Treatment Modalities

The goals of treatment are to reduce the pain, prevent permanent irreversible damage to the teeth and surrounding structures and reduce grinding as much as possible. Starting with home self-care remedies would be the initial conservative approach for treatment.^4,54

Home Care

• Apply ice or heat to sore jaw muscles

• Avoid eating hard foods

• Avoid chewing gum

• Drink plenty of water

• Do stretching exercises for the face

• Massage the muscles of the neck shoulders and face

• Relax the face and jaw muscles

Night Guards – Custom Made or Generic

Night guards are one of the most popular treatment options for sleep bruxism (Figure 9). The goal of a nighttime therapy appliance is to redistribute occlusal forces, relax the masticatory muscles, stabilize the TMJ, protect the dentition and dental work, decrease the symptoms and, hopefully, reduce bruxism.^16,56 Night guards can last an average of a few months to years depending on the force and frequency of grinding. There are a variety of night guards; choosing and advising the patient on the correct night guard is important.

Figure 9. Night guard

Figure 9. Night guard

Courtesy of Glidewell Laboratories.

Night guards should be worn to protect restorations and be recommended to patients who grind and have multiple crowns, bridges or implants due to quicker failure of restoratives. Periodontal patients who show any symptoms of bruxism, or if the patient acknowledges they grind their teeth, should be educated on the need of a night guard for protection. The patient must maintain the periodontium since they have less bone and tissue attachment, and additional loss is more detrimental to periodontal treatment plans. Night guards also maintain space between the teeth so the muscles of the jaw cannot fully contract and remain relaxed.

Custom Night Guards

For aggressive consistent grinders, a harder night guard should be recommended. A hard/soft type is 1 mm soft polyurethane for the inner layer and a 3 mm hard, more durable co-polyester outer layer.⁵⁴ For less aggressive and episodic grinders, a softer night guard may be recommended.

Custom made night guards are usually the best option for the patient. The fact they are custom fitted makes them the most comfortable and, therefore, patient compliance is improved with custom guards. The process for constructing this appliance is a two-appointment procedure. At the first appointment, impressions of the maxillary and mandibular arches are taken. The impressions can be sent to a dental laboratory or the appliance can be fabricated in the office. Usually mouth guards are fitted to the maxillary. Sometimes a mandibular night guard will be made if the patient has trouble with gagging or comfort. The second appointment is for delivery and to confirm the night guard fits, feels right to the patient and to instruct them on the care of the night guard.

Figure 10. Daytime night guard

Figure 10. Daytime night guard

Courtesy of JS Dental Lab.

Figure 11. An example of a back cut night guard from Sporting Smiles

Figure 11. An example of a back cut night guard from Sporting Smiles

Figure 12. NTI night guard

Figure 12. NTI night guard

Courtesy of Dr Lori Burchell.

Generic Night Guards

Since custom-made night guards can be expensive and insurance companies sometimes do not cover the cost, another option would be to purchase an over-the counter generic night guard. There are “stock” night guards which come in small, medium and large. These night guards tend to be bulky, uncomfortable and hard. Their discomfort can lower patient compliance.

Another option is the boil and bite night guards. These tend to be more comfortable than the stock night guards, although damage due to biting pressures reduce the life of this type of guard. The night guard is boiled until the plastic softens, cooled enough so as not to burn the soft tissues, and then placed in the mouth. The patient is instructed to press against their lips to aid in overall formation. As it hardens, it conforms to the teeth for a better fit.

Figure 13. Boil and bite, back-cut night guard

Figure 13. Boil and bite, back-cut night guard

Courtesy of Dentemp.

Figure 14. Boil and bite night guard

Figure 14. Boil and bite night guard

Courtesy of Oral labs.

Figure 15: Anterior night guard

Figure 15: Anterior night guard

Courtesy of SmartGuard Rx Inc.

Some patients may have a learning curve period with an oral appliance. Many times, patients will wake up during the night or in the morning with the night guard out of their mouth. It is suggested the patient wear the appliance for short amounts of time throughout the day or right before bedtime. This will help the night guard not feel as foreign, make it easier to fall asleep and increase the chance it will remain in place all night.

Some patients have not worn night guards previously so may not know how a night guard should or shouldn’t fit. To determine a good fit of a night guard it should feel snug but not painful. The night guard should feel secure and not loose on the teeth. When the teeth come together it should not move. It should not rub on the gums or cheeks as it can cause soft tissue trauma.

A night guard should be flat or indented depending on the severity of grinding. A flat occlusal surface is meant for severe teeth grinders as there is less resistance when grinding which can lessen jaw pain. An indented occlusal surface is meant for light grinders and allows the teeth to rest naturally in occlusion. The indentions are designed to prevent or lower the act of grinding.

