Nocturnal teeth-grinding—or bruxism—is a back and forth, side-to-side motion that consists of the lower teeth rubbing against the upper teeth, creating a characteristic grinding sound. Daytime grinding (clenching) is a rocking motion of the lower teeth against the upper teeth without the teeth making the side-to-side motion. While bruxing only happens during sleep, clenching can occur both during the day and at night. These are “parafunctional activities,” as they are not part of normal chewing and swallowing.
Dentists are recording increasing cases of involuntary bruxism. The problem is thought to affect one in 10 of us.
Dental surgeon Dr. Nigel Carter, head of the British Dental Health Foundation, explains: “There’s no doubt that teeth-grinding is an increasing problem – and a feature of the stress brought on by modern lifestyles.”
Why is bruxism dangerous? Normal chewing has been shown to apply forces of around 25lbs to 50lbs (roughly 11-22 Kgs) on the back molar teeth. Parafunctional clenching or grinding, on the other hand, has been shown to create forces as high as 250 lbs. (113.6 Kg) during sleep. During normal chewing, the upper and lower teeth come into contact only for about 25-30 minutes in a 12-hour day. During nocturnal bruxism, however, teeth may be in contact as much as 40 minutes per hour of sleep. The increase in both force and contact between teeth is impressive and can lead to a variety of dental conditions.
This is how bruxism sounds:
Our teeth are built up of layers: on the inside is pulp – soft tissue that houses nerves and blood vessels. This is the part that hurts when teeth become decayed. Protecting the pulp is dentine, calcified tissue that supports the outer layer of enamel.
When dentine becomes damaged, it can lead to faster tooth decay and even destroy the shape of the mouth. Faces can become visibly shorter, by which time there is little that can be done to reverse the process.
Dr. Shivani Patel, a specialist at Elleven Orthodontics in London, says: “[…] Once you grind down to the dentine level, the damage is irreparable, and you become very sensitive to heat and cold, too.”
During the day, the individual can control the parafunctional activities. Once the individual falls asleep, however, this ability is lost. As such, the majority of diagnoses and treatments are aimed at reducing nocturnal bruxism or nighttime tooth grinding. Because most adults will grind in their sleep at some time in their life, sleep bruxism has been considered by some to be a physiological release mechanism for stress. This leads them to view it as a positive symptom and to discourage treatment. While this may be true of bruxism in the milder form, as the duration and severity of grinding increases there is more concern about such forces causing damage to the masticatory system of teeth, bones, muscles, and nerves.
Signs and Symptoms of Bruxism
• Rhythmic crunching or grating noises resembling chewing on crackers or on ice
• Headaches and stiffness of the neck upon awakening in the morning
• Muscle pain in the jaw muscles or a feeling of tightness in the jaws
• Awakening with the teeth clenched together
• Temporomandibular joint pain and clicking sounds
• Chronic facial pain
• Ear pain, stuffiness, or even ringing in the ears
• Increased tooth sensitivity, especially in the morning, which slowly gets better as the day progresses
• Wearing the teeth, chipping or fractures to the teeth in the absence of trauma
• Chewing the inner aspects of the cheeks or biting the tongue
• Teeth that are loose or moving
• Inability to chew without jaw muscles tightening and feeling tired
• Tiredness and sleepiness in the daytime
• Damage from Nighttime Bruxism
The damage from daytime clenching and nighttime bruxism primarily affect the dental structures. Here a concept of the “Weak Link theory” comes into effect. The Weak Link Theory relies on the principle that bruxism causes damage to the teeth, the gums, and their supporting bones -the jaw joints (TMJ) and supporting muscles- but very rarely all three. Whichever area is the weakest will be the first to be affected by bruxism, and what is affected can vary from patient to patient. This often leads to misdiagnoses, as some dentists have been trained to look for only one symptom of bruxism.
