If you’ve noticed a greater number of patients presenting with orofacial pain, jaw complaints, headaches or tooth wear, you’re not alone.
A recent study published in the Journal of Clinical Medicine revealed that stress-related bruxism has been on the rise throughout the COVID-19 pandemic.
The study found that orofacial pain jumped 12% during the pandemic, and day-time jaw clenching has increased by about 15% among the nearly 1,800 patients surveyed.
So with dentists potentially facing a surge in bruxism, we think the time is right to take an in-depth look at the common condition that’s typically characterised by excessive tooth grinding and clenching.
The Avant Dental team sat down with specialist prosthodontist Dr Neil Peppitt to understand bruxism, and get his expert advice on when, why and how to treat the condition.
Dr Peppitt runs a busy prosthodontic practice in Sydney, is an adjunct associate professor at The University of Sydney School of Dentistry, and a former president of the Australian Dental Association in NSW.
Surprisingly, Dr Peppitt says teeth grinding and clenching is a normal stress response. And many dentists, including Dr Alexander Holden, associate professor at The University of Sydney, agree that stress is a significant contributing factor to bruxism.
Dr Peppitt also believes that bruxism may only require treatment if pain is present, or tooth function or appearance is compromised.
He shares some helpful tips to identify bruxism-related tooth wear, and reveals his favoured bruxism splint types.
Bruxism is simply defined as the grinding or clenching of teeth. While sleep bruxism may be considered a sleep-related movement disorder, Dr Peppitt says bruxism also occurs during waking hours.
“I tend to think that bruxism is normal in that we all grind and clench our teeth from time to time,” he says. “It may occur during sleep, but it’s just as likely to occur when the patient is awake.
“Look around any university lecture theatre and you’ll see people clenching their jaws. Or watch your patients next time you’re delivering bad news. I bet they will be clenching their teeth. It’s a normal stress response.”
However, excessive bruxism can certainly damage teeth. Common bruxism symptoms include flattened, fractured, chipped or loose teeth. Worn tooth enamel or increased tooth pain or sensitivity may also indicate bruxism.
Patients suffering from moderate to severe bruxism may also experience sore or tight jaw muscles; jaw, neck or face pain; dull headaches or earaches; tissue damage to the inside of the cheek; and sleep disruption.
Dr Peppitt says there is no single known cause of bruxism. Rather, he believes bruxism causes are multifactorial, and vary between patients. However, Dr Peppitt often sees jaw overload in patients with bruxism.
“It’s a bit like holding up a glass of water,” he explains. “It’s quite light and easy to hold it up for a short time. However, if I ask you to hold a glass of water up for an hour, your arm is going to get sore.
“It’s the same thing with the jaw. Some teeth grinding or clenching is a normal stress response, and won’t cause any problem for the patient. However, excessive bruxism is going to overload the jaw muscles.”
Smoking, alcohol, caffeine and recreational drugs including ecstasy and cocaine have all been associated with bruxism. Some medications such as antidepressants may also contribute to bruxism, and bruxism may be present in other medical disorders such as Parkinson’s disease, dementia, epilepsy, sleep apnea and gastroesophageal reflux disorder (GERD).
Dr Peppitt says dentists should also consider behavioural and psychological causes — including assessing a patient’s stress response.
“Bruxism might be a habit that the patient is unaware of, or it could be due to psychological stress,” he explains. “We all have different emotional responses to stress. We might shout, get quiet or burst into tears. Teeth clenching is a common physiological response to stress.”
As such, Dr Peppitt believes bruxism treatment may not be required for patients experiencing a mild case.
“The reason for treating bruxism is that the patient is experiencing pain or sensitivity, or has concerns around the appearance or function of affected teeth,” he says. “If none of those factors are present, then the patient may not require bruxism treatment.”
Bruxism treatment may also be required if the patient is undergoing restorative or cosmetic treatment. Teeth grinding or clenching may risk damaging new dental work. In that case, a protective bruxism splint or bruxism mouthpiece may be required to prevent damage to surrounding dentition.
While bruxism may cause tooth wear, not all tooth wear is caused by bruxism. Dr Peppitt says it’s vital to identify the type of tooth wear — and what’s causing it — before moving ahead with a bruxism treatment.
“There are four types of tooth wear, and not all are caused just by bruxism,” he explains. “There may be other factors present such as acid wear or forceful toothbrushing. Treating bruxism alone will not stop the other factors that contribute to tooth wear.”
The four types of tooth wear are:
— Abrasion: This is physical wear to the surface of the tooth and the tooth enamel due to an external action such as overly vigorous toothbrushing or the use of abrasive substances such as some tooth-whitening toothpastes. Tooth abrasion can cause pain or sensitivity when eating hot, cold, sweet or sour food, and can expose inner layers of the tooth. This makes the patient more vulnerable to plaque build up and bacterial infections.
— Erosion: This is the dissolving of the tooth enamel by acids in the mouth. It may initially appear as yellowing of the teeth, and/or teeth appearing glazed and smooth. Patients may also experience increased sensitivity or pain. Diet is a major contributor to dental erosion. Acidic food and drinks such as red wine and soft drinks have been linked to tooth erosion. Gastric reflux disorders such as GERD that introduce stomach acid to the mouth can also contribute to tooth erosion.
