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Bruxism, why this strange name?
Bruxism is a term that comes from Greek and means “to grind your teeth”. Nowadays, the term bruxism encompasses not only teeth grinding, but also the clenching of teeth that is the prolonged and forceful contraction of jaw and face muscles. Bruxism can occur during sleep or daytime, and is therefore known as sleep bruxism and awake bruxism respectively. Some individuals may have both. Sleep bruxism, a self-reported condition that is most frequently confirmed by parents or sleep partners, can impact people of all ages. It is more frequent in children (12-20%), a bit less frequent in adults (8-16%) and less common in the elderly (3-6%).
What are the causes of sleep bruxism?
The origin of sleep bruxism is not yet fully identified and there is not one isolated factor or cause that can explain it. Nowadays, it is known that an incorrect bite or a poorly positioned tooth are not among the etiological factors. Sleep bruxism is most likely generated in the brain centers controlling vigilance and jaw muscles, and is most likely under environmental, social and genetic influences. It can be aggravated by emotional factors, such as stress, anxiety and overactive life style. Those factors may also be present in people with awake bruxism. Bruxism can also be related to sleep disorders or to the overuse of alcohol, coffee, nicotine, medications (e.g., antidepressants) or certain illicit drugs such as cocaine, amphetamines, or ecstasy. This suggests that some individuals may need to control their bruxism during some stages of their lives, but not necessarily all the time.
There is no classical profile for individuals with sleep bruxism and there is also no one unique mechanism, but there are various contributing factors for its occurrence. The association with sleep arousals, a marker of overactivity in motor and cardiac systems, some of the body’s chemical messengers, familial and genetical factors, upper airway obstructions and emotional stress factors are among the mechanisms that can explain the occurrence of sleep bruxism.
How to recognize if you suffer from sleep bruxism?
Bruxism is an unconscious habit, not only during sleep, but also when awake. In the latter, vulnerable individuals “unload” life pressure onto their teeth to relief their worries, anxieties and emotional tensions. It doesn’t mean that people who have bruxism have an anxiety disorder, but we’re all exposed to peak levels of stress in our everyday life, and sometimes to intense task to accomplish with high level of performance in little time. For some people, sleep and awake bruxism are part of a reactive activity to escape the stress, a valve to discharge the tension. The critical issue is that behaviour is ‘attacking’ the teeth and can induce discomfort or pain in your jaw and head muscles.
You may not be aware that you have sleep bruxism. Most individuals do not complain in absence of pain or complaints from sleep partners. However, some individuals with sleep bruxism may feel dental sensitivity, often damage their tooth and/or break their filling and complain of head and jaw muscles discomfort or fatigue or stiffness when they wake up. Furthermore, most individuals are informed their sleep bruxism by their sleep partner, since most bruxers make an intense grinding sound, like the sound of two stones rubbing against each other.
Finally, some people do not have notable consequences or associated comorbidities (i.e., when two or more health problems occur at the same time; such as bruxism and headaches or migraines, sleep apnea, chronic insomnia or difficulties in initiating or maintaining sleep).
Indeed, the reports from sleep partners are very useful when the dentist is trying to make a diagnosis. Some individuals may also complain about esthetics since sleep bruxism can cause dental damage including fracture and dental wear. It can also change the smile curve with time. Dental crown and bridge destruction is also possible but rarely seen.
Sleep laboratory polysomnography, with video and sound recordings during a full night of sleep is not always necessary. But when indicated, it can quantify the number and severity of events and identify a possible association with other events or sleep disorder during sleep. In some cases, a home sleep test using a portable electromyography device (i.e., a device that records the electrical activity of muscles using electrodes attached to the skin) can be sufficient.
Then, what are the main symptoms and consequences of sleep bruxism?
There is a large variability of symptoms in individuals presenting sleep bruxism, but they can be summarized as:
| DAYTIME SIGNS AND SYMPTOMS | SLEEPTIME SIGNS AND SYMPTOMS |
|---|---|
|
|
Even though sleep bruxism can often only be a behaviour with no major consequences, in some individuals its presence has been related to other serious sleep disorders such as sleep apnea, periodic limb movement, or insomnia. In addition, the grinding noises can disturb sleep partners, which should not be underestimated.
What to do or not do?
WHAT NOT TO DO: purchase an over the counter oral device
It is not recommended to use an over-the-counter oral device for a long period of time that is not fitted closely to the mouth without a dental examination. This type of device may do more harm than good such as pain and gum infection. An inappropriate choice of an oral device may exacerbate jaw pain and breathing problems such as snoring and apnea. Also, when temporomandibular disorders (i.e., jaw muscles, temporomandibular joints and associated structures disorders) are present with sleep bruxism, a non customized oral device can be more harmful for the jaw and face muscles than not using any kind of appliance.
WHAT TO DO: consult a health professional
- As a result of complaints such as waking up with pain or jaw discomfort, unrefreshing sleep or tooth damage (tooth wear, small or big fractures or even loss of teeth), consulting a specialist for a dental diagnosis and a clinical evaluation is highly recommended.
