The Effects of the COVID-19 Pandemic on Bruxism
During the COVID-19 pandemic, dentists and their patients were in uncharted waters. Patients faced social isolation, economic concerns and health worries. They suffered from loneliness, which produces stress-related hormones and increases the risk of emotional disorders.1
“Patients were also eating more of the wrong things, such as sugary, crunchy foods, or chewing on ice. People were home more and lost the distinction between home time and office time,” said Saul M. Pressner, DMD, FAGD, who practices in Manhattan, New York.
The uncertainty and loss of control led to stress and anxiety, which can negatively impact oral health. A 2021 report in Cranio on psychological status and bruxism during the pandemic concluded that almost half of the subjects reported an increase in bruxism, and about one-third indicated an increase in temporomandibular disorder (TMD) symptoms.2 Out of 506 participants, 36% reported an increase in temporomandibular joint (TMJ) pain, 32.2% reported an increase in facial muscle pain and almost 50% reported more frequent migraines and/or headaches.2
More Cases of Bruxism and Broken Teeth
Per an American Dental Association (ADA) survey, 59.3% of dentist respondents reported seeing an increase in bruxism, 55.9% saw an increase in chipped teeth, 56.6% saw an increase in cracked teeth, 52.5% saw an increase in TMD symptoms, and 35.8% saw an increase in dental caries during COVID-19.3
Some of the tooth decay may have come from xerostomia (dry mouth). “When people wear masks, they tend to breathe more through the mouth, which causes dry mouth,” said Jeffrey W. Lineberry, DDS, FAGD, Carolina Center for Comprehensive Dentistry, Mooresville, North Carolina.
In the early stages of the pandemic, dentists could only treat emergencies, place temporaries and prescribe antibiotics; no aerosol-generating procedures were permitted in order to limit droplet formation. Dentists noticed more cases of broken restorations and bruxism. Even nonrestored teeth were cracking.
“I have seen a threefold increase in bruxism during COVID-19. It affects all age groups,” said Mark G. Sayeg, DDS, FAGD, Start Smiling Dental, Sandy Springs, Georgia. “My belief is that people are very stressed and don’t have anyone to really blame, so they are internalizing their feelings.”
Pressner reports nearly 50% of his patients who’ve come in since the COVID-19 pandemic began have started to have TMJ discomfort or broken teeth. And he’s been making more nightguards for patients due to bruxism.
“We had a 15% increase in patients with bruxism compared to years prior,” said Arthur R. Volker, DDS, FAGD, Dent Care Dental LLC, Sunnyside, New York.
Bruxism Symptoms
Symptoms of bruxism include tooth wear, jaw pain, neck aches, headaches and earaches. Bruxism can cause cracked teeth, chipped restorations and tenderness in the mastication muscles.
“What I have seen is an increase in the incidence of sleep disordered breathing, which can then manifest as bruxism. Years ago, we were taught that bruxism was a nighttime activity, but now we know that bruxism is more of a daytime habit that sets you up for doing it at night. I have a mature practice, so I see everyone from two-year-old children to 90-year-old adults,” said Francis A. Bertolini, DDS, FAGD, whose practice is in North Canton, Ohio.
Patients may clench while concentrating on activities, such as driving or working on the computer. A 2016 pre-COVID-19 article reported that awake bruxism was present in 22.1%–31% of adults and sleep bruxism was present in 13% of adults.4
“The majority of patients don’t know they are grinding. I see patients who have severe bruxism and are completely unaware, and their spouses have never even heard them,” Lineberry said.
Most sleep bruxism occurs during light non-rapid eye movement (REM) sleep, with 10% occurring during REM sleep.5 “Either way, it is harmful. You can put hundreds of pounds of pressure on the second molar when you are bruxing,” Bertolini said.
Diagnosing Bruxism
Observation and questioning the patient leads to diagnosis. Scalloped tongue, sensitive teeth and difficulty opening the mouth are some signs of bruxism.
“We see wear on their teeth from the grinding as well as abfraction, which is cervical breakdown of dental tissue at the gum line from clenching. The temporomandibular muscles are also sore,” said Sayeg.
