Eric G. Jackson, DDS, MAGD, FICOI, FASD, FICD, FADI

For many of us, it’s inevitable that the end of the calendar year brings a welcome season of joy.....and an unfortunate season of stress.  Work, school, family, and holiday travel are common December stressors that I hear about from patients when they visit the office.  Stress can cause a multitude of physical ailments including elevated blood pressure, increased susceptibility to illness, and even dental pain.  If this sounds all too familiar, you may be suffering from a dental condition called bruxism.

What is bruxism?

Bruxism (pronounced Bruk-siz-um) is a condition in which you grind, gnash, or clench your teeth and is often accompanied by clenching of the jaw.  While these events typically occur at night, I have had patients express grinding and clenching during the day as well.  An often-unknown fact about bruxism while sleeping is that it’s classified as a type of sleep disorder.  This makes sense however when you consider that individuals who grind (brux) at night have a higher incidence of other sleep disorders such as snoring and sleep apnea.  For more on snoring and sleep apnea, visit our OHCP newsletter archive on our website and read my 4^th Quarter 2011 article “Adult & Pediatric Obstructive Sleep Apnea.”

What causes bruxism?

Bruxism can be caused by a variety of factors, both physiological and psychological, that vary from patient to patient.  Possible causes may include:

• Emotions, such as anxiety, stress, anger, frustration or tension
• Aggressive, competitive or hyperactive personality type
• Abnormal alignment of upper and lower teeth (malocclusion)
• Other sleep problems, such as sleep apnea
• Response to pain from an earache or teething (in children)
• Stomach acid reflux into the esophagus
• An uncommon side effect of some psychiatric medications, such as phenothiazines or certain antidepressants
• A coping strategy or focusing habit
• Complication resulting from a disorder such as Huntington's disease or Parkinson's disease

Who is prone to bruxism?

These factors can increase your risk of bruxism:

• Stress:  Increased anxiety or stress can lead to teeth grinding.  So can anger and frustration.
• Age:  Bruxism is common in young children, but it usually goes away by the teen years.
• Personality type: Having a personality type that is aggressive, competitive, or hyperactive can increase your risk of bruxism.
• Stimulating substances:  Smoking tobacco, drinking caffeinated beverages or alcohol, or taking illegal drugs such as methamphetamine or Ecstasy may increase the risk of bruxism.

What are some signs that I might have bruxism?

Signs and symptoms of bruxism may include:

• Teeth grinding or clenching, which may be loud enough to awaken your sleep partner
• Teeth that are flattened, fractured, chipped or loose
• Worn tooth enamel, exposing deeper layers of your tooth
• Increased tooth sensitivity
• Jaw or face pain or soreness
• Tired or tight jaw muscles
• Pain that feels like an earache, though it's actually not a problem with your ear
• Dull headache originating in the temples
• Damage from chewing on the inside of your cheek
• Indentations on your tongue

How is bruxism treated?

Most people with bruxism aren’t aware they have the condition.  This can be true not only with mild cases but moderate and severe cases as well.  Like snoring and sleep apnea, it is often the patient’s sleeping partner that will notice the bruxism before the patient is even aware of it.  If one sleeps alone, this obviously can’t occur.  For these patients I find that the most common symptoms that push the patient to seek treatment are 1) visible changes to their teeth (chipping/fracture or chronic wear/shorter than they used to be) and 2) waking up with symptoms (headaches, TMJ issues/pain, muscular pain of the face/head/neck region).  Sudden unexpected chips can sometimes be smoothed out, other times repaired with cosmetic bonding, and still other times require a crown or veneer.  Slow chronic grinding is a different animal entirely.  As the teeth slowly wear down over years, they also erupt out of the gums and bone.  This phenomenon is an essential evolutionary development because the teeth remain in contact throughout the individual’s lifetime despite heavy wear and annual loss of height/volume.  Restoring these teeth to their original size/shape often involves a massive overhaul of not just the teeth that have worn down but the entire arch of teeth (all upper or all lower...sometimes both).  Bonding is no longer an option if the majority of the tooth is missing.  Restorative dentistry of this magnitude, often termed partial or full mouth reconstruction, involves quite a bit of time/effort, and can be quite costly.  It is immensely better to prevent the loss of height/volume if at all possible.  This is typically accomplished with a simple full arch hard nightguard.