Insurance and Night Guards

While some insurances cover a portion of the cost of a night guard, many do not. Insurances are all so different depending on the insurance company and the plan the patient has.

Dental insurance codes that may apply:

• D7880 Occlusal Orthotic Device, by report: Presently includes splints provided for treatment of temporomandibular joint dysfunction.

• D7899 Unspecified TMD therapy: Used for procedure that is not adequately described by a code. Describe procedure.

• D8210 Removable Habit Appliance: Removable indicates patient can remove; includes appliances for thumb sucking or tongue thrusting.

• D9944 Occlusal guard-hard appliance, full arch: A removable dental appliance designed to minimize the effects of bruxism or other occlusal factors. Not to be reported for any type of sleep apnea, snoring, or TMD appliances.

• D9945 Occlusal guard-soft appliance-full arch: A removable dental appliance designed to minimize the effects of bruxism or other occlusal factors. Not to be reported for any type of sleep apnea, snoring, or TMD appliances.

• D9946 Occlusal Guard, by report: A removable dental appliance designed to minimize the effects of bruxism or other occlusal factors. Provides only partial occlusal coverage such as anterior deprogrammer. Not to be reported for any type of sleep apnea, snoring, or TMD appliances.

• For Medical Submission: CPT21110-52 Interdental Fixation Device/D7880 Orthotic Appliance.

HSA/FSA commonly cover night guards

Insurances who do offer coverage of night guards may need a detailed description of the reason of diagnosis along with radiographs and intra/oral pictures. Some descriptions to include in the narrative are:

• Multiple craze lines or fractures on teeth which may lead to future crowns, root canals or implants.

• The severity of the wear: a flattened cusp, dentin exposure, the amount of enamel left or gone, in some cases the size of the tooth, are they nubs now, has it affected the occlusion and bite.

• Chips or breaks: generalized or localized, frequency: at every appointment are there new ones and how many. To show a pattern.

• History of teeth: restoratives that were placed due to bruxism. Include crowns, class V fillings, root canals, implants, or bridges. As to prove a night guard is cheaper in the longer run.

• Periodontal conditions: bone loss, recession, any previous grafting, mobility of teeth.

• Tori: buccal or lingual, maxillary or mandibular, and size.

Advocating for the patient in providing everything that is clinically dental and even better if a picture can confirm it for insurance payment. Many patients will suffer because they cannot afford a decent night guard.

Patient acceptance of night guards

• Cash payment discounts will help with affordability.

• Helping the patient save their teeth, maintain restoratives and quality of life, relieve pain, and even improve sleep all through a night guard is satisfying.

• A night guard is an investment, and they are cheaper than a crown, root canal or implant and more comfortable than having a missing tooth.

• Mentioning the possibility of having to replace a crown, bridge or implant is motivation for acceptance.

Medications

Different medications have been prescribed by a physician or dentist to treat bruxism including benzodiazepines, anticonvulsants, beta-blockers, dopamine agents and muscle relaxants.

Anxiolytic (muscle relaxers) are prescribed for sedation and hypnotics to treat anxiety and insomnia. These drugs have a temporary effect on jaw muscle activity. The maintenance of their therapeutic efficacy is resourceful, however the long-term tolerability and risk of addiction could be harmful.⁴

Benzodiazepines have hypnotic, anti-anxiety, anticonvulsive and muscle relaxing effects. They affect the central nervous system and focus on the inhibitory neurotransmitter, mainly the GABA. The effects on the spine are mainly related to the muscle relaxing effect, while the action in the limbic system and cortical areas affect behaviors and emotions.⁴

Buspirone’s mechanism of action is based on its angonism for serotonergic receptors, interacting mainly with the 5-HT1A receptor, at both the presynaptic and postsynaptic levels. Its treatment in bruxism is owed to its anxiolytic action and its interaction with the serotonergic and dopaminergic systems.⁴

Antiepileptics (anticonvulsants) are prescribed for epilepsy and clinical management of orofacial pain such as idiopathic trigeminal and postherpetic neuralgia.⁴ The beneficial effects on neuromotor diseases, such as epilepsy, has led clinicians to test for the treatment of bruxism.