Dentists generally use the same modalities they used to treat bruxism prior to COVID-19, but they may change the way they approach patient visits.
“Most patients who come in are more anxious than prior to the pandemic. They are much more sensitized and feel vulnerable. My approach to treating patients has involved more empathy, understanding and listening,” said Pressner.
Appliances and Other Treatments
A customized hard acrylic appliance can reduce bruxism symptoms. The appliances, also called nightguards or bite guards, are cost efficient and noninvasive. They can be fabricated to cover a patient’s top or bottom teeth. Patients may tolerate lower appliances better and can wear them during the day, but upper appliances are more common.
“Clinical findings determine the approach. One needs to examine a patient and perform a thorough history. Fabricating an appliance is one approach. About half of the dental plans cover appliances, and these devices can also help prevent further dental issues,” Pressner said.
Typically, the dentist makes a mold or impression of the patient’s teeth, sends that impression to a lab and receives a custom appliance in one to two weeks.
Volker’s office has an intraoral scanner that can scan a patient’s teeth and check for wear. The 3Shape Unite platform lets him overlay scans to see changes in surface topography over time. His colleague, Aadel Soleymani, DDS, makes a custom nightguard from a durable plastic resin using a 3D printer. He then delivers it to the patient in the waiting room within 90 minutes.
“It is not more expensive to the patient — the investment is to the dentist in the way of materials. There are fewer steps, an easy workflow to the design and an excellent return on investment. All that comes off the printer is the actual mouthguard. Traditionally, cast is made first, then a thermoplastic material is vacuum- or pressure-fit over the cast and hand-trimmed to the appropriate shape. Directly printing the mouthguard saves a tremendous amount of time and is typically more accurate than the conventional method. It fits beautifully, and it is very smooth,” said Volker.
Bertolini intercedes with a diagnostic appliance called an anterior jig. The appliance typically covers the maxillary central incisors and is worn for seven to 10 days. He also uses another appliance, a cushioned, water-filled bag, which can help to deprogram the bite. If those two devices help, he educates the patient or makes a simple bite appliance.
“We are not meant to have a piece of plastic in our mouths our whole lives. With the patient’s help — maybe lifestyle, habit or nutrition changes — we can titrate them away from the appliance. For a lot of people, you can make their dentition their appliance. This can lead to recontouring teeth, occlusal equilibration, and/ or reshaping of existing teeth by the addition of material, such as composites,” Bertolini explained.
As far as other alternatives, a soft diet and warm compress can help patients with jaw discomfort. An oral surgeon can prescribe a muscle relaxant like cyclobenzaprine or inject botulinum toxin (Botox®) into the mastication muscles.
“The problem with Botox is the effects of the injection only last about three months,” said Sayeg.
Addressing the Root Causes
In his courses as Spear Education visiting faculty, Lineberry tells dentists, “We should try to figure out the etiology of bruxism and then address that. The appliance will not stop it, but it will prevent teeth from wearing together. The other thing is that some patients who have bruxism also have signs of TMDs. They are all kind of tied together.”
Bruxism cases are multifactorial. If a patient clenches and grinds their teeth at night, a sleep study should be considered to rule out any sleep-related breathing disorders. An open bite may be a factor, too.
“I do not think an abnormal bite is a main contributor, but it is one of the things that exacerbates a case of bruxism. I think skeletal type and the maxillo-mandibular relationship matter. We are talking malocclusion. We are talking jaw size. We are talking maybe a narrow palate and retruded mandible. Airway, adenoid, intranasal health — all of that is involved,” said Bertolini.
Anxiolytic medicines and antidepressants can cause bruxism. A high-sugar diet can cause flora and dietary changes, which contribute to bruxism as well. “There is a strong relationship between stress and microbiome and diet and the effects on the gastrointestinal system,” Lineberry said.
Patients may wish to take magnesium for optimal enzymatic activity and muscle function. Vitamin D prevents decay and periodontal disease, and some studies suggest a connection between vitamin D deficiency and the etiology of temporomandibular disorders, meaning supplementation may be beneficial for patients with these disorders.6
“The most cost-efficient approach for bruxism is education. For instance, if a patient has a lot of stress and they manage the stress, that is best. I would say exercises like running, cardio, walking and yoga are stress-relieving. As far as apps like Calm, I think there is some validity to those,” said Lineberry.
