What are the different types of bruxism, what should general practitioners look out for, and what are the keys to effective patient management? The SingHealth Duke-NUS Sleep Centre shares all about how bruxism can be managed in primary care.
Awake bruxism vs. sleep bruxism In the International Classification of Diseases 10th Revision (ICD-10), bruxism is classified into awake bruxism (AB) and sleep bruxism (SB).
In AB, there is repetitive jaw muscle activity with clenching of teeth in the daytime
SB is characterised by repetitive rhythmic (phasic) tooth-grinding and/or sustained (tonic) masticatory muscle tooth-clenching activity during sleep
The two conditions, AB and SB, are aetiologically distinct. The latter is a parasomnia, an undesirable sleep-related phenomenon.
When does bruxism become a disorder?
In healthy individuals, bruxism is a behaviour and not a disorder.
Bruxism becomes a disorder when it is symptomatic with medical and dental comorbidities, namely:
Temporomandibular disorders (TMD)
Excessive tooth wear
Rapid progression of periodontal disease
Primary vs. secondary bruxism
Primary bruxism exists without pre-existing medical conditions or medication, whereas secondary bruxism is associated with:
Diseases or disorders such as:
Obstructive sleep apnoea (OSA)
Periodic limb movements of sleep (PLMS)
Rapid eye movement (REM) behaviour disorder (RBD)
Or medical comorbidities such as:
Gastro-oesophageal reflux disease (GERD)
and stimulants such as tobacco, caffeine, alcohol or recreational drugs.
Bruxism is common with a higher prevalence in children than adults.
AB occurs in approximately 22% to 30% of adults. SB is more common in children and its prevalence decreases as the child matures – from 49% in children to 15% in adults, and to 3% in those over 60 years of age.
The sleep stage in which SB events occur is important.
The garden variety SB, experienced by the majority, occurs during light non-rapid eye movement (NREM) sleep and can be asymptomatic.
Destructive bruxism with severe symptoms occurs in approximately 10% of individuals with SB during the REM phase of sleep.
The risk of bruxism can be inherited, and between 20% to 50% of those with SB report at least one immediate family member with a history of the condition. The odds ratio for SB increases in association with the following:
Heavy alcohol intake
High stress and anxiety
The diagnosis of bruxism may involve the following:
Medical history takingThe patient’s medical history will be taken, including any neurodegenerative diseases, neurodevelopmental disorders, epilepsy, GERD, sleep disorders, sleep parasomnias, and medication for anxiolytic, antipsychotic and antidepressant therapy.
Looking at signs and symptomsDaytime sleepiness, transient morning headaches, jaw and muscle pain or fatigue, and presence of abnormal tooth wear are the discriminatory items with high concordance for SB diagnosis. Others to look out for are scalloped tongue edges, linea alba or white lines in the buccal mucosa, torus mandibularis or torus palatinus, which are hard bony exostoses of the upper and lower jaws.
Overnight polysomnographyThe overnight polysomnography (PSG) is the gold standard for confirmation of SB diagnosis.
While there is no cure for bruxism, it can be treated to manage its severity and consequences.
Patient management is complex and addresses the main concerns, associated sleep disorders, orofacial pain and prevention of damage to teeth and gums.
Patient education in sleep hygiene, relaxation, coping with anxieties and stresses, and avoiding risk factors such as consumption of stimulants (e.g., nicotine, alcohol, caffeine and recreational drugs) is important.
In medication-induced bruxism, a change in prescription or the use of a customised dental splint or tooth protector is advised.
2. Patient counselling
This involves training patients in self-monitoring and reversal of behaviours and habits.
3. Psychological or psychiatric interventions
This includes stress management, cognitive behavioural therapy (CBT) and biofeedback methods.
These pharmaceuticals include muscle relaxants, analgesics, anxiolytics, benzodiazepines and botulinum toxin injections of the masseter and temporalis muscles to reduce muscle tension and pain.
Plates are removable dental splints almost similar to customised retainers. They are fitted over the upper or lower teeth, or both.
The aim is to unload, stabilise and improve the functions of the temporomandibular joints (TMJ), reduce abnormal muscle activity and muscle pain, and protect teeth, restorations and TMJ.
Two-jaw dental splints with mandibular advancement, or a single-jaw dental splint with continuous positive airway pressure (CPAP) therapy, can be used to manage OSA and SB concurrently.
General practitioners may consider sending patients to be assessed and sleep-tested for bruxism if they have:
Frontal headaches on waking up
Orofacial or masseter/temporalis pain
Daytime sleepiness/tiredness and snoring
Integrated multidisciplinary medical and dental management can best address the multiple problems of patients with symptomatic bruxism.
The SingHealth Duke-NUS Sleep Centre offers these services at its clinical sites at the National Dental Centre Singapore, Singapore General Hospital, Changi General Hospital and Sengkang General Hospital, as well as at KK Women’s and Children’s Hospital for children under 16 years of age.
Bulanda et al., 2021. Sleep Bruxism in Children: Etiology, Diagnosis, and Treatment - A Literature Review. Int J Environ Res Public Health. doi: 10.3390/ijerph18189544.
Carra et al., 2015. Overview on Sleep Bruxism for Sleep Medicine Clinicians. Sleep Med Clin. doi: 10.1016/j.jsmc.2015.05.005.
Mayer et al., 2016. Sleep Bruxism in Respiratory Medicine Practice. Chest. doi: 10.1378/chest.15-0822.
Melo et al., 2019. Bruxism: An Umbrella Review of Systematic Reviews. J Oral Rehabil. doi: 10.1111/joor.12801.
Dr Mimi Yow is the Director of Clinical Services at the SingHealth Duke-NUS Sleep Centre. She has practiced hospital-based orthodontics for more than three decades with the orthognathic surgery, sleep, and cleft and craniofacial multidisciplinary teams.
GPs can call the SingHealth Duke-NUS Sleep Centre for appointments at the following hotlines or click here to visit the website:
Singapore General Hospital: 6326 6060 Changi General Hospital: 6788 3003 Sengkang General Hospital: 6930 6000 KK Women's and Children's Hospital: 6692 2984 National Dental Centre Singapore: 6324 8798 National Neuroscience Institute: 6330 6363
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