grinding and clenching management

Grinding and or clenching of the teeth is extremely widespread.  It can occur during the day and or night and most commonly people are unaware of the habit.

Grinding or ‘bruxism’ involves moving the jaw with the teeth held together that is not a normal chewing action. Over time this usually results in visible wear and flattening of the teeth which is obvious to a dentist and often to the patient.

Clenching involves squeezing the teeth together and tightening the jaw muscles. Clenching generally results in less obvious wearing of the teeth but can still result in substantial muscular spasm,soreness, pain, and damage to the jaw joint.

Some prefer to split these concepts into separate behaviours while others group them together. They very commonly happen in combination, which results in even greater damage and discomfort. Studies have now confirmed that bruxism at night is a sleep disorder.

What causes bruxism?
The exact cause is not known and still being studied, however, it has been found to be associated with a combination of physical and psychological factors including the following:

  • daytime stress, anxiety and tension
  • obstructive sleep apnoea/ loud snoring
  • physical stress, eg illness, dehydration
  • heavy alcohol use, caffeine, smoking
  • certain antidepressant drugs
  • abnormal anatomy of the teeth or jaws eg a filling that is too big and interfering in the bite

Recently, studies have shown that bruxing episodes during sleep are preceded by an increase of brain activity and heart rate. This suggests that central nervous system factors may play a important role in the initiation of bruxing. Being outside conscious control during sleep, unregulated extreme forces of up to one tonne have been measured during the night; imagine the full weight of a one tonne truck going through the teeth!

How is bruxism diagnosed?
Dentists can usually diagnose sleep bruxism by taking a thorough history and performing a clinical examination. Signs and symptoms will vary depending on whether clenching or grinding is more dominant. For example grinding usually produces more wear and clenching more tension headaches. Look out for the following signs and symptoms, which often occur in combination:

  • Stiffness/pain/ fatigue of the jaw muscles and or joint.
  • Restricted opening/difficulty chewing.
  • Excessive tooth wear/chipping.
  • Loose teeth and possible damage to underlying jaw bone.
  • A partner hearing the noises from grinding.
  • Enlarged jaw muscles, very tight muscles.
  • Morning headaches.
  • Generalised tooth sensitivity to hot or cold.
  • Earache, facial and or neck pain.

Interrupted breathing during sleep or excessive daytime sleepiness; this is suggestive of the more serious conditione called sleep apnoea (in addition to bruxing) and needs further investigation

Why is grinding and clenching worth treating?
If the habit continues irreversible damage to the teeth can occur with fracture, loosening or tooth wear, eventually right down and completely! When these events happen major treatments are required to address the damage, for example crowns, bridges, root canal treatments, partial dentures, implants;  even complete dentures may be needed.

Not only can severe grinding damage teeth and result in tooth loss, it can also affect your jaw, cause or worsen TMD, speed up the progression of deep gum disease periodontitis . The appearance of your face can change as the overused jaw muscles become enlarged and the bite closes down as the teeth wear.

How is bruxism treated?
Daytime bruxism can usually be effectively treated by behavioural modification and habit reversal. Awareness has been shown to be the most useful strategy and very often this alone is enough to break the habit.  One option is to place visual cues as a reminder to check and be sure that the teeth are apart.  Seeing psychologist or counsellor may be very helpful to address the underlying causes.

Sleep bruxism that is clearly established as an ongoing habit usually requires a physical barrier to be made that prevents tooth contact. This protects the teeth from wearing down and breaking and also takes the pressure off the jaw muscles and joint.  This is made in adults not children. The mouthguard is called an ‘occlusal splint’ and the most commonly used design involves a high strength acrylic material covering all the biting surfaces of either the upper or lower teeth.  It is worn only at night and is a major part of the treatment.  If things are very severe, medications may be used for short term control of the activity and include muscle relaxants,painkillers and antianxiety drugs.

To treat bruxism comprehensively, it is necessary to identify and remove the causes and repair the damage done. For example if stress is identified as a factor, stress management techniques that work for the individual must form part of the treatment, or if possible removal of the cause(s) of the stress. If sleep apnoea is suspected as a cause this needs to be diagnosed and managed.

There are many simple measures you can try to help reduce grinding and clenching and alleviate the symptoms, as listed below. Often prior to making a splint, these are trialled. Sometimes, they are enough to break the habit.

TIPS FOR REDUCING THE LOAD ON THE JAW JOINTS AND MUSCLES:

  • Awareness; the teeth should only contact each other during chewing. At all other times, a space needs to be present between them, called the ‘freeway space’. The more aware of any tooth contact you are while you are awake, the less it occurs while you sleep. Remember ‘lips together, teeth apart’. You can set an hourly phone reminder to check in and relax your jaw to help break the habit. Clenching often occurs just under the radar of your awareness, commonly in the following situations: when you are trying hard e.g. during exercise, while driving,stressed,angry, or very focussed e.g while studying.
  • Damp heat e.g. a wheat bag or hot water bottle on the jaw muscles. This is very helpful to do shortly before bed.
  • Massage of the jaw closing muscles, which are usually carrying the most tension. Both self massage and professional muscle release by a physiotherapist or osteopath can be extremely helpful. The muscles that are usually very tight include the masseters, temporalis and medial pterygoids. Dry needling, deep tissue, trigger point massage and acupressure are all useful techniques here.
  • Avoidance of very wide opening e.g. yawning, and very loud singing to rest the jaw. If you push your tongue into the roof of the mouth as you yawn, this will help avoid opening too widely.
  • Avoidance of heavy chewing, to rest the overworked jaw muscles.e.g: tough meat, nuts,raw vegetables,hard crusts of bread. While you are in pain, it’s better to avoid biting into foods with your front teeth. Instead cut your food up into small pieces and and chew with your back teeth.
  • Avoid caffeine, alcohol and smoking.
  • Jaw relaxation exercises.
  • Avoid chewing on pencils or pens or anything that is not food. Avoid chewing gum as it allows your jaw muscles to get more used to clenching and makes you more likely to continue the habit.
  • Train your tongue to sit when it’s resting just behind your upper front teeth on the roof of your mouth; this is the most relaxed position for the jaw joint and muscles.
  • Avoid pushing your lower jaw forward or to one side e.g when biting nails,shaving,applying lipstick.
  • Try to breathe through your nose at all times, hold your head upright and keep the neck and shoulders relaxed. Tension in the neck, shoulder and back muscles usually contributes to tight jaw muscles; these muscles all influence each other.