Background

Sleep-related bruxism, also known as tooth grinding, is a sleep disorder characterized by the involuntary clenching, grinding, or gnashing of teeth during sleep. It is a relatively common condition that can affect both adults and children.  

The potential contributing factors to bruxism include: 

• Psychological Factors: Bruxism has been associated with stress, anxiety, and tension. Individuals who experience high-stress levels or have certain personality traits such as aggression or competitiveness may be more prone to bruxism. 
• Dental Factors: Malocclusion (improper alignment of the teeth), missing teeth, or other dental conditions may contribute to bruxism. The misalignment of teeth can cause an abnormal bite, leading to grinding or clenching during sleep. 
• Sleep Factors: Sleep-related bruxism is more common during certain sleep stages, particularly during deep sleep or rapid eye movement (REM) sleep. It may be associated with disruptions in sleep patterns or other sleep disorders such as sleep apnea. 

Epidemiology

The prevalence of sleep-related bruxism can vary depending on the population studied. The overview of the epidemiology of sleep-related bruxism includes: 

Adults: 

• The prevalence of sleep-related bruxism in the adult population ranges widely from 8% to 31%. 
• A systematic review and meta-analysis estimated the overall prevalence of sleep-related bruxism in adults at around 13%. 
• Sleep-related bruxism is more prevalent in women than in men.  
• It is more commonly observed in younger adults and tends to decrease with age. 

Children: 

• Sleep-related bruxism is relatively common in children, with reported prevalence rates ranging from 14% to 35%.  
• The prevalence tends to peak around the age of 6 years and gradually decreases with increasing age. 
• Children with certain medical conditions or neurodevelopmental disorders, such as ADHD-attention deficit hyperactivity disorder or intellectual disabilities, may have a higher prevalence of bruxism. 

Anatomy

Pathophysiology

The pathophysiology of sleep-related bruxism includes: 

Central Nervous System (CNS) Mechanisms: 

• Dysregulation of neurotransmitters: Alterations in the central dopaminergic, serotonergic, and GABAergic systems have been suggested to play a role in the pathophysiology of sleep-related bruxism. Imbalances in these neurotransmitter systems may lead to hyperactivity or disinhibition of the motor neurons involved in jaw movement. 
• Abnormalities in the basal ganglia and limbic system: Dysfunction in the basal ganglia and limbic system, which are involved in motor control and emotional regulation, respectively, may contribute to the development of bruxism. 

Peripheral Mechanisms: 

• Dental and occlusal factors: Dental malocclusion, improper tooth alignment, and abnormalities in the temporomandibular joint (TMJ) may contribute to bruxism. 
• Peripheral sensory feedback: Abnormal sensory feedback from the teeth and oral structures may trigger or perpetuate bruxism. The sensory input from the periodontal ligament and other oral tissues can influence the jaw muscles’ activity during sleep. 

Sleep Disorders and Arousal: 

• Sleep arousal response: Bruxism episodes often occur during arousals from sleep, suggesting a relationship between bruxism and sleep disturbances. Increased sympathetic activity during arousals may contribute to initiating or exacerbating bruxism episodes. 
• Sleep architecture and stages: Bruxism is more commonly observed during certain sleep stages, such as REM-rapid eye movement and NREM-non-rapid eye movement stage 2 sleep. 

Etiology

The pathophysiology of sleep-related bruxism includes: 

Central Nervous System (CNS) Mechanisms: 

• Dysregulation of neurotransmitters: Alterations in the central dopaminergic, serotonergic, and GABAergic systems have been suggested to play a role in the pathophysiology of sleep-related bruxism. Imbalances in these neurotransmitter systems may lead to hyperactivity or disinhibition of the motor neurons involved in jaw movement. 
• Abnormalities in the basal ganglia and limbic system: Dysfunction in the basal ganglia and limbic system, which are involved in motor control and emotional regulation, respectively, may contribute to the development of bruxism. 

Peripheral Mechanisms: 

• Dental and occlusal factors: Dental malocclusion, improper tooth alignment, and abnormalities in the temporomandibular joint (TMJ) may contribute to bruxism. 
• Peripheral sensory feedback: Abnormal sensory feedback from the teeth and oral structures may trigger or perpetuate bruxism. The sensory input from the periodontal ligament and other oral tissues can influence the jaw muscles’ activity during sleep. 

