Bruxism: Advice, Links, Resources

You may find out more about me (Dr. Moti Nissani--the writer of these lines) by visiting my internet homepage or looking up my resume. (Unfortunately, owing to a shift in my research inerests and to the great volume of mail I receive on a daily basis, I can no longer respond to individual requests for therapy, help, and advice).

All forms of bruxism entail forceful contact between the biting surfaces of the upper and lower teeth. In grinding and tapping this contact involves movements of the lower jaw and unpleasant sounds which can often awaken housemates. Click here to hear the grinding of one patient (who has been grinding her front teeth, some 12 minutes a night, for the past 50 years). Clenching (or clamping), on the other hand, involves inaudible, sustained, forceful tooth contact unaccompanied by mandibular movements.

Note: The recommendations below are based on my own experiences and interpretations of the extensive bruxism literature. Needless to say, my efforts to portray an accurate picture may have failed. I may have, for instance, overlooked or misinterpreted some critical research. So the material below should be read critically and supplemented by other readings.

Educate Yourself. The first step for both clinicians and bruxers involves education. Although you need not become an expert, in this context even a little knowledge is a good thing. You may wish to begin with my Definition of Bruxism , then do some reading about the Incidence of Bruxism. It is particularly important for both clinicians and patients to become fully cognizant about the Effects of Chronic Bruxism . Among other things, bruxism may cause severe tooth damage, headaches, and hearing loss. It may (or may not) lead to temporomandibular disorders (TMDs, also known as temporomandibular joint--TMJ--syndrome)--a condition which can, according to one expert, "devastate its victim" (Goldman, 1992, p. 191; see also Reynolds, 1994).

One convenient way of approaching the professional literature is Medline (PubMed), a database which you may be able to access at no cost from your home or at the nearest public or academic library. Once you are there, you need only type in a term (such as bruxism) to get the summaries (=abstracts) of most scholarly manuscripts on the subject. Similarly, you can type the name of a bruxism specialist (e.g., Glaros) to read summaries of his/her medically-related articles. Another useful source is WorldMedicus.

In their professional writings (but not, one hopes, in their personal lives), researchers are required to use jargon-filled, technical language. Such language has much to recommend it, but it renders the scientific literature inaccessible to most people. So, when you start looking up articles in Medline and in a dental library, you may wish to consult a glossary of medical and dental terms. Such glossaries can be found in most medical and dental libraries. Simpler versions are also available online (cf. The On-line Medical Dictionary).

Another interesting online source is the United States Patent Office, which provides uncopyrighted full texts and images of all patents awarded since 1976. But be careful: the main criterion for awarding patents is novelty, not effectiveness!

If you want to consult the original literature, you may wish to visit the nearest dental, and perhaps also medical, libraries. If it's your first visit to an academic library, the reference librarian will show you how to navigate that system. You can then look up the references you identified in your Medline search and elsewhere.

However, the number of articles on the subject is enormous; besides, many are either outdated or of little practical value. Also, Medline at the moment doesn't include the best and most accessible general source: chapters in books on sleep disorders, dentistry, or clinical psychology. My bruxism bibliography may help your library self-education program by supplementing Medline and other useful databases.

Search engines such as Alta Vista or Mamma are becoming increasingly important in clinical research. It used to be said that the internet, like the Platte River, is one-mile wide and one-foot deep. But this is no longer true. Governments, research institutions, and academics increasingly put their best materials online. The trick here is to separate wheat from chaff, using common sense and intuition. For example, all things considered, a government or a university source (with the endings .edu or .gov) is more trustworthy than a private (.com) source. Likewise, an internet copy of an article that appeared first in a refereed professional journal should be taken more seriously than most commercial, profit-driven, claims.

A couple of hints may facilitate your online search. If you are looking for a complex term like teeth grinding in a search engine like Alta Vista, type "teeth grinding" (bracketed by quotation marks) and not just teeth grinding. Alta Vista will then only produce pages where the two words are joined together. For a less stringent search, type +teeth +grinding (this will cull all the pages in which both words appear, even if they are separated by other words). Here is another useful example of how to limit your search. Go to www.alltheweb.com/advanced, and in the filters, choose:

This restricted search will only yield results posted by educational institutions.

But no one has developed yet a magic formula for separating wheat from chaff--there is no substitute for critical thinking, no matter where you find yourself! To see one example of irresponsibility in action, click here.

