- Email: [email protected]
The clinical management of awake bruxism
ORIGINAL CONTRIBUTIONS
The clinical management of awake bruxism Ronald E. Goldstein, DDS; Wendy Auclair Clark, DDS, MS
M
any oral habits exist that can cause damage to the stomatognathic system. Several of these are well documented or readily identified by the patient. Many people, however, clench or grind their teeth while they are awake without realizing they are doing so. For brevity, throughout this article we will refer to this activity as awake bruxism. This term is consistent with the definition of bruxism in the 8th edition of the Glossary of Prosthodontic Terms: 1: the parafunctional grinding of teeth 2: an oral habit consisting of involuntary rhythmic or spasmodic nonfunctional gnashing, grinding, or clenching of teeth, in other than chewing movements of the mandible, which may lead to occlusal trauma—called also tooth grinding, occlusal neurosis.1
There are multiple kinds of diurnal oral parafunctions that can affect the stomatognathic system, including but not limited to nail-biting, chewing on cheeks or other mucosa, and chewing on pens or other objects. Although clinicians should be aware of these conditions and educate patients about the effects, for brevity, in this article we will focus specifically on awake bruxism— tooth-to-tooth contact while the patient is awake. In our clinical experience, this is a relatively common habit that frequently results in the need for dental work (Figure 1). Compounding the problem, there is a lack of awareness specific to awake tooth clenching and grinding. In addition, the personal awareness of these other habits is not present with bruxism2; we will address the lack of awareness and its sequelae. We believe it is our responsibility as clinicians not only to diagnose disease and treat patients but also to educate patients about the possible causes and effects of awake bruxism. However, the paucity of available literature on the subject and the low level of self-awareness of patients who exhibit this behavior present a challenge. Copyright ª 2017 American Dental Association. All rights reserved.
ABSTRACT Background. Awake bruxism is a common clinical condition that often goes undetected, often leading to pain or damaged teeth and restorations. Methods. The authors searched electronic databases regarding the treatment and effects of awake bruxism compared with those of sleep bruxism. The authors used the search terms diurnal bruxism and oral parafunction. The authors combined information from relevant literature with clinical experience to establish a recommended protocol for diagnosis and treatment. Results. The authors found articles regarding the diagnosis and treatment of bruxism. The authors combined information from the articles with a review of clinical cases to establish a treatment protocol for awake bruxism. Conclusions. Literature and clinical experience indicate a lack of patient awareness and, thus, underreporting of awake bruxism. As a result, myriad dental consequences can occur from bruxism. The authors propose a need for increased awareness, for both patients and professionals, particularly of the number of conditions related to awake bruxism. Practical Implications. Clinicians should look for clinical signs and symptoms of awake bruxism and use minimally invasive treatment modalities. Key Words. Diurnal; bruxism; clenching; occlusal guard; parafunction. JADA 2017:148(6):387-391 http://dx.doi.org/10.1016/j.adaj.2017.03.005
The purpose of this article is to help establish a protocol to identify patients at high risk of having this behavior, review treatment modalities, and develop a predictable dialogue to educate patients about awake bruxism. The prevalence of bruxism varies greatly across studies, varying from as low as 5% to greater than 90%.3 However, there seems to be a consensus that public awareness of bruxism is low and that it generally is underreported.4 In addition, Gibbs and colleagues5 reported that bite strength in people exhibiting parafunctional activity can be up to 6 times greater than that
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ORIGINAL CONTRIBUTIONS
waking oral habits that that have been identified and that may require a different type of treatment.8,12,15 If a clinician (or patient) desires a more definitive method of diagnosis, they can use various techniques. To differentiate between sleep and awake bruxism, for example, Figure 1. A. Despite reported nightly compliance with a guard, this 46-year-old man showed continued wear on his the clinician can meaanterior teeth. B. On questioning, we determined that the patient had an awake bruxism habit—grinding his anterior teeth in times of stress. sure the electromyographic activity of the 16-18 The dentist can prescribe easyin those without parafunctional habits. Therefore, para- masticatory muscles. to-use electromyographic devices to use during sleep to functional activity (such as awake bruxism) can induce confirm muscle activity (for example, BiteStrip, Great detrimental effects on the stomatognathic system Lakes Orthodontics). After initial screening and suspicion quickly. Restoration failure, such as material chipping of a parafunctional habit, more in-depth patient quesand fractures, is an unfortunate and costly occurrence tionnaires (with clear definitions) and at-home journaling that happens all too often. can help further identify what type of parafunctional acIDENTIFICATION tivities the patient engages in and how often.7,8 For clinicians to treat awake bruxism, they first must diagnose it. A simple first screening step is to ask patients CORRELATIONS AND COMORBIDITIES (on a medical history or examination form) whether A strong correlation exists between temporomandibular they clench or grind their teeth. Much parafunctional disorders (TMDs) and bruxism.9,19-21 Whether bruxism activity is not accompanied by noise, however, which can causes TMDs is undetermined, but there is support to make self-awareness difficult. This likely results in