Dental damage is usually noticed by the dentist as wear of the tooth structures (enamel and dentin) occurring between your regularly scheduled dental visits. You may also notice the wear on the lower front teeth yourself when you look in the mirror to brush or floss your teeth. To check if this wear is from bruxism, try to match the edges of the upper teeth to the worn shapes of the lowers by moving your jaw around. If there are matching worn surfaces, this suggests the position of your grinding pattern at night.
Dentists look at worn or flattened teeth as a sign of active bruxism (see image above for an example of worn teeth). However, the wear could have been created at an early age and then, like the Grand Canyon formed by the effect of water over time, the patterns remain. Teeth once worn will always show the wear unless new fillings or crowns are created to cover the worn surfaces. The only sure ways to tell if active grinding is still going on is if you wake yourself up by grinding or if a family member hears the sounds while you sleep. There are some dental guards, such as a Bruxcore diagnostic guard or some surface Electromyography (EMG) techniques, that indicate bruxism. By and large, however, it is the self-report that is the best evidence of bruxism.Depending on the severity of the bruxing, you may also have fracture lines or tiny chips breaking from the grinding surfaces of the teeth. Excessive force can sometimes lead to the need for a root canal if the wear reaches the inner surfaces of the teeth, causing an inflammation of the nerve (pulp) of the tooth. Forces on the teeth can sometimes cause a bending of the tooth at the gum margin. If the bending is to the outer gum side, there is a shearing of the outer layer of tooth structure called an abfraction. An abfraction is a shiny, smooth, scooped out gouge on the outer surface of a tooth, usually in the back teeth, caused by rocking forces on the tooth.
Periodontal and Bone damage
In the presence of existing gum inflammation (gingivitis) or infection (periodontal disease), bony changes can occur from excessive force on teeth over an extended period. This has been termed “trauma from occlusion,” and is a potential consequence of bruxism. This can lead further to bone loss, loosening of the teeth, the mobility of the teeth, or even tooth movement related to the reduction of the bone support for the tooth.
Temporomandibular (TMJD) and muscle damage
If the teeth do not wear and the surrounding bone is strong, the forces of bruxism can cause damage to the muscles and the joints of the jaw.
Clicking, popping, and grating sounds are indicators of internal damage to the TM Joints and can possibly lead to dental instability and difficulty chewing. Pain in the muscles of jaw and tension of the neck muscles leading to headaches and neck pain are also common consequences of nighttime bruxism. Chronic clenching and grinding have also been known to trigger nerve-related pain and sometimes appear as sharp shooting pains mimicking Trigeminal Neuralgia, or tooth pain such as Atypical Odontalgia.
Conditions related to Bruxism
Bruxism is also considered to be a sleep-related disorder in the same family as sleepwalking and restless body movements. It occurs during stage 2 sleep, the Rapid Eye Movement (REM) stage of sleep, and during the change from deeper to shallower levels of sleep. Bruxism, therefore, can also affect the nature of sleep while being affected by it. Bruxism also has an impact on mood and brain wave activity and can raise anxiety and pulse rate.
Common causes of Bruxism
There is no clear consensus on what causes people to clench or grind their teeth at night. However, the following causes are generally agreed upon:
In children, bruxism is most common around 5 to 7 years of age, during the time of growth and development of the jaws. This is also considered to be the start of the mixed dentition period- when children begin to develop their new teeth. The working theory is that discomfort from irritation to the gums caused by new teeth coming into the mouth, along with an unstable bite, triggers the need for clenching and tooth grinding in children.
Pain from other issues, such as earaches, tonsils, and adenoids, may also cause grinding in children. Sometimes food allergies, such as to milk or dairy products, can lead to grinding. As with adults, anger, frustration, and tension, as well as certain medications for childhood behavior such as ADHD, can also increase grinding.
In most children, bite appliance therapy is quite effective. The good news is that bruxism in children almost always goes away as the child grows older and no ongoing treatment is necessary.
In adults, there are four main causes of bruxism– dental, psychological, neurological, and sleep related.