Consult a Bruxism Specialist. A second, related, step, involves the realization that most dentists, doctors, and other clinicians are not bruxism experts. You can overcome this problem by either becoming an expert yourself or by consulting a bruxism specialist.

We Don't Know Much about the Subject. As you read, you will, sooner or later, realize that we know precious little about bruxism. In particular, there are 1001 speculations about the causes of bruxism, but not a single proof. All suggested cures depend therefore on hit and miss, trial and error, approaches, not on deep understanding of the condition itself. Incidentally, this is yet another way of separating wheat from chaff: When a dentist or a bruxism expert is too sure of himself, whatever he says should be taken with a grain of salt.

TMJ Syndrome. You need to realize, in particular, that a TMJ or (TMDs) expert is not necessarily a bruxism expert, and vice versa. The two conditions are related, but far from being identical. Unfortunately, busy clinicians often fail to make this distinction. Thus, long-term bruxism may or may not lead to TMDs while TMDs may, or may not, be caused by bruxism.

I do not recommend the following approaches (the evidence and references leading me to this lukewarm appraisal are given in this link)

Not recommended: Splint (in all its infinite varieties: soft, hard, maxillary, mandibular, partial, aqualizer, etc.; see for example, Wright, 1999). As the accompanying literature review recounts, for a few weeks the splint (and most other intraoral devices) may be truly successful in stopping bruxism, but this is a temporary effect that may lull patients and dentists alike to the virtual uselessness of the splint over the long term. In particular, while the splint may provide some protection for the teeth, it does not stop bruxism and such grave potential consequences as hearing loss and TMJ syndrome. Moreover, the splint itself may cause health problems. Sooner or later, this $1 billion industry (in the USA alone) will give way to better treatment modalities.

Note: Psychotherapy and hypnosis may help to reduce stress, and thus to alleviate bruxism. But, despite sporadic claims to the contrary, there is little evidence that they can, by themselves, prevent bruxism.

Given the limited success of traditional approaches, and given, moreover, the high incidence of bruxism and its harmful consequences, clinicians and sufferers may occasionally be interested in experimenting with non-intrusive, safe, less widely known, treatment modalities. To meet this need, the remainder of this link focuses on such comparatively unpopular or recent approaches.

It must be emphasized at the outset that no miracle treatment for bruxism is yet available. A bruxer may need to try several approaches, sequentially or simultaneously, and at the end may--or may not--gain control of this destructive habit. At any rate, at the moment the following alternative approaches seem worth experimenting with.

Wait and See. In a few lucky cases, bruxism may vanish spontaneously. In others, grinding and clenching may occur so seldom, or are so weak, as to hardly justify any action at all.

In particular, young children often require different therapeutic approaches than adults. To begin with, the damage to their teeth, for the most part, is transitory, for only the primary teeth may be affected, not the permanent teeth. Moreover, bruxism in children usually resolves spontaneously. In one study, for example, 126 children between the ages of 6 and 9 were diagnosed with bruxism. Five years later, upon re-examination, only 17 children retained the bruxing habit. Thus, juvenile bruxism is probably "a self-limiting condition which does not progress to adult bruxism and which appear to be unrelated to TMJ symptoms (Kieser & Groeneveld, 1998). This suggests that "observation and reassurance, rather than intervention, are warranted in most cases" (Thompson, Blount, and Krumholtz, 1994). Obviously, however, even in children, when the damage is severe (as in a recent case described by Dr. Bubon), or when the habit persists, treatment is mandatory.

Recommendation: If bruxism occurs only sporadically and intermittently, especially in children, waiting may provide the best strategy. If the condition does not spontaneously disappear in a few months, keeps recurring, or is accompanied by worrisome side effects (as hearing loss or locked jaw), then action is required.

Stress. In some cases, emotional stress may trigger, or exacerbate, bruxism. On the other hand, the popular belief that stress is the leading cause of bruxism (and not merely one aggravating factor among many) is, in all likelihood, mistaken. Still, negative stress is bad for one's health anyway, regardless of its effects on bruxism. It may be worth while therefore to try to reduce stress levels (with such things as yoga, hypnosis, changed lifestyle, or autosuggestion tapes).

