Partnering with dentists can help in diagnosis, management of bruxism
Anupama R.Tate, D.M.D., M.P.H. and Karen R.Fratantoni, M.D., M.P.H., FAAP
Focus on Subspecialties
Maggie, a 5-year-old nonverbal female with cerebral palsy, presents with her mother.
The mom believes her daughter has oral pain but cannot look in her mouth. The mother’s
chief complaint is “I’m at the end of my rope! My daughter grinds her teeth all night
Bruxism usually presents as clenching or grinding of teeth. It is defined as the involuntary,
habitual, nonfunctional forceful contact of teeth. Similar to chewing pencils, nails,
lips or cheeks, bruxism is a parafunctional oral habit, defined as the use of the
mouth for something other than the typical functions of eating, drinking or speech.
Bruxism has a highly variable prevalence and is equally common in boys and girls.
The incidence can be higher in children with developmental disabilities, autism, Down
syndrome or sleep disorders.
The loud grinding sound commonly occurring in bruxism typically occurs while sleeping
and is classified as a sleep-related movement disorder. Bruxism during wakefulness
is rare, and when it does occur, generally produces little or no audible sound.
Bruxism can be temporary or intermittent, making the diagnosis challenging.
Importance of history, physical exam
When bruxism is suspected, the pediatrician should take a thorough history, including
Bruxism is a multifactorial process that includes oral-motor activities, sleep-wake
cycle regulation, and hereditary and psychosocial influences.
The pediatrician can ask the parents about psychological factors, including tension
related to stress or anger and post-traumatic stress disorder.
Systemic factors associated with bruxism include sleep-disordered breathing due to
brain injury, obstructive sleep apnea and tonsil/adenoid hypertrophy. Of the associated
sleep symptoms and disorders, obstructive sleep apnea has the highest risk factor
for bruxism. Therefore, parents should be asked about a history of snoring and mouth
breathing. Asthma, allergies and some medications also have been linked.
Based on self-reports, many children with sleep bruxism have an immediate family member
who experienced bruxism as a child. Therefore, families should be asked if anyone
else in the family grinds their teeth.
Does the family have a dental home?
Dental factors have a role in approximately 10% of cases.
Inquire if the family has a dental home and if not, help them find one. A thorough
dental history and exam can be helpful in the diagnosis.
A dentist will investigate dental factors, including malocclusion of the dentition,
poorly adjusted (too high) fillings or crowns, or a sharp tooth cusp causing interference.
Muscle tenderness or spasm can be present in the lateral pterygoids or the medial
pterygoids and masseters. Patients often report limitations of mandibular range of
motion, trismus or muscle spasm, frequent headache and parasomnias.
A dentist may ask about temporomandibular joint symptoms of pain, clicking and popping
when opening or closing.
The dentist also can follow changes in tooth wear or note broken fillings, which is
important in understanding disease progression. Gingival inflammation leading to periodontal
diseases (alveolar bone loss) can be a sign of bruxism severity.
Inform caregivers that palliative treatment of symptoms is the first approach. Warm
compresses to soothe sore muscles can be offered. Analgesics or anti-inflammatory
medications may help with muscle pain. Children with special health care needs who
have chronic bruxism habits often are managed with palliative treatment.
Patient education including identifying sources of stress is important. Meditation,
music therapy and biofeedback exercises can benefit patients. Depending on the type
of comorbidities or diagnoses, counseling/psychotherapy have been recommended.
Patients should be advised to avoid chewing gum, take care while opening wide and
to take small bites of food.
A multidisciplinary team approach that includes a dentist is best. The dentist can
fabricate a plastic bite guard for older children and adolescents to help slow the
progression of tooth wear.
Case reports of treatment with custom-fitted mouthguards or botulinum toxin injection
are noted in the literature. The risks and potential benefits of these approaches
would need to be considered.
Importantly, irreversible procedures should be avoided. The literature does not support
dental tooth adjustment, which is the grinding of tooth cusp tips to balance the occlusion.
Tonsillectomy and adenoidectomy have been reported as treatments that can improve
bruxism in patients who have obstructive respiratory symptoms; however, these procedures
should be performed to address the underlying diagnosis and not for improvement in
Finally, the pediatrician can ease the family’s mind by letting them know that bruxism
peaks in early childhood and decreases as children grow older.
Dr. Tate is a member of the AAP Section on Oral Health Executive Committee. Dr. Fratantoni
is medical director of the Complex Care Program at Children's National Medical Center
and assistant professor of pediatrics at George Washington University School of Medicine.