show that diurnal bruxism exacerbates TMD symptoms, underreporting and, hence, the wide variation in freincluding headache, muscle and joint pain, and jaw 6 quency of reported bruxism, both sleep and awake. locking.7,22-24 The activity of bruxism results in muscle There is encouraging evidence, however, that once a hyperactivity, particularly the masseteric sling muscles person is made aware of waking oral habits, he or she is (masseter and medial pterygoid) and the lateral pterymore likely to give accurate feedback.7,8 This initial goids. Therefore, myalgia and muscle spasm can result, as screening can serve as an opening dialogue for clinicians well as temporal headaches.9,11,25-27 Subsequently, it is not to educate and inform patients about awake bruxism. uncommon to see hypertrophic masseters as a result of Another critical way for clinicians to identify a patient long-term bruxing. Some TMDs can elicit symptoms, with a parafunctional habit is by damage to tooth struc- including tinnitus, vertigo, and auditory changes, which ture. This damage includes wear facets, fractured teeth also can worsen with diurnal bruxism.28 Any patient who and restorations, craze lines, abfractive lesions, and ulti- self-reports TMD, morning masticatory muscle pain or mately loss of teeth (Figure 2).4,9-12 Although many stiffness, or joint noises should be considered a possible times these are readily identifiable through a clinical bruxer and then identified as a sleeping or awake bruxer. examination, clinicians should use mounted diagnostic Bruxing is also a common phenomenon in children, models to detect these defects more accurately and particularly as deciduous and secondary dentition thoroughly. Other intraoral signs include indentations erupts. Carlsson and colleagues19 found that most selfalong the side of the tongue, as well as bony exostoses or identified adult bruxers were also bruxers as children. tori.9,10,13 Periodontal changes, including widening of Specifically, awake bruxers continued to exhibit awake the periodontal ligament, tooth mobility, and recession, bruxism, and people with other parafunctional habits also may occur.11,14 If clinicians note this kind of damage, carried those into adulthood. they should discuss the damage with the patients and In addition, there are also medical conditions related review their medical history to determine the cause. to awake bruxism. These include dystonias and other When the clinician suspects a patient has a sleeping or waking parafunctional habit, it is important to discern what that habit specifically is. Although this article ABBREVIATION KEY. TMD: Temporomandibular disorder. focuses on awake bruxism, there are multiple types of
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ORIGINAL CONTRIBUTIONS
muscle-related issues, as well as developmental disabilities (including various types of autism)29,30 and neurologic diseases (including environmental and traumatic causes).20,31-34 Use of medications can cause bruxism, particularly selective serotonin reuptake inhibitors and other classes of drugs that affect dopamine and other neurotransmitters.32,33,35-37 There is also a known correlation between both awake and sleep bruxism and neurotransmitters (particularly dopamine and serotonin).38 Therefore, there is an emotional and psychological component that cannot be ignored. There is a strong psychosocial component to bruxism, particularly awake bruxism.39 Consequently, awake bruxism seems to be related strongly to emotional stress,9,10,40,41 perhaps even more than is sleep bruxism.42 This stress includes that in people with type A personalities and those in high-stress professions.43-45
Figure 2. The patient who had a history of awake and sleep bruxism previously had received metal ceramic restorations. While clenching his teeth during a strenuous situation, he fractured his right maxillary canine through the fiber post and core.
TREATMENT MODALITIES
In addition to decreasing the risk of causing harm to teeth and restorations, minimizing the frequency of awake bruxism also can decrease pain. The damage and consequences of nocturnal bruxism usually can be prevented by the nightly use of an occlusal guard (Figure 3); the treatment of awake bruxism, however, can be more of a challenge. Although patients can use a daytime occlusal guard, compliance can be a major challenge. Consequently, the clinician should consider behavior modification to help curb waking behaviors.46 To customize an effective treatment plan, it is critical to understand the reasons behind each patient’s habit, as well as to assist patients in recognizing that they do, in fact, have this behavior. At first, many patients deny the habit, and some even get angry or defensive at the suggestion. A follow-up statement such as, “Do you ever find your teeth clenched together when you are in heavy traffic, or at your desk reviewing a difficult report or e-mail, or even during a difficult afternoon with the kids?” can defuse the situation and allow the realization that it is indeed possible. Once patients are open to the possibility, the clinician can ask them to pay attention to their daily behaviors to see whether they find themselves holding their teeth together or grinding throughout the day. Once patients are aware, their reports are likely to be a more accurate indicator of their parafunctional behavior.8 Lobbezoo and colleagues47 conducted a thorough systematic review of the treatment modalities for both waking and sleeping bruxism. In their article, they reinforced the lack of clinical trials to support treatment recommendations. They summarized the best approach as the “triple-P” approach: plates, pep talk, and pills. Specifically, they referred to stabilization splints, counseling, and short-term pharmacotherapy. OCCLUSAL APPLIANCES AND CONSIDERATIONS
As mentioned, compliance can be a challenge with a daytime splint. Patients have reported that it affects
Figure 3. Stabilization splint for sleep bruxism, with bilateral balance and an anterior ramp.
