Sleep Bruxism and OSA

Bruxism, the involuntary grinding or clenching of teeth, can present as awake bruxism, sleep bruxism, or in both situations (combined bruxism). Awake bruxism is often linked to stress, anxiety, or habits like jaw clenching while concentrating. In contrast, sleep bruxism happens during the night, characterized by rhythmic jaw muscle activity that occurs unconsciously.

Sleep bruxism has a complex set of causes, involving neurological, physiological, and sleep-related factors. About 8 percent to 10 percent of adults in the general population report having sleep bruxism.¹

That percentage is thought to be significantly higher in individuals with obstructive sleep apnea (OSA). A 2023 prospective cross-sectional study of more than 900 patients found that nearly 50 percent of adults with OSA had comorbid sleep bruxism.²

Research suggests that sleep bruxism and OSA frequently coexist and influence each other in ways that can significantly disrupt sleep and health. Yet, the literature also suggests a large number of individuals with OSA are unaware that they have sleep bruxism.²

This presents dental professionals and sleep specialists with an important opportunity to educate patients about the common prevalence of sleep bruxism in individuals with OSA and the negative impact on health due to the interaction between these two sleep-related disorders.

In this article, we’ll dig deeper into the causes of sleep bruxism, the effects of the condition if left untreated, and effective remedies to treat this sleep-related movement disorder, particularly the role of advanced oral appliances in managing both sleep bruxism and OSA.

Causes of Sleep Bruxism

Sleep bruxism arises from a combination of psychological, physiological, and external factors rather than a singular cause.

Studies have indicated that it likely has hereditary components. While estimates vary, as many as 50 percent of individuals with sleep bruxism have reported at least one family member with the condition.³

Anatomically, dental and structural influences can also play a part. Malocclusion (misaligned teeth) or a poorly balanced bite can lead to grinding as the jaw attempts to find a comfortable position.

Neurological and sleep-related factors are also heavily involved. Sleep bruxism is a motor activity influenced by the central nervous system. Research suggests that it often occurs during transitions between light sleep and REM sleep, triggered by micro-arousals.

Although sleep bruxism is less directly tied to emotional stress than awake bruxism, it can be exacerbated by underlying psychological conditions such as depression or post-traumatic stress disorder (PTSD). Certain medications, such as selective serotonin reuptake inhibitors (SSRIs), have also been linked to increased bruxism, along with alcohol and stimulants like caffeine and nicotine.

Coexisting sleep disorders like OSA, insomnia, or restless leg syndrome can amplify bruxism.  An epidemiological study of sleep bruxism and risk factors in the general population found that patients with sleep-disordered breathing have a higher number of risk factors for sleep bruxism.⁴

OSA often triggers bruxism as the body reflexively clenches the jaw to stabilize the airway. This feedback loop can lead to fragmented sleep, fatigue, and oral health complications, such as tooth damage and temporomandibular joint (TMJ) pain.⁵

Effects of Untreated Sleep Bruxism

Sleep bruxism impacts oral health, jaw function, and overall well-being in several ways:¹

• Tooth damage: The constant grinding and clenching of teeth lead to enamel wear, increased sensitivity, and a higher risk of cavities. Severe bruxism can cause fractures, chipping, and even loss of teeth. Dental restorations such as crowns and veneers are particularly vulnerable.
• TMJ disorders: The temporomandibular joint (TMJ) endures immense pressure during bruxism episodes, leading to jaw pain, stiffness, and dysfunction. Symptoms often include difficulty opening or closing the mouth, clicking or popping sounds, and radiating pain to the head, neck, and shoulders.
• Systemic fatigue: Sleep bruxism disrupts sleep architecture, causing fatigue, reduced focus, and daytime sleepiness. Chronic sleep disruptions may contribute to mood disorders, impaired memory, and cardiovascular stress.
• Headaches and migraines: Bruxism often results in tension-type headaches or migraines due to prolonged muscle strain in the jaw and surrounding areas.
• Sleep disturbances: Frequent micro-arousals caused by bruxism prevent restorative sleep, further compounding fatigue and health issues.

Diagnosing Bruxism

As outlined by the International Classification of Sleep Disorders, Third Edition, Text Revision (ICSD-3-TR), the diagnostic criteria for sleep bruxism includes:⁶

• Repetitive jaw-muscle activity characterized by grinding or clenching of the teeth during sleep.
• The presence of one or more of the following clinical signs or symptoms consistent with the above reports of tooth grinding or clenching during sleep:
  • Abnormal tooth wear.
  • Transient morning jaw muscle pain or fatigue, or temporal headache.