 There are MANY different types of nightguards available to both dentist and patient.  Over-the-counter “Boil & Bite,” custom fabricated soft, hard acrylic, hard thermoplastic, anterior NTI style...the list goes on and on.  With all these options, how do you choose?  Although each style does have merit in certain situations, I feel that bruxism patients benefit most from a hard, full coverage, nightguard custom fabricated by their dentist.  All the other styles can work but I feel they are generally less predictable long term for most patients.  The density of the material is an important attribute to discuss.  Believe it or not, soft nightguards of any kind can actually CAUSE problems in the long run.  While comfortable and functional at first, the jaw musculature and joint eventually get wise to the fact that something pliable and semi-firm is between the teeth...and often assumes it is FOOD.  Patients who elect to wear the soft nightguards long term often find themselves with pain/symptoms from their Tempromandibular Joints (TMJ) because throughout the night they unconsciously chew and “mush” the nightguard while they sleep.  Imagine chewing gum all night long...every night!  What do you think your jaw would feel like??  Tired to say the least!  A hard nightguard prevents this from occurring because the density of the material does not “give” and more closely mimics hard tooth structure than food.  Therefore, the body simply grinds down the nightguard material thinking it is tooth enamel while the real teeth are protected under the nightguard.  Another important fact is that hard nightguards will typically last years and possibly decades while both the custom soft as well as the soft “Boil & Bite” are quite short lived in comparison.  Over time, this can certainly have a negative effect on a patient’s wallet if they require multiple replacements.

So we’ve established that in general I recommend getting a custom made, hard, nightguard but is there more to the story?  YES!  Now we have to choose between my favorite subcategories of hard nightguards: solid acrylic, solid thermoplastic, and a combination of the two.  This decision is quite case dependent for each patient.  For patients who have very few fillings and a long history of stable checkups without cavities, I would typically recommend a hard thermoplastic nightguard.  It is the least expensive of the group and is quite comfortable.  The comfort comes from the fact that a hard thermoplastic is briefly run under warm water by the patients in order to slightly relax the material prior to wear.  The relaxed material is easy to fit to the teeth and yields quite a comfortable fit.  Their downside is that adjustments to a thermoplastic nightguard after fillings/crowns are difficult and sometimes impossible.  

Therefore, while initial cost is low, a patient may need to completely remake the nightguard if dental work is completed in the future.  For patients who have multiple large/old amalgam fillings that will likely need future dentistry or have a history of instability with multiple cavities at many checkups, I would typically recommend a solid acrylic nightguard.  This style is initially more expensive than the thermoplastic but can be easily relined after fillings or crowns to keep an exact custom fit.  The only downside to the solid acrylic nightguard is that it is VERY rigid and some patients find them uncomfortable.  All nightguards should be worn every night, forever, just like an orthodontic retainer.  If they’re not worn nightly, the teeth may shift.  This can cause discomfort with an acrylic nightguard because it is so rigid.  If enough shifting occurs, the nightguard simply won’t fit at all and the patient will need to purchase a new one.  A third hard nightguard option is my favorite:  the combination thermoplastic/acrylic nightguard.  A very hard acrylic shell houses the hard yet thermoplastic inner liner and provides a middle ground between the two worlds of all thermoplastic and all acrylic.  They are incredibly comfortable and long lasting.  Although sometimes difficult, they can be relined/adjusted after dental work in certain situations.  Most importantly, the combination thermoplastic/acrylic nightguard feels and fits fantastic.  This means patients will actually wear the device and protect their teeth!  The key to dentistry is in the planning, and nightguards are no different.  Open conversation between dentist and patient is essential and vital to the success of any case. 

If you would like to speak about bruxism, nightguards, or any other topic, please feel free to contact the office and schedule an appointment.

Sincerely,

Eric G. Jackson, DDS, MAGD, FICOI, FASD, FICD, FADI