Figure 4. Example of a waking appliance. The thin material allows for normal function.
speech and increases salivary flow.48 Nevertheless, this treatment is noninvasive and is a popular first treatment option. The splints usually are made of hard acrylic because soft splints are more difficult to adjust and actually may encourage parafunctional activity (Figure 4).10,49
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ORIGINAL CONTRIBUTIONS
Historically, there was some belief that occlusal interferences could promote bruxism, with occlusal equilibration as a recommended solution. Clinicians should be aware that there is no clinical evidence or literature support to indicate that occlusion plays a causal role in bruxism.47,50,51 Therefore, occlusal equilibration is not a recommended treatment for bruxism. Likewise, if occlusal equilibration or restorative treatment is to be completed for other reasons, the patient should be made aware that it likely will not improve his or her bruxism habit. PSYCHOSOCIAL APPROACHES
Investigators in the literature have presented multiple treatment approaches to address the psychosocial component of awake bruxism. These modalities include stress reduction, counseling, lifestyle changes, and hypnotherapy.10,41 Bringing a therapist to the team can be helpful in achieving success. Investigators in the literature have reported cue conditioning or cuing as another treatment option, particularly with children and people who are mentally challenged. With this treatment, vocal or physical cues are repeated when a patient bruxes. This cue could be anything from saying a phrase such as “say ‘ah’” or “open” to a gentle touch on the chin or using ice on the chin or cheeks.30,52-54 Another alternative (albeit more experimental) treatment option involves biofeedback to curb the behavior. A small electric impulse is emitted during the muscle activity, ultimately stopping the action of bruxism.55 MEDICAL TREATMENTS
Investigators have proposed medications, including muscle relaxers, to treat bruxism.47 Clinicians should prescribe these medications for only short periods, and patients need to be aware that they can cause drowsiness. Another pharmacologic approach involves the use of botulinum toxins in the treatment of bruxism.10,20 The clinician injects botulinum toxins into the masticatory muscles that are triggered with bruxism, including the temporalis and masseter. Study results indicate that the use of this treatment can cause some bruxism-related muscle pain to subside and may reduce bruxism events.31 Lobbezoo and colleagues47 advocate that because this treatment does not have as much literature support, clinicians should advocate it only after attempting more minimally invasive approaches. In our practice, we begin with the psychosocial component. Our team educates patients, letting them know that teeth should touch only during eating or swallowing and that bracing the teeth throughout the day can cause extensive damage. We teach patients the phrase “lips together, teeth apart” for them to repeat when they find themselves bruxing. We also provide 6 reminder stickers with the phrase for the patient to place in areas to help remember to relax the jaw. These
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stickers have been helpful when patients place them in their cars, at their desks or computers, as well as in other potential areas of daily stress—thus, the plan to solve the problem of awake bruxism begins. Beyond this, we refer patients with more complex issues to local psychiatrists, psychologists, and other therapists— including one who practices hypnosis. We fabricate hard acrylic occlusal appliances, most commonly for the lower arch. If there is a compliance issue, we make a vacuform retainer that covers all the lower teeth. If the patient is having substantial pain, we prescribe a short-term regimen of muscle relaxers and partner with oral and plastic surgeons to administer botulinum toxins. CONCLUSIONS
Identification and treatment of awake bruxism can present a challenge for the clinician. He or she may not know or be told what stresses the patient has been under since the last prophylaxis or clinical examination. Therefore, it is incumbent on the entire dental team to be alert to patient conversation about what has been and is going on in the patient’s everyday life that could be contributing to awake bruxism, which often is associated with clenching rather than grinding. Unfortunately, it often goes unnoticed until a dental emergency (pain or fracture) occurs. Because awake bruxism is linked more closely to emotional stress than is nocturnal bruxism, psychological treatment may be indicated in conjunction with dental treatment. In addition, we recommend lifestyle changes. A concrete plan of patient education is a first step to solving the problem of awake bruxism. Once aware of the bruxism events, the patient can begin to make the necessary change in behavior. If behavioral change is not successful, we recommend a daytime appliance not only to prevent damage but also to promote awareness. A person tends to be more aware of clenching or grinding when he or she bites on an appliance rather than the opposing teeth. When possible, it is best to prevent the need for extensive dental treatment. Inhibiting bruxism, both awake and sleeping, is in the patient’s best interest. Thus, it is imperative for the dentist, hygienist, and dental assistant to educate and reeducate the patient during and after any restorative treatment. n Dr. Goldstein is a restorative dentist, Goldstein, Garber & Salama, Atlanta, GA; a clinical professor, Oral Rehabilitation, The Dental College of Georgia, Augusta, GA; an adjunct clinical professor, Prosthodontics, School of Dental Medicine, Boston University, Boston, MA; and an adjunct professor, Restorative Dentistry, University of Texas Health Science Center at San Antonio, San Antonio, TX. Address correspondence to Dr. Goldstein at 600 Galleria Pkwy, #800, Atlanta, GA 30339, e-mail RGoldstein@ mydentalmail.com. Dr. Auclair Clark is a prosthodontist, Goldstein, Garber & Salama, Atlanta, GA; and an assistant clinical professor, University of North Carolina, Chapel Hill, NC. Disclosure. Drs. Goldstein and Auclair Clark did not report any disclosures.
