Bruxism (Teeth Clenching or Grinding)

Advice, Links, Resources

(El bruxismo: Consejos, Enlaces, Recursos)

This page was last updated on June 2014

 

Clickable Table of Contents:  1. Educate yourself  2. Diagnosis of bruxism  3. Consult a specialist  4. Uncertainty about bruxism  5. Bruxism and TMJ (TMDs)  6. Treatment Options to Avoid  7. Wait & see?  8. Stress?  9. Trauma  10. Drugs  11. Human alarms   12. Mechanical Biofeedback Approaches (e.g., sound alarms, vibrations)   13. Taste biofeedback  14.  Nutritional supplements  15. Vacuum prevention  16. NTI-tss  17. Works cited

 

This hypertext provides a literature review, internet and library resources, and practical advice for bruxers (teeth clenchers or grinders) and for dentists, physicians, and other clinicians concerned with the treatment of bruxism.  Clinicians may also wish to consult, offline, a similar review in the Journal of Oral Science.

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 interests, frequent field work in places where I have no ready access to the internet, and the great volume of mail I receive on a daily basis, I am unable to provide bruxism-related advice or therapy. 

Please bear in mind that 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.  Moreover, I can only update this page once every two years or so.  So the material below should be read critically and supplemented by these readings and others.

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 significant mandibular movements.  Although the two conditions are often grouped together or not even distinguished in the professional and lay literature, they may actually be quite distinct, with different etiologies, symptoms, and consequences.  

Educate Yourself. The first step for both clinicians and bruxers involves education.  Although you may not become an expert, here even a little knowledge is a good thing.  You may wish to begin with my Definition of Bruxism, then read about the Incidence of Bruxism.   It is particularly important for both clinicians and patients to become fully aware of 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).

Other useful links are the Online Sleep Disorders Guide and especially their bruxism guide.  As well, the hypertext you are reading offers the following links:

One convenient way of approaching the professional literature is PubMed, a database which you may be able to access at no cost from your home or the nearest public or academic library. 

In their professional writings (but not, one hopes, in their personal lives), researchers are required to use jargon-filled, technical language.  Such language has something to recommend it, but it needlessly renders the scientific literature inaccessible to most people.  So, when you start looking up articles in PubMed 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 US Patent Full-Text Database Boolean Search, which provides un-copyrighted 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 scientific or 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 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 place 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.

But no one has developed yet a magic formula for detecting quality€”there is no substitute for critical thinking, no matter where you find yourself!  To see one example of irresponsibility in action, click here. 

Diagnosis of Bruxism.   How can you tell a bruxing patient when you see one?  How can you tell if you yourself suffer from chronic bruxism?  Here, I'd like to draw your attention to a few non-invasive early detection procedures. 

Unfortunately, because bruxism only involves minor symptoms and inconveniences in its initial stages, it is often ignored by both patients and clinicians. At a certain juncture, however, the symptoms begin to noticeably affect one€™s quality of life. It is typically at this juncture that a patient starts looking for a cure. This delay is unfortunate, for by then the habit is ingrained and has already brought about irreversible losses.  

Diagnosis of grinding is fairly straightforward.  If you noisily grind your teeth, and if you live in the same household with other people, diagnosis usually is straightforward, for your housemates or family members would often let you know.  If not sure about their cooperation, tell them that this is important, and ask them to monitor the situation and provide you with feedback.  Explain that this is important to your health, that you will not be offended, and that you would appreciate knowing the truth.

If you live alone, or if the people you live with cannot be relied upon to provide the information you need (they are, for example, heavy sleepers, or young children, or too polite), there is a more reliable way of detecting or disproving the presence of teeth grinding and of determining its duration.  To do this, get hold of a sound-activated tape recorder (the most recent one in my possession is Olympus Pearlcorder S724 with an ultra sensitive microphone ME7).  Calibrate the distance from your head while sleeping (4 ft is about right, located at about the same height as your head while you sleep), and check it for any sounds every morning (this would also tell you if you talk or snore at night!).  If you grind your teeth most nights for more than a few seconds per night, then you probably need to do something about the condition.  

