American Family Physician

Treatment Approaches 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. KRUMHOLZ, LCDR, MC, USN, Fallon Naval Air Station, Nevada

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 diagnose. In addition to complaints from sleep
partners, signs of teeth grinding inciude
masticatory pain or fatigue, headaches, tooth
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, alteration of sleep
positioning, drug therapy, biofeedback training, physical therapy and dentai evaluation, if
significant tooth attrition, mobility 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 prevent sequelae such as headaches, muscle
pain, temporoniandibular joint dysfunction and permanent tooth damage.
The reported incidence of bruxism varies,
depending on the population that is studied, the definition that is used and the diagnostic criteria that are applied. The incidence of this condition in adults ranges
from 5 to 96 percent' and is approximately
15 percent in children, with equal distribution between the sexes.^
Elements of bruxisni have been observed in infants, but the condition occurs
May 15,1994

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 persons with this condition are aware of their
behavior.^
Etiology
The etiology of bruxism is not well imderstood, although the condition has been
associated with many factors, most notably 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 who 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 compulsion/ Clinically, bruxism commonly accompanies the stress of marital strife, school
examinations or difficult work situations,
and it may resolve as these stresses lessen.**
OCCLUSAL DISCREPANCIES

The link between bruxism and occlusal

discrepancies is controversial** but is still
accepted by many health care professionals, including dentists, oral surgeons
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Bruxism

TABLE 1

Common Oinical
Manifestations of Bruxism
and physicians. Occlusal discrepancies
linked to bruxism include malocclusion,'
premature contact between the teeth,**
faulty dentition in children,^ faulty restorations^ and dental trauma."*
It has been hypothesized that as a person
attempts to reduce improper contact between the teeth, reflex receptors elicit contraction of the jaw muscles.'^ However, a
number of investigators"^"'- believe that the
link between bruxism and occlusal discrepancies is unclear. In experimental studies
by Rugh and colleagues," occlusal deflections 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 unpredictable.
OTHER POSSIBLE ETIOLOGIES

Since teeth grinding often occurs in more

than one member of a family, a genetic predisposition for the condition may exist."-^'
Bruxism has also been found to occur
three times more frequently in children
with allergies tlian in those without allergies.'"* Teeth grinding appears to relieve
the itching, sneezing and coughing associated with allergies. The pathophysiology

The Authors
BENJAMIN A. THOMPSON, err, MC, USA
is a third-year resident in family practice at Womack
Army Medical Center, Fort Bragg, N.C. He received his
medical degree from the University of California,
Irvine, Coilege of Medicine and served an internship in
family practice at Fort Ord, Calif.
B. WAYNE BLOUNT, i.TC, MC, USA
is chairman of the Department of Family and
Community Medicine at Eisenhower Army Medical
Center, Fort Cordon, Ca. After graduating from the
University of Miami School of Medicine, he completed
a family practice residency at Fort Belvoir, Va., a twoyear faculty development fellowship at Madigan Army
Medical Center, Seattle, and a master's degree in public
health at the University of Washington Schooi of Public
Health, Seattle.
THOMAS S. KRUMHOLZ, LCDR, MC, USN
is a staff dentist at Fallon Naval Air Station, Nev. He is a
graduate of the University of Califomia, Los Angeles,
School of Dentistry.

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Grinding noise noted by sleep partner

Abnormal tooth attrition, especially of the
maxillary canines
Tender temporomandibular joint and associated
musculature
Headaches
Decreased jaw-opening range
Excessive tooth mobility
Sensitive teeth
Masseter muscle hj'pertrophy

is postulated to be stimulation of the trigeminal nuclei by increased negati\'e pressure from mucosal edema of the eustachian tubes.'-''
Another hypothesis is that bruxism
relates to a dysfunctional central nervous
system.*^ Supporting the CNS etiology is
the finding that various drugs, such as amphetamines, phenothiazines, levodopa and
alcohol, precipitate bruxism.'* Further evidence for a CNS etiology is the occurrence
of bruxism in brain-damaged children, comatose patients and persons with cerebral
palsy."* However, the CNS structures associated with teeth grinding have not yet
been identified.
Bruxism also occurs more frequently iii
persons with sleep disturbances.'"''^ The
condition has been found to occur in every
sleep stage, except the first. The most
destructive teeth grinding occurs in rapideye-movement (REM) sleep.
Clinical Manifestations
The average person with bruxism h a s
five eight-second episodes of teeth grinding
per night, with these episodes generatiiig
substantial force on the teeth.'" The average
maximum biting force is 162 p o u n d s per
square inch (psi), while the highest recorded biting force durmg teeth grinding is 975
psi.'^ Thus, if teeth grinding persists, various problems can occur, often before the
patient is aware of the condition (Table I).
A patient may present for medical help
because another person, such as a sleep
partner, has heard the grinding or grating
sounds. Such sounds are nearly impossible
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American Family Physician