Sleep Disorders and Arousal: 

• Sleep arousal response: Bruxism episodes often occur during arousals from sleep, suggesting a relationship between bruxism and sleep disturbances. Increased sympathetic activity during arousals may contribute to initiating or exacerbating bruxism episodes. 
• Sleep architecture and stages: Bruxism is more commonly observed during certain sleep stages, such as REM-rapid eye movement and NREM-non-rapid eye movement stage 2 sleep. 

Genetics

Prognostic Factors

• Severity of Bruxism: The severity of bruxism episodes, including the frequency and intensity of tooth grinding, can influence the prognosis.  
• Presence of Dental Factors: Dental factors such as dental malocclusion, tooth misalignment, and abnormal occlusion may affect the prognosis of sleep-related bruxism.  
• Treatment Response: The response to treatment interventions can be a prognostic factor. Some individuals may respond well to treatment modalities, such as oral appliances or behavioral interventions, while others may respond less favorably. 
• Co-existing Conditions: Coexisting conditions, such as temporomandibular disorders (TMD), sleep disorders, or psychological factors like stress or anxiety, can influence the prognosis of sleep-related bruxism.

Clinical History

The clinical presentation of sleep-related bruxism can vary depending on the age group, associated comorbidities, and the acuity of the presentation. Here are some general observations: 

Age Group: 

• Children: Sleep-related bruxism is relatively common in children, with a prevalence which is ranging from 14% to 20%. Children may present with complaints of jaw pain, headaches, tooth sensitivity, or disrupted sleep. 
• Adults: Bruxism can persist into adulthood, affecting approximately 8-10% of adults. Symptoms may include jaw pain, facial muscle fatigue, headaches, tooth sensitivity, and excessive tooth wear. 

Physical Examination

Oral Examination: 

• Dental Evaluation: The dentist will examine the teeth for wear, chipping, fractures, or other abnormalities that may indicate bruxism. They may also look for signs of enamel erosion or exposed dentin. 
• Bite Assessment: The dentist will evaluate the patient’s bite, looking for any misalignment or irregularities that could contribute to bruxism. 
• Oral Tissue Examination: The soft tissues inside the mouth, such as the cheeks, tongue, and palate, may be examined for any signs of trauma or irritation caused by bruxism. 

Temporomandibular Joint (TMJ) Evaluation: 

• Palpation: The dentist may palpate the jaw and temporomandibular joint muscles to check for tenderness, muscle hypertrophy, or joint abnormalities. 
• Range of Motion: They may assess the patient’s ability to open and close their mouth fully and smoothly, as well as their lateral and protrusive jaw movements. 
• TMJ Sounds: The dentist may listen for any clicking, popping, or grinding sounds when the patient moves their jaw. 

Additional Assessments: 

• Neurological Examination: In some cases, a neurological examination may be performed to rule out any underlying neurological conditions that could contribute to bruxism. 
• Sleep Study: Polysomnography, a sleep study, may be conducted in some instances to evaluate the presence and severity of bruxism episodes during sleep. This involves monitoring brain waves, muscle activity, and other physiological parameters. 

Age group

Associated comorbidity

• Stress and Anxiety: Bruxism is often associated with increased stress and anxiety levels. Individuals experiencing high stress or anxiety levels may exhibit more severe bruxism symptoms. 
• Temporomandibular Joint (TMJ) Disorders: Bruxism can exacerbate symptoms of TMJ disorders, leading to jaw pain, clicking, or popping of the jaw, limited jaw movement, and discomfort while eating. 
• Medications or Substances: Certain medications (e.g., selective serotonin reuptake inhibitors) or substances (e.g., caffeine, alcohol) can contribute to bruxism or exacerbate its symptoms. 

Associated activity

Acuity of presentation

• Mild: Some individuals may have mild bruxism symptoms that are not overly bothersome or do not cause significant damage to the jaw or teeth. These individuals may be unaware of their bruxism until it is brought to their attention by a sleep partner or dentist. 
• Moderate: Moderate bruxism may involve more noticeable symptoms such as jaw pain, headaches, tooth sensitivity, and tooth wear. Regular dental check-ups may reveal signs of enamel erosion or tooth fractures. 
• Severe: In severe cases, bruxism can lead to chronic jaw pain, temporomandibular joint disorders, severe tooth wear, and damage to dental restorations. Severe bruxism can significantly impact an individual’s quality of life. 