Diagnosis of clenching is difficult, leading clinicians to often fail to detect the presence of clenching (false negatives), or to mistakenly tell people that they clench when in fact they aren't (false positives).  Extreme care must therefore be taken to provide a correct diagnosis, preferably by relying on as many independent diagnostic approaches as possible.  At present, and incredible as it may seem, most dentists will only provide the sophisticated diagnostic service described here at the patient's insistence.  If your dentist declines, it may be high time to look for a new dentist!

The surest sign of both grinding and clenching is sensitive, worn-out, decayed, fractured, loose, or missing teeth (McGuire and Nunn, 1996).  Prolonged grinding or clenching break down the enamel, sometimes, in long-term bruxers, reducing teeth to stumps. Instead of a white enamel cover, one often sees the yellowish and softer dentin. The back teeth of some chronic bruxers often lose their cusps and natural contours, appearing instead flat, as if they had been worked over with a file or sandpaper. When anterior teeth are affected, their biting surfaces are damaged. As well, the absence of enamel makes it easier for bacteria to penetrate the softer part of the teeth and produce cavities. With time, the condition may lead to bridges, crowns, root canals, implants, partial dentures, and even complete dentures.  But none of these symptoms provides a surefire diagnostic procedure.  For one thing, such symptoms may be traceable to other reasons and not to bruxism..  They also take time to develop, and hence a patient may be bruxing for years before she herself, or her clinician, notices the problem.  Likewise, such symptoms are often present in a patient who used to brux but who does not brux now (see Baba et al., 2004).

Other signs that may or may not be present (for images and fuller explanations, go to this link) are jaw pain; fatigue of facial muscles; headaches; neck pains; earaches; hearing loss; ear ringing, changes in appearance (damaged teeth, receding chin, hypertrophy of facial muscles); inflammation and blockage of some salivary glands; periodical swelling, pain, inflammation, and abnormal dryness of the mouth.  

Chronic bruxism is one of the leading causes of TMJ syndrome (or perhaps the leading cause, see Johansson et al., 2006), a condition that entails damage to the temporomandibular joints (TMJs), and, at times, soreness of jaws and muscles, clicking or popping sounds when opening the jaws or while chewing, and difficulties in fully opening the mouth.  A sufferer may wake up, for example, totally unable to open the mouth; or the jaw may suddenly lock or dislocate during chewing.

Other possible signs of bruxism include high levels of mercury in the bloodstream (for bruxers with mercury-containing fillings) and malocclusion (bad bite) (click here for more details).

Clenchers who need additional confirmation may wish to resort to one more diagnostic tool.  There are several options here.  One promising approach with minimum side effects is provided by the BruxChecker, a comparatively non-invasive, thin, transparent, polyvinyl chloride plate, painted red, which can probably be ordered by a dentist.  Tooth grinding leaves clear marks on this thin plate, thus serving as confirmation of the bruxism diagnosis.

The BrassChecker can be used to diagnose teeth grinding

 

 

 

I'd suggest staying away from expensive diagnostic devices.  Here is one example of such questionable devices in action. 

A recent study assessed the effectiveness "in detecting sleep bruxism (SB) episodes by combined surface electromyography and heart rate (HR) signals recorded by a compact portable device (Bruxoff®). SB episodes are preceded by a sudden HR change. Thus, HR detection increases the precision of automatic detection of SB."  Predictably, the authors found that the "Bruxoff device showed a good reproducibility of measurements of sleep bruxism episodes over time."  And they correctly remind us that "these findings are important in the light of the need for simple and reliable portable devices for the diagnosis of SB both in the clinical and research settings." 