ORIGINAL CONTRIBUTIONS
1. The glossary of prosthodontic terms. J Prosthet Dent. 2005;94(1):10-92. 2. Panek H, Nawrot P, Mazan M, Bielicka B, Sumisławska M, Pomianowski R. Coincidence and awareness of oral parafunctions in college students. Community Dent Health. 2012;29(1):74-77. 3. Lavigne GL, Khouy S, Abe S, Yamaguchi T, Raphael K. Bruxism physiology and pathology: an overview for clinicians. J Oral Rehabil. 2008; 35(7):476-494. 4. Kawakami S, Kumazaki Y, Manda Y, Oki K, Minagi S. Specific diurnal EMG activity pattern observed in occlusal collapse patients: relationship between diurnal bruxism and tooth loss progression. PLoS One. 2014;9(7):e101882. 5. Gibbs CH, Mahan PE, Mauderli A, Lundeen HC, Walsh EK. Limits of human bite strength. J Prosthet Dent. 1986;56(2):226-229. 6. Rouse JS. The bruxism triad: sleep bruxism, sleep disturbance, and sleep-related GERD. Inside Dent. 2010:32-44. 7. Glaros AG, Williams K. “Tooth contact” versus “clenching”: oral parafunctions and facial pain. J Orofac Pain. 2012;26(3):176-180. 8. Kaplan SE, Ohrbach R. Self-report of waking-state oral parafunctional behaviors in the natural environment. J Oral Facial Pain Headache. 2016; 30(2):107-119. 9. Okeson JP. Etiology of functional disturbances in the masticatory system. In: Okeson JP, ed. Management of Temporomandibular Disorders and Occlusion. 4th ed. St. Louis, MO: Mosby Year Book; 1998:149-179. 10. 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. 11. Glaros AG, Rao SM. Bruxism: a critical review. Psychol Bull. 1977; 84(4):767-781. 12. Goldstein RE, Curtis JW, Farley BA, Molodtsova D. Oral habits. In: Goldstein RE, ed. Esthetics in Dentistry. 3rd ed. Hoboken, NJ: Wiley; 2017. 13. Yoshinaka M, Ikebe K, Furuya-Yoshinaka M, Hazeyama T, Maeda Y. Prevalence of torus palatinus among a group of Japanese elderly. J Oral Rehabil. 2010;37(11):848-853. 14. Machado NA, Fonseca RB, Branco CA, Barbosa GA, Fernandes Neto AJ, Soares CJ. Dental wear caused by association between bruxism and gastroesophageal reflux disease: a rehabilitation report. J Appl Oral Sci. 2007;15(4):327-333. 15. Orbach R, Marckiewicz MR, McCall WD. Waking-state parafunctional behaviors: specificity and validity as assessed by electromyography. Eur J Oral Sci. 2008;116(5):438-444. 16. Piquero K, Sakurai K. A clinical diagnosis of diurnal (non-sleep) bruxism in denture wearers. J Oral Rehabil. 2000;27(6):473-482. 17. Kumazaki Y, Naito M, Kawakami S, Hirata A, Oki K, Minagi S. Development of a speech-discriminating electromyogram system for routine ambulatory recordings for the low-level masseter muscle activity. J Oral Rehabil. 2014;41(4):266-274. 18. Lund JP, Widmer CG. Evaluation of the use of surface electromyography in the diagnosis, documentation, and treatment of dental patients. J Craniomandib Disord. 1989;3(3):125-137. 19. Carlsson GE, Egermark I, Magnusson T. Predictors of bruxism, other oral parafunctions, and tooth wear over a 20-year follow-up period. J Orofac Pain. 2003;17(1):50-57. 20. Watts MW, Tan EK, Jankovic J. Bruxism and cranial-cervical dystonia: is there a relationship? Cranio. 1999;17(6):196-201. 21. Macfarlane TV, Gray RJM, Kincey J, Worthington HV. Factors associated with the temporomandibular disorder, pain dysfunction syndrome (PDS): Manchester case-control study. Oral Dis. 2001;7(6):321-330. 22. Aydin G, Keles I, Zög G, Orkun S. How does the habit of teeth clenching affect the symptoms and signs of patients with temporomandibular disorders? [in Turkish]. Kulak Burun Bogaz Ihtis Derg. 2004;13(1-2): 19-24. 23. Kalaykoya SI, Lobbezoo F, Naeije M. Risk factor for anterior disc displacement with reduction and intermittent locking in adolescents. J Orofac Pain. 2011;25(2):153-160. 24. Glaros AG, Hanson AH, Ryen CC. Headache and oral parafunctional behaviors. Appl Psychophysiol Biofeedback. 2014;39(1):59-66. 25. Troeltzsch M, Troeltzsch M, Cronin RJ, Brodine AH, Frankenberger R, Messlinger K. Prevalence and association of headaches, temporomandibular joint disorders, and occlusal interferences. J Prosthet Dent. 2011;105(6):410-417. 26. Glaros A, Tabacchi KN, Glass EG. The effect of parafunctional clenching on TMD pain. J Orofac Pain. 1998;12(2):145-152. 27. Glaros AG, Williams K, Lausten L. The role of parafunctions, emotions and stress in predicting facial pain. JADA. 2005;136(4):451-458.