Gapapentin was studied and used for severe bruxism incurred by SSRI drugs and showed significant improvement.⁴

Clonazepam has evidence-based proof in managing sleep bruxism for the short-term. Its risks include addiction and mild respiratory depression.^29,33

Tiagabine is used for muscle spasms, neuropathic pain, anxiety and post-traumatic stress disorder. It inhibits the reuptake of the neurotransmitter GABA at the synaptic terminals. Besides its anticonvulsive actions, it increases the sleep stages 3 and 4, therefore, decreasing sleep bruxism. It is the only antiepileptic drug which helps increase the sleep stages.^4,29,57

Adrenergic antagonists and agonists are beta blockers that are prescribed for hypertension, ischemic cardiopathies and some arrhythmias.⁵⁵ These medications have shown a beneficial effect on bruxism–specifically the medications propranolol and clonidine. The hypothesis is these adrenergic antagonist drugs are useful in the clinical management of bruxism through the cardiac rhythm increasing during episodes of sleep bruxism. This suggests a possible relation between the activation of the sympathetic system and bruxism. Since tachycardia occurs in bruxism episodes, the data has strongly suggested a relationship between the autonomous nervous system and mechanisms of bruxism.²⁰

Propranolol has shown relief for bruxism. Clonidine’s pharmacological effect is generating changes in arterial pressure and heart rate. This medication decreases the sympathetic activity during sleeping and decreases sympathetic tone during the minutes preceding the onset of sleep bruxism.

Dopamine agents (agonists of dopaminergic receptors) are prescribed to activate dopamine receptors. Bromocriptine is a dopaminergic D2 agonist that works both at the central and peripheral levels. Small doses have proven to reduce bruxism, but in the study many participants abandoned the drug because of the side effects.⁴

Another Dopaminergic D1/D2 agonist is Pergolide (Prascend). This drug was used for severe bruxism and studied in patients prior to receiving dental implants. Studies showed a significant improvement in bruxism episodes lasting up to a year even with interrupted use.⁵³ This medication is no longer available in the US market due to a link of increased rates of valvular heart disease. It is still used in other countries for the treatment of Parkinson’s disease.⁵⁸

Acupuncture

Acupuncture is meant to re-align structural imbalances, reduce muscular tension, pain management and calm the nervous system. By unblocking the energy circuits that run through the jaw area, along with a general tonification of yin energy will usually do the trick. When dental pain is the issue, acupuncture treatment opens the channels toward the maxillary or mandibular jaw and soothes and detoxifies the meridians near the affected area, bringing pain relief.⁶⁵

CBD Oil

CBD (Cannabidoil) oil is a relatively new treatment used for many symptoms. Its effectiveness is still an item of debate in many medical communities. It is also illegal in some states, so be sure and check your state laws before use. It can be used as a natural alternative for treatment of pain and inflammation. CBD oil is derived from the cannabis plant and separated from the THC component, making it non-psychoactive. It produces effects in the body to target specific receptors in providing natural pain relief and anti-inflammatory properties. This should be used as a topical treatment for application to the painful areas including the jaw, TMJ and cheek muscles, to ease muscle tension and reduce inflammation. It should not be used intraorally. A side effect could be an interference of metabolism with medication or supplements — especially ones with a grapefruit warning. Medications that effect CBD oil are blood thinners, IV antibiotics, and medications where exact dosage is crucial and needs to be monitored.⁷⁰

Medical Marijuana

Cannabis may be a good alternate treatment for relieving bruxism, depending on the individual and the laws in your state. Cannabis helps to relieve depression, anxiety, and stress. It also can help in muscle relaxation and alleviating sleep disorders. Medical marijuana enables individuals to fall asleep quicker and stay asleep longer. The chemical compound in medical marijuana is cannabinoid. In low doses this can reduce motor activity which minimizes the jaw muscles from grinding and clenching. It also reduces inflammation and pain. Medical marijuana may have side effects depending on the individual and the strain used. Side effects may include: increased appetite, paranoia, lethargy, slow reaction time, dizziness, dry mouth, trouble thinking, impaired judgement, mood changes and increased heart rate.⁷¹

Massage

Grinding and clenching affects the masseter muscle the most often, since it is the largest and strongest muscle of the orofacial structure. When patients grind their teeth, it is usually the masseter muscle that is sore and inflamed. Massaging brings the circulation of the blood and nourishments to the muscles for healing while releasing the inflammation of the jaw, face, TMJ, neck, shoulders and upper back areas.⁶⁴

Other massage benefits are: decreasing muscle pain and tension, relieving anxiety, stress and tension, relaxing muscles, alleviating headaches, facilitating removal of waste and inflammation by-products, stimulating the immune system and promoting relaxation and comfort.⁶⁰

Chiropractic

Chiropractic treatments may help alleviate headaches, TMD, restricted opening of the mandible, jaw pain, tight masseter muscles, and ear pain that may be caused by bruxism. Bruxism is a reaction of spasms of the temporalis muscle. This muscle covers the side of the head and is important for chewing. While being upright the body can better compensate with the spasms. When lying down the body has a harder time compensating the spasm and relaxing the tight temporalis muscle, that moves the jaw back and forth, therefore grinding the teeth. Misalignment of the bones and spine can also provoke bruxism. Chiropractors can help with relief from the side effects of bruxism by helping relax the muscles and aligning the posture.⁶²

Botulinum toxin (Botox)