A diagnostic tool that is available to both grinders and clenchers involves the use of beeswax or similar material.  You can ask your dentist to take an impression of your teeth and then have a dental lab make something like the following appliance:

How to diagnose clenching: Part 1.  A dental appliance equipped with posterior rods (22) to which a capsule filled with beeswax can be attached.  It consists of a curl (26) in one posterior rod to prevent slippage of capsule, hinges (30) to secure the appliance to the teeth, and anterior connection (34) of the two sides to preclude mobility or swallowing of the appliance

 

 

 

 

 

 

 

To this appliance you now attach two bilaterally-sleeved food-grade plastic capsules filled with a thin layer of beeswax: 

 

How to diagnose clenching: Part 2. A beeswax filled (14), bilaterally sleeved (18) plastic bag (10) is attached to the appliance above.  The patient sleeps with appliances and bags.  Malformations in the wax help to determine the presence, extent, type, and severity of bruxism

 

 

 

 

The rest is simple.  First, you'll need to wear this appliance every night for a couple of weeks, in order to get used to it.  This transitional period is necessary because, for the first few nights any appliance is highly likely to inhibit bruxing.  The appliance is fairly comfortable and does not seem to be associated with any side effects (to avoid the potential hazard of developing an open bite as a result of wearing this appliance, make sure that the wax layer is just thick enough to show signs of bruxism).   

After this transitional period, if the wax shows obvious signs of tampering when you wake up, you might have to conclude that you are, indeed, a bruxer.    

Consult a Bruxism Specialist.   A second, related, step, involves the realization that most dentists, doctors, and other clinicians are not bruxism experts.  Moreover, capitalist medicine itself--where money is king and where the education of healthcare professionals leaves much to be desired--suggests that the best road to better health is self-education.  Indeed, if you read and assimilate this entire page (including the various links it provides), you'd almost certainly know more about bruxism than your dentist!  So you need to find someone who specializes in bruxism (university-affiliated psychologists and  dentists, overall, are a far better bet than your typical run-of-the-mill psychologists or dentists).  Better still, at the moment your best (perhaps only) bet may be educating yourself and managing your own treatment program (with or without the help of a clinician). 

We Don't Know Much about the SubjectAs you read, you will, sooner or later, realize that we know precious little about this condition.  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 finding helpful clinicians:  When dentists or other professionals act as if they are sure that a particular treatment will work for you, they are acting irresponsibly and should be give the slip.  

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

Treatment Options to Avoid

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 (see also Harada et al., 2006).  In particular, while the splint may provide some protection for the teeth, it does not stop bruxism nor such grave potential consequences as hearing loss and TMJ syndrome.  Moreover, the splint itself may cause health problems (.e.g., "complications from long-term use of splints, however, can be severe and irreversible"--Widmalm, 1999).  Sooner or later, this $1 billion industry (in the USA alone) will give way to better treatment modalities.  So: "orthopaedic devices . . . have not demonstrated their medium- and long-term usefulness in reducing masticatory muscle activity during sleep (de la Hoz-Aizpurua et al., 2011)." 

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Four Views of the Common Acrylic Splint

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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, treat bruxism

What, Then, Shall We Do With a Bruxing Patient?

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 page focuses on such comparatively unpopular approaches.

It must be emphasized at the outset that no miracle treatment for bruxism is yet available.  A recent professional review, for instance, concludes that "there is at present no specific, effective treatment to permanently eliminate the habit of SB [sleep bruxism]. There are only palliative therapeutic alternatives steered at preventing the pathological effects of SB" (de-la-Hoz, 2013).  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, perhaps, worth considering.

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, according to some studies, 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 seemed to have retained the bruxing habit.  Thus, juvenile bruxism is probably "a self-limiting condition which does not progress to adult bruxism and which appears to be unrelated to TMJ symptoms" (Kieser & Groeneveld, 1998).  Another study suggests that "observation and reassurance, rather than intervention, are warranted in most cases" (Thompson, Blount, and Krumholtz, 1994).  In contrast, a more recent report suggests that childhood bruxism might be more persistent than previously believed (Carlsson, Egermark, and Magnusson, 2003).  Either way, when the damage to a child (as in this case) or adult is severe, 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 (e.g., hearing loss or locked jaw), action is required.

Stress.  In some cases, emotional stress is alleged to trigger, or exacerbate, bruxism.  However, 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, 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. For instance, a new high crown may be ground down a bit to reduce any possible interferences, or an old mercury amalgam may be replaced.

