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Propositions for a cognitive behavioral
approach to bruxism management

Jean-Daniel Orthlieb, Thi-Nguyen-

Ny Tran, Ariane Camoin & Bernard
Mantout

international journal of stomatology

& occlusion medicine

ISSN 1867-2221
Volume 6
Number 1

J. Stomat. Occ. Med. (2013) 6:6-15

DOI 10.1007/s12548-012-0072-5

1 23
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 Author's personal copy
original article
J. Stomat. Occ. Med. (2013) 6:6–15
DOI 10.1007/s12548-012-0072-5
Propositions for a cognitive behavioral approach
to bruxism management
Jean-Daniel Orthlieb, Thi-Nguyen-Ny Tran,
Ariane Camoin, Bernard Mantout
Received: 20 September 2011 / Accepted: 21 December 2012 / Published online: 24 January 2013
© Springer-Verlag Wien 2013
Abstract  In dentistry bruxism patients are common
during routine daily practice and their situation is dif-
ficult to manage. The excessive forms are particularly
challenging because severe bruxism leads to major me-
chanical risks to the survival of dental elements espe-
cially artificial crowns or roots. In this case it is prob-
ably interesting, perhaps necessary, to try to establish
a management procedure to reduce these phenomena.
Parafunctional awareness and cognitive behavioral
therapy represent a non-invasive and potentially simple
approach.
At present the classical therapeutic options pills or
splint are deceiving. The aim of this article is to propose
to optimize a cognitive behavioral approach for brux-
ism management. Cognitive behavioral therapy could
be beneficial as a simple and effective method when the
precise steps of an established protocol are followed:
diagnosis, building trust, self-management of stress,
awareness of awake bruxism and reprogramming of the
automatisms of mandibular resting posture and swal-
lowing. By definition a dentist is a behavioral clinician
dedicated to oral dysfunctions related to oral hygiene
as well as bruxism. A cognitive behavioral approach is
probably a necessary step in a management plan for se-
vere forms. The proposed approach could be tested us-
ing a research protocol.
Keywords:  Bruxism, Stress, Cognitive, Behavioral ther-
apy, Parafunction
J.-D. Orthlieb () · A. Camoin · B. Mantout
Unité d’Occlusodontologie, Faculté d’Odontologie de Marseille,
Pôle Odontologie – Assistance publique des Hôpitaux de Marseille,
Aix-Marseille Université, 27 bd Jean Moulin,
13355 Marseille Cedex 7, France
e-mail: jean-daniel.orthlieb@univ-amu.fr
T.-N.-N. Tran
Department of Fundamental Dentistry, Faculty of
Odontostomatology, Ho Chi Minh University of Medicine and
Pharmacy, Ho Chi Minh, Vietnam
6   Propositions for a cognitive behavioral approach to bruxism management
Introduction: what is known about bruxism?
Bruxism patients are frequent in the daily dental prac-
tice and bruxism is always a challenging situation to deal
with, especially when excessive forms occur along with
an altered dental system. For the time being the classi-
cal therapeutic options pills or splint are deceiving. The
objective of this paper is to propose an approach to opti-
mize a cognitive behavioral approach to bruxism man-
agement in dental practice.
Definition
Bruxism has been defined as an oral parafunctional
activity. This broad definition from the 1990s includes
not only tooth grinding and clenching but also other oral
habits, such as nail biting, tongue pushing and jaw brac-
ing. The American Academy of Sleep Medicine defines
bruxism as a stereotyped oral motor disorder character-
ized by sleep-related grinding and/or clenching of the
teeth [1], whereas the American Academy of Orofacial
Pain extends the definition to the same movements that
occur during wakefulness [2].
The two forms of bruxism have been classified as pri-
mary (idiopathic) and secondary [3–5]. According to this
proposal the primary form includes awake clenching and
sleep bruxism without a medical cause while the second-
ary form is associated with one or more of the following:
neurological and/or psychiatric disorders, sleep disorder
syndrome and use of medication. However, because of
the two different neurophysiological states a differentia-
tion between bruxism occurring during wakefulness and
sleep bruxism should be made. It might also be perti-
nent to try to differentiate bruxism types in terms of the
prevelant behavior of subjects, sleep grinding or awake