Seeing a therapist can be helpful to patients. Biofeedback, which trains patients to control their skeletal musculature, can be worthwhile. Stress management can help both patients and dentists. Meditation can be valuable.
“I like Jon Kabat-Zinn, who founded the Center for Mindfulness at the University of Massachusetts Memorial Health Center. I have his CDs, which are helpful in learning meditation techniques,” said Pressner, who meditates for half an hour per day. “As dentists, we also have to nurture ourselves. Just as patients are under more stress, we as dentists are as well. We also have to practice good self-care in order to best be present for our patients.”
Sarah Louise Klose is a freelance writer based in Chicago. To comment on this article, email impact@agd.org.
References
1. Leland, John. “How Loneliness Is Damaging Our Health.” The New York Times, 20 April 2022, nytimes.com/2022/04/20/nyregion/loneliness-epidemic.html. Accessed 9 May 2022.
2. Colonna, Anna, et al. “COVID-19 Pandemic and the Psyche, Bruxism, Temporomandibular Disorders Triangle.” Cranio: The Journal of Craniomandibular Practice, 15 Oct 2021, pp. 1-6.
3. “Economic Outlook and Emerging Issues in Dentistry. Week of February 14, 2022.” American Dental Association Health Policy Institute, ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/feb2022_hpi_economic_outlook_dentistry_report_main.pdf?rev=7b4f0b57356341b6b7d637122b4920cb&hash=890D98FF67473CBF 182159E13E4FC772.
4. Yap, Adrian U., and Ai Ping Chua. “Sleep Bruxism: Current Knowledge and Contemporary Management.” Journal of Conservative Dentistry, vol. 19, no. 5, 2016, pp. 383-389.
5. Klasser, Gary D., et al. “Sleep Bruxism Etiology: The Evolution of a Changing Paradigm,” Journal of the Canadian Dental Association, vol. 81, 2015, p. f2.
6. Kui, Andreea, et al. “Vitamin D and Temporomandibular Disorders: What Do We Know So Far?” Nutrients, vol. 13, no. 4, 2021, p. 1286.
“Patients were also eating more of the wrong things, such as sugary, crunchy foods, or chewing on ice. People were home more and lost the distinction between home time and office time,” said Saul M. Pressner, DMD, FAGD, who practices in Manhattan, New York.
The uncertainty and loss of control led to stress and anxiety, which can negatively impact oral health. A 2021 report in Cranio on psychological status and bruxism during the pandemic concluded that almost half of the subjects reported an increase in bruxism, and about one-third indicated an increase in temporomandibular disorder (TMD) symptoms.2 Out of 506 participants, 36% reported an increase in temporomandibular joint (TMJ) pain, 32.2% reported an increase in facial muscle pain and almost 50% reported more frequent migraines and/or headaches.2
More Cases of Bruxism and Broken Teeth
Per an American Dental Association (ADA) survey, 59.3% of dentist respondents reported seeing an increase in bruxism, 55.9% saw an increase in chipped teeth, 56.6% saw an increase in cracked teeth, 52.5% saw an increase in TMD symptoms, and 35.8% saw an increase in dental caries during COVID-19.3
Some of the tooth decay may have come from xerostomia (dry mouth). “When people wear masks, they tend to breathe more through the mouth, which causes dry mouth,” said Jeffrey W. Lineberry, DDS, FAGD, Carolina Center for Comprehensive Dentistry, Mooresville, North Carolina.
In the early stages of the pandemic, dentists could only treat emergencies, place temporaries and prescribe antibiotics; no aerosol-generating procedures were permitted in order to limit droplet formation. Dentists noticed more cases of broken restorations and bruxism. Even nonrestored teeth were cracking.
“I have seen a threefold increase in bruxism during COVID-19. It affects all age groups,” said Mark G. Sayeg, DDS, FAGD, Start Smiling Dental, Sandy Springs, Georgia. “My belief is that people are very stressed and don’t have anyone to really blame, so they are internalizing their feelings.”