Recommendation:  In those comparatively rare instances when bruxism seems to immediately follow dental manipulation, mouth surgery, or injury, correction may succeed.  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, Medications, fillings and other dental manipulations.  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 (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).  [In fact, the only certain thing about anti-depressants is that they are over-prescribed].  Still, clinicians and bruxers should bear in mind the risk that drugs or medications may induce or exacerbate bruxism.

Recommendations: Clinicians should routinely inquire about their patients' habits of consuming tobacco, alcohol, and antidepressants. Cutting down on smoking or drinking may help in some cases to reduce bruxing. 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.

It is likewise possible that some bruxism cases are caused by such dental manipulations as mercury fillings and other types of fillings, dental implants, and the like. There is no proof that this is so (and even if there were, such proof would never be published in a dentistry journal), but it seems possible that teeth clenching or grinding are merely the body's futile attempt to deal with such interventions. Bearing this possibility in mind may help lower the incidence of bruxism in the general population.  For instance, most (but not all) dental X-rays are harmful and serve one, and only one, purpose: free income for your dentist.  Likewise, most fillings are unnecessary.  If there is a tiny hole in your tooth, your dentist is likely to recommend enlarging it and filling it with porcelain or even with mercury (deceptively called silver) amalgam.  My recommendation: Let nature do the enlargement for you--a process that might take several lifetimes to reach the size of the hole your dentist is sure to make in one seating!

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 bruxing 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 below, 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, 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 be attentive 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. 

Mechanical Biofeedback Approaches

These biofeedback variants are based on the belief that the habit of bruxism was likely to develop in the first place only because it has not been accompanied by immediate sensations of pain.  Indeed, when it comes to the habits of teeth grinding or clenching, nature failed to provide the pain or awareness signal which often blocks or minimizes self-destructive behavior.  Sleep feedback approaches attempt to artificially reintroduce this missing signal.

Such approaches often successfully treat other sleep disorders. For instance, idiopathic primary enuresis (bedwetting) can sometimes be cured by sounding an alarm at the moment urine is released (Broughton, 1994, p. 395; cf. U.S. Pat. No. 1,772,232). This alerts a sleeper to the bedwetting at the moment in which it is taking place, as opposed to finding out that it happened upon waking, hours later, as a bedwetter would in the absence of such an alarm system. The sleeping brain, apparently, is capable of responding to signals and modifying ingrained patterns of behavior.

A. Sound Alarms

In the treatment of bruxism, sleep feedback may involve electromyographic (EMG)-activated alarms (Cassisi, McGlynn, and Belles, 1987; U.S. Pat. No. 4,934,378). Bruxism, as we saw, requires tensing of certain facial muscles. This tensing involves an increase in electrical activity of the muscles, which can in turn be recorded by an electromyograph. The electrodes of this instrument are placed on the facial area where these muscles are located. When the tenseness exceeds a certain, predetermined, level, the alarm goes off. The loudspeaker can be free-standing, or, to prevent waking others, connected to earphones which the patient wears during sleep.

Most clinicians recommend overcorrection right after the alarm sounds. The patient is advised to fully wake up after each bruxing episode and to stay awake for a few minutes, usually by performing such meaningless, harmless tasks as hand washing or recording time in a bruxism log (Cassisi, McGlynn, and Belles, 1987). In either case, the alarm can be turned off manually by the awake bruxer or be turned off automatically when the sleeper's facial muscles relax.

This approach is sensible and is fairly unobtrusive--one needs not insert anything into the mouth, but needs only attach electrodes externally, to the face. On the other hand, this procedure may fail to correct any bruxing behavior which is associated with muscle tension lower than the predetermined intensity or duration threshold. Another obvious problem is that muscle tension may occur in the absence of bruxism: "numerous other types of orofacial movements unrelated to bruxism . . . can easily be confused with bruxism if only EMG criteria are used for scoring" (Miguel et al., 1992). So a patient may sometimes not receive a signal when a signal is needed, while at other times a patient may be jolted out of deep sleep for nothing.

