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Bruxism

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Medilink Consultant clinic

Saad Ullah Siddiqui

Overview

Bruxism is a condition that&nbsp;involves an&nbsp;involuntary grinding, clenching, or gnashing of the teeth. 
Bruxism can occur during wakefulness or sleep. Awake bruxism is more common in adults, while sleep bruxism mostly affects children. Sleep bruxism can start to appear as early as age 4, but it usually peaks between the ages of 10 and 14. Most cases of sleep bruxism go unnoticed until complications have set in. Therefore, knowing the symptoms and getting regular dental checkups are important. 
&nbsp;

The mechanism of teeth grinding involves rubbing the lower and upper teeth together by repeatedly&nbsp; thrusting the mandible using the masticatory muscles. These muscles are responsible for carrying out the chewing movements while eating. Bracing or clenching involves rigidly holding a mandibular position without a back-and-forth movement. Grinding of the teeth can lead to the loss of tooth structure, also called attrition.<a href="#accordion">[10]</a>

According to research, bruxers clench or bite down with a force six times greater than the average force<a href="#accordion">[10]</a>. The United Kingdom&nbsp;Bruxism Association&nbsp;estimates that 8&ndash;10% of people suffer from the condition<a href="#accordion">[1]</a>.

While sleep bruxism does not exhibit any gender differences, awake bruxism is more common in females than in males<a href="#accordion">[2]</a>. According to self-report and cross-sectional survey research, 8 to 10% of adults and 15 to 40% of children experience sleep-related bruxism<a href="#accordion">[4]</a>. Bruxism can be detected in children as early as the emergence of the first teeth, with a frequency of around 30% by the age of six years. Regarding adults, rates peak at around 12% in young people and drop to 2&ndash;4% by the time they reach 60<a href="#accordion">[4]</a>. 
&nbsp;

The two types of bruxism are<a href="#accordion">[3]</a>: 
&nbsp;

<ul>
	<li>Sleep Bruxism - This is a type of sleep disorder. It is characterized by rhythmic or nonrhythmic teeth grinding during sleep. Although often asymptomatic, individuals may notice jaw pain and stiffness, facial pain, a dull headache, and a clicking, popping, or grinding noise while moving the jaw upon waking. 
	&nbsp;</li>
	<li>Awake Bruxism - As the name implies, teeth grinding takes place during periods of wakefulness. It is mostly related to emotional disturbances, such as due to anxiety, stress, or anger. The movement is more of an unconscious habit. People are more likely to clench their teeth than grind their teeth. Jaw pain, dull headaches, and stiffness are common symptoms of awake bruxism. Moreover, some people may grind their teeth in concentration.&nbsp; 
	&nbsp;</li>
</ul>

Bruxism can also be classified based on its causes: 
&nbsp;

<ul>
	<li>Primary Bruxism - It happens on its own without any underlying condition. Factors such as stress, a misaligned bite, growing teeth, and smoking can contribute to primary bruxism 
	.</li>
	<li>Secondary Bruxism - It results from other medical conditions or circumstances., such as anxiety, depression, Parkinson&rsquo;s disease, and sleep apnea. 
	&nbsp;</li>
</ul>

Signs and Symptoms

Most people are unaware they have bruxism, especially if they grind their teeth at night. The signs and symptoms may include:

<ul>
	<li>The natural anatomy of the tooth is such that there are curves, grooves, and elevated surfaces in order to aid in chewing. These surfaces may appear to be flattened out due to the upper and lower teeth grinding one another down.</li>
	<li>The excessive forces applied while grinding can often cause a tooth to fracture, become loose, or chip off.</li>
	<li>The outer layer of the tooth, known as enamel, is worn off due to attrition, exposing the second layer of the tooth called dentin. Dentin is yellow in color, so once it gets exposed, the tooth looks discolored.</li>
	<li>Dentin houses the innervation and blood supply of the tooth known as pulp. Dentinal tubules connect the dentin to the pulp. Hence, if the dentin is exposed, any external stimulus can trigger the pulp and cause pain. Once enamel and dentin are worn off, the tooth becomes more sensitive, especially to hot and cold.</li>
	<li>The muscles used for chewing are involved in bruxism. The lower jaw moves with the help of the temporomandibular joint (TMJ). Both the TMJ and chewing muscles can feel tired or sore if they have been strained for long periods of time. The jaw can even become locked which means it can not open or close completely. A clicking or popping sound may also come from the TMJ.</li>
	<li>There can be ear pain without any ear problems.</li>
	<li>Dull headache</li>
	<li>Neck, jaw, and facial pain</li>
	<li>The insides of the cheeks may be injured from the chewing</li>
	<li>Disrupted sleep</li>
	<li>Pain while eating</li>
	<li>Tooth fillings can break or become loose<a href="#accordion">[5]</a> <a href="#accordion">[6]</a> 
	&nbsp;</li>
</ul>

