Bruxism, also known as teeth grinding, is a sleep-related movement disorder that involves clenching jaw muscles together to grind upper and lower teeth together.
This condition causes a lot of symptoms that are quite uncomfortable, like a sore jaw, facial pain, and chronic headaches. It can also negatively impact your oral health and lead to the need for expensive dental work.
So…why do you grind your teeth?
There are two types of bruxism, and they’re both caused by a combination of factors. Plus, some of the previous assumptions about grinding, like that it’s usually stress-related, have been challenged by science over the last couple of decades.
Actually, researchers have discovered that sleep apnea might play a part in some cases of bruxism. Treatments that have been “first line” in the past have been replaced with more effective (and sometimes less invasive) options.
Let’s take a look at the types and causes of bruxism, as well as the treatment options available to you. Grinding your teeth doesn’t have to be a lifetime sentence.
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What happens when you grind your teeth?
Your teeth are made of incredibly strong particles of hydroxyapatite, the minerals that make up enamel (and bone structure). When you brux (grind), you’re exerting hundreds of pounds of force on these strong, but small, tooth structures.
Over time, your teeth will wear and your oral health will suffer. All the consequences of bruxism worsen the longer you grind your teeth. Here are the most common results of grinding your teeth for a long time without treatment.
Consequences of Untreated Teeth Grinding
Fractured teeth: Teeth can cave to the unrelenting pressure of grinding and end up cracked or fractured, requiring a root canal or even extraction. (2)
Yellowed teeth: The best way to make your teeth look whiter is to prevent yellowing or discoloration. Grinding can prematurely age teeth, accelerating their yellowing and worsening their aesthetics.
Gum recession: Grinding can exert 250 pounds of force per square inch of tooth surface. This muscle activity can push the gums away from the teeth and cause irreversible gum recession. Receding gums can then lead to decay as bacteria settles into the recessed space, as well as significant tooth sensitivity. (3)
Temporomandibular joint disorder (TMD): Grinding teeth also puts a lot of pressure in the temporomandibular joint, which can lead to TMD. TMD is also sometimes called TMJ, and the disorder can cause ongoing pain in the joint muscles, clicking or popping of the jaw, as well as difficulty chewing and, sometimes, speaking. (2)
Migraine headaches: Because of the force exerted on your facial muscles, grinding your teeth can cause tension headaches, migraine episodes, and chronic migraines. (4)
Common Conditions Associated with Bruxism
There are also a number of conditions and other symptoms closely associated with teeth grinding and/or sleep apnea. I’ll explain the connection between grinding and sleep apnea below.
It’s not clear whether or not all of these conditions are caused by grinding or obstructed sleep breathing, or the other way around. But it’s possible that you’re at a higher risk for these medical conditions if you grind your teeth:
- Restless leg syndrome (these findings are somewhat controversial) (5)
- Chronic kidney disease (6, 7)
- Depression (8)
- Sleep-disordered breathing (9)
- Behavioral problems in children (10, 11, 12)
- Gastroesophageal reflux disease (GERD) (13)
- Obstructive sleep apnea (more on this below) (13)
Types of Grinding
In the past, all bruxism was attributed to similar causes. But today, science shows that there are two distinct types of grinding, and they aren’t always correlated with the same causes. All bruxism, though, seems to affect the teeth in the same way.
Ever notice you’re staring at your computer screen and suddenly unclench your teeth? That’s an experience of tooth grinding while awake. If this happens often, you might have awake bruxism.
Awake bruxism may be due to emotions like anxiety, stress, anger, frustration, or tension. It could also be a coping strategy or simply a habit you practice while in deep concentration.
Grinding at night is a totally different issue for most people than grinding teeth throughout the day. While daytime grinding is often an emotional or habitual issue, sleep bruxism is more likely related to sleep quality. This sleep-related chewing activity could be happening in relation to being awakened during the night (even if you don’t remember waking up).
These arousals during sleep happen in the course of sleep apnea or other forms of sleep-disordered breathing.
Common Causes of Bruxism
Bruxism is what’s known as a “multifactorial” health issue. That means it’s often caused by a combination of factors, or that it can be hard to distinguish what actual causes are at play in a single person’s case. There isn’t a single cause of bruxism in every case.