To bypass this problem, many United States patents rely on an alarm system, but take the more reliable bruxing activity itself (instead of enhanced muscle activity) as their point of departure (please go to U.S. Patent Office and search the following Patent Numbers:  4,220,142; 4,976,618; 4,979,516; 4,989,616; 4,995,404; 5,078,153; 5,190,051; 5,586,562). The extra pressure may be registered, for example, by securely inserting a strain gauge between the teeth. When the pressure exceeds a predetermined level, the alarm goes off.

A typical sound alarm setup for the treatment of bruxism (Source: U.S. Patent #5,078,153, Jan. 7, 1992)

Feedback approaches employing sound alarms share some of the drawbacks of EMG-activated alarms. They also suffer from machine breakdowns and are often unsightly, invasive, intimidating, and expensive; they thus do not lend themselves readily to wide use, and especially not to long-term use. As well, they are only partially effective. In evaluating EMG-activated studies, Pierce and Gale (1988) found that bruxing only decreased by about 50% during two weeks of biofeedback therapy, but that, following withdrawal of treatment, the condition returned to baseline levels. Piccione et al. (1982), to cite another example, found that "biofeedback does not appear to be effective in reducing nocturnal bruxing," probably because, over time, "subjects learned to ignore the tone and to maintain sleep."

B. Vibrational Alarms

In one typical study (Gu et al., 2013) "an electric resistance strain gauge was embedded in the canine position of a maxillary splint in order to monitor abnormal clenching or grinding movements of teeth during sleep. The relevant details of bruxism events, including value of relative force, time of occurrence, and duration were recorded and analyzed by the receiver device and monitoring program respectively.  Meanwhile, for the purpose of nerve system and muscle relaxation, a watch-style device around the patient's wrist vibrates to alert the patient of teeth grinding or clenching if the value of biting force and duration exceed the threshold. Total average episodes of bruxism and duration were observed during eight hours sleep." [revised translation is mine]

In this study, after 6 weeks therapy, the average incidence of bruxism declined dramatically from 10 to 3 times during any given night, and the average duration of bruxism events was reduced from 21 seconds to 10.  By the end of three months, average episodes declined to 3 seconds and average duration declined to 9.

The authors conclude: "The pressure-based wireless biofeedback device is able to monitor clenching and grinding of bruxism. The results suggest that biofeedback therapy may be an effective, novel, and convenient approach for the treatment of bruxism."

Recommendation:  Many similar claims and gadgets abound.  Such mechanical biofeedback approaches, at best, achieve long-term reductions in the incidence and duration of bruxing episodes, not their prevention.  So, at best, they slow the development of the deleterious effects of bruxism but do not stop them.  On the other, such approaches are associated with few minor side effects.  If all you want is reduction (not total cessation) of episodes, you might wish to try one of these biofeedback modalities.

A Taste-Based Biofeedback Modality to the Prevention of Bruxism.Here, a mildly aversive, safe liquid (e.g., sea water), is inserted into, and sealed in, small plastic capsules. One or two capsule(s) 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 bruxing is attempted, the capsule(s) 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 resume sleep while awake patients resume their normal activities. fig5a.jpg (65365 bytes)

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), 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 capsule ruptures).  When worn, it eliminates (not just reduces) bruxing behavior.  Moreover, as we have seen, this appliance (attached to wax capsules) could be used to diagnose bruxism and to assess the effectiveness of all other treatment modalities.  On the negative side, the first few 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. 

Two users wrote:

I've tried just about everything over the years, and yet my condition continued to get worse.  Dentures, hearing aids, and TMJ were waiting for me around the corner. The taste-based approach worked wonders for me.  It saved my ever-flattening teeth. It totally stopped my earaches, hearing loss, splitting headaches, and clicking jaws.  I still wear the device every night, so for me this approach only provided an effective treatment, not a cure.  The appliance is far more comfortable than the splint though, and is not associated with any side effects.  About once every two weeks now a bag breaks, but that's all right, given all the other alternatives!  Half-asleep, I remove it, replace it with the spare appliance which is always ready on my nightstand, and go back to sleep. 

