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Ronald E. Goldstein, DDS; Wendy Auclair Clark, DDS, MS

Journal of the American Dental Association (2017)
Volume 148(6), Pg – (387-391)
• Introduction
• Risk Factors
• Recognition and Diagnosis
• Correlations and comorbidities
• Treatment modalities
Occlusal appliances and considerations
Psychosocial approaches
Medical treatments
• Conclusion
• References

• Bruxism is the parafunctional grinding of teeth; an oral habit

consisting of involuntary rhythmic or spasmodic nonfunctional
gnashing, grinding, or clenching of teeth, in other than
chewing movements of the mandible, which may lead to
occlusal trauma.(GPT – 9)

• Also called occlusal neurosis, tooth grinding.


Diurnal Nocturnal
Central factors

• It is hypothesized that the direct and indirect pathways of the

basal ganglion, a group of five subcortical nuclei that are
involved in the coordination of movements is disturbed in
bruxism patients.

• An imbalance between both the pathways, results in

movement disorder like Parkinson’s disease and this
imbalance occurs with the disturbances in the dopamine
mediated transmission of action potential. In case of bruxism
there may be an imbalance in both the pathways.

F. Lobbezoo & M. Naeije. Bruxism is mainly regulated centrally, not peripherally. Journal of Oral
Rehabilitation 2001; 28: 1085-1091
Psychosocial factors

• Awake bruxism or diurnal bruxism can be associated with

stress due to familial responsibility or work pressure.

Peripheral factors

• Bruxism is commonly considered to be related to deviations in

dental occlusion and articulation. Giffin et al has mentioned
that for an effective management of bruxism, establishment
of harmony between maximum intercuspation and centric
relation is required.

F. Lobbezoo & M. Naeije. Bruxism is mainly regulated centrally, not peripherally. Journal of Oral
Rehabilitation 2001; 28: 1085-1091

Are you ever

aware or have
you been told of
clenching your

Has anyone Do you feel

heard you QUESTIONS fatigue or
grinding your soreness in your
teeth? jaw?

Do you ever feel

your teeth or
gums being sore?

Presence of tooth
wear seen in
normal and
eccentric jaw

oral activity INDICATORS OF Masticatory
waxing in BRUXISM muscle
wakefulness and ACTIVTY discomfort,fatiq
waning in sleep ue,stiffness

Clicking or locking
of TMJ
• Awake bruxism has been reported to have an estimated
prevalence of 22.1–31% among the adult population.

• In the absence of subjective awareness, past bruxism can be

inferred from presence of clear wear facets that are not interpreted
to be the result of masticatory function. Contemporary bruxism can
be observed through sleep laboratory recordings.(American
Academy of Orofacial Pain 2008).

• It is much more difficult to discriminate awake bruxism with or

without TG from early signs of Parkinson’s disease or other
neurodegenerative diseases .

• Dentists need to be able to recognize the oromandibular

manifestations of the movement disorders so that patients can be
referred to a neurologist for diagnosis and management.

G. J. Lavigne et al. Bruxism physiology and pathology: an overview for clinicians. Journal of Oral
Rehabilitation 2008; 35: 476–494

• Psychological stress/Anxiety
• Selective serotonin reuptake inhibitors(SSRI)
• Drug abuse (Cocaine,Amphetamine,Ecstasy)

Takafumi Kato et al.Current knowledge on Awake and Sleep Bruxism:Overview.Alpha Omegan


• Parafunctions during an awake state can be diagnosed by

means of direct questions and visual observation of patient

• Another critical way for clinicians to identify a patient with a

parafunctional habit is by damage to tooth structure.
The patient had an awake bruxism habit—
grinding his anterior teeth in times of stress.

H/O awake and sleep bruxism.While clenching his

teeth during a strenuous situation, he fractured
his right maxillary canine through the fiber post
and core.
• Other intraoral signs include indentations along the side of
the tongue, as well as bony exostoses or tori.

• Periodontal changes, including widening of the periodontal

ligament, tooth mobility, and recession,also may occur.

• Oromandibular movements can be described as usual,unusual

but acceptable or abnormal.

• It is important for the clinician to discern what that habit

specifically is.
• The dentist can prescribe easy to use electromyographic
devices to use to confirm muscle activity (BiteStrip).

• After initial screening and suspicion of a parafunctional habit,

more in-depth patient questionnaires and at-home journaling
can help further identify what type of parafunctional activities
the patient engages in and how often.
Very low bruxism – Less than 40 events
Mild bruxism - 40-74 events
Moderate bruxism – 75-124 events
Severe bruxism - 125 or more events
E (Error) - Study too short or other

Bite Strip

Bite Strip placed over Masseter

• For a grading of ‘definite’ awake bruxism
Clinical examination
Electromyographic recording
are needed, preferably combined with the so-called ecological
momentary assessment methodology, which enables a true
estimate to be obtained of, amongst others, the frequency of
tooth contacts during wakefullness.
• A strong correlation exists between temporomandibular
disorders (TMDs) and bruxism.