Differential Diagnoses

• Temporomandibular Disorders (TMD): TMD encompasses a range of conditions affecting the temporomandibular joint and associated muscles. Symptoms like pain, limited jaw movement, clicking or popping sounds, and muscle tenderness can overlap with sleep-related bruxism. 
• Sleep Disorders: Sleep Apnea is characterized by breathing pauses during sleep. Some individuals with sleep apnea may exhibit bruxism as a compensatory mechanism to maintain airway patency. REM Sleep Behavior Disorder (RBD): RBD involves abnormal behavior during REM sleep, including dream-enacting movements. In some cases, bruxism can occur concurrently with RBD. 
• Medication-Induced or Substance-Related Bruxism: Certain medications (e.g., antipsychotics, selective serotonin reuptake inhibitors) or substances (e.g., amphetamines, stimulants) can cause or exacerbate bruxism symptoms. 
• Dental Malocclusion: Misalignment or malocclusion of the teeth can lead to increased stress on the temporomandibular joint and muscles, potentially resulting in bruxism-like symptoms. 
• Primary Headaches: Conditions like tension-type headaches and migraines can cause facial or jaw pain, which may be mistakenly attributed to bruxism. 
• Psychiatric Disorders: Some psychiatric conditions, such as anxiety disorders, can manifest with bruxism-like symptoms. Stress and anxiety can contribute to both bruxism and other psychiatric disorders. 
• Primary Sleep Disorders: Other primary sleep disorders, such as periodic limb movement disorder, may present with rhythmic movements during sleep that resembles bruxism. 
• Parafunctional Habits: Other parafunctional habits, such as nail-biting or lip-chewing, can cause oral and facial symptoms like bruxism. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

The treatment paradigm for sleep-related bruxism (tooth grinding) typically involves a combination of behavioral interventions, dental approaches, and, in some cases, pharmacological management. Here’s an overview of the treatment options: 

Behavioral Interventions: 

• Awareness and Education: Patients are educated about sleep-related bruxism, its potential causes, and the importance of addressing the condition. 
• Behavioral Modification Techniques: Patients may be advised to practice stress reduction techniques, such as relaxation exercises or meditation, to minimize stress-related bruxism. 
• Sleep Hygiene: Maintaining a regular sleep schedule, avoiding stimulating substances (e.g., caffeine, alcohol) before bed, and creating a comfortable sleep environment which improves the sleep quality and reduce bruxism episodes. 
• Oral Habits Awareness: Patients are encouraged to develop an awareness of their oral habits during the day and try to eliminate or control habits that may contribute to bruxism, such as clenching or biting non-food objects. 

Dental Approaches: 

• Dental Splints or Mouthguards: Dentists may fabricate custom-fitted dental splints or mouthguards to be worn during sleep. These devices provide a physical barrier between the upper and lower teeth, preventing damage caused by grinding and clenching. 
• Occlusal Adjustments: Dentists may perform selective grinding or reshaping of the teeth to create a more harmonious bite, reducing the impact of bruxism. 
• Restorative Dentistry: In cases where bruxism has caused significant tooth damage, restorative procedures such as dental crowns or veneers may be necessary to repair and protect the affected teeth. 

Pharmacological Management: 

• Medications: In some cases, medicines may be prescribed to manage sleep-related bruxism. These may include muscle relaxants, such as benzodiazepines, or medications that modulate neurotransmitters, such as dopamine agonists. However, the evidence for pharmacological interventions is limited, and medication use should be carefully considered based on the individual’s specific circumstances. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

use-of-a-non-pharmacological-approach-for-treating

Non-pharmacological approaches can be effective in managing sleep-related bruxism (tooth grinding). Here are some non-pharmacological interventions commonly used for treatment: 

Behavioral Modification Techniques: 

• Awareness and Education: Patients are educated about the nature of bruxism, its potential causes, and its impact on oral health. 
• Stress Reduction Techniques: Stress and anxiety can contribute to bruxism. Patients may be advised to practice stress reduction techniques such as relaxation exercises, meditation, or calming activities before bedtime. 
• Sleep Hygiene: Maintaining a regular sleep schedule, avoiding stimulating substances (e.g., caffeine, alcohol) before bed, and creating a comfortable sleep environment which helps to improve the sleep quality and reduce bruxism episodes. 
• Oral Habits Awareness: Patients are encouraged to develop an awareness of their oral habits during the day and try to eliminate or control habits that may contribute to bruxism, such as clenching or biting non-food objects. 

