children suffer from bruxism. There are two peak times for this to occur in children. First, when their baby teeth emerge and second, when their permanent teeth emerge. The majority of children cease to grind their teeth after the two sets of teeth have fully settled. Sleep bruxism is the most common form in children, and potential causal factors include irregular contact between upper and lower teeth, improperly aligned teeth, ill health and medical conditions including pinworm, endocrine disorders, allergies and nutritional deficiencies. Psychological disorders, such as anxiety and stress are also contributing factors. There are rarely problems as a result of grinding of baby teeth, however, bruxism can always cause headaches, jaw pain, tooth wear and, potentially, Temporomandibular Joint Disorder (TMJD). If your child complains of tooth sensitivity or pain, please consult your dentist.

There are however, basic tips you could follow to help your child stop grinding his or her teeth. These include:

  • Ensuring your child's diet includes plenty of water, as dehydration has been linked to teeth grinding.
  • Asking your dentist to monitor your child's teeth if he or she suffers from bruxism.
  • Decreasing your child's stress levels, especially before bedtime.
  • Massaging and stretching exercises could be used to relax the muscles.
  • Older children may require temporary crowns or alternative methods, such as wearing a night guard, to prevent bruxism.

It is harmful? What are the effects of bruxism?

If teeth grinding becomes chronic, this can result in tooth loss, loosening or fracturing. Teeth may become worn down to stumps. In such cases, bridges, crowns, implants, partial or complete dentures or root canal treatment may be required. Severe teeth grinding may also affect your jaws, result in a loss of hearing, cause TMD/TMJ, and in extreme cases, alter the appearance of your face. Some of the negative effects of bruxism are short-term and fade when the disorder ends. For example, bruxism sufferers are three times more likely to experience headaches. Tightness of the shoulders, sleep disruption, ear ache, facial myalgia, excess tooth mobility, limitation of mouth opening and inflamed or receding gums are other short term effects. More serious, long-term, and even permanent effects, can include Temporomandibular Joint Disorder (TMJD), tooth wear and breakage.

Effects of bruxism on children often include obstructive nasal and breathing symptoms as a result of overlarge tonsils and adenoids. Children experience more sleep arousals than adults but this may not be solely due to bruxism. Studies have shown, however, that there is a greater frequency of attention and behaviour difficulties in children with bruxism.

How can I Stop Grinding My Teeth?

Although many treatments have been suggested for bruxism, the only proven treatments are mandibular advancement devices, occlusal splints and hypnosis.

Occlusal Splints
Occlusal splints are plastic mouth guards that are available for wear immediately without the need for specialist fitting. The splints are deemed to be the most successful treatment as they protect the teeth from wearing prematurely, reduce jaw muscle activity and also reduce the noise of teeth grinding. The occlusal splint is popular as it works without substantial adverse effects. Splints reduce muscle activity associated with sleep bruxism, working as a good control, albeit not a cure. There are many forms of occlusal splints including occlusal bite guards, bruxism appliances, bite plates and night guards, which vary in appearance and properties, but essentially all prevent inadvertent tooth movement. Some fit over your top teeth, and some over your bottom teeth. They may be designed to maintain your jaw in a more relaxed position or provide another function. If one type doesn't work, another may be more suitable, and you may also find that some splints lose their effectiveness over time. After splint therapy, your dentist may suggest orthodontic adjustment of the bite pattern. However, surgery should be considered a last resort.

Psychological and behavioural treatments
If your bruxism is stress-induced you should consult your dentist or doctor about options in managing your stress levels. Options that may be offered include stress counselling or exercise. There are many behavioural changes you could adopt in order to help prevent teeth grinding. These include reducing your intake of caffeine and alcohol and avoiding chewing gum as it encourages jaw muscles to clench, making teeth grinding more likely. Also, if you notice that you suffer from awake bruxism, positioning the tip of your tongue between your teeth trains your jaw muscles to relax. At night jaw muscles can be relaxed by holding a warm flannel against your cheek. Autosuggestion, hypnosis, progressive relaxation, self-monitoring, meditation, sleep hygiene and habit reversal/habit retaining have all been suggested as bruxism treatment. For example, the autosuggestion 'I will wake up if I grind my teeth' used immediately before going to bed, is reported by psychoanalysts to aid the bruxist to become more aware of the habit, even while sleeping. However, this method lacks scientific strength. Hypnosis appears to be a more promising alternative for sleep bruxism, with one study showing the effects on bruxism to last for in excess of 36 months.

Rehabilitation techniques
Physical rehabilitation techniques that develop or strengthen the jaw opening muscles to hold the mandible in balance have also been suggested as a bruxism treatment, for example using facial muscle exercisers. There is little evidence to show that these techniques are effective, however.

Pharmacology
Drugs such as muscle relaxants have shown to have a temporary effect on muscle activity in the jaw and have been suggested as an alternative treatment for bruxism. However, their therapeutic efficacy, risk of addiction and long term tolerability as yet require further research. For the majority of people, antidepressant drugs are ineffective in reducing bruxism. Other drugs, for example sedative and anxiolytic drugs used to treat anxiety, seem to be more effective a solution, although the safety of their use is under questioning as severe morning hypotension has been identified in 20% of patients. Botulinum toxin (BTX) is a biological toxin that works as a paralytic. Although highly toxic, it is used in minute doses to treat painful muscle spasms. It is administered by intramuscular injection and its effects are thought to last for 3-6 months. A study revealed, however, that patients required several sessions of treatment and even then, researchers were unclear as to whether the results were favourable. Overall, pharmacological studies suggest that different classes of drugs may impact on muscle activity related to bruxism, but safety issues are in need of much further investigation at this stage.

MADs (Mandibular Advancement Devices)
Mandibular advancement devices are commonly used to manage snoring and sleep apnoea, yet they have also been proposed for the management of sleep bruxism. Many studies report promising results in reducing sleep bruxism, but also shown negative side effects. One study compared the effectiveness of an MAD to the effectiveness of an occlusal splint. A slight reduction in sleep bruxism was found with the splint, but a significantly larger reduction in bruxism was shown with the MAD. Researchers suggested that this was due to two thirds of the study patients reporting pain when using the MAD, concluding that with the presence of pain, bruxism is reduced.

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