A dentist will provide a diagnosis of bruxism after a physical exam and a review of symptoms. In some cases, polysomnography (PSG) or home sleep testing (HST) with electromyography (EMG) sensors on the masseter and temporalis is required for a differential diagnosis of sleep bruxism. (See Figure 1.)

This polysomnographic recording captured a 30-second epoch showing a tonic sleep bruxism episode in a patient who’s been diagnosed with sleep bruxism

Common Treatments for Bruxism

Given the number of contributing factors and causes of bruxism, managing this chronic condition requires a multifaceted approach that addresses both symptoms and underlying causes.Treatment strategies typically involve a combination of behavi

oral approaches and lifestyle modifications to reduce muscle activity, protective measures to prevent dental damage, and interventions to address root causes.

Behavioral Approaches

Behavioral strategies focus on reducing stress and teaching relaxation techniques to decrease muscle activity in the jaw.

• Stress management: Techniques such as mindfulness meditation, progressive muscle relaxation, and yoga can help patients manage stress and reduce daytime clenching.
• Biofeedback therapy: Wellness devices like ClenchAlert^®, intended for awake clenching and grinding use biofeedback to remind users to relax their jaw muscles. ClenchAlert vibrates when excessive clenching is detected, prompting the wearer to relax their jaw. Over time, this real-time feedback fosters awareness and can help break the habit of clenching. A 2019 systematic review of 10 papers found that patients with sleep bruxism have also been shown to respond to nightly use of biofeedback devices to treat bruxism.⁷ . There is still a need for more clinical investigation of biofeedback for sleep bruxism.
• Sleep hygiene: Improving sleep routines, such as maintaining consistent sleep schedules and avoiding stimulants before bed, can also minimize sleep bruxism episodes.

Protective Strategies

Dentist-made night guards are an excellent first-line defense and proven method to protect teeth from damage during sleep bruxism. These custom-fitted devices act as a physical barrier, preventing tooth wear and fractures. However, they do not address the underlying causes of the condition. Night guards are primarily designed to reduce damage rather than stop bruxism itself.

Advanced Therapy Options

While protective strategies and behavioral approaches can help manage bruxism, some patients may require additional interventions to relieve symptoms and prevent long-term complications. These options can be particularly beneficial for individuals with persistent or severe bruxism that does not fully respond to first-line treatments.

Botox Injections

Botox (botulinum toxin) injections are a minimally invasive option for reducing muscle activity in the jaw. By injecting small amounts of Botox into the masseter or temporalis muscles, the overactive muscles responsible for grinding and clenching are temporarily weakened.

This reduction in muscle strength decreases the force of grinding, alleviating associated pain, preventing tooth damage, and reducing TMJ stress.

Physical Therapy

Physical therapy is an effective way to reduce TMJ pain and improve jaw function in patients with bruxism. Techniques include:

• Stretching and strengthening exercises: Targeted exercises to relax and strengthen the jaw, neck, and facial muscles.
• Manual therapy: Hands-on techniques to improve joint mobility and reduce tension in surrounding muscles.
• Posture training: Correcting head and neck posture to alleviate strain on the TMJ.

Physical therapy is often combined with other treatments, such as oral appliances or stress management, to provide holistic care.

Oral Appliance Therapy for Sleep Bruxism and OSA

For patients with coexisting sleep bruxism and OSA, mandibular advancement devices  (MADs) offer dual benefits. MADs reposition the jaw to support an open airway and can reduce OSA-related clenching. This not only protects the teeth but also helps to reduce occurrences of airway collapse that may be contributing to the bruxism and disrupting sleep.

To encourage compliance with nightly use, it’s important to consider a lightweight design and precise fit that will enhance patient comfort. Selecting a MAD that’s made with medical-grade construction and durable material is key in ensuring the device will be able to withstand the substantial forces generated during grinding.

Integrating Treatment for Better Outcomes

Bruxism and OSA often coexist, making diagnosis and treatment more complex but addressing both conditions together can lead to significant improvements in oral health, sleep quality, and overall well-being. Ultimately, the key to effective treatment lies in understanding the patient’s specific needs and combining protective, behavioral, and therapeutic approaches.

Collaboration between dental professionals and sleep specialists ensures that patients receive tailored care that addresses both the symptoms and underlying causes of bruxism. By investing in innovative tools and techniques, healthcare providers can help patients to restore restful sleep and healthy smiles, along with significant improvements in quality of life.

