When is Bruxism Bad?

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Patient Presentation
An 11-year-old female came to clinic for her junior high health examination. She was well and had no concerns. She noted that she was going to get braces soon. Her mother said, “Yeah the dentist also started her wearing a mouth guard at night because she was grinding her teeth and was wearing away her teeth. The orthodontist thinks that some of it will be better with aligning her teeth better.” She denied any problems otherwise with sleeping including no snoring, and no headache, mouth or neck pain. She and others did not notice the bruxism during the day. The past medical history revealed a broken arm from a playground fall.

The pertinent physical exam revealed a healthy female with normal growth parameters, who did have noticeable wearing on her molars and many malpositioned teeth. The diagnosis of a healthy female with bruxism was made. “I don’t have anything else to offer you. It looks like you are otherwise healthy so keep wearing the mouthguard and do what your dentist and orthodontist say to do,” the pediatrician recommended.

Discussion
Bruxism “is a masticatory muscle activity that may occur during sleep ([sleep bruxism, SB] characterized as rhythmic or non-rhythmic) and/or wakefulness ([awake bruxism, AB] characterized as repetitive or sustained tooth contact and/or by bracing or thrusting the mandible.)” Bruxism was first described in 1907. Bruxism studies are quite variable in their results given the lack of standardized diagnostic methods.

Patients or family members will often report tooth grinding noises, and on physical examination there will be abnormal tooth wear, tooth mobility, hypertrophy of the masseter muscles and other problems such as fatigue, pain or discomfort in the mouth/jaw and/or headache. Tooth grinding noises by themselves is not necessarily a problem. Usually minimal criteria for SB include “…tooth grinding or clenching while asleep and one or more of the following: abnormally worn teeth, bruxism-related sounds, and mandible muscle discomfort.” Prevalence in adults for AB = 22-30%, SB = 1-15%, and in the pediatric population is 3-49%. Peak age is 10-14 years.

Factors that seem to be associated with SB include second-hand smoke, caffeine, tobacco and alcohol use, gastroesophageal acidification and some psychotropic medications (including serotonin reupdate inhibitors, antipsychotics, norepinephrine reuptake inhibitors, amphetamines, and Ecstasy).

Bruxism can also be considered a sleep-related movement disorder and can be associated with sleep disturbances such as obstructive sleep apnea, restless leg syndrome, rapid-eye movement disorders and mandibular myoclonus. Bruxism can have direct problems such as pathological tooth destruction, dental procedure failure, temporomandibular joint dysfunction [commonly in teens], mandibular joint movement problems and headaches.

Etiology is probably multifactorial but some data suggest potential risk factors including anxiety and stress, personality traits, genetic predisposition, socioeconomic and sleep problems. SB may offer some benefit by protecting the airway or stimulating saliva production. Gastroesophageal reflux may also stimulate saliva production and therefore SB may be partially protective as well.

Learning Point
Bruxism is probably a continuation from no bruxism to some that is not clinically significant and thus not needing treatment to some that is clinically significant and/or severe and needs treatment. Treatment also has a range of options, from patient and family education to occlusal appliances to more substantive treatments. Those can include physiotherapy, psychotherapy including biofeedback, medications such as benzodiazepines, and surgical treatment. Good sleep hygiene is good for any patient. In addition to dentistry, other consultants may be necessary such as sleep medicine, psychology and otorhinolaryngology. Per one study their decision making included the following questions:

  • Is the bruxism frequent and is the tooth wear severe? Needs dental evaluation
  • Is the patient anxious? Needs psychology and psychiatry expertise
  • Does the patient show signs of ventilatory disorders (snoring, oral ventilation, dark circles, daytime sleepiness, etc.)? Needs otolaryngology and pulmonary expertise. Sleep medicine is also a consideration.
  • Does the patient present with associated sleep disorders such as night terrors or agitation? Needs primary care and developmental expertise

Questions for Further Discussion
1. What are common parasomnias? A review can be found here
2. What causes temporomandidibular pain? A review can be found here
3. What causes jaw pain? A review can be found here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Tooth Disorders and Sleep Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Melo G, Duarte J, Pauletto P, et al. Bruxism: An umbrella review of systematic reviews. J Oral Rehabil. 2019;46(7):666-690. doi:10.1111/joor.12801

Bulanda S, Ilczuk-Ryputa D, Nitecka-Buchta A, Nowak Z, Baron S, Postek-Stefanska L. Sleep Bruxism in Children: Etiology, Diagnosis, and Treatment – A Literature Review. Int J Environ Res Public Health. 2021;18(18):9544. doi:10.3390/ijerph18189544

Casazza E, Giraudeau A, Payet A, Orthlieb JD, Camoin A. Management of idiopathic sleep bruxism in children and adolescents: A systematic review of the literature. Arch Pediatr. 2022;29(1):12-20. doi:10.1016/j.arcped.2021.11.014

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Published