28. Rubinstein B. Tinnitus and craniomandibular disorders: is there a link? Swed Dent J Suppl. 1993;95:1-46. 29. Fuertes-González MC, Silvestre FJ. Oral health in a group of patients with Rett syndrome in the regions of Valencia and Murcia (Spain): a casecontrol study. Med Oral Patol Oral Cir Bucal. 2014;19(6):e598-e604. 30. Armstrong A, Knapp VM, McAdam DB. Functional analysis and treatment of the diurnal bruxism of a 16-year-old girl with autism. J Appl Behav Anal. 2014;47(2):415-419. 31. Lang R, White PJ, Machalicek W, et al. Treatment of bruxism in individuals with developmental disabilities. Res Dev Disabil. 2009;30(5):809-818. 32. Melis M, Abou-Atme YS. Prevalence of bruxism awareness in a Sardinian population. J Craniomandibular Pract. 2003;21(2):1-8. 33. Yi HS, Kim HS, Set MR. Trial of oral metoclopramide on diurnal bruxism of brain injury. Ann Rehabil Med. 2013;37(6):871-874. 34. Liang CS, Chou MK, Yang FW. Delayed-onset diurnal bruxism, psychic akinesia and depression after carbon monoxide poisoning: a case report. Gen Hosp Psychiatry. 2011;33(1):82. 35. Fitzgerald K, Healy D. Dystonias and dyskinesias of the jaw associated with the use of SSRIs. Hum Psychopharmacol. 1995;10(3):215-219. 36. Winocur E, Gavish A, Voikovitch M, Emodi-Perlman A, Eli I. Drugs and bruxism: a critical review. J Orofac Pain. 2003;17(2):99-111. 37. Micheli F, Fernandez Pardal M, Gatto M, Asconapé J, Giannaula R, Parera IC. Bruxism secondary to chronic antidopaminergic drug exposure. Clin Neuropharmacol. 1993;16(4):315-323. 38. Gómez FM, Ortega JE, Horrillo I, Meana JJ. Relationship between non-functional masticatory activity and central dopamine in stressed rats. J Oral Rehabil. 2010;37(11):827-833. 39. Katayoun E, Sima F, Naser V, Anahita D. Study of the relationship of psychosocial disorders to bruxism in adolescents. J Indian Soc Pedod Prev Dent. 2008;26(suppl 3):S91-S97. 40. Basson RA. The Significance of Sub Threshold Symptoms of Anxiety in the Aetiology of Bruxism [master’s thesis]. Cape Town, South Africa: University of the Western Cape; 2007. 41. Thompson BA, Blount WB, Krumholz TS. Treatment approaches to bruxism. Am Fam Physician. 1994;49(7):1617-1622. 42. Glaros A. Incidence of diurnal and nocturnal bruxism. J Prosthet Dent. 1981;45(5):545-549. 43. Rao SK, Bhat M, David J. Work, stress, and diurnal bruxism: a pilot study among information technology professionals in Bangalore City, India. Int J Dent. 2011;2011:650489. 44. Pingitore G, Chobrak V, Petrie J. The social and psychologic factors of bruxism. J Prosthet Dent. 1991;65(3):443-446. 45. Lurie O, Zadik Y, Einy S, Tarrasch R, Raviv G, Goldstein L. Bruxism in military pilots and non-pilots: tooth wear and psychological stress. Aviat Space Environ Med. 2007;78(2):137-139. 46. Glaros AG. Temporomandibular disorders and facial pain: a psychophysiological perspective. Appl Psychophysiol Biofeedback. 2008;33(3):161-171. 47. Lobbezoo F, van der Zaag J, van Selms MK, Hamburger HL, Naeije M. Principles for the management of bruxism. J Oral Rehabil. 2008; 35(7):509-523. 48. Miyawaki S, Katayama A, Tanimoto Y, et al. Salivary flow rates during relaxing, clenching, and chewing-like movement with maxillary occlusal splints. Am J Orthod Dentofacial Orthop. 2004;126(3):367-370. 49. Okeson JP. The effects of hard and soft occlusal splints on nocturnal bruxism. JADA. 1987;114(6):788-791. 50. Manfredini D, Visscher CM, Guarda-Nardini L, Lobbezoo F. Occlusal factors are not related with self-reported bruxism. J Orofac Pain. 2012;26(3):163-167. 51. Michelotti A, Cioffi I, Landino D, Galeone C, Farella M. Effects of experimental occlusal interferences in individuals reporting different levels of wake-time parafunctions. J Orofac Pain. 2012;26(3):168-175. 52. Blount RL, Drabman RS, Wilson N, Stewart D. Reducing severe diurnal bruxism in two profoundly retarded females. J Appl Behav Anal. 1982;15(4):565-571. 53. Bebko JM, Lennox C. Teaching the control of diurnal bruxism to two children with autism using a simple cuing procedure. Behav Ther. 1988; 19(2):249-255. 54. Barnoy EL, Najdowski AC, Tarbox J, Wilke AE, Nollet MD. Evaluation of a multicomponent intervention for diurnal bruxism in a young child with autism. J Appl Behav Anal. 2009;42(4):845-848. 55. Needham R, Davies SJ. Use of the Grindcare device in the management of nocturnal bruxism: a pilot study. Br Dent J. 2013;215(1):E1.