Dental Approaches: 

• Dental Splints or Mouthguards: Custom-fitted dental splints or mouthguards can be worn during sleep to provide a physical barrier between the lower and upper teeth, preventing damage caused by grinding and clenching. 

Relaxation Techniques: 

• Biofeedback: Biofeedback techniques can help patients become more aware of their muscle tension and provide real-time feedback, allowing them to learn to relax their jaw muscles consciously. 
• Physical Therapy: Some patients may benefit from physical therapy techniques, such as jaw exercises and massage, to relieve muscle tension and improve jaw alignment. 

Stress Management: 

• Cognitive Behavioral Therapy (CBT): CBT can help individuals identify and modify the negative thought patterns and behaviors associated with stress and bruxism. 
• Counseling: Counseling or therapy sessions may be beneficial in managing stress, anxiety, or any underlying psychological factors contributing to bruxism. 

Role of Muscle relaxants as an adjunctive treatment

Muscle relaxants may be prescribed as an adjunctive treatment for sleep-related bruxism (tooth grinding) when other interventions have been ineffective.  

benzodiazepines: benzodiazepines, such as clonazepam and diazepam, are commonly prescribed muscle relaxants for bruxism. benzodiazepines have muscle relaxant and soothing properties, which can help reduce the intensity of tooth-grinding episodes during sleep. 

• clonazepam: clonazepam is a long-acting benzodiazepine that affects the central nervous system by enhancing the effects of GABA, a neurotransmitter that inhibits nerve activity in the brain. It has muscle relaxant, anxiolytic (anti-anxiety), and soothing properties. clonazepam is sometimes prescribed off-label for bruxism to help reduce muscle activity during sleep and alleviate symptoms associated with tooth grinding. It is typically taken orally in tablet form. 
• diazepam: diazepam is another benzodiazepine that acts on GABA receptors in the brain. It has muscle relaxant, sedative, anxiolytic, and anticonvulsant properties. diazepam is occasionally used off-label to manage bruxism to help reduce muscle activity and tension during sleep. It is available in various forms, including tablets, oral solutions, and injectable formulations. 

baclofen: baclofen is a muscle relaxant that acts as a gamma-aminobutyric acid (GABA) agonist. It primarily treats muscle spasticity in conditions such as multiple sclerosis or spinal cord injuries.

baclofen may be considered for bruxism in specific cases where other treatments have been unsuccessful. However, the evidence for its effectiveness in bruxism is limited. 

dopamine modulators for the maintenance of Bruxism

dopamine is a neurotransmitter regulating movement, reward, and pleasure in the brain. It has been suggested that dopamine dysregulation may contribute to developing or maintaining bruxism. 

One dopamine modulator studied for its potential use in treating bruxism is pramipexole. pramipexole is a dopamine agonist commonly used to treat Parkinson’s disease and restless legs syndrome. Stimulating dopamine receptors modulate dopamine activity in the brain and potentially reduce bruxism symptoms. 

Several studies have investigated the use of pramipexole for sleep-related bruxism, and some have reported positive outcomes in reducing bruxism episodes and associated symptoms. However, the evidence is still limited, and more research is needed to establish the effectiveness and safety of dopamine modulators in sleep-related bruxism. 

Use of Botulinum toxin type A injections as a potential treatment

Botulinum toxin types A injections, such as Botox®, have been explored as a potential treatment option for bruxism, including sleep-related bruxism (tooth grinding).

Botulinum toxin is a neurotoxin that blocks the release of acetylcholine, a neurotransmitter involved in muscle contraction. Botulinum toxin injections aim to reduce the intensity and frequency of teeth grinding and clenching by temporarily weakening or paralyzing the muscles involved in bruxism. 

Several studies have investigated botulinum toxin type A injections for bruxism, and the results have been mixed. Some studies have reported positive outcomes, reducing bruxism symptoms and associated pain. However, other studies have shown limited effectiveness or reported only short-term benefits. 

Use of Antidepressant as Off label medication

Using antidepressants to treat sleep-related bruxism (tooth grinding) is not a standard or recommended approach. Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs), are primarily indicated for treating depression, anxiety disorders, and other psychiatric conditions. 

While bruxism can sometimes be associated with underlying psychological factors or as a side effect of certain medications, the use of antidepressants for bruxism is considered off-label. 