For over fifteen years I have suffered from bruxism and have journeyed from promise to promise with little success.  The body being such a wonderful thing, I couldn't believe that it was capable of committing  nightly sabotage at that level!  I decided to make the dental appliance and bags myself, and the taste-based approach is the one and only method that has worked!  This approach changed my life.

However, this approach requires discipline, motivation, and will power. Also, because this approach is not commercially available (the average time lag between invention and adoption of an effective medical treatment is 12 years€”click here to read about this lamentable aspect of science and medicine), users must possess exceptional technical skills.  Here is a report of someone who tried the taste-based approach on his own:

While this device proved to be highly effective initially, a number of problems prevented it from treating the disorder over the long-term.  Firstly, over time I  began to remove the device unconsciously during the night despite the fact that it was tightly fitted. Secondly, I developed an amazing tolerance to the aversive solutions so that even the spiciest concoctions of chili would fail to awaken me after the pouch(es) burst. Thirdly, I had health concerns about the safety of the pouches.

It would appear, then, that at the moment, no support is available (from your dentist or anyone else) and therefore, that the great majority of those who try this approach on their own are bound to fail.

Recommendation:  Owing to the commercial unavailability of the taste-based approach, and despite its very great promise, for now I  emphatically do not recommend trying it.  However, if you decide to ignore my recommendation (you may succeed if you are a trained natural scientist€”or missed your calling by not becoming one), 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.  A 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 in the frequency and duration of grinding episodes (and at times, their complete cessation) 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 intake of supplements 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.  If proven correct, such claims would put out of business an entire industry.  Hence, they are likely to be ignored by the medical establishment.

The only feedback I have received regarding this approach is this:

I have found that I have unbearable daytime teeth clenching when I have been exercising a lot and sweating heavily.  Calcium and magnesium are the only things that stopped the clenching.  Interestingly, I do not clench at night at all.

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, bruxer should continue taking these pills. If no improvement is observed within 8 weeks or so, the approach should be given up.

Notes:

  1. In these nutritional studies, bruxers typically take a number of vitamins and minerals, not just one; thus, it is not yet possible to pinpoint the effective nutritional agent.  Moreover, these supplements often work synergistically or cooperatively, so a few minerals and vitamins need to be taken to correct a deficiency in one. That is why, until we know more about the subject, all the supplements above should be taken, not just magnesium or calcium.
  2. The available evidence tells us little about optimal dosages, so there is an element of uncertainty in deciding how much to take.
  3. Children should take proportionately less. For instance, an eight-year-old weighing about 70 lbs. should take about half the recommended dosage.
  4. Magnesium should be avoided in cases of renal impairment and acute dehydration. It should not be taken if it causes diarrhea, other adverse reactions, or if it interferes with other medicines. One should refrain from prescribing more than 100 mg a day, as taking too much, or prolonged treatment, may cause fatigue and respiratory problems. Taking too much magnesium may even cause hypermagnesaemia, leading to nausea, vomiting, lethargy, and blockage of the bladder. As in the case of most drugs, dosage should be roughly determined by weight. In my view, roughly 0.7 mg a day per pound of body weight is all that should be taken (so a person weighing 143 lbs. needs to take no more than 100 mg of magnesium).
  5. A large-scale experiment on the effectiveness of nutritional supplements is long overdue.

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.

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          long.jpg (6389 bytes)

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 might 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 your nostrils for a few nights to check the vacuum prevention claim (see below).  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. 

The NTI-tss (formerly NTI) Clenching Suppression Device.  The inventor of this mini-splint, Dr. Jim Boyd, described 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 and its current status, go to Dr. Jim Boyd's web page.