Causes

Bruxism does not have a single identifiable cause. Instead, it is associated with multiple factors. These factors vary depending on the type of condition: 
&nbsp;

<h5>Primary Bruxism</h5>

Primary bruxism does not result from an underlying condition, but rather, on its own. Some common causes of primary bruxism are: 
&nbsp;

<ul>
	<li>Growing Teeth - Up to 40% of youngsters&nbsp;exhibit bruxism, which commonly occurs when their teeth are developing. However, because the jaw and teeth develop fast in children, bruxism typically goes away on its own without causing any long-term harm. 
	&nbsp;</li>
	<li>Misaligned Teeth - In certain people, bruxism may occur as a result of either a misaligned bite or missing teeth. Grinding or clenching may also be caused by oral irritation. 
	&nbsp;</li>
	<li>Stress - Stress is one of the key factors that contribute to bruxism in adults, whether it happens when they are awake or asleep. As per a 2020 systematic review, there is a considerable correlation between stress and bruxism. However, further research is required to fully comprehend the connection. 
	&nbsp;</li>
	<li>Alcohol, Smoking, and Caffeine - Several studies have found a link between the usage of these substances and bruxism. While individuals who consume more than eight cups of coffee per day are 1.5 times more likely to develop bruxism, those who routinely smoke or drink alcohol are roughly two times more likely to do so. 
	&nbsp;</li>
</ul>

<h5>Secondary Bruxism</h5>

Secondary bruxism results from an underlying condition. Common causes are: 
&nbsp;

<ul>
	<li>Mental Health Conditions - Bruxism is linked to depression and anxiety. Stress, which can exacerbate these disorders, may be partially to blame for this link. 
	&nbsp;</li>
	<li>Neurological Conditions - Huntington&#39;s disease and Parkinson&#39;s disease often cause movement during sleep. This can lead to bruxism. 
	&nbsp;</li>
	<li>Medication - Some antidepressants and antipsychotics, among others, might cause bruxism as a side effect. A 2018 study discovered a connection between bruxism and selective serotonin reuptake inhibitors (SSRIs). Out of the medicines under study, fluoxetine and sertraline were the most frequently implicated. 
	&nbsp;</li>
	<li><a href="https://merisehat.pk/disease/sleep-apnea-91">Sleep Apnea</a> - Sleep apnea is a condition in which breathing temporarily stops while sleeping. It may be a risk factor for bruxism since it can affect the quantity and quality of sleep and lead to frequent awakenings. Disturbed sleep due to sleep apnea can cause teeth grinding or clenching. 
	&nbsp;</li>
</ul>

<h5>Awake Bruxism</h5>

It may be brought on by feelings like stress, anger, annoyance, or tension. Teeth grinding or clenching of the jaw is often a habit or a coping mechanism, used when concentrating intensely.<a href="#accordion">[6]</a> 
&nbsp;

<h5>Sleep Bruxism</h5>

There can be a chewing motion connected with sleep arousals.<a href="#accordion">[6]</a> 
&nbsp;

<h5>Bruxism During Pregnancy</h5>

Although pregnancy is a joyful time, there is also a lot of emotional, physical, and mental stress. This stress can cause teeth grinding and clenching, resulting in headaches, jaw pain, and tooth damage.&nbsp; Additionally, the jaw joint may relax and become more prone to dislocation due to the hormone relaxin, which assists the body&#39;s joints in loosening up for the delivery of the baby. The hormone can also cause the teeth to shift and move, making the bite less comfortable and causing one to grind their teeth more frequently. 
&nbsp;

Note: If you experience discomfort in your teeth, gums, or jaw, it&#39;s critical to visit the dentist. 
&nbsp;

There are no specific screening tests for bruxism. 
&nbsp;

Diagnosis

A dentist can diagnose bruxism with the help of some questions and a simple dental examination. The patient will be asked about their sleeping habits, routine, and the use of any medications. During the dental examination, the dentist may notice: 
&nbsp;

<ul>
	<li>Worn-down enamel</li>
	<li>Chipped, fractured, or flattened teeth</li>
	<li>Damaged or loose fillings</li>
	<li>Strained, enlarged, or stiff jaw muscles</li>
	<li>Damage to the insides of the cheeks 
	&nbsp;</li>
</ul>

To diagnose sleep bruxism better, the dentist will ask the individual&rsquo;s partner, caregiver, or parent if they have ever heard or seen them grinding their teeth during sleep. They can also be asked about any signs and symptoms of sleep apnea, like snoring and pauses in breathing during sleep.

Children and adults with sleep-related bruxism have both been reported to have elevated catecholamine levels in their urine<a href="#accordion">[4]</a>.