This is a controversial area of research. However, in general, there are three basic parts defined in the etiology (cause) of bruxism. They are: (14)
These would be factors like misalignment of teeth that may cause grinding of teeth. Peripheral factors like poor occlusion of the teeth aren’t as clear a cause of bruxism as the other factors. (15)
That being said, if your teeth aren’t lined up correctly, it may cause your jaw to be unstable. (16) Especially if you’ve recently had a tooth extracted or had other major dental work done, talk to your dentist about misalignment. Although it may not be a direct “cause” of bruxing, it can contribute to the TMJ/TMD pain you may be experiencing.
It’s hard to draw conclusions about cause-and-relationship with psychosocial factors for bruxism. That’s because the types of studies that look at the relationships are larger studies of populations known as “epidemiological” studies. While epidemiological studies can help establish a correlation, these aren’t the same as clinical trials that establish direct conclusions.
Teeth grinding often happens more often in people who simultaneously deal with:
- High levels of and sensitivity to stress
- Abnormally high levels of hostility towards others
As you might have connected from the above section, psychosocial factors for teeth grinding are more often associated with awake bruxism, not sleep bruxism. If you catch yourself grinding during the day, relaxation techniques may help—but may not be as effective for sleep bruxism. Some cases of anxiety and stress-related bruxism during the day can exacerbate nighttime teeth grinding, though.
These causes, also called “pathophysiological factors,” are the focus of a lot of current research into sleep bruxism. Central factors for teeth grinding have to do with internal systems that may be out of balance in some way in the presence of bruxism, like the central nervous system.
For one, nighttime grinding is closely associated with arousal responses during sleep. “Arousal responses” refers to moments during sleep that you’re awakened or brought from a deep sleep into a lighter sleep, like REM sleep.
Often, you won’t remember most of your nighttime arousals, but a sleep study (and some home sleep tests) can help you identify whether or not you’re sleeping soundly or being aroused.
More and more, clinicians are beginning to see that sleep bruxism may be one of the first signs of obstructive sleep apnea (OSA). I’ll discuss more on that below.
In bruxism, there’s also a connection between some neurotransmitters and the act of grinding. In fact, one of the systems your brain uses to communicate movement to the body seems to be disrupted in bruxism. This same system is implicated in the development of Parkinson’s disease, although it’s disrupted in a different way during teeth grinding.
Another central factor for teeth grinding is heritability. Teeth grinding (and the resulting pain) seems to run in families. (17)
- SSRIs (a type of antidepressant)
- L-dopa (although this can help with grinding when taken in very short-term periods)
- Amphetamines, including drugs for ADHD
- Anti-anxiety medications
- Antipsychotics (neuroleptics)
Other Risk Factors for Bruxism
In addition to the etiological factors I listed already, you may be more at risk for bruxism if you: (21)
- Frequently drink alcohol, especially at night
- Drink more than six cups of coffee each day
- Smoke or chew tobacco
Bruxism and Obstructive Sleep Apnea
As it turns out, your dentist might be the first person to warn you that you might have sleep apnea—because s/he is the first to see the signs of bruxism. Sleep disorders like sleep apnea (and the less severe UARS) could be a contributing factor to grinding.
Long considered a disease only common in obese, older men, obstructive sleep apnea may actually be more common than previously thought. According to the National Sleep Foundation, somewhere between 2-3% of Americans struggle with sleep apnea.
A large epidemiological study in the UK, comprising over 13,000 subjects, found that obstructive sleep apnea (OSA) was the highest risk factor for nighttime grinding. (21)
It’s not all that surprising that sleep apnea and bruxism are connected. During an apneic episode, the airway is closed and airway pressure drops to zero. In order to alert the body to re-open the airway, the brain will initiate arousal and essentially draw one out of deeper sleep. This arousal can happen by grinding the teeth together, which will cause some movement and re-start breathing.