NTI.gif (20980 bytes)

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.  Here are the independent testimonials of two chronic bruxers:

I have been wearing Dr. Jim Boyd's NTI appliance three and a half weeks and it does suppress clenching. My sore muscles are healing and I haven't felt better in two and a half years. It feels so good to go to bed and know that I will not be beating up my muscles, nerves, joints, etc. with clenching I cannot control.  As for cost. I went to California to a dentist there who charged me an outrageous price that is not typical. In addition, the NTI was not correctly fitted.   Dr. Boyd had met me in Las Vegas and  modified it to correctly fit it at no charge. To give you a better idea of cost, my adult daughter also clenches, so we called her dentist.  His total cost is $190.  There are no lab costs because the NTI can be fitted right in the office.  Also, no dental impressions or molds are needed. It takes approximately half an hour to fit the appliance.

I checked out Dr. Boyd's device from your website link. The NTI-TSS involves a small oral appliance which was fitted by my dentist, preventing contact of the front teeth.  The manufacturer asserts that the majority of bite force is generated by the rear teeth and, as such, by preventing their ability to connect, bruxing forces are reduced and symptoms of sleep bruxism alleviated.  I experienced a problem with the device, which rendered it ineffective, for I continued to brux and simply became sore in new areas.  Moreover, recent literature has discussed a number of cases where the NTI-TSS has been swallowed. 

Another user writes:

In my personal experience, Dr Boyd's NTI clenching incisor device should NOT be used in patients with a crown on either of the center incisors. The crown will fracture because of the leverage applied by the device from the activity of clenching and grinding.

Dr. Alan Budd, a clinician, summarizes his experiences with the traditional splint and the NTI-tss thus:

Once I realized the inescapable effects of bruxism, I began treating patients with splints.  Then I learned about the NTI, and I haven't made but one or two full-arch splints since. I find the NTI everything it's cracked up to be. It takes practice to get good, and an anterior (never posterior) open bite may occur. As you say, the patient must be warned in advance of this potential side effect, and a treatment plan can be devised to deal with it if the patient so desires.  Sore masticatory muscles, headache, neck ache, ear congestion, tinnitus, and sinus pain -- I've had one or more patients with each of these problems. They all got better.  If there's a true joint disease, the NTI may not work and then it becomes a diagnostic tool. 

A preliminary short-term study (Baad-Hansen et al., 2007) found that, unlike the ordinary splint, the NTI has an inhibitory effect on jaw-closing muscles during sleep, thus suggesting that the NTI-tss may effectively inhibit bruxism in some cases.  A 2008 similar review concluded that the "NTI-tss device may be successfully used for the management of bruxism and TMDs. . . . The NTI-tss bite splint may be justified when a reduction of jaw closer muscle activity (e.g., jaw clenching or tooth grinding) is desired, or as an emergency device in patients with acute temporomandibular pain and, possibly, restricted jaw opening."

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

Plugging the Nose During Sleep.  This technique involves plugging your nose (with cloth, paper, or even special plugs adopted for that purpose), so that you can only breathe through your mouth while asleep.  Obviously, most people wouldn't welcome the idea of  breathing through their mouth all night long.  Also, at least some people can clench or grind their teeth while awake and still breathe--by opening their lips (try this).  As well, a bruxer using this technique might clench or grind for a few seconds with a close mouth, open her mouth to take a breath, brux again, and repeat the process.  On the other hand, this technique enjoys the advantages of simplicity and self-sufficiency.  It might work in some cases and hence deserves a careful study. 

Recommendation:  Common sense argues against this approach.  However, there is no cost or harm involve in trying it.  So, try it for a few nights and see how it works for you.

 A Parting Word:  If you are a clinician with a heart, you may wish to consult all links and references in this hypertext before prescribing a splint to one more bruxer (Harada et al., 2006).  If you are a bruxer, I hope this hypertext helps you take charge of your health.  

Good Luck!

References

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

Broughton, R. J. (1994). Parasomnias. In S. Chokroverty (Ed.). Sleep Disorders Medicine (pp. 381-99). Boston: Butterworth-Heinemann.

Baad-Hansen L, Jadidi F, Castrillon E, Thomsen PB, Svensson P. (2007).   Effect of a nociceptive trigeminal inhibitory splint on electromyographic activity in jaw closing muscles during sleep. Journal of Oral Rehabilitation, 34 (2): 105-111.