Both doctors and researchers find it convenient to use self-reports to evaluate bruxism presence and absence, yet it has been discovered that roughly 80% of bruxism episodes do not include noise. So many adults and kids don&#39;t recognize themselves as bruxers since they are ignorant of their bruxism activity<a href="#accordion">[2]</a>. 
&nbsp;

The doctor might suggest a sleep medicine specialist if the bruxism appears to be connected to serious sleep problems. Additional tests can be performed by a sleep medicine specialist, such as a sleep study, which will look for instances of teeth grinding and evaluate whether the individual has sleep apnea or other sleep disorders. Moreover, a qualified therapist or counselor may also be referred to if anxiety or other psychological problems seem to be connected to teeth grinding. 
&nbsp;

Treatment

There are various ways to treat bruxism. They include: 
&nbsp;

<h5>Mouthguard&nbsp;</h5>

A dentist may advise a mouth guard or mouth splint to be worn while sleeping to protect the teeth. It works by distributing the pressure evenly across the jaw, creating a physical barrier between the teeth, and attenuating the sound of teeth grinding. The majority of bruxism mouthguards are made of flexible rubber or plastic. One can either purchase an over-the-counter (OTC) version or have one customized to their teeth by a dentist. OTC versions are less comfortable. Usually constructed of tougher plastic, mouth splints are custom-fit to the teeth. While some splints fit on the bottom teeth, others fit over the top teeth. Depending on the design, a splint will either keep the jaw in a more relaxed position or act as a barrier to prevent damage to the teeth.<a href="#accordion">[1]</a> 
&nbsp;

<h5>Medication</h5>

Ibuprofen is an example of a nonsteroidal anti-inflammatory medicine (NSAID) that may be used to treat any discomfort or swelling brought on by bruxism. In some circumstances, a physician may also advise the brief use of a drug to relax the muscles and break the vicious cycle of teeth grinding. This method allows the jaw muscles to relax, which can lessen symptoms. A patient may want to talk to their doctor about switching to a different medicine if they suspect that one is contributing to their bruxism.<a href="#">[1]</a> 
&nbsp;

Note: Never stop taking a drug or adjust the dosage without first talking to your doctor. 
&nbsp;

<h5>Biofeedback</h5>

A form of therapy called biofeedback teaches patients how to manage their involuntary body functions, such as breathing or heart rate, by making them aware of the activity.&nbsp;The usefulness of biofeedback for treating bruxism is not well studied. However,&nbsp;a 2018 study did uncover some evidence that a particular biofeedback instrument called contingent electrical stimulation alleviated symptoms after nightly use.<a href="#accordion">[1]</a> 
&nbsp;

<h5>Botox</h5>

In severe cases, botulinum toxin injections, often known as botox, can paralyze the muscles causing the condition, and cease teeth grinding. However, this is a costly treatment, and repeated injections are required to keep the results.<a href="#accordion">[1]</a> 
&nbsp;

<h5>Reductive Coronoplasty</h5>

A dental surgery called reductive coronoplasty may be used to reshape or level the biting surface of the teeth. It is typically effective if bruxism is due to crowded, crooked, or poorly aligned teeth. To build up&nbsp;the teeth, a second surgery known as additive coronoplasty may be applied in some cases. Either procedure can be carried out by the dentist.<a href="#accordion">[7]</a> 
&nbsp;

<h5>Management Of The Lost Tooth Structure</h5>

The lost tooth structure may be built up with filling material to manage attrition or a chipped-off portion of the tooth. If the tooth loss is severe, the dentist will provide restorative options to choose from, like using crowns. If the tooth is cracked, it may require a root canal treatment along with the placement of a crown over it for long-term preservation of the tooth. In some cases, a cracked tooth may need to be removed entirely.<a href="#accordion">[6]</a> 
&nbsp;

<h5>Stress Reduction</h5>

Some individuals may experience teeth grinding in conjunction with mental health conditions like stress, depression, and anxiety. Some techniques to reduce stress are:<a href="#accordion">[7]</a> 
&nbsp;

<ul>
	<li>Meditation</li>
	<li>Yoga</li>
	<li>Talk therapy</li>
	<li>Exercise</li>
	<li>Cognitive behavior therapy 
	&nbsp;</li>
</ul>

<h5>Tongue And Jaw Muscle Exercises</h5>

Exercises for the tongue and jaw muscles can help relax the jaw and facial muscles and keep the mouth in the right position. These are things one can practice at home or with a physical therapist. Examples of tongue and jaw muscle exercises are:<a href="#accordion">[7]</a> 
&nbsp;

<ol>
	<li>Widen the mouth while&nbsp;placing&nbsp;the tongue against the front teeth. This aids with jaw relaxation.</li>
	<li>Say the letter &lsquo;N&rsquo; out loud. This can prevent clenching and contact between the top and bottom teeth. 
	&nbsp;</li>
</ol>