How can I find out if I have Bruxism?
The dentist will first ask for a full history of your problem. It is best to take some time before your visit to make a list of your symptoms. You will need to list all the medications you are taking and have taken in the last few years, including any herbal remedies or vitamin and mineral combinations you are taking. These are important as the dentist or physician will need to know about potential interactions that could be causing nervousness and hyperactivity.
The dentist will conduct an intra-oral dental examination of the teeth for cavities, wear of the teeth, missing teeth, and signs of injury to the gum tissues.
An intra-oral examination of the tissues of the cheek, tongue and the roof of the mouth will be done as part of a cancer check.
An examination of the head and neck muscles and the temporomandibular joints will be done to evaluate the effects of bruxism. The dentist may ask to check your range of motion of the head and neck as well as the jaw to assess the tension level in the muscles.
If you snore or wake yourself up gasping for breath, you may need to speak to your physician or a dentist who is familiar with sleep apnea. This is important if you also have signs of daytime sleepiness and fatigue since these can have serious consequences if you drive or handle machinery.
If you are diagnosed with bruxism you should also check with your physician to see if your condition can affect your general health.
If you have ear symptoms of pain, ringing, dizziness, or stuffiness of the ears your physician may want you to see an ENT (ear nose and throat) doctor.
If you are experiencing heightened stress, anxiety, or are feeling blue you should talk to your dentist or physician to see if a referral to a psychologist or psychiatrist would be appropriate.
If you are having headaches, you should see your physician, who in turn might refer you to a headache specialist or a pain center.
What can I do for my Bruxism?
• Do not eat or drink for at least one hour before bedtime.
• Do not drink alcohol at night. A glass of wine may calm you but alcohol in any quantity has been found to aggravate bruxism.
• Do not take vitamins, minerals, or any herbal medicine that might excite you at night before bed.
• Do not work up to the time you plan to go to sleep. Let yourself relax and settle down before you plan on going to bed.
• Use techniques of deep breathing and progressive relaxation before bedtime.
• If you have pain in the face or jaw, use ice on your jaw joints or a wet hot towel on the face to help relax the muscles until you can get to the dentist.
• Analgesics like Tylenol, Aspirin, Advil, or Aleve can help reduce minor pains. If the pain continues for more than three days, you should see your physician or your dentist.
• Stretching the jaw muscles can help relax them. Take the knuckles of your hands, place them under your cheekbones and slowly drag them down towards the angles of your jaws on both sides while keeping your teeth apart and repeat the stretch five times. You can repeat this process five to six times a day if needed.
• Another stretch you can try involves your tongue. Placing your tongue tip behind the upper front teeth, slowly open your mouth to a slow long stretch. Only open until you feel a stretch and not if you have pain when you do so.
• There are over-the-counter mouth guards that have been now approved by the U.S. Food and Drug Administration for bruxism or tooth grinding. These are usually “boil and bite guards” that can be used on a temporary basis till you see your dentist. They are usually found at your local pharmacy or larger stores that carry healthcare products.
Mild bruxism does not generally need treatment unless your dentist sees the beginnings of wear on your teeth. Moderate or severe bruxism requires treatment.
The primary treatment by a dentist is a night guard. The dentist will take impressions of your teeth and then make a formed, hard upper night guard that covers your teeth and prevents the upper teeth from coming together with the lower teeth. Some dentists will make a lower guard, depending on your bite and the structure of the teeth. If there is a misalignment of the teeth that the dentist thinks is triggering your grinding, he or she may plan dental treatment such as caps or crowns or orthodontics to help the bite fit better.
Your doctor might also suggest stress management treatments and sleep treatments as necessary.
An uncommon treatment is a hypnotherapy, as recommended by the Bruxism Association based on some studies that support its use. In 1991, a report in the American Journal of Clinical Hypnotherapy found it could reduce grinding noticeably, with results lasting for up to 36 months.
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