Baba, K., Haketa, T., Clark, G. T., Ohyama T. (2004). Does tooth wear status predict ongoing sleep bruxism in 30-year-old Japanese subjects?  International Journal of Prosthodontics, 17(1): 39-44.

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.

Bubon, M. S. (1995).  Documented instance of restored conductive hearing loss. Functional Orthodontist,12: 26-9.

Carlsson GE, Egermark I, Magnusson T.  (2003).  Predictors of bruxism, other oral parafunctions, and tooth wear over a 20-year follow-up period. Journal of  Orofacial Pain, 17(1): 50-7.

Cassisi, J. E., Mcglynn, F. D., & Belles, D. R. (1987). EMG-activated feedback alarms for the treatment of nocturnal bruxism: current status and future directions. Biofeedback & Self Regulation, 12, 13-30.

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

de la Hoz-Aizpurua, J.-L. (2013).  Sleep bruxism: review and update for the restorative dentist. Alpha Omegan; 106(1-2):23-8.

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: Still one of the best and most accessible books on TMD's).

Gu W. P. et al. (2013).  Preliminary study of wireless biofeedback therapy for treatment of bruxism.  Zhonghua Kou Qiang Yi Xue Za Zhi, 48(2):105-8 (a Chinese journal--an English abstract is available here).

Harada, T, Ichiki, R, Tsukiyama, Y, Koyano, K. (2006). The effect of oral splint devices on sleep bruxism: a 6-week observation with an ambulatory electromyographic recording device. Journal of Oral Rehabilitation,33(7): 482-8.

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.

Johansson, A., Unell, L., Carlsson, G.E., Soderfeldt, B, Halling A. (2006). Risk factors associated with symptoms of temporomandibular disorders in a population of 50- and 60-year-old subjects. Journal of Oral Rehabilitation, 33(7): 473-81.

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.

Long, J. H. Jr.  (1998). A device to prevent jaw clenching. Journal of Prosthetic Dentistry, 79(3): 353-4.

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.

Nissani, M. (2000).   Can Taste Aversion Prevent Bruxism? Applied Psychophysiology and Biofeedback, 25 (#1): 43-54. 

Nissani, M.  (2001). A bibliographical survey of bruxism with special emphasis on non-traditional treatment modalities.  Journal of Oral Science, 43 (2): 73-83  (2001).

Onodera, K, Kawagoe, T., Sasaguri, K., Protacio-Quismundo, C. Sato, S. (2006). The use of a bruxChecker in the evaluation of different grinding patterns during sleep bruxism. CRANIO: The Journal of Craniomandibular Practice, 24: 292-9.

Piccione, A., Coates, T. J., George, J. M., Rosenthal, D. & Karzmark, P. (1982). Nocturnal biofeedback for nocturnal bruxism. Biofeedback and Self-Regulation, 7, 405-19.

Pierce, C. J. & Gale, E. N. (1988). A comparison of different treatments for nocturnal bruxism. Journal of Dental Research, 67, 597-601.

Ploceniak, C. (1990).  Bruxism and magnesium, my clinical experiences since 1980. Revue de Stomatologie et de Chirurgie Maxillo-Faciale, (French; English abstract in Medline€”a full translation of the article is given in the accompanying link), 91 Suppl. 1:127.

Reynolds, Burt.  (1994).  My Life (Chapters 49, 50).  

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.

Watson, T. S. (1993).  Effectiveness of arousal and arousal plus overcorrection to reduce nocturnal bruxism. Journal of Behavior Therapy and Experimental Psychiatry 24: 181-185.

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

Clickable Table of Contents:  1. Educate yourself  2. Diagnosis of bruxism  3. Consult a specialist  4. Uncertainty about bruxism  5. Bruxism and TMJ (TMDs)  6. Treatment Options to Avoid  7. Wait & see?  8. Stress?  9. Trauma  10. Drugs  11. Human alarms   12. Mechanical Biofeedback Approaches (e.g., sound alarms, vibrations)   13. Taste biofeedback  14.  Nutritional supplements  15. Vacuum prevention  16. NTI-tss  17. Works cited

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