Recommendation: Stress reduction is easier said than done. Besides, it's unlikely to prevent bruxism, even if successful. So, while of great value in its own right, stress reduction will, in most cases, need to be complemented by other treatment modalities.

Counteracting Trauma. In some cases, bruxism may commence shortly after such dental procedures as fillings, crowns, or bridges; after an injury to the mouth; or after a prolonged operation in or through the mouth. To be sure, at times bruxism may be caused by the psychological stress of the treatment or injury (and not by the injury itself). In other cases, coincidence may play a key role (that is, bruxism starts after trauma but is not traceable to it). Nevertheless, it may be still worth while looking into a causal connection and taking remedial actions right away, before the new bruxing habit becomes entrenched. A new high crown may be ground down a bit, for example, to reduce any possible interferences.

Recommendation: In those comparatively rare instances when bruxism seems to immediately follow dental manipulation, mouth surgery, or injury, correction may succeed in treating bruxism. In this case, the corrective procedure should be undertaken as soon as possible, to prevent entrenchment of the bruxing habit.

Bruxism as a Side Effect of Drugs and Medications. In some cases, bruxism may be traceable to drugs. Smoking (Madrid et al., 1998) and alcohol (Hartmann, 1994) may cause, or at least exacerbate, the condition. Antidepressant and antipsychotic medications may trigger bruxism in non-bruxers (reviewed in Brown & Hong, 1999; Gerber & Lynd, 1998). For example, within a few days of initiating velafaxine therapy for depression, a man with a bipolar disorder developed bruxism. In another study (Ellison & Stanziani, 1993), daily intake of the antidepressants fluoxetine (=prozac) or sertraline triggered sleep bruxism in four non-bruxers.

The effect of anti-depressants is still uncertain (Stein, Van Greunen, & Niehaus, 1998). Still, clinicians should bear in mind the theoretical possibility that drugs or medications may induce or exacerbate bruxism.

Recommendation: Clinicians should routinely inquire about their patients' habits of consuming tobacco, alcohol, and antidepressants. Cutting down on smoking or drinking may help improve bruxism. If bruxism developed shortly after the beginning of antidepressant therapy, the prescribing clinician should be notified and consulted about the desirability of reducing the dose of the antidepressant, switching to another antidepressant, or prescribing a drug which will counteract the bruxism-inducing effect of the antidepressant. Thus, the effects of venlafaxine may be counteracted with gabapentin; while the effects of fluoxetine and sertraline may be neutralized with buspirone.

Here, a mildly aversive, safe liquid (e.g., sea water), is inserted into, and sealed in, small plastic capsules. Two capsules are attached to a specially-designed dental appliance which comfortably and securely places them between the lower and upper teeth. The appliance and capsules are worn at night or at other times when bruxism is suspected to occur. Whenever bruxism is attempted, the capsules rupture and the liquid is released into the mouth. The liquid then draws the bruxer's conscious attention to, and forestalls, any attempt of teeth clenching or grinding. After the capsules are replaced, sleeping patients then resume sleep while awake patients resume their normal activities.

This approach is described in greater detail in the accompanying article. On the positive side, it involves wearing a comfortable dental appliance similar to a child's retainer; hence (unlike the splint), it is probably not associated with any worrisome side effects. It is based on the known effectiveness of taste stimuli in aversive conditioning (click here to find out more about the theoretical promise of the taste approach, as opposed to any other biofeedback modality), and on documented research that the sleeping brain is capable of learning. It is less costly and cumbersome than sound alarms, and, unlike sound alarms, it virtually precludes habituation (not waking when the alarm sounds). When worn, it eliminates (not just reduces) bruxing behavior. Moreover, this appliance (attached to wax capsules) can be used to diagnose bruxism and to assess the effectiveness of all other treatment modalities. This approach worked wonders for me: it totally stopped my earaches, hearing loss, splitting headaches, clicking jaws, and ever-flattening teeth.

On the negative side, the first couple of weeks of wearing this appliance are trying. Also, as in the case of all other bruxism therapies, a large scale, double-blind, experiment confirming the effectiveness of this approach has yet to be carried out.

Recommendation: Read the attached article and decide for yourself. However, despite its great promise, the approach is not yet commercially available (the average time lag between the invention and adoption of an effective medical treatment is 12 years). If you wish to try this approach on your own, click here for technical advice.