The use of SSRIs for bruxism is based on the understanding that serotonin dysregulation may play a role in the pathophysiology of bruxism. By increasing the availability of serotonin in the brain, SSRIs help regulate the neurotransmitter’s activity and potentially reduce bruxism symptoms. 

use-of-intervention-with-a-procedure-in-treating-sleep-related-bruxism-tooth-grinding

When it comes to the treatment of sleep-related bruxism (tooth grinding), interventions with procedures are not typically the first-line approach.

However, certain procedures may be considered in severe cases where other treatments have been ineffective or if specific dental or structural issues contribute to the bruxism. Here are a few examples: 

• Dental Splints or Mouthguards: One of the most common procedures to manage bruxism is fabricating and using dental splints or mouthguards. These devices are custom-made to fit over the teeth and provide a protective barrier between the upper and lower jaws. They can help reduce the damage caused by grinding and clenching and alleviate symptoms associated with bruxism. 
• Dental Restorations: In some cases, dental restorations, such as dental crowns or bridges, may be used to correct misalignment or damaged teeth caused by bruxism. These restorations can help improve the alignment of the teeth, reduce grinding forces, and prevent further damage. 
• Orthodontic Treatment: Orthodontic treatment may be recommended if malocclusion (misalignment of the teeth) contributes to bruxism. This can involve using braces, aligners, or other orthodontic appliances to correct the positioning of the teeth and improve the bite, reducing grinding and clenching. 
• Temporomandibular Joint (TMJ) Treatments: Bruxism can sometimes be associated with temporomandibular joint disorders (TMJ). In such cases, treatments targeted at managing TMJ dysfunction may be considered. These may include physical therapy, jaw exercises, oral splints, or surgical interventions in rare cases. 

use-of-phases-in-managing-sleep-related-bruxism-tooth-grinding

The management of sleep-related bruxism (tooth grinding) typically involves different phases aimed at assessing and addressing the underlying causes and symptoms of the condition.  

Evaluation and Diagnosis: 

• Assessment: The healthcare provider will conduct a comprehensive evaluation that includes taking a detailed medical and dental history, performing a physical examination, and assessing the signs and symptoms of bruxism. 
• Sleep Study: In some cases, polysomnography or other sleep study may be recommended to monitor and evaluate the individual’s sleep patterns, including episodes of tooth grinding. 
• Diagnosis: Sleep-related bruxism is diagnosed based on the evaluation findings and diagnostic criteria. 

Non-pharmacological Interventions: 

• Behavioral Modification: The healthcare provider may recommend various behavioral strategies to manage bruxism, such as stress reduction techniques, relaxation exercises, and avoiding stimulating substances like caffeine or alcohol before bedtime. 
• Sleep Hygiene: Improving sleep habits and creating a conducive sleep environment can help reduce the likelihood of bruxism episodes during sleep. This may involve establishing a regular sleep schedule, maintaining a comfortable sleep environment, and practicing good sleep hygiene. 
• Oral Appliances: Custom-fitted oral appliances, such as occlusal splints or night guards, may be prescribed by a dentist to protect the teeth from grinding and alleviate the symptoms of bruxism. 

Pharmacological Interventions: 

• Medications: In some cases, medications may be prescribed to manage underlying factors associated with bruxism, such as stress or anxiety. These may include muscle relaxants, antidepressants, or anti-anxiety medications. The choice of medication and dosage will depend on individual factors and the healthcare provider’s judgment. 
• Medication Monitoring: Regular follow-up visits are essential to assess the effectiveness of the prescribed medications, monitor any side effects, and adjust if necessary. 

Ongoing Management and Monitoring: 

• Long-Term Follow-up: Individuals with sleep-related bruxism may require periodic follow-up visits to monitor their symptoms, evaluate the treatment effectiveness, and make any necessary adjustments to the management plan. 
• Multi-disciplinary Collaboration: Collaboration between dentists, sleep specialists, psychologists, or other healthcare professionals may be beneficial to provide comprehensive care and address any associated conditions or contributing factors. 

Medication

Future Trends

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References

Bruxism Management: ncbi.nlm.nih. 

Clonazepam:ncbi.nlm.nih 

Role of psychosocial factors.ncbi.nlm.nih 

Management of sleep bruxism: ncbi.nlm.nih.gov 

Sleep bruxism:ncbi.nlm.nih 

The prevalence of sleep:ncbi.nlm.nih