FIGURE 1. Tooth attrition, with worn incisors

and cuspids with flat occlusal surfaces.

FIGURE 2. Tooth attrition, with scooping out of

teeth, gingival erosions and spacing between the
teeth.

to produce consciously, imless the person

has organic brain disease.^
Signs of teeth grinding include hypertrophy and tenderness of the masseter and
temporal muscles, limited jaw opening,
inflammation of the gingiva, temperaturesensitive teeth, broken restorations, fractured cusps and abnormal wear of the
^ Tooth abrasion is the most com-

TABLE 2

Screening Questions for Bruxism

Do you dench or grind your teeth, or has anyone ever told you that you do?
Do you ever have headaches or pain in your neck or shoulders?
Do you have a clicking jaw?
Do your teeth or jaws ever feel tired when you wake up?
Do you have sensitive teeth?
Do you have, or have you ever had, pain in your jaw or in the sides of your
face in the area of your ears?
On which side of your mouth do you chew?
Adapted from Nasedkin /M. Occlusal dysfunction: screening procedures and initial
treatment planning. Gen Dent 1978;26:52-7. Used with permission.

May 15,1994

monly reported sign, and is perhaps the

best guide for the diagnosis in adults. In
children, however, some wear on the primary teeth is normal.""
Attrition occurs in both primary and permanent dentition and can affect one or
more teeth (Figures 1 and 2).^ Teeth grinding
can destroy most of the thin enamel in primary dentition, sometimes exposing the
pulp and resulting in abscess formation.Fortunately, these abrasive forces initiate
dentin production and the pulp is protected.^ In permanent teeth, damage occurs
slowly, but it is irreversible and the teeth
are difficult to restore.
The maxillary canines are usually the
first teeth to show signs of wear, but the
posterior teeth are also c o m m o n l y affected.**'*'^ The wear may be so great that it
diminishes vertical facial height.'* With persistent bruxism, periodontal ligaments can
be injured, thereby increasing tooth mobility."* The pressi-u^ on the teeth can interfere
with local blood supply and lead to alveolar bone loss.'^ Other effects of bruxism
i n c l u d e m a s t i c a t o r y m u s c l e pain a n d
fatigue, and locking and cracking of the
jaws."
Bruxism can incite a myofascial pain
syndrome and contraction headaches due
to fatigue of the masseter, temporal, and
lateral and medial pterygoid muscles.** In
time, the constant force of bruxism can
cause muscle hypertrophy. If the masseter
muscle h y p e r t r o p h i e s , it can block the
parotid duct, resulting in a condition that
imitates parotitis or sialolithiasis."
For the detection of bruxism, Nasedkin^^
recommends the use of a simple, 30-second screening examination that is designed to evaluate most types of occlusal
disease. In addition to the seven questions
listed in Table 2,'" the screening examination includes measurement of the maximal jaw opening (the average intercisal
distance is 40 to 60 mm) and palpation of
the temporomandibular joints and the lateral pterygoid muscles. If there are multiple positive responses, further investigation of bruxism is warranted.
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American Family Physician

Bruxism

Treatment
While the symptoms of bruxism in
adults can be treated, the condition usually
cannot be cured. Treatment focuses on relieving acute symptoms and limiting permanent sequelae. Treatment should be provided jointly by the patient's family
physician and dentist. Because bruxism
may have a number of causes, a variety of
treatments has been proposed (Figure 3).
The success of treatment is determined by
symptom resolution and improved mandibular range of motion.
The possible etiologies in the individual
patient must be investigated, and treatment must be targeted at the suspected

causes. This approach can be frustrating to

both the physician and the patient, and the
physician should explain why it may be
necessary to try several different treatments. Patient compliance may be improved if the patient is shown pictures,
diagrams or models that illustrate the
pathology of bruxism.
Treatment approaches include biofeedback 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 signs of bruxism or positive screening

examination (see text and Table 2)