Nutritional Supplements. Magnesium's vital role in nerve and muscle function led at least two researchers to the suspicion that bruxism may be traceable to insufficient consumption, or inefficient utilization, of this metal. Magnesium-deficient diet is said to cause frequent teeth grinding in both sleeping and awake pigs (cf. Lehvila, 1994, p. 219). In humans, the suggested treatment involves magnesium supplements. According to Ploceniak (1990), for instance, prolonged magnesium administration nearly always provides a cure for bruxism. This confirms the earlier report of Lehvila (1974), which claimed remarkable reductions (and sometimes even disappearance) in the frequency and duration of grinding episodes in six patients who took, once a day, a tablet of assorted vitamins and minerals (which included 25 mg {in children} or 100 mg {in adults} of magnesium), for at least five weeks. When the supplements intake stopped, the symptoms returned.

Earlier, a similar logic led Cheraskin & Ringsdorf (1970) to study the effects of nutritional supplements on teeth grinders or clenchers. Of these, 16 took calcium, vitamin A, vitamin C, Vitamin B₅ (pantothenic acid), iodine, and vitamin E. When surveyed a year later, they reported that bruxism vanished. In contrast, the 15 bruxers who only took vitamins A, C, E and iodine showed no improvement. It seemed reasonable to conclude that the active agents were calcium and pantothenic acid (vitamin B₅).

More research is clearly needed in this area. Indeed, if such claims apply to even a small proportion of bruxers, they merit a close look because taking these supplements is comparatively convenient, safe, and free of side effects.

Recommendation: Until such claims are confirmed, narrowed down, or refuted in a large-scale, double-blind study, the best strategy may involve taking the following on a daily basis: magnesium (approximately 100 mg), calcium (150 mg), and pantothenic acid (50 mg), combined with at least the following: vitamins A (1,000 IU), C (300 mg), E (60 mg), and iodine (0.1 mg=100 mcg). If bruxism subsides, patients should be advised to continue taking these pills. If no improvement is observed after 8 weeks or so, the approach should be given up.

Vacuum Prevention. Dr. Long (1998) believes that "to clench the jaw for a long time, an intraoral vacuum must be formed and maintained." To prevent the formation of such vacuum, one may construct the simple, stainless steel wire appliance shown below. Over this appliance two plastic straws are fitted, which are in turn held in place with two rubber washers aimed at preventing the creation of vacuum.

It remains to be seen just how effective this approach is. In view of its simplicity, low cost, and few probable side effects, technical improvements and further experimental and clinical evidence would be of interest. In the meantime, some reservations come to mind.

The appliance itself may often float in the mouth of a sleeping patient, or even be expelled. The evidence that a vacuum is required for sustained clenching is sketchy, at best. The appliance is said to prevent prolonged clenching, not to prevent clenching of short duration, nor to prevent grinding. Thus, it may merely lead to a change in the pattern of bruxing, with more numerous bouts of shorter durations, so that the total amount of bruxing remains the same. The total effect may be equivalent to breathing through the mouth, which is not as healthy or comfortable as breathing through the nose. Indeed, it is difficult to see how the same effect could not be achieved by the simpler means of plugging one's nose before going to sleep. The appliance cannot serve as a cure; it must be worn to mitigate clenching. Apart from subjective patient reports, it would be difficult to know whether this treatment is effective.

Recommendation: If this claim strikes you as sound, and if the idea doesn't bother you, you may plug the nostrils for a few nights, and check the vacuum prevention claim for yourself. Alternatively, look up Long's paper and either construct his device yourself or take his paper to your dentist and ask her to construct it for you. Try it for a few days. If it works for you (unlikely, but one never knows), you are home free.

Sleep Feedback: Human Alarms. One long-term experiment (Watson, 1993) involved a 28-year-old man with a six-month history of sleep grinding and a 24-year-old woman with a three-month history of sleep grinding. The treatment only involved the first two hours of sleep and consisted of the following sequence: 1. Baseline: during the first few nights, the spouses of both grinders were instructed to merely record grinding noises. 2. Waking: For the next few nights, they woke their spouses when grinding noises were heard. 3. Baseline. 4. Waking. 5. Baseline. 6. Waking plus overcorrection (an enforced wakeful period—performing a series of meaningless activities, e.g., face washing for ten minutes before going back to sleep). 7. Baseline. 8. Follow-up recordings taken at intervals of up to 18 months post-treatment. In both individuals, almost complete cessation of grinding occurred.