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The clinical management of awake bruxism Ronald E. Goldstein, DDS; Wendy Auclair Clark, DDS, MS
M
any oral habits exist that can cause damage to the stomatognathic system. Several of these are well documented or readily identified by the patient. Many people, however, clench or grind their teeth while they are awake without realizing they are doing so. For brevity, throughout this article we will refer to this activity as awake bruxism. This term is consistent with the definition of bruxism in the 8th edition of the Glossary of Prosthodontic Terms: 1: the parafunctional grinding of teeth 2: an oral habit consisting of involuntary rhythmic or spasmodic nonfunctional gnashing, grinding, or clenching of teeth, in other than chewing movements of the mandible, which may lead to occlusal trauma—called also tooth grinding, occlusal neurosis.1
There are multiple kinds of diurnal oral parafunctions that can affect the stomatognathic system, including but not limited to nail-biting, chewing on cheeks or other mucosa, and chewing on pens or other objects. Although clinicians should be aware of these conditions and educate patients about the effects, for brevity, in this article we will focus specifically on awake bruxism— tooth-to-tooth contact while the patient is awake. In our clinical experience, this is a relatively common habit that frequently results in the need for dental work (Figure 1). Compounding the problem, there is a lack of awareness specific to awake tooth clenching and grinding. In addition, the personal awareness of these other habits is not present with bruxism2; we will address the lack of awareness and its sequelae. We believe it is our responsibility as clinicians not only to diagnose disease and treat patients but also to educate patients about the possible causes and effects of awake bruxism. However, the paucity of available literature on the subject and the low level of self-awareness of patients who exhibit this behavior present a challenge. Copyright ª 2017 American Dental Association. All rights reserved.
ABSTRACT Background. Awake bruxism is a common clinical condition that often goes undetected, often leading to pain or damaged teeth and restorations. Methods. The authors searched electronic databases regarding the treatment and effects of awake bruxism compared with those of sleep bruxism. The authors used the search terms diurnal bruxism and oral parafunction. The authors combined information from relevant literature with clinical experience to establish a recommended protocol for diagnosis and treatment. Results. The authors found articles regarding the diagnosis and treatment of bruxism. The authors combined information from the articles with a review of clinical cases to establish a treatment protocol for awake bruxism. Conclusions. Literature and clinical experience indicate a lack of patient awareness and, thus, underreporting of awake bruxism. As a result, myriad dental consequences can occur from bruxism. The authors propose a need for increased awareness, for both patients and professionals, particularly of the number of conditions related to awake bruxism. Practical Implications. Clinicians should look for clinical signs and symptoms of awake bruxism and use minimally invasive treatment modalities. Key Words. Diurnal; bruxism; clenching; occlusal guard; parafunction. JADA 2017:148(6):387-391 http://dx.doi.org/10.1016/j.adaj.2017.03.005
The purpose of this article is to help establish a protocol to identify patients at high risk of having this behavior, review treatment modalities, and develop a predictable dialogue to educate patients about awake bruxism. The prevalence of bruxism varies greatly across studies, varying from as low as 5% to greater than 90%.3 However, there seems to be a consensus that public awareness of bruxism is low and that it generally is underreported.4 In addition, Gibbs and colleagues5 reported that bite strength in people exhibiting parafunctional activity can be up to 6 times greater than that
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ORIGINAL CONTRIBUTIONS
waking oral habits that that have been identified and that may require a different type of treatment.8,12,15 If a clinician (or patient) desires a more definitive method of diagnosis, they can use various techniques. To differentiate between sleep and awake bruxism, for example, Figure 1. A. Despite reported nightly compliance with a guard, this 46-year-old man showed continued wear on his the clinician can meaanterior teeth. B. On questioning, we determined that the patient had an awake bruxism habit—grinding his anterior teeth in times of stress. sure the electromyographic activity of the 16-18 The dentist can prescribe easyin those without parafunctional habits. Therefore, para- masticatory muscles. to-use electromyographic devices to use during sleep to functional activity (such as awake bruxism) can induce confirm muscle activity (for example, BiteStrip, Great detrimental effects on the stomatognathic system Lakes Orthodontics). After initial screening and suspicion quickly. Restoration failure, such as material chipping of a parafunctional habit, more in-depth patient quesand fractures, is an unfortunate and costly occurrence tionnaires (with clear definitions) and at-home journaling that happens all too often. can help further identify what type of parafunctional acIDENTIFICATION tivities the patient engages in and how often.7,8 For clinicians to treat awake bruxism, they first must diagnose it. A simple first screening step is to ask patients CORRELATIONS AND COMORBIDITIES (on a medical history or examination form) whether A strong correlation exists between temporomandibular they clench or grind their teeth. Much parafunctional disorders (TMDs) and bruxism.9,19-21 Whether bruxism activity is not accompanied by noise, however, which can causes TMDs is undetermined, but there is support to make self-awareness difficult. This likely results in show