Yes

1. Stress present

2. Malocclusion

1
Refer to a dentist
Education
Counseling
Visual imagery
Autosuggestion
Aversive conditioning
Massed negative practice
Biofeedback training

i
1

Unsuccessful

Trial of an
mlidepressant

If appropriate, refer to a dentist

3. Muscle pain
and fatigue

i
NSAID Iherapy
Soft diet
Biofeedback training
Isotonic exercises
Changes in sitiep
positioning

4. Primary dentition
vfithout attrition

Observation

1
Unsuccessful

1
Physical therapy or trial
Ota muscle relaxant

Unsuccessful

1
Psychotherapy

FIGURE 3. An approach to the treatment of buixism. Note that items 1 through 4 are not mutually exclusive. (NSAID = nonsteroidal anti-inflammatory drug.)
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American Family Physician

ships should be made. 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 lifestyle changes.
Stress reduction can be achieved using a
number 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 sleeping while the mouth is in this relaxed position. This method of jaw relaxation is easily taught and, in conjunction with other
modalities, may be helpful.
AVERSIVE CONDITIONING

Moderate success has been achieved

using aversive conditioning, such as awakening the patient during episodes of teeth
grind ing. ^"'^' When practiced consistently,
aversive conditioning can at least temporarily 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 seconds and then relaxes the jaws for five seconds.^ The patient repeats this exercise
five times in succession, six different times
a day, for two weeks. This simple treatment is cost-effective in that it requires little trairung time.
PEDIATRIC TREATMENTS

Since bruxism in children usually resolves spontaneously, observation and

reassurance, rather than intervention, are
warranted in most cases.^ For the child
May 15,1994

with bruxism, the home and school environments 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 during the day.
PHARMACOLOGIC THERAPY

Pharmacologic therapies that suppress

REM sleep may be beneficial in severe
cases. Normalizing sleep patterns and
eliminating depression with a REM-suppressant 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 (Robaxin) and injections of botulinum toxin
have been anecdotally reported to be useful in the management 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 supporting the shoulder and arm. Sleeping in
this position removes strain from the neck
and decreases lateral forces on the teeth.^''
It may also decrease pain and muscle
fatigue.
OTHER TREATMENTS

A soft food diet (to allow masticatory

rest), nonsteroidal anti-inflammatory
drugs, vapocoolant spray therapy, muscle-stretching exercises, heat therapy,
and isotonic exercises of the masseter
and temporal muscles may be helpful if
the primary symptoms of bruxism are
muscle fatigue and pain.^'^ If symptoms
have not abated after one week, physical
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American Family Physician

Bruxism

therapy or a trial of a muscle relaxant may

be considered."-^''
If the patient does not respond to initial
treatment after tu'o to three weeks, referral
to a dentist for an intraoral appliance is
warranted, if this has not already been
done. Frequently, the dentist and the physician will already be working together.
The purpose of intraoral appliances is to
correct muscle posture" and protect the
teeth from further abrasion.^^ Intraoral
appliances have been effective in relieving
the symptoms of temporomandibultir joint
disorder and myofascial pain disorder.
However, no agreement exists on the effectiveness of these appliances in permanently decreasing teeth grinding."-^- Treatment
should be provided by a dentist and is
usually continued for one to three months.
Techniques that are being investigated
for the treatment of bruxism include transcutaneous electrical nerve stimulation,
ultrasound therapy, hypnotherapy and
acupressure.**-^
Final Comment
The family physician should approach
bruxism as a behavior with multiple etiologies, with each cause having a variety
of management options. The disorder
needs to be identified, because it can cause
severe damage. If no damage is visible, the
patient with bruxism may be treated with
stress reduction tecliniqucs, physical therapy and drug therapy. If fractured cusps,
teeth mobility and dental sensitivity are
present or if the family physician is
uncomfortable evaluating the teeth for
damage, the patient should be referred to a
dentist.
Figures '1 and 2 from 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 authors and should not be construed as official or as
reflecting the views of the Department of the Army,
the Department of the Navy or the Department of
Defense.

1622

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