Pressner reports nearly 50% of his patients who’ve come in since the COVID-19 pandemic began have started to have TMJ discomfort or broken teeth. And he’s been making more nightguards for patients due to bruxism.
“We had a 15% increase in patients with bruxism compared to years prior,” said Arthur R. Volker, DDS, FAGD, Dent Care Dental LLC, Sunnyside, New York.
Bruxism Symptoms
Symptoms of bruxism include tooth wear, jaw pain, neck aches, headaches and earaches. Bruxism can cause cracked teeth, chipped restorations and tenderness in the mastication muscles.
“What I have seen is an increase in the incidence of sleep disordered breathing, which can then manifest as bruxism. Years ago, we were taught that bruxism was a nighttime activity, but now we know that bruxism is more of a daytime habit that sets you up for doing it at night. I have a mature practice, so I see everyone from two-year-old children to 90-year-old adults,” said Francis A. Bertolini, DDS, FAGD, whose practice is in North Canton, Ohio.
Patients may clench while concentrating on activities, such as driving or working on the computer. A 2016 pre-COVID-19 article reported that awake bruxism was present in 22.1%–31% of adults and sleep bruxism was present in 13% of adults.4
“The majority of patients don’t know they are grinding. I see patients who have severe bruxism and are completely unaware, and their spouses have never even heard them,” Lineberry said.
Most sleep bruxism occurs during light non-rapid eye movement (REM) sleep, with 10% occurring during REM sleep.5 “Either way, it is harmful. You can put hundreds of pounds of pressure on the second molar when you are bruxing,” Bertolini said.
Diagnosing Bruxism
Observation and questioning the patient leads to diagnosis. Scalloped tongue, sensitive teeth and difficulty opening the mouth are some signs of bruxism.
“We see wear on their teeth from the grinding as well as abfraction, which is cervical breakdown of dental tissue at the gum line from clenching. The temporomandibular muscles are also sore,” said Sayeg.
Dentists generally use the same modalities they used to treat bruxism prior to COVID-19, but they may change the way they approach patient visits.
“Most patients who come in are more anxious than prior to the pandemic. They are much more sensitized and feel vulnerable. My approach to treating patients has involved more empathy, understanding and listening,” said Pressner.
Appliances and Other Treatments
A customized hard acrylic appliance can reduce bruxism symptoms. The appliances, also called nightguards or bite guards, are cost efficient and noninvasive. They can be fabricated to cover a patient’s top or bottom teeth. Patients may tolerate lower appliances better and can wear them during the day, but upper appliances are more common.
“Clinical findings determine the approach. One needs to examine a patient and perform a thorough history. Fabricating an appliance is one approach. About half of the dental plans cover appliances, and these devices can also help prevent further dental issues,” Pressner said.
Typically, the dentist makes a mold or impression of the patient’s teeth, sends that impression to a lab and receives a custom appliance in one to two weeks.
Volker’s office has an intraoral scanner that can scan a patient’s teeth and check for wear. The 3Shape Unite platform lets him overlay scans to see changes in surface topography over time. His colleague, Aadel Soleymani, DDS, makes a custom nightguard from a durable plastic resin using a 3D printer. He then delivers it to the patient in the waiting room within 90 minutes.
“It is not more expensive to the patient — the investment is to the dentist in the way of materials. There are fewer steps, an easy workflow to the design and an excellent return on investment. All that comes off the printer is the actual mouthguard. Traditionally, cast is made first, then a thermoplastic material is vacuum- or pressure-fit over the cast and hand-trimmed to the appropriate shape. Directly printing the mouthguard saves a tremendous amount of time and is typically more accurate than the conventional method. It fits beautifully, and it is very smooth,” said Volker.
Bertolini intercedes with a diagnostic appliance called an anterior jig. The appliance typically covers the maxillary central incisors and is worn for seven to 10 days. He also uses another appliance, a cushioned, water-filled bag, which can help to deprogram the bite. If those two devices help, he educates the patient or makes a simple bite appliance.
“We are not meant to have a piece of plastic in our mouths our whole lives. With the patient’s help — maybe lifestyle, habit or nutrition changes — we can titrate them away from the appliance. For a lot of people, you can make their dentition their appliance. This can lead to recontouring teeth, occlusal equilibration, and/ or reshaping of existing teeth by the addition of material, such as composites,” Bertolini explained.