I want to point out here that some of the evidence points to bruxism as a result of the poor sleep quality in sleep apnea, whereas other research suggests it’s a direct response to apneas (like I just described). (22, 21)
This is one area where the idea of the typical “old, overweight, male” patient as the most likely to have sleep apnea begins to truly fall apart. In large UK study above, researchers discovered that younger people actually ground their teeth at night more often than older subjects. Bruxism also doesn’t discriminate by gender: women are just as likely as men to grind their teeth. (21)
Fortunately, it seems that resolving sleep apnea, for some people, will also correct issues with grinding teeth. (23)
But one area that might be of utmost importance with bruxism and breathing disorders are the way they impact our children.
Teeth Grinding in Kids
Children grind their teeth at night more often than you might think. A 2008 survey of parents of preschoolers found that almost 40% of the children were grinding their teeth at least once a week, with just under seven percent grinding four or more times every week. Kids in the second group were also more withdrawn and socially awkward.
Bruxism in children is associated with: (24)
- Mouth breathing
- Restless sleep
- Stomach sleeping
- Lack of sleep
There’s also a close relationship between childhood sleep apnea and grinding teeth. (25, 26) Why does this matter? Sleep apnea in children exhibits very similar symptoms to ADHD, and it can be difficult to distinguish the two. (27) One meta-analysis estimates that up to half of children with ADHD may be misdiagnosed and actually suffer from sleep apnea. (28)
I recommend to parents with children who have signs of bruxism, especially if they’re also experiencing behavioral issues, to have a sleep study done. This can help determine if the behavioral symptoms are related to the same root cause as the grinding.
Even if you can’t afford a sleep study right away, I would highly recommend observing your child at night. Does s/he breathe through the mouth? Sleep on his/her stomach? Drool frequently? Wet the bed more than would be typical for his/her age?
These are symptoms you can discuss with your child’s dentist and pediatrician to figure out how to proceed with treatment.
How can I find out if I’m grinding my teeth at night?
There are several symptoms of sleep-related bruxism, like: (21)
- Daytime sleepiness
- The need to urinate in the middle of the night
- Waking up frequently at night
- Jaw pain or clicking in the jawbone when you open your mouth
- Chronic headaches
- Tooth sensitivity
- A metallic taste in your mouth, which can happen as a result of grinding on metal fillings
The best way to diagnose grinding, whether it’s related to sleep or not, will be to see your dentist. At your next six-month cleaning, ask your dentist if s/he sees signs of grinding. In dental school, we’re trained to look for signs such as:
- Abnormal tooth wear
- Flattened teeth, worn down by excessive pressure
- Abfractions (tooth tissue loss along the gum line)
Treatment Options for Bruxism
There is no known “cure” for bruxism in all patients. Because of the complicated nature of this condition, it’s hard to offer concrete medical advice without a very complete picture of an individual’s symptoms, medical history, and other important factors.
However, there are some ways to treat bruxism that are effective, depending on the root of your symptoms.
1. Night Guard
As a sleep medicine dentist, I’m trained in using oral appliance therapy to help resolve sleep-disordered breathing, including the prescription for night guards.
A night guard is often the first tool in a dentist’s arsenal in treating bruxism. It’s still the first recommendation of the American Dental Association (ADA) for nighttime grinding, accompanied by stress relief techniques. These devices are called an occlusal splints, because they are a specific type of night guard used to prevent damage from grinding
There’s one major problem with this, though—a night guard can potentially worsen mouth breathing and even symptoms of sleep apnea. (29)
Sure, your teeth may be protected from some breakage and wear, but if disordered sleep breathing is the cause of your symptoms, it’s better to deal with that. A night guard should only be a temporary solution in many cases.
How does a night guard potentially worsen sleep apnea? When you have sleep apnea, your airway gets closed during what’s called an “apneic episode,” and you stop breathing temporarily. Grinding and other sleep movements are triggered by your brain’s attempt to push your jaw forward to re-open the airway.
Unfortunately, a night guard can actually push your jaw back further and/or interfere with the thrusting or grinding your body is using to re-open your airway.
So, should you use a night guard for bruxism? I talk more about the debate here, but a night guard will protect your teeth from some of the wear and tear caused by grinding. On the other hand, it could worsen sleep apnea, if that’s truly the cause of your bruxism. I recommend getting a sleep study before relying on a night guard to protect your teeth.
A dentist can help fit you for a night guard, so if you want to go this route, your first step should be to book an appointment with your general dentist.