— Attrition: This is loss of tooth structure that is typically due to excessive tooth-to-tooth contact as seen in bruxism. It can also wear down enamel and expose the dentin of the tooth. It is often identified as changes in tooth shape, the presence of tooth pain or discolouration, gum or oral tissue damage, or damage to fillings and dental restoration work.
— Abfraction: This is the loss of tooth structure at the gum line, and is typically caused by long-term stress on teeth from bruxism, malocclusion or misalignment of teeth, and/or mineral loss due tooth erosion or abrasion.
Dr Peppitt says that it’s also important to determine when the damage occurred, what caused it, and whether it is ongoing.
“You can refer to an eruption chart to determine when the major damage occurred — and whether it was intrinsic or extrinsic,” he explains. “Intrinsic means ‘from within’, which includes things like GERD and acid reflux. Extrinsic refers to external factors such as acidic drinks or brushing habits.
“If the cause is extrinsic, you’ll need to address behavioral factors before you conduct any restoration work. For example, I had a patient who liked to hold red wine in her mouth. It eroded a lot of the enamel from her lower teeth, and would have damaged the restoration work we were planning. We had to identify the cause of the erosion and address the behaviour with the patient before we went ahead with other treatments.”
Dr Peppitt says bruxism is most commonly associated with attrition and abfraction — and a combination of both could be present in some cases.
“You’re looking for quite polished and cut-off teeth, with shiny wear marks possibly present,” he explains. “Tongue indentation may also indicate bruxism. When people clench their teeth, they tend to lock the jaw together, seal their lips and such moisture out of the mouth. This pushes the tongue against the cheeks and may cause tongue indentations.”
Dr Peppitt adds that changes in tooth position can also indicate bruxism. The clenching of teeth can change pressures in the mouth.
“Excessive teeth clenching can change the balance in the neutral zone which may cause tooth movement. That’s a common indication that moderate to severe bruxism may be present.”
While bruxism is certainly treatable, Dr Peppitt is quick to point out that treating the underlying cause of bruxism — not just bruxism symptoms — is vital to achieving a successful treatment outcome.
If the cause of the patient’s bruxism is behavioural, Dr Peppitt says a conversation with the patient is required.
“You need to explain to people that they are grinding or clenching their teeth, and help them identify when and why they are doing it,” he explains. “For example, a farmer came to see me and we worked out that he was clenching his teeth while driving his old tractor. These habits need to be identified so the patient can be aware when and why they are doing it, and address the behaviour.”
Dr Peppitt says poor sleep hygiene is another behavioural factor that commonly contributes to bruxism during sleep, and dentists may need to suggest stress management techniques.
“You need to relax and wind down before bed, and that includes not looking at light-emitting screens for a period before you go to sleep,” he advises. “Patients who are experiencing periods of high stress that’s contributing to bruxism may benefit from stress management interventions such as exercise, relaxation therapy and psychological treatments like cognitive behavioural therapy (CBT).”
Dr Peppitt says that while some people may have success using hypnotherapy to treat bruxism, it doesn’t work for everyone. He also points out that some medications such as SSRI antidepressants have been linked to bruxism.
Once behavioural factors have been addressed, Dr Peppitt says the dentist may choose to move on to treatment with an oral appliance such as a bruxism splint or bruxism mouthpiece.
He also warns against the use of medications to treat bruxism.
“There is no evidence to support the long-term use of sedatives, NSAIDs and muscle relaxants to treat bruxism,” he says.
Dr Peppitt says a bruxism splint or bruxism mouthpiece is predominately used to protect the teeth of tooth-to-tooth contact during grinding or clenching.
“When the patient is wearing a bruxism splint, they are grinding on the plastic splint rather than on their teeth,” he explains.
This protects the teeth from bruxism-related attrition, and can help to spread the load to ease abfraction.
Dr Peppitt adds that a bruxism splint or bruxism mouthpiece might also be used to biomechanically unload the joints and ease jaw pressure, or to protect full-mouth restorations in patients who tend to clench or grind their teeth.
There are a wide range of dental splints available on the market, however Dr Peppitt favours hard splints with full coverage.
“I always go for full coverage over partial coverage,” he says. “Full coverage provides maximum contact over limited contact. It protects all the teeth, and helps to spread the load.”
“I also like hard splints,” he adds. “Soft splits can create a trampolining effect under high pressure and put more tension through the muscles. This may also give worse headaches. And I find that while hard/soft splints are easier to fit than hard splints, they are more prone to breakage.”
While upper arch splints have traditionally been favoured over lower arch splints, Dr Peppitt says there is not much difference between the two.
“There is no real reason to use an upper arch splint over a lower arch splint,” he concludes. “A lower arch splint may actually be more comfortable to wear during the day.”
For more information about the different types of dental splints, the latest splint materials and technology, and how Avant Dental can help you deliver better bruxism splint therapy, read our Ultimate Guide to Occlusal Splints.