clenching (Fig. 1).
In this way Manfredini and Lobbezoo [5, 6] proposed
a synthesis of ideas in which sleep and awake bruxism
are two different disorders with a dissimilar etiopatho-
genesis. They suggested that sleep bruxism is character-
 Author's personal copy
Different forms of bruxism
Primary bruxism Secondary bruxism
Awake bruxism Sleep bruxism Awake bruxism
(automac, reacon to
(reacon to smuli) (automac)
smuli)
Grinding
Clenching Clenching Grinding Clenching Grinding
Fig. 1  Diagram showing the different forms of bruxism. (Modi-
fied from [4])
ized by both grinding and clenching-type activities and
is associated with complex microarousal phenomena,
breathing disorders occurring during sleep, the patho-
physiology of which is yet to be clarified. Awake bruxism
is then characterized by only a clenching-type activity
more associated with psychosocial factors and a number
of psychopathological symptoms [7].
Etiology of bruxism
Bruxism is the result of contractions often involuntary of
the masticatory muscles. The etiology of different forms
of bruxism is complex and unclear but it is well estab-
lished that contraction originates from the central ner-
vous system (CNS). Current data continues to suggest
that peripheral sensory influences play only a minor role
in the etiopathogenesis of bruxism while central nervous
system-related factors are given much more importance
[7]. Klineberg [8] presented the thegosis theory initially
proposed in the 1960s by Every [9] as a term describing
a biological basis for tooth wear rather than a pathologi-
cal basis. In this concept the effects of stress on modern
man were linked to a presumed inherited predisposition
to keep teeth sharp. In another way it was proposed that
rhythmic masticatory muscle activity (RMMA) char-
acterized by repetitive jaw muscle contractions during
sleep has a role in lubricating the upper alimentary tract
and increasing airway patency [7] but the relationship
between sleep microarousals, sleep RMMA/swallowing
and salivation during sleep need further investigation
before the above hypotheses can be confirmed [10].
Infracortical level and bruxism
Sleep bruxism is most probably not a primary disor-
der of the autonomic nervous function. Kato et al. [10]
suggested that the CNS and/or the autonomic nervous
system had a dominant role in the genesis of bruxism
although the pathophysiology is not clearly understood.
For example, bruxism observed in some subjects with
neurological disabilities [11, 12] or induced by some
neuroleptics suggests that bruxism might concern the
subcortical areas normally under the influence of inhibi-
tory phenomena dependent on cortical control. In chil-
dren the prevalence of bruxism seems to decrease after 6
original article
years of age when in child development cortical control
increases with the maturation of the CNS [13, 14].
Supracortical level: stress and bruxism
Sleep bruxism
(automac)
Current data does not reflect a clear association between
Clenching Grinding stress and bruxism. This hypothesis was underlined by
Olkinuora in 1972 who claimed that daytime clenching is
a response to stress [15]. Studies showed that stress was
recognized as an initial, predisposing, perpetual factor
of physical disorders, psychological symptoms and sleep
disturbances [16, 17]. Among psychological disorders,
the phenomena of anxiety appeared to be more related
to bruxism. Some authors showed activities of sleep
bruxism to be a reflex reaction of the CNS unrelated to
stress. Studies on the bruxism-stress relationship main-
tained the suggestion that peripheral sensory influences
play only a minor role in the etiopathogenesis of bruxism
while CNS-related factors are given much more impor-
tance [18].
In another way self-reported sleep bruxism signifi-
cantly increases the odds for awake bruxism and vice
versa [19]. According to the systematic review of Man-
fredini and Lobbezoo awake clenching seems to be more
associated with psychosocial factors and a number of
psychopathological symptoms, whereas there was little
evidence linking sleep bruxism with psychosocial disor-
ders [5]. It therefore appears useful for these authors to
better distinguish in future research two types of brux-
ism: awake bruxism (clenching, characterized more by
emotions) and sleep bruxism (grinding, further charac-