Botulinum toxin (Botox) can lessen bruxism’s effects. In an extremely diluted form, botulinum toxin is injected to weaken (partially paralyze) muscles and has been used extensively in cosmetic procedures to ‘relax’ the muscles of the face.⁶¹ Bruxism is regarded as a disorder of repetitive, unconscious contraction of the masseter muscle. In the treatment of bruxism, Botox weakens the muscle enough to reduce the effects of grinding and clenching, but not so much as to prevent proper use of the muscle. Although the intent of Botox injections is for the Botox to go into the muscle and not into the rest of the body, it has been shown some percentage of injected Botox winds up in the vascular system and migrates to other parts of the body. Botox treatment typically involves five or six injections into the masseter muscles.⁶² It takes a few minutes per side, and the patient usually starts feeling the effects the next day. Headaches and TMJ injuries could also be relieved with these injections.⁶¹

Biofeedback

Biofeedback is a treatment used to treat daytime clenchers by using electronic instruments to measure muscle activity and teach patients how to reduce muscle activity when the biting force becomes too great.⁴

Behavior Modification

Focusing on mouth position may help with bruxism that occurs while awake. Teeth should only touch when eating or swallowing. Practicing keeping teeth apart will train the mouth and brain muscles. Keep lips closed and teeth apart with tongue resting on the roof of the mouth just lingually of teeth #8 and #9. When the jaw starts to clench, drop the jaw down and hold to relax the muscles.

Another training technique involves holding the tongue between the teeth for a resting position and if clenching starts it will put pressure on the tongue to help stop the process.

Orthodontics

Malocclusion includes crowded, crooked, missing teeth, abnormal alignment of the teeth and/or the jaw, abnormally shaped teeth and an open bite. All these conditions may promote grinding. Teeth need to come together properly to function in a healthy manner, and when they don’t, issues arise such as grinding. If the maxillary and mandibular teeth are not functioning well together the body’s mission is to fix it. Grinding can adjust the teeth to make them feel the same and give the impression they are fitting well. If the reason for bruxism is malocclusion, then orthodontics can relieve the problem, by adjusting the bite and straightening the teeth for the top and the bottom teeth to work well together. Orthodontics also may help relieve TMJ issues correlated with bruxism. After completion of orthodontics wearing a night guard and using a retainer is important to help maintain the teeth’s position.⁶³

Exercise

Exercise helps relieve stress by increasing the immune and circulatory systems which helps with a peaceful night’s sleep and increases serotonin and dopamine. Hobbies for relaxation such as meditation or yoga can relieve bruxism tendencies.

Natural Remedies

A deficiency in certain vitamins can cause emotional stress and nutritional difficulties which may lead to bruxism.

Calcium and Magnesium

Some research states bruxism could be caused by deficiencies in magnesium and calcium. Magnesium’s vital role is in nerve and muscle function. A magnesium deficiency causes muscle spasms. Increasing magnesium intake will help relieve muscle tension. Calcium deficiency causes muscle cramps and involuntary movement of muscles, the facial muscles included. Increasing calcium levels will help with muscle cramps and support bone strength which can prevent bruxism by supporting neural development.⁶²

There are some recommended calming herbs such as Chamomile, Hops, Skullcap, and Valerian. These all have relaxing properties known to reduce anxiety and to help the body fall into a deeper sleep.⁶³ The use of essential oils, such as lavender and chamomile oil, may also promote a deep energizing sleep.

Vitamin C

Vitamin C is essential for making dopamine, which helps control smooth muscle movements. For this reason, may help reduce bruxing. Vitamin C is also used by the adrenal glands in their response to stress.

Vitamin B

Vitamin B5 treats common issues that promote bruxism. It helps reduce stress, hyperactivity, depression, and anxiety. B5, also, helps stimulate and regulate the adrenal glands. If the adrenal glands are compromised sleeping becomes restless and daytime fatigue is unbearable. These symptoms can cause an increase in poor lifestyle habits such as: increased smoking, alcohol use and caffeine and sugar intake to achieve that missing boost of energy.⁷²

Pillows

Bruxism can be caused by a variety of sources, but a pillow can help with positioning of the head and neck and lessen bruxism. Lying on the back is the best for relieving bruxism. Finding the right pillow to support and align the head, neck and jaw can be beneficial. Pillows geared specifically for bruxism and TMJD are meant to relieve pressure on your jaw and/or face, maintain a neutral sleep position with spinal support, and supports airway opening. Details to look for in a pillow are comfort that allows back sleeping and takes pressure off the jaw. Support to take pressure off the jaw and allows support for the jaw, neck and shoulders. Filling materials include memory foam, latex, feather, buckwheat, cotton and polyester. Choosing the right one for pressure is important to relieve jaw, neck, and shoulder pressure. Another factor is the firmness as there are different levels based on soft, moderate, and hard. Soft pillows are recommended for back and stomach sleepers.