- When a sleep bruxism diagnosis is established, a customized clinical management is also highly recommended.
- Sometimes, sleep bruxism is also associated with poor sleep quality and with difficulty initiating or maintaining sleep (e.g., insomnia). Sleep bruxism is not harmful for most individuals but in conjunction with jaw pain and headache or a sleep disorder (sleep apnea, insomnia, chattering teeth) it may be wise to consult a sleep expert in medicine or in dentistry.
- Also, you may need to be referred to another health professional, such as a therapist, if comorbidities (i.e., developing other medical conditions at the same time) are present.
- For sure, if someone hears two stones rubbed together, typical of what sleep bruxism sounds like, it may interfere with the sleep quality of the partner and generate tension between the partners. Again, seeking help would be wise.
How to turn the ship around?
Independently of the clinical complaints, people with sleep bruxism need to receive a dental diagnosis to control the risk of comorbidities (i.e., developing other medical conditions at the same time) and to exclude the risk of consequences for teeth, gum, muscles and temporomandibular joints.
For individuals with normo-bruxism (i.e., those whose bruxism activity is not associated with symptoms) who seek treatment primarily for complaints of dental noise and dental wear, the following recommendations can be helpful:
Follow sleep hygiene rules
Awake and sleep bruxism are chronic conditions but can be a transient in life. They can be linked to stress and lifestyle. Therefore, although the presence of other medical conditions requires a medical/dental evaluation, changing one’s routine and lifestyle as well as improving sleep hygiene are always beneficial! (For more information about sleep hygiene, consult “10 simple tips for better sleep”)
Use a personalized or customized mouthguard (acrylic interocclusal) made by the dentist
Even in the absence of pain, the mouthguard made by a dental s specialist from a dental impression remains the most common treatment which will protect the teeth from wear. This type of splint reduces the grinding sound that is disruptive to the sleep partner. Avoid silicone over the counter mouthguards when possible.
Address Stress management
The body reacts to stress! It can be in the form of a headache, sleep disorder, gastrointestinal changes, and musculoskeletal pain. If the bruxism occurs during the day, it is important to be aware of the habit. Nowadays some mobile applications are available for that. Facial exercises and cervical stretching, application of heat or cold (depending on the situation), and using awareness techniques (mobile apps) help to reduce pain and discomfort. Relaxation techniques, pleasurable physical activity and meditation help to control the problem in the long term.
For individuals with patho-bruxism (i.e., those whose bruxism activity is associated with dental damage, harmful symptoms or other medical conditions) other therapeutic options may be required in addition to incorporating a good sleep hygiene:
Control pain and other symptoms
A consultation with a pain specialist or another health professional is needed to select the best management for each situation (a mouthguard, specifically an acrylic interocclusal splint or an oral appliance for snoring/sleep apnea, medication, therapy, etc.). In some rare cases, when teeth have been seriously damaged, dental rehabilitation may be needed.
Take into consideration your complete health condition
A consultation with a sleep medicine specialist is highly recommended when you have sleep bruxism and sleep-disordered breathing. Indeed, it has been shown that 40% of patients may increase the severity of obstructive sleep apnea when using a regular mouthguard (acrylic interocclusal splint). This is why it is important to evaluate all possible comorbidities (i.e., developing other medical conditions at the same time), in the event of sleep bruxism and obstructive sleep apnea. In this case, the treatment may change from an acrylic interocclusal splint to another type of appliance (e.g., mandibular advancement appliance) to treat the obstructive sleep apnea and to protect the teeth from sleep bruxism. On the other hand, it has been observed that a mandibular advancement appliance significantly reduces sleep bruxism more than a regular mouthguard (acrylic interocclusal splint). Thus, patients should talk about their sleep bruxism, snoring and sleep apnea with their dentist and physician to ensure the best treatment for their particular condition.
Medication
Currently, there is no consensus on the use of drugs for sleep bruxism and experimenting with different drugs has been explored with mixed results. These include but are not limited to bromocriptine and L-dopa (medications used in Parkinson disease), amitriptyline (antidepressant), muscle relaxants, benzodiazepines (tranquilizers), and clonidine (anti-hypertensive). While some of these reduced the intensity of the bruxism or the number of episodes, those medications are associated with important side effects which make the benefit-risk ratio questionable. Moreover, some other medications such as antidepressants (particularly, selective serotonin reuptake inhibitors) may aggravate bruxism in some individuals. Thus, if you are taking antidepressants or other drugs and you feel that you are clenching or grinding your teeth more, during wake or sleep, talk with your physician about the possibility of changing medication or the dosage. Do not stop your medication without medical advice.
Additionally, the application of botulinum toxin, a relatively popular medication, is controversial. Although it shows promise to reduce pain, some studies have shown that Botulinum Toxin reduces the intensity of contractions, but not their frequency. Moreover, it can cause serious side effects if not used properly, such a muscular paralysis. Therefore, caution is recommended with its use.
It is worth remembering that more research is awaited to assess efficacy and safety.