terized as being less related to emotions). This dichot-
omy, not as simplistic in clinical practice, could explain
differences in results. From one point of view, it has been
thought that sleep bruxism genesis is facilitated by a psy-
chological response to stress although little physiologi-
cal information is available [3]. On the other hand, day
clenching is influenced by psychological factors among
which the phenomena of anxiety appears to be most
related to bruxism [20, 21]. The findings of Manfredini et
al. [22] may support the view that features related to indi-
vidual management of anxiety, namely trait, are likely
to be more significant than acute episodes of anxiety,
namely state, in the etiology of sleep-time masticatory
muscle activity.
Bruxism: beneficial behavior or pathogenic
phenomenon?
For a number of years Slavicek [23] supported the
hypothesis that bruxism in adults is a protective reflex
of the psychic stress valve acting as a physiological dis-
charge of emotional tensions. The organic reaction gen-
erated by emotional constraint, stress, would not be just
the classical fight or flight [24] but fight, flight, or bruxism
which means fight, flight or unload emotional stress by
clenching teeth. Such bruxism could be beneficial for the
organism and only the side effects of bruxism (excessive
structural loading, tooth wear etc.) can become patho-
Propositions for a cognitive behavioral approach to bruxism management   7
 Author's personal copy
original article
genic in severe forms. Recently, some scientific evidence
supporting this hypothesis highlighted the beneficial
effects of bruxism as indicated by some biological effect
or functional magnetic resonance imaging (MRI) mark-
ers of stress in rats and humans [25–30]. As previous
authors considered bruxism to be a positive function
of the stomatognathic apparatus, only excessive forms
can be interpreted as a dysfunction and necessitate a
therapeutic approach. If bruxism has a possible positive
effect for the patient (emotional discharge) practitioners
should be aware that bruxism must be allowable through
mandibular stability offered by occlusal stability. They
should also know that severe or excessive bruxism gen-
erates major mechanical risks for the survival of dental
elements especially if they are artificial (crown or root).
It is also possible that bruxism could remain excessive
without a high level of anxiety, simply by habituation, as
can frequently be observed in oral behavior, such as the
sucking habit, chewing habit and smoking.
Management of bruxism
Classical forms of bruxism management are
deceiving
For practitioners bruxism management often generates
a strong sense of powerlessness faced with forces that
are potentially destructive to natural and artificial den-
tal system. This is because currently proposed bruxism
management methods are frequently deceiving. Occlusal
approaches, including occlusal equilibration, prosthesis
or orthodontic treatment, have not provided evidence of
long-term effects on bruxism. Because of this non-effect
and their invasive nature, these approaches should not
be recommended to treat bruxism. Other therapeutic
approaches, such as the injection of botulinum toxin
often having ephemeral effects and other drug treat-
ments may sometimes be effective but with significant
side effects [31]. Biofeedback and hypnosis techniques
appear to be beneficial; however, they significantly
increase the burden of therapeutic management (e.g.
time, structure and cost). These methods should there-
fore be reserved as second line options for severe cases of
excessive bruxism.
Bruxism and oral appliances
According to a Cochrane review [32] there is not enough
evidence in the literature to show that occlusal splints
can reduce sleep bruxism. Occlusal splint indications
are then questionable with regard to sleep bruxism out-
comes although a splint may be beneficial to some extent
with regard to tooth wear.
This unexciting status of the therapeutic approach
generally results in a defeatist reaction of resignation.
Typically, the practitioner will recommend nocturnal
wear of an oral appliance (occlusal splint). Although it
does not treat bruxism it will hopefully protect the den-
8   Propositions for a cognitive behavioral approach to bruxism management
tal structures or the dental prosthesis [33, 34] unless the
