March 18, 2009

Economic Grind

The financial meltdown is setting people’s teeth on edge—literally. Dentists are seeing an uptick in nighttime grinding, and chipped and broken teeth and painful jaws are just a few of the symptoms

By Jacqueline Mitchell

Stock market sent you into a swoon? From causing headaches to heart disease, stress makes us sick. And one of the most common ways we respond to anxiety is sleep bruxism, the unconscious nighttime tooth grinding or clenching that can cause serious damage to oral and overall health.

Though there isn’t yet data documenting an uptick in bruxism related to the recent economic turmoil, “we do know that heightened anxiety and/or depression can affect tooth grinding,” says Noshir Mehta, DG73, DI77, director of the craniofacial pain center at the Tufts School of Dental Medicine.

Illustration: Dan Page

At his Manhattan practice, Andrew Kaplan, D80, a temporomandibular joint (TMJ) specialist, has noticed an increase in bruxism-related complaints, especially in men. Traditionally, women experience bruxism four or five times as often as men. Lately, though, the men are catching up.

“It’s anecdotal,” Kaplan says, “but I think it speaks to people who have either lost their jobs or are worried about losing their jobs, and we certainly have a lot of bankers as patients in Manhattan.”

Most people will grind their teeth at some point during their lives, but because the clenching and grating happens mainly during sleep, most patients are unaware they do it. Unless a significant other complains about the nightly noise—which Mehta likens to listening to someone chewing ice chips or chomping on crackers in bed—it’s often a dentist who identifies bruxism, which is categorized as a sleep disorder.

“People who wake up with headaches should be examined by a dentist,” says Mehta, who lists neck or jaw pain, tooth sensitivity and ringing of the ears among the other telltale signs of bruxism.

A simple visual exam for distinctive patterns of wear on the teeth (the tooth edges actually flatten) and palpating the jaw to detect tight muscles is usually enough to diagnose bruxism. In rare cases, Mehta has used a sound-triggered tape recorder or observed a patient in a sleep lab to confirm the diagnosis.

And a Dose of Valium…

Patients who clench or grind their teeth may exert as much as 250 pounds per square inch of pressure on their teeth, gums and jaws, resulting in chipped or broken teeth, gingivitis and receding gum lines. If the bruxing continues, patients can develop arthritis and inflammation, and the temporomandibular joint in the jaw can start to degenerate.

Preventing initial damage to oral tissues is usually a dentist’s first priority.

Kaplan, a former president of the American Academy of Orofacial Pain, distinguishes between episodic grinders, who brux in response to a life transition such as moving, getting married or losing a job, and intractable grinders, for whom the behavior seems “hard-wired into the system.”

For an episodic grinder, Kaplan, who is also an associate clinical professor at Mount Sinai School of Medicine and an associate attending at Mount Sinai Medical Center, will create an appliance to “get them through this period without hurting themselves.” A custom-fitted night guard will keep the teeth apart during grinding and redistribute the forces that can be so destructive to the teeth, gums and jaw muscles. Nightly use will also help relax clenched jaw muscles in about 80 percent of patients, Kaplan says, reducing further grinding.

Night guards are also a first line of defense for intractable grinders. “These people are really destroying their teeth,” he says. “An appliance at the very least prevents that.” Then Kaplan may prescribe a course of physical therapy focused on relaxing the jaw muscles through stretching, massage and ultrasound. Medication, including muscle relaxants to prevent grinding and anti-inflammatories like ibuprofen to stave off discomfort and damage to the TMJ, may be in order.

While stress is known to trigger bruxism in many people, so are some of the most common remedies for anxiety and depression. Some selective serotonin re-uptake inhibitors (SSRIs) like Prozac have been found to cause grinding, as have some herbal remedies and even small quantities of alcohol. For his patients using SSRIs, Kaplan works closely with the prescribing psychiatrist to find a more suitable medication. Kaplan is treating one patient who grinds to cope with her pre-nuptial jitters with a low dose of Valium. “It’s an old medication, but it works nicely,” he says. Mehta also advocates stress reduction techniques, including biofeedback and relaxation training.

It’s Not Just Stress

Oral orthopedist Harold Gelb, D47, argues that dentists focus too much on stress as the cause of bruxism. A former president of the American Equilibration Society and the American Academy of Orofacial Pain, Gelb believes that grinding and clenching is orthopedic in nature, resulting from misaligned jaws as well as muscles in the head and neck.

The founder of Tufts’ Gelb Craniomandibular and Orofacial Pain Center, Gelb analyzes three-dimensional images of a patient’s jaw to determine the exact misalignment, which he corrects with a specialized night guard invented by his son, Michael, who practices with him in New York City. The appliance was designed to reduce snoring by keeping the tongue and jaw properly aligned. It also relieves TMJ disorders and prevents grinding. “The moment they put it in, they stop hurting, and the muscles become stronger,” says Gelb.

But whether orthopedic misalignment or tension is at the root of bruxism, Gelb, Kaplan and Mehta agree that each case demands comprehensive and specific care. “All patients need to be worked up properly, and a proper diagnosis needs to be made,” says Kaplan. “We can’t just label patients as a TMJ case when it might be a much more complex problem.”

Mehta agrees: “If you can target a patient’s individual behavior, then you can reduce grinding significantly, if not eliminate it completely.”

So if the roller-coaster economy has you gnashing your teeth at night, see your dentist. And then relax. Kaplan recalls a more severe increase in bruxism in his patients in the aftermath of the terrorist attacks on September 11. “It was an extremely stressful time, but complaints died down within three or four months. People tend to adapt to change.”

This story first appeared in the Winter 2009 issue of Tufts Dental Medicine magazine.

Jacqueline Mitchell can be reached at

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