that diurnal bruxism exacerbates TMD symptoms, underreporting and, hence, the wide variation in freincluding headache, muscle and joint pain, and jaw 6 quency of reported bruxism, both sleep and awake. locking.7,22-24 The activity of bruxism results in muscle There is encouraging evidence, however, that once a hyperactivity, particularly the masseteric sling muscles person is made aware of waking oral habits, he or she is (masseter and medial pterygoid) and the lateral pterymore likely to give accurate feedback.7,8 This initial goids. Therefore, myalgia and muscle spasm can result, as screening can serve as an opening dialogue for clinicians well as temporal headaches.9,11,25-27 Subsequently, it is not to educate and inform patients about awake bruxism. uncommon to see hypertrophic masseters as a result of Another critical way for clinicians to identify a patient long-term bruxing. Some TMDs can elicit symptoms, with a parafunctional habit is by damage to tooth struc- including tinnitus, vertigo, and auditory changes, which ture. This damage includes wear facets, fractured teeth also can worsen with diurnal bruxism.28 Any patient who and restorations, craze lines, abfractive lesions, and ulti- self-reports TMD, morning masticatory muscle pain or mately loss of teeth (Figure 2).4,9-12 Although many stiffness, or joint noises should be considered a possible times these are readily identifiable through a clinical bruxer and then identified as a sleeping or awake bruxer. examination, clinicians should use mounted diagnostic Bruxing is also a common phenomenon in children, models to detect these defects more accurately and particularly as deciduous and secondary dentition thoroughly. Other intraoral signs include indentations erupts. Carlsson and colleagues19 found that most selfalong the side of the tongue, as well as bony exostoses or identified adult bruxers were also bruxers as children. tori.9,10,13 Periodontal changes, including widening of Specifically, awake bruxers continued to exhibit awake the periodontal ligament, tooth mobility, and recession, bruxism, and people with other parafunctional habits also may occur.11,14 If clinicians note this kind of damage, carried those into adulthood. they should discuss the damage with the patients and In addition, there are also medical conditions related review their medical history to determine the cause. to awake bruxism. These include dystonias and other When the clinician suspects a patient has a sleeping or waking parafunctional habit, it is important to discern what that habit specifically is. Although this article ABBREVIATION KEY. TMD: Temporomandibular disorder. focuses on awake bruxism, there are multiple types of
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muscle-related issues, as well as developmental disabilities (including various types of autism)29,30 and neurologic diseases (including environmental and traumatic causes).20,31-34 Use of medications can cause bruxism, particularly selective serotonin reuptake inhibitors and other classes of drugs that affect dopamine and other neurotransmitters.32,33,35-37 There is also a known correlation between both awake and sleep bruxism and neurotransmitters (particularly dopamine and serotonin).38 Therefore, there is an emotional and psychological component that cannot be ignored. There is a strong psychosocial component to bruxism, particularly awake bruxism.39 Consequently, awake bruxism seems to be related strongly to emotional stress,9,10,40,41 perhaps even more than is sleep bruxism.42 This stress includes that in people with type A personalities and those in high-stress professions.43-45
Figure 2. The patient who had a history of awake and sleep bruxism previously had received metal ceramic restorations. While clenching his teeth during a strenuous situation, he fractured his right maxillary canine through the fiber post and core.
TREATMENT MODALITIES
In addition to decreasing the risk of causing harm to teeth and restorations, minimizing the frequency of awake bruxism also can decrease pain. The damage and consequences of nocturnal bruxism usually can be prevented by the nightly use of an occlusal guard (Figure 3); the treatment of awake bruxism, however, can be more of a challenge. Although patients can use a daytime occlusal guard, compliance can be a major challenge. Consequently, the clinician should consider behavior modification to help curb waking behaviors.46 To customize an effective treatment plan, it is critical to understand the reasons behind each patient’s habit, as well as to assist patients in recognizing that they do, in fact, have this behavior. At first, many patients deny the habit, and some even get angry or defensive at the suggestion. A follow-up statement such as, “Do you ever find your teeth clenched together when you are in heavy traffic, or at your desk reviewing a difficult report or e-mail, or even during a difficult afternoon with the kids?” can defuse the situation and allow the realization that it is indeed possible. Once patients are open to the possibility, the clinician can ask them to pay attention to their daily behaviors to see whether they find themselves holding their teeth together or grinding throughout the day. Once patients are aware, their reports are likely to be a more accurate indicator of their parafunctional behavior.8 Lobbezoo and colleagues47 conducted a thorough systematic review of the treatment modalities for both waking and sleeping bruxism. In their article, they reinforced the lack of clinical trials to support treatment recommendations. They summarized the best approach as the “triple-P” approach: plates, pep talk, and pills. Specifically, they referred to stabilization splints, counseling, and short-term pharmacotherapy. OCCLUSAL APPLIANCES AND CONSIDERATIONS
As mentioned, compliance can be a challenge with a daytime splint. Patients have reported that it affects
Figure 3. Stabilization splint for sleep bruxism, with bilateral balance and an anterior ramp.