2. Sleep Apnea Treatment
If obstructive sleep apnea is the cause of your bruxing, you’ll need to follow through with sleep apnea treatment in order to stop or reduce grinding.
First-line treatments for sleep apnea include the use of positive airway pressure machines, known as CPAPs or APAPs. These are typically used for cases of moderate-to-severe sleep apnea and are very effective in reducing nighttime arousals due to interrupted sleep breathing.
Sadly, the “old school” of thinking frequently overlooks cases of mild sleep apnea or the less severe UARS (upper airway resistance syndrome). I believe this to be a mistake—just a few nights of poor sleep and mouth breathing can have negative impacts on your dental and overall health.
Here’s a quick list of some of the most common sleep apnea treatments (excluding oral appliance therapy, which I discuss in the following section). If you’ve been diagnosed with mild sleep apnea or UARS and given few treatment options, the first two on this list may give you some relief.
Sleeping on our backs may be one reason sleep breathing is often problematic in modern society. Positional therapy is one way that you may be able to correct mild obstructed sleep breathing.
Gravity dictates that, when you sleep on your back, your jaw and tongue fall on the back of your throat. This position makes your airway more likely to collapse. Switching to a side sleeping position, however, uses gravity to free the airway.
If your sleep breathing is interrupted because you’re a back sleeper, changing positions can significantly improve the position of your airway. (30) There are devices that can help out with sleeping in new positions, but I’ve seen people alter their sleeping position with home hacks like a backpack with a tennis ball in the large pocket.
Essentially, do what you can to sleep on your side throughout the entire night.
I’ve been a good sleep breather for years, but I still go to bed every night wearing mouth tape. This seemingly bizarre habit is a great way to retrain yourself to breathe through your nose.
In my experience with some patients—and even my oldest daughter, Catharine—mouth tape can actually reverse mild cases of interrupted sleep breathing.
My favorite mouth tape is Somnifix Sleep Strips, which are comfortable and extremely gentle, even for sensitive skin. The folks at Somnifix have offered a buy-one-get-one free offer for my readers using coupon code DOCTORB.
If your skin doesn’t tend to react badly to normal adhesives, you may want to try 3M Micropore Tape, which is more cost-effective but not as high quality of a product.
Improving your airway pressure with a CPAP or APAP machine may be able to resolve bruxism that happens as a result of sleep apnea. (23)
The two major drawbacks of these machines is that, for one, they can be intrusive and awkward at first. Secondly, CPAP and APAP machines are rendered useless if you sleep with your mouth open. Therefore, I would use mouth tape along with your CPAP or APAP machine to get the most out of this therapy.
Your sleep specialist will work with you to find the best CPAP or APAP machine for your lifestyle and insurance plan.
3. Oral Appliance Therapy
Even if you don’t have sleep apnea (but do grind your teeth), the two oral appliances for sleep apnea can help reduce bruxism and cut down on related symptoms, like snoring and daytime sleepiness.
Both of these devices show similar improvements in treating obstructive sleep apnea, but they work uniquely. (31)
Mandibular Advancement Device (MAD)
The standard go-to device for mild-to-moderate sleep apnea, a MAD can help to position your jaw forward and improve sleep breathing.
You’ll need to see your dentist for a custom-made MAD. Consult your insurance company before requesting a MAD—some providers don’t cover them at all, while others may require you to try a different treatment first.
For instance, many insurance providers insist beginning sleep apnea treatment with CPAP or APAP before other methods of treatment are covered. You may qualify for combination therapies for sleep apnea, one of which is the use of a MAD with an APAP machine, possibly after implementing positional therapy.
While a MAD can be a great solution for poor airway position, it can take months to get used to the way it feels. It’s uncomfortable at first, but is well worth the effort when it’s needed.
If you do not have a diagnosis of sleep apnea but struggle with bruxism, you may be able to request a MAD from your dentist. But consider first that the device will not be covered by health or dental insurance in these cases.
Tongue Retention Device (TRD)
Rather than pulling your jaw forward, a tongue retention device works by positioning your tongue properly. Often, your airway can be limited when your tongue isn’t in the right place.
The main benefits of a TRD are lower cost and ease of access. While a MAD is a custom-made device ordered through your dentist, you can order a universal TRD online for a small fraction of the cost.