Randy Clare is president of Hawkeye Group, the developer of ClenchAlert®, a wellness device for the treatment of awake sleep apnea

References

1. Lal SJ, Sankari A, Weber, DDS KK. Bruxism Management. [Updated 2024 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482466/.
2. Li D, Kuang B, Lobbezoo F, de Vries N, Hilgevoord A, Aarab G. Sleep bruxism is highly prevalent in adults with obstructive sleep apnea: a large-scale polysomnographic study. J Clin Sleep Med. 2023;19(3):443–51. doi: 10.5664/jcsm.10348.
3. Strausz T, Strausz S; FinnGen; Palotie T, Ahlberg J, Ollila HM. Genetic analysis of probable sleep bruxism and its associations with clinical and behavioral traits. Sleep. 2023 Oct 11;46(10):zsad107. doi: 10.1093/sleep/zsad107.
4. Ohayon MM, Li KK, Guilleminault C. Risk factors for sleep bruxism in the general population. Chest. 2001;119(1):53-61. doi: 10.1378/chest.119.1.53.
5. Balasubramaniam R, Klasser GD, Cistulli PA, Lavigne GJ. The link between sleep bruxism, sleep disordered breathing and temporomandibular disorders: an evidence-based review. J Dent Sleep Med. 2014;1(1):27–37.
6. American Academy of Sleep Medicine. International Classification of Sleep Disorders. 3rd ed, text revision (ICSD-3-TR). American Academy of Sleep Medicine; 2023.
7. lorjanski W, Malysa A, Orzeszek S, et al. Evaluation of biofeedback usefulness in masticatory muscle activity management-a systematic review. J Clin Med. 2019;8(6):766. doi: 10.3390/jcm8060766.

Sidebar

Exploring PTSD, Uncontrolled Anxiety, and Bruxism

Post-traumatic stress disorder (PTSD) is a psychiatric condition that develops following exposure to traumatic events, such as combat, natural disasters, or severe accidents. Characterized by flashbacks, nightmares, hyperarousal, and intrusive memories, PTSD is frequently accompanied by uncontrolled anxiety—a persistent state of excessive worry and fear.¹ A lesser‐known but increasingly recognized physical manifestation associated with these conditions is bruxism, which involves the involuntary grinding, clenching of teeth, and thrusting or bracing the jaw.

Awake bruxism is commonly linked to stress and anxiety.² For many, it serves as a subconscious physical outlet for tension. Individuals with PTSD often experience a heightened state of alertness, a remnant of the body’s fight-or-flight response. This chronic hyperarousal is a core component of PTSD and contributes to uncontrolled anxiety. The constant state of alertness leaves the body with little opportunity to relax, resulting in sustained muscle tension. When this tension concentrates in the jaw and facial muscles, it can trigger episodes of bruxism.

Uncontrolled anxiety amplifies the body’s stress response by activating the hypothalamic-pituitary-adrenal (HPA) axis. This activation leads to increased secretion of stress hormones such as cortisol and adrenaline. While these hormones are critical for immediate survival responses, their prolonged elevation can lead to chronic muscle contractions and tension. Over time, the excessive and continuous tension in the masticatory muscles may manifest as bruxism. Patients and their dentists often report dental wear and damage, jaw pain, and headaches, which can further contribute to discomfort and anxiety.

Bruxism can create a feedback loop that exacerbates anxiety. The discomfort and pain from teeth grinding may interfere with sleep quality, which is already compromised in many PTSD patients. Poor sleep, in turn, heightens stress levels and anxiety, perpetuating the cycle of hyperarousal. This interplay suggests that bruxism is not merely an isolated dental problem but rather an outward sign of underlying psychological distress.

Understanding the connection between PTSD, uncontrolled anxiety, and bruxism is essential for comprehensive treatment approaches. Effective management may require a multidisciplinary strategy that addresses both the psychological aspects of trauma and the physical manifestations of chronic stress. Interventions such as stress reduction techniques, biofeedback, cognitive behavioral therapy, and, when appropriate, dental interventions for bruxism could collectively improve patient outcomes by breaking the cycle of anxiety and physical tension.

1. Du J, Diao H, Zhou X, et al. Post-traumatic stress disorder: a psychiatric disorder requiring urgent attention. Med Rev (2021). 2022;2(3):219-43. doi: 10.1515/mr-2022-0012.
2. Wieckiewicz M, Paradowska-Stolarz A, Wieckiewicz W. Psychosocial aspects of bruxism: the most paramount factor influencing teeth grinding. Biomed Res Int. 2014;2014:469187. doi: 10.1155/2014/469187.

By Randy Clare

Source: SleepWorld Magazine Feb/March 2025