Figure 4. Example of a waking appliance. The thin material allows for normal function.
speech and increases salivary flow.48 Nevertheless, this treatment is noninvasive and is a popular first treatment option. The splints usually are made of hard acrylic because soft splints are more difficult to adjust and actually may encourage parafunctional activity (Figure 4).10,49
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Historically, there was some belief that occlusal interferences could promote bruxism, with occlusal equilibration as a recommended solution. Clinicians should be aware that there is no clinical evidence or literature support to indicate that occlusion plays a causal role in bruxism.47,50,51 Therefore, occlusal equilibration is not a recommended treatment for bruxism. Likewise, if occlusal equilibration or restorative treatment is to be completed for other reasons, the patient should be made aware that it likely will not improve his or her bruxism habit. PSYCHOSOCIAL APPROACHES
Investigators in the literature have presented multiple treatment approaches to address the psychosocial component of awake bruxism. These modalities include stress reduction, counseling, lifestyle changes, and hypnotherapy.10,41 Bringing a therapist to the team can be helpful in achieving success. Investigators in the literature have reported cue conditioning or cuing as another treatment option, particularly with children and people who are mentally challenged. With this treatment, vocal or physical cues are repeated when a patient bruxes. This cue could be anything from saying a phrase such as “say ‘ah’” or “open” to a gentle touch on the chin or using ice on the chin or cheeks.30,52-54 Another alternative (albeit more experimental) treatment option involves biofeedback to curb the behavior. A small electric impulse is emitted during the muscle activity, ultimately stopping the action of bruxism.55 MEDICAL TREATMENTS
Investigators have proposed medications, including muscle relaxers, to treat bruxism.47 Clinicians should prescribe these medications for only short periods, and patients need to be aware that they can cause drowsiness. Another pharmacologic approach involves the use of botulinum toxins in the treatment of bruxism.10,20 The clinician injects botulinum toxins into the masticatory muscles that are triggered with bruxism, including the temporalis and masseter. Study results indicate that the use of this treatment can cause some bruxism-related muscle pain to subside and may reduce bruxism events.31 Lobbezoo and colleagues47 advocate that because this treatment does not have as much literature support, clinicians should advocate it only after attempting more minimally invasive approaches. In our practice, we begin with the psychosocial component. Our team educates patients, letting them know that teeth should touch only during eating or swallowing and that bracing the teeth throughout the day can cause extensive damage. We teach patients the phrase “lips together, teeth apart” for them to repeat when they find themselves bruxing. We also provide 6 reminder stickers with the phrase for the patient to place in areas to help remember to relax the jaw. These
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stickers have been helpful when patients place them in their cars, at their desks or computers, as well as in other potential areas of daily stress—thus, the plan to solve the problem of awake bruxism begins. Beyond this, we refer patients with more complex issues to local psychiatrists, psychologists, and other therapists— including one who practices hypnosis. We fabricate hard acrylic occlusal appliances, most commonly for the lower arch. If there is a compliance issue, we make a vacuform retainer that covers all the lower teeth. If the patient is having substantial pain, we prescribe a short-term regimen of muscle relaxers and partner with oral and plastic surgeons to administer botulinum toxins. CONCLUSIONS
Identification and treatment of awake bruxism can present a challenge for the clinician. He or she may not know or be told what stresses the patient has been under since the last prophylaxis or clinical examination. Therefore, it is incumbent on the entire dental team to be alert to patient conversation about what has been and is going on in the patient’s everyday life that could be contributing to awake bruxism, which often is associated with clenching rather than grinding. Unfortunately, it often goes unnoticed until a dental emergency (pain or fracture) occurs. Because awake bruxism is linked more closely to emotional stress than is nocturnal bruxism, psychological treatment may be indicated in conjunction with dental treatment. In addition, we recommend lifestyle changes. A concrete plan of patient education is a first step to solving the problem of awake bruxism. Once aware of the bruxism events, the patient can begin to make the necessary change in behavior. If behavioral change is not successful, we recommend a daytime appliance not only to prevent damage but also to promote awareness. A person tends to be more aware of clenching or grinding when he or she bites on an appliance rather than the opposing teeth. When possible, it is best to prevent the need for extensive dental treatment. Inhibiting bruxism, both awake and sleeping, is in the patient’s best interest. Thus, it is imperative for the dentist, hygienist, and dental assistant to educate and reeducate the patient during and after any restorative treatment. n Dr. Goldstein is a restorative dentist, Goldstein, Garber & Salama, Atlanta, GA; a clinical professor, Oral Rehabilitation, The Dental College of Georgia, Augusta, GA; an adjunct clinical professor, Prosthodontics, School of Dental Medicine, Boston University, Boston, MA; and an adjunct professor, Restorative Dentistry, University of Texas Health Science Center at San Antonio, San Antonio, TX. Address correspondence to Dr. Goldstein at 600 Galleria Pkwy, #800, Atlanta, GA 30339, e-mail RGoldstein@ mydentalmail.com. Dr. Auclair Clark is a prosthodontist, Goldstein, Garber & Salama, Atlanta, GA; and an assistant clinical professor, University of North Carolina, Chapel Hill, NC. Disclosure. Drs. Goldstein and Auclair Clark did not report any disclosures.
ORIGINAL CONTRIBUTIONS
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