• Studies shows that diurnal bruxism exacerbates TMD

symptoms,including headache, muscle and joint pain, and jaw

• Any patient who self-reports TMD, morning masticatory

muscle pain or stiffness, or joint noises should be considered
a possible bruxer and then identified as a sleeping or awake
• The activity of bruxism results in muscle hyperactivity,
particularly the masseteric sling muscles (masseter and
medial pterygoid) and the lateral pterygoids.

• Therefore, myalgia and muscle spasm can result, as well as

temporal headaches.

• Carlsson and colleagues found that most self identified adult

bruxers were also bruxers as children.

• Specifically, awake bruxers continued to exhibit awake

• Lobbezoo and colleagues conducted a thorough systematic
review of the treatment modalities for both waking and
sleeping bruxism.

• They summarized the best approach as the “triple-P”

approach: plates, pep talk, and pills.

• Specifically, they referred to stabilization splints, counselling,

and short-term pharmacotherapy
• This treatment is noninvasive and is a popular first treatment

• The splints usually are made of hard acrylic because soft

splints are more difficult to adjust and actually may encourage
parafunctional activity.

Example of a waking appliance. The thin material allows for

normal function.
• Treatment modalities include stress reduction,
counseling, lifestyle changes, and hypnotherapy.

• Cue conditioning or cuing is another treatment option,

particularly with children and people who are mentally

• With this treatment, vocal or physical cues are repeated

when a patient bruxes.
• Another alternative treatment option involves biofeedback to
curb the behavior.

• A small electric impulse is emitted during the muscle activity,

ultimately stopping the action of bruxism
• Medications such as muscle relaxants are used.

• Clinicians should prescribe these medications for only short


• Another pharmacologic approach involves the use of

botulinum toxins in the treatment of bruxism.

• The clinician injects botulinum toxins into the masticatory

muscles that are triggered with bruxism, including the
temporalis and masseter.
• Studies indicate that the use of this treatment can cause
some bruxism-related muscle pain to subside and may reduce
bruxism events.

• Clinicians should advocate it only after attempting more

minimally invasive approaches.

Cyclobenzaprine 10 mg tid 60 mg/day

Metaxalone 800 mg 3-4 times/day 2400 mg/day
Methocarbamol 1000 mg qid 8000 mg/day
Carisoprodol 250 mg tid 1400 mg/day
max 2-3 weeks
Chlorzoxazone 250-500 mg tid 1500 mg/day
(750 mg max
single dose)
• Identification and treatment of awake bruxism can present a
challenge for the clinician.

• Because awake bruxism is linked more closely to emotional

stress than is nocturnal bruxism, psychological treatment may
be indicated in conjunction with dental treatment.

• In addition, lifestyle changes are recommended.

• A concrete plan of patient education is a first step to solving

the problem of awake bruxism.

• Once aware of the bruxism events, the patient can begin to

make the necessary change in behavior.
• If behavioral change is not successful, a daytime appliance not
only to prevent damage but also to promote awareness is

• When possible, it is best to prevent the need for extensive

dental treatment.

• Inhibiting bruxism, both awake and sleeping, is in the patient’s

best interest.

• Thus, it is imperative for the dentist, hygienist, and dental

assistant to educate and reeducate the patient during and
after any restorative treatment.
• The glossary of prosthodontic terms. J Prosthet Dent. 2005;94(1):10-92.

• Panek H, Nawrot P, Mazan M, Bielicka B, Sumisławska M,Pomianowski R.

Coincidence and awareness of oral parafunctions in college students.
Community Dent Health. 2012;29(1):74-77.

• Lavigne GL, Khouy S, Abe S, Yamaguchi T, Raphael K. Bruxismphysiology

and pathology: an overview for clinicians. J Oral Rehabil. 2008;35(7):476-

• Kawakami S, Kumazaki Y, Manda Y, Oki K, Minagi S. Specific diurnalEMG

activity pattern observed in occlusal collapse patients: relationship
between diurnal bruxismand tooth loss progression. PLoSOne.
• Gibbs CH, Mahan PE, Mauderli A, Lundeen HC, Walsh EK. Limits of
human bite strength. J Prosthet Dent. 1986;56(2):226-229.

• Rouse JS. The bruxism triad: sleep bruxism, sleep disturbance, and
sleep-related GERD. Inside Dent. 2010:32-44.

• Glaros AG, Williams K. “Tooth contact” versus “clenching”: oral

parafunctions and facial pain. J Orofac Pain. 2012;26(3):176-180.

• Kaplan SE, Ohrbach R. Self-report of waking-state oral

parafunctional behaviors in the natural environment. J Oral Facial
Pain Headache. 2016;30(2):107-119.
• Okeson JP. Etiology of functional disturbances in the
masticatory system. In: Okeson JP, ed. Management of
Temporomandibular Disorders and Occlusion. 4th ed. St.
Louis, MO: Mosby Year Book; 1998:149-179.

• Shetty S, Pitti V, Satish Babu CL, Surendra Kumar GP, Deepthi

BC.Bruxism: a literature review. J Indian Prosthodont Soc.

• Glaros AG, Rao SM. Bruxism: a critical review. Psychol Bull.