In a similar study (Blount, Drabman, Wilson, and Stewart, 1982), ice was applied to the cheeks of two profoundly retarded wakeful grinders when they were heard bruxing, leading to significant long-term reductions in the incidence of bruxism.

Along with the magnesium therapy discussed earlier, such little-used behavioral approaches deserve further study. Yet, even if these approaches are shown to be effective in a large-scale study, they suffer from obvious shortcomings. They are inapplicable to clenchers. Moreover, the four individuals in these two studies may have simply learned to grind inaudibly, clench instead, or shift grinding behavior to periods when feedback was unavailable. Such approaches depend on the presence of another individual nearby, and on the willingness of that individual to lose sleep and provide the needed feedback over a period of many months.

Recommendation: If you are a grinder (and not a silent clencher), if you don't sleep alone, and if your sleep partner is willing and able to provide the needed feedback, you may wish to try this approach for a while. If it works, your problem is fairly painlessly solved. If it doesn't, move on to something else.

The NTI Clenching Suppression Device. The inventor of this mini-splint, Dr. Jim Boyd, describes it as "a patented pre-fabricated, easily retro-fitted anterior-point-stop device which suppresses clenching intensity in all excursive and protrusive movements." The device is said to effectively reduce clenching behavior. To find out more about this device, go to Dr. Jim Boyd's web page.

According to Dr. Boyd, the device may cause an annoying anterior open bite (this link contains a photo of a severe open bite). As well, as in the case of all other bruxism claims, a systematic, large-scale, double-blind study remains to be carried out. All the same, here is the independent testimonial of one chronic bruxer:

Recommendation: Visit Dr. Boyd's web site, compare his approach to others in this page, and decide for yourself.

Note: Double-click underlined titles for either a summary of the article or the article itself.

Blount, R. L., Drabman, N. W., Wilson, W., & Stewart, D. (1982). Reducing severe diurnal bruxism in two profoundly retarded females. Journal of Applied Behavior Analysis, 15, 565-71.

Brown. E. S., & Hong, S. C. (1999). Antidepressant-induced bruxism successfully treated with gabapentin. Journal of the American Dental Association, 130(10):1467-9.

Cheraskin E., & Ringsdorf, W. M. Jr. (1970). Bruxism: a nutritional problem? Dental Survey, 46(12), 38-40.

Ellison J. M., & Stanziani P. (1993). SSRI-associated nocturnal bruxism in four patients. J Clin Psychiatry, 54: 432-4.

Gerber P. E., & Lynd, L. D. (1998). Selective serotonin-reuptake inhibitor-induced movement disorders. Ann Pharmacother, 32(6):692-8.

Goldman, J. R. (1991). Soft Tissue Trauma. In Kaplan, A. S. and Assael, L. A. Temporomandibular Disorders. Philadelphia: Saunders, pp. 191-223 (Note: Sstill one of the best and most accessible books on TMD's).

Hartmann E. (1994). Bruxism. In: Kryger M. H. & Roth T, Dement W. C. (eds). Principles and Practice of Sleep Medicine, 2nd ed. Philadelphia: W. B. Saunders, pp. 598-601.

Kieser J. A., & Groeneveld, H. T. (1998). Relationship between juvenile bruxing and craniomandibular dysfunction. Journal of Oral Rehabilitation,(Sep), 25(9): 662-5.

Lehvila, P. (1994). Bruxism and magnesium: Literature Review and Case Reports. Proceedings of the Finnish Dental Society, 70, 217-224.

Madrid G., Madrid S., Vranesh J. G., & Hicks R. A. (1998). Cigarette smoking and bruxism. Perceptual and Motor Skills, 87:898.

Matthews E. (1942). A treatment for the teeth-grinding habit. Dental Record, 62, 154-5.

Stein, D. J., Van Greunen, G., & Niehaus, D. (1998). Can bruxism respond to serotonin reuptake inhibitors? Clinical Psychiatry, 59 (3), 133.

Thompson, B. H., Blount, B. W., & Krumholtz, T. S. (1994). Treatment approaches to bruxism. American Family Physician, 49, 1617-22.

Wright, E. F. 1999. Using soft splints in your dental practice. General Dentistry 47, 506-510.