A gentle massage can also help relax the muscles in the jaw. 
&nbsp;

<h5>Remedies For Bruxism In Babies</h5>

Babies often grind their teeth because of teething pain from tooth eruption. Chewing on the following items can help soothe the pain and prevent bruxism in babies:<a href="#accordion">[8]</a> 
&nbsp;

<ul>
	<li>Natural rubber teether</li>
	<li>Ice teether</li>
	<li>Wooden teether</li>
	<li>Silicone teether 
	&nbsp;</li>
</ul>

In older children, bruxism could be due to stress. In this case, the following measures can help<a href="#accordion">[11]</a>.

<ul>
	<li>A calming bedtime routine to avoid grinding in the nighttime.</li>
	<li>A massage before bedtime can also relax the child&rsquo;s muscles.</li>
	<li>Make sure the child drinks plenty of water because dehydration and bruxism may be linked</li>
	<li>A customized night guard can help if the child grinds their teeth at night 
	&nbsp;</li>
</ul>

Note: It is essential to visit a dentist regularly, especially if you doubt that you may have bruxism. Untreated bruxism can lead to complications. 
&nbsp;

In severe cases, bruxism can lead to complications, such as: 
&nbsp;

<ul>
	<li>Damage to the teeth (fractured or loosened teeth)</li>
	<li>Loss of teeth</li>
	<li>Temporomandibular joint (TMJ) disorders</li>
	<li>Tension-type headaches</li>
	<li>The American Tinnitus Association states that injury to the TMJ might result in tinnitus. Tinnitus may result from bruxism since it directly affects this joint<a href="#accordion">[1]</a>.</li>
	<li>Due to the wearing down of the protective layer of the teeth (enamel), the tooth may become more susceptible to cavity formation. 
	&nbsp;</li>
</ul>

The following factors may increase the risk of bruxism: 
&nbsp;

<ul>
	<li>Stress, <a href="https://merisehat.pk/disease/anxiety">anxiety</a>, anger, and frustration</li>
	<li>Age - It is most common in children and usually goes away by adulthood</li>
	<li>Personality type - An aggressive, competitive, or hyperactive personality can increase the risk of bruxism</li>
	<li>Medications, such as antidepressants may have bruxism as a side effect</li>
	<li>Family history of bruxism</li>
	<li>In children, <a href="https://merisehat.pk/disease/attention-deficit-hyperactivity-disorder-adhd">ADHD </a>can increase the risk of bruxism</li>
	<li>Smoking tobacco</li>
	<li>Caffeine</li>
	<li>Alcohol consumption</li>
	<li>Sleep apnea and other sleep disorders 
	&nbsp;</li>
</ul>

To prevent or reduce the symptoms of bruxism: 
&nbsp;

<ul>
	<li>Avoid the use of caffeine, tobacco, and alcohol</li>
	<li>Avoid chewing gum, as it can lead to further wear and tear</li>
	<li>Apply heat to the jaw to relieve tension and pain</li>
	<li>Reduce avoidable stress and take steps to manage unavoidable stress</li>
	<li>Quit smoking and consuming alcohol 
	&nbsp;</li>
</ul>

Key Points

<ul>
	<li>Bruxism is a condition that&nbsp;involves an&nbsp;involuntary grinding, clenching or gnashing of the teeth.</li>
	<li>The mechanism of teeth grinding involves rubbing the lower and upper teeth together by repeatedly thrusting the mandible using the masticatory muscles.</li>
	<li>Bruxism can occur during wakefulness or sleep. Awake bruxism is more common in adults, while sleep bruxism mostly affects children.</li>
	<li>Based on the causes, bruxism can be divided into primary and secondary.</li>
	<li>Common signs and symptoms of bruxism include jaw pain, tooth sensitivity, dull headache, facial pain, and problems of the temporomandibular joint (TMJ).</li>
	<li>Stress, anxiety, and anger are common causes of awake bruxism. While sleep bruxism is a sleep-related chewing activity that causes periods of wakefulness during sleep.</li>
	<li>Severe cases can result in complications like TMJ disorders, tooth loss, severe facial or jaw pain, and tension-like headaches.</li>
	<li>There are no medications to treat bruxism. However, night guards, jaw exercises, and stress management techniques can help reduce teeth grinding, especially at night. 
	&nbsp;</li>
</ul>

[1] Bruxism (teeth grinding): Causes and management. Medical News Today.

[2] Shetty S, Pitti V, Satish Babu CL, Surendra Kumar GP, Deepthi BC. Bruxism: a literature review. J Indian Prosthodont Soc. 2010;10(3):141-148. doi:10.1007/s13191-011-0041-5