As far as other alternatives, a soft diet and warm compress can help patients with jaw discomfort. An oral surgeon can prescribe a muscle relaxant like cyclobenzaprine or inject botulinum toxin (Botox®) into the mastication muscles.
“The problem with Botox is the effects of the injection only last about three months,” said Sayeg.
Addressing the Root Causes
In his courses as Spear Education visiting faculty, Lineberry tells dentists, “We should try to figure out the etiology of bruxism and then address that. The appliance will not stop it, but it will prevent teeth from wearing together. The other thing is that some patients who have bruxism also have signs of TMDs. They are all kind of tied together.”
Bruxism cases are multifactorial. If a patient clenches and grinds their teeth at night, a sleep study should be considered to rule out any sleep-related breathing disorders. An open bite may be a factor, too.
“I do not think an abnormal bite is a main contributor, but it is one of the things that exacerbates a case of bruxism. I think skeletal type and the maxillo-mandibular relationship matter. We are talking malocclusion. We are talking jaw size. We are talking maybe a narrow palate and retruded mandible. Airway, adenoid, intranasal health — all of that is involved,” said Bertolini.
Anxiolytic medicines and antidepressants can cause bruxism. A high-sugar diet can cause flora and dietary changes, which contribute to bruxism as well. “There is a strong relationship between stress and microbiome and diet and the effects on the gastrointestinal system,” Lineberry said.
Patients may wish to take magnesium for optimal enzymatic activity and muscle function. Vitamin D prevents decay and periodontal disease, and some studies suggest a connection between vitamin D deficiency and the etiology of temporomandibular disorders, meaning supplementation may be beneficial for patients with these disorders.6
“The most cost-efficient approach for bruxism is education. For instance, if a patient has a lot of stress and they manage the stress, that is best. I would say exercises like running, cardio, walking and yoga are stress-relieving. As far as apps like Calm, I think there is some validity to those,” said Lineberry.
Seeing a therapist can be helpful to patients. Biofeedback, which trains patients to control their skeletal musculature, can be worthwhile. Stress management can help both patients and dentists. Meditation can be valuable.
“I like Jon Kabat-Zinn, who founded the Center for Mindfulness at the University of Massachusetts Memorial Health Center. I have his CDs, which are helpful in learning meditation techniques,” said Pressner, who meditates for half an hour per day. “As dentists, we also have to nurture ourselves. Just as patients are under more stress, we as dentists are as well. We also have to practice good self-care in order to best be present for our patients.”
Sarah Louise Klose is a freelance writer based in Chicago. To comment on this article, email impact@agd.org.
References
1. Leland, John. “How Loneliness Is Damaging Our Health.” The New York Times, 20 April 2022, nytimes.com/2022/04/20/nyregion/loneliness-epidemic.html. Accessed 9 May 2022.
2. Colonna, Anna, et al. “COVID-19 Pandemic and the Psyche, Bruxism, Temporomandibular Disorders Triangle.” Cranio: The Journal of Craniomandibular Practice, 15 Oct 2021, pp. 1-6.
3. “Economic Outlook and Emerging Issues in Dentistry. Week of February 14, 2022.” American Dental Association Health Policy Institute, ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/feb2022_hpi_economic_outlook_dentistry_report_main.pdf?rev=7b4f0b57356341b6b7d637122b4920cb&hash=890D98FF67473CBF 182159E13E4FC772.
4. Yap, Adrian U., and Ai Ping Chua. “Sleep Bruxism: Current Knowledge and Contemporary Management.” Journal of Conservative Dentistry, vol. 19, no. 5, 2016, pp. 383-389.
5. Klasser, Gary D., et al. “Sleep Bruxism Etiology: The Evolution of a Changing Paradigm,” Journal of the Canadian Dental Association, vol. 81, 2015, p. f2.
6. Kui, Andreea, et al. “Vitamin D and Temporomandibular Disorders: What Do We Know So Far?” Nutrients, vol. 13, no. 4, 2021, p. 1286.