Teeth grinding (bruxism)

Introduction

Bruxism is the medical term for the repetitive grinding, clenching, or gnashing of teeth. It can occur during wakefulness (awake bruxism) or sleep (sleep bruxism). While occasional teeth grinding is common and may not cause harm, chronic or severe bruxism can lead to tooth wear, jaw pain, temporomandibular joint (TMJ) disorders, headaches, and disrupted sleep.

Bruxism affects both children and adults, with prevalence rates of 8–31% in adults and higher in children. Early identification and management are crucial to prevent permanent dental damage and associated complications.

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Types of Bruxism

1. Awake Bruxism

   • Conscious or semi-conscious clenching of teeth during the day.

   • Often linked to stress, concentration, or habit.

2. Sleep Bruxism

   • Involuntary grinding during sleep.

   • Considered a sleep-related movement disorder.

   • Often coexists with sleep apnea, snoring, or other parasomnias.

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Causes and Risk Factors

1. Psychological and Behavioral

• Stress and anxiety (major triggers).

• Anger or frustration.

• Personality traits (competitive, hyperactive).

2. Neurological and Medical

• Sleep disorders: obstructive sleep apnea, snoring.

• Neurological conditions: Parkinson’s disease, Huntington’s disease.

• Gastroesophageal reflux disease (GERD).

3. Dental and Structural

• Malocclusion (improper bite).

• Missing or misaligned teeth.

4. Medications and Substances

• Stimulants: caffeine, nicotine.

• Recreational drugs: cocaine, MDMA (ecstasy).

• Antidepressants (SSRIs, such as fluoxetine, paroxetine, sertraline).

5. Genetic Factors

• Family history of bruxism increases risk.

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Symptoms and Clinical Presentation

• Audible teeth grinding during sleep (often reported by partner).

• Jaw pain, tightness, or fatigue, especially in the morning.

• Headaches (particularly temporal).

• Ear pain or fullness without ear disease.

• Tooth sensitivity or damage: worn enamel, flattened or chipped teeth.

• Indentations on tongue or inner cheeks.

• Temporomandibular joint (TMJ) clicking or pain.

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Complications

• Severe tooth wear and fractures.

• Gum recession and tooth mobility.

• TMJ dysfunction.

• Chronic facial or jaw pain.

• Sleep disturbances (in both patient and partner).

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Diagnosis

History

• Symptom inquiry: jaw pain, morning headaches, partner reports of grinding.

• Medical and dental history, including medication use and stress levels.

Examination

• Dental inspection for enamel wear, cracks, and abnormal tooth surfaces.

• Palpation of jaw muscles for tenderness or hypertrophy.

• TMJ evaluation for crepitus, clicking, or restricted movement.

Additional Investigations

• Polysomnography (sleep study): if sleep bruxism suspected, especially in presence of sleep apnea.

• Bite analysis: to assess occlusion.

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Treatment and Management

1. General and Lifestyle Approaches

• Stress reduction: relaxation techniques, mindfulness, meditation.

• Sleep hygiene: regular sleep schedule, avoiding caffeine/alcohol before bedtime.

• Jaw exercises and physiotherapy: to improve muscle relaxation.

• Avoid chewing gum or hard foods to reduce strain.

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2. Dental Interventions

Occlusal Splints / Mouthguards

• Custom-made acrylic devices worn at night.

• Prevent tooth damage by absorbing grinding forces.

• Do not cure bruxism but protect teeth.

Dental Corrections

• Orthodontic treatment for malocclusion.

• Restorations or crowns to repair damaged teeth.

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3. Pharmacological Management

There are no FDA-approved medications specifically for bruxism, but several agents are used off-label for relief:

• Muscle Relaxants

  • Diazepam: 2–10 mg orally at night (short-term use only).

  • Cyclobenzaprine: 5–10 mg at bedtime.

• Botulinum Toxin (Botox) Injections

  • Injected into masseter and temporalis muscles.

  • Reduces muscle activity and pain for 3–6 months.

  • Dose: 25–40 units per masseter muscle (specialist use).

• Anxiolytics and Antidepressants

  • Clonazepam: 0.25–0.5 mg orally at bedtime (sleep bruxism).

  • Antidepressant adjustment if bruxism is drug-induced (switching from SSRI to another class, e.g., bupropion).

• Analgesics (for symptomatic relief):

  • Paracetamol: 500–1000 mg every 6 hours (max 4 g/day).

  • Ibuprofen: 200–400 mg every 6–8 hours.

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4. Behavioral and Psychological Interventions

• Cognitive-behavioral therapy (CBT) for stress-related bruxism.

• Biofeedback therapy: EMG-based devices that alert patients when clenching is detected.

• Habit reversal training: awareness techniques to reduce daytime clenching.

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5. Treating Underlying Disorders

• Sleep apnea: CPAP therapy may reduce sleep bruxism.

• GERD: proton pump inhibitors (omeprazole 20–40 mg daily) if reflux contributes.

• Neurological disease-related bruxism: managed alongside neurologist.

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Pediatric Considerations

• Common in children, often self-limiting.

• Usually does not require treatment unless tooth damage or TMJ pain develops.

• Focus on stress reduction and monitoring.

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Prognosis

• Mild bruxism often resolves spontaneously, especially in children.

• Chronic bruxism requires ongoing management but can be controlled effectively.

• Long-term complications (tooth wear, TMJ damage) are preventable with early intervention.

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Summary of Key Treatments with Doses

• Paracetamol: 500–1000 mg PO q6h (max 4 g/day).

• Ibuprofen: 200–400 mg PO q6–8h.

• Diazepam: 2–10 mg PO at night (short-term use).

• Cyclobenzaprine: 5–10 mg PO at bedtime.

• Clonazepam: 0.25–0.5 mg PO at bedtime.

• Botulinum toxin type A: 25–40 units per masseter muscle injection (specialist).

• Omeprazole: 20–40 mg PO daily (if GERD-related).

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Red Flags (Need Referral)

• Severe tooth wear, cracks, or mobility.

• Persistent jaw pain or restricted mouth opening.

• Suspected sleep apnea with bruxism.

• Pediatric bruxism associated with seizures or neurological disease.