I’ve tested the results of a TRD called Good Morning Snore. I found it to be very comfortable and easy to use, so it’s my go-to recommendation for a tongue retention device. At around $100, it’s significantly cheaper than options offered in a dental office, which can run anywhere from $300-500.
4. Muscle Relaxant Medications
A medication-based approach to bruxism may work in certain cases, but the research results are inconsistent. Botox injections, for instance, can help to reduce bruxism by acting as a paralytic, but is indicated mostly for extreme cases, like patients with coma, brain injury, amphetamine abuse, Huntington’s disease, and autism.
Because daytime grinding is often associated with concurrent psychological issues, like anxiety or depression, some research has focused on the impact of medications for these to reduce symptoms of bruxism. But long-term use of most medications tested can actually result in more bruxing. (14)
One medication that might help with bruxism is clonidine, a drug typically used for high blood pressure.
Unfortunately, the human trial testing clonidine for bruxism found that about a fifth of the patients in the study woke up with dangerously low blood pressure, so more research will need to be conducted before this is a viable option. (32)
5. Biofeedback and Psychotherapy
Biofeedback techniques like using EMG (electromagnetic) techniques or splints have been used with moderate success for daytime grinding. Read more about biofeedback here. In addition, the use of counseling and psychiatric counseling has been suggested.
Various forms of biofeedback or psychotherapy that have been tested in small human trials or case studies for sleep bruxism, like taste stimuli, noises, or behavior modification. None of these has been proven effective in the long term for grinding during sleep, so they’re not suggested treatments at this time. (33, 14)
6. Relaxation Techniques
Long thought to be the best way to deal with bruxism, relaxation techniques have been shown to do very little to resolve sleep bruxism. (34)
However, if you grind your teeth throughout the day as a result of high stress situations, it’s a good idea to employ relaxation techniques. These may include focusing on your breath, mindfulness meditation, guided imagery, yoga, or even prayer.
7. Bruxer Crowns
When I’m working with a patient with clear signs of bruxing and who is in need of a dental crown, I consider using what is sometimes referred to as a “bruxer crown.” These are also referred to as “all porcelain” crowns but are, in reality, made of cubic zirconia.
If you read my article on crowns, you’ll notice I don’t recommend most people use these types of crowns. While they’re much more resistant to wear from grinding, large amounts of pressure that breaks down the material at a microscopic level (e.g., grinding) can expose the cubic zirconia particles to your airway. Unfortunately, these particles may cause some respiratory issues.
However, this decision is sometimes a tradeoff. In patients who suffer from severe bruxism, especially those with neurological conditions like Huntington’s or Parkinson’s that are unable to control the motion, offering crowns that are incredibly strong is often the best choice. I’d rather see these patients avoid breaking their teeth or developing early gum recession, so a bruxer crown is a better option.
If you are offered (or are considering) a bruxer crown, I would recommend some of the above methods first. In my experience, it’s best to utilize bruxer crowns only in extreme cases where the grinding can’t be treated another way.
8. Orthodontic Treatment
As many cases of bruxing aren’t actually caused by poor bite, orthodontic therapy isn’t a great first option for most. However, if you suffer from TMJ from grinding and have poor occlusion, orthodontic treatments like Invisalign or occlusal equilibration can help to correct your bite and relieve some of that pain. (35)
Key Takeaways: Teeth Grinding (Bruxism)
The habit of grinding your teeth, whether during the day or at night, is a complicated matter. There’s no “one-size-fits-all” cause—or cure—for bruxism.
There are a few things I can say with confidence, though: For one, sleep bruxism may be associated with sleep apnea. For this reason, I don’t recommend continuing with treatment for bruxism with a night guard until you’ve confirmed whether or not you have sleep apnea.
Second, if your child shows signs of bruxism and also displays behavioral issues, it’s very important to get a sleep study to determine if sleep apnea is the culprit.
Lastly, there are bruxism treatments available for any budget, insurance plan, and/or lifestyle. I encourage you to get to the root cause of your grinding issue so that you can experience the best results possible.
Have more questions about teeth grinding? Send me a message.Learn More: Sleep Apnea: The Real Reason You Grind Your Teeth?
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