occlusal splint is particularly aimed at protecting the
dentists from judicial complaints! Sleep wear of an occlu-
sal splint for months even for years as the only way to
manage excessive bruxism, is probably not very satisfy-
ing. An occlusal splint may reinforce behavioral modifi-
cation by its presence and its habitual wear but it can also
occasionally act as an unconscious protective proprio-
ceptive trigger if it is not used every night. However, the
inhibitory effect on bruxism of an occlusal splint usually
decreases with habitual wear and probably at the same
time the unconscious feeling that the teeth are protected
could increase the bruxism habit. Therefore, it is possible
that once past some initial neuromuscular inhibitory
effect, the subject will continue to practice bruxism in
confidence on the occlusal splint even more than on the
teeth! This would in effect reinforce the oral parafunction
instead of inhibiting it.
When dealing with destructive bruxism practitioners
will then have to deliberately refuse to be resigned to a
passive attitude and try to establish a pragmatic manage-
ment plan to decrease the harmful effects by reducing
excessive bruxism without invasive treatment.
Central nervous system is the target of bruxism
management
Because the origin of bruxism is the CNS this factor must
be targeted for management. Oral sensors and cognitive
behavioral therapy could be more efficient than a phar-
macological approach as they enable positive results
without side effects. So it is surprising to observe the evo-
lution of previous publications on bruxism management.
In the 1960s and 1980s a high proportion of articles were
devoted to behavioral therapy. This topic was supplanted
in the 1990s by occlusal approaches (including occlusal
splints) and 10 years later there seems to have been a
strong decrease in research on behavioral management
and a driven increase in scientific papers dealing with
pharmacological approaches [33]. It is not impossible
that this evolution was only related to the technical dif-
ficulties of psychobehavioral clinical research combined
with less financial support. In any case, in 2010 behav-
iorist research finally picked up. For example around
20 published papers were more oriented to the behav-
ioral approach in temporomandibular disorders (TMD).
Interestingly, several publications showed positive and
often predominant effects of simple behavioral counsel-
ing and changing lifestyle on TMD care [35, 36].
Cognitive behavioral approach
Cognitive behavioral therapies
Cognitive behavioral therapies (CBT) are a psychothera-
peutic approach aiming to solve problems concerning
dysfunctional emotions, behavior and cognition through
a goal-oriented, systemic procedure [37]. The behavioral
 Author's personal copy
model says that an individual’s behavior can be changed if
the right contingencies or conditions are set up. The cog-
nitive model asserts that cognition, i.e. how people think
and what they think about, is an important mediator in
the pathway to behavior and that altering cognition will
alter behavior. Because both human relationships and
internal representations are critical aspects of healthy
functioning limits of the cognitive behavioral approach
should of course be acknowledged [38]. Cognitive behav-
ioral models are composed of a variety of procedures and
tactics which include relaxation skills training, self-mon-
itoring of problematic behavior and symptoms, a self-
disciplined approach for introducing new behavior and
exercises that incorporate new proprioceptive learning
and alter dysfunctional behavioral patterns. In addition,
the clinician must use strategies for alteration of cogni-
tion, including psychoeducation regarding mind-body
relationships. All of these approaches require sufficient
guidance, feedback and support from the care provider
[38].
Interestingly, Ohrbach [38] underlined some topics of
interest in behavioral therapy concerning anxiety, self-
monitoring, coaching, attention to the exercises.
• A nxiety
A common difficulty in learning how to relax is high
anxiety. Anxiety leads to preoccupation with the bodily
state and any change in that state, such as via relax-
ation, can be frightening; thus, a paradoxical increase
in anxiety accompanies relaxation in highly anxious
patients when they first learn how to relax. Rather
than let this paradoxical increase