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 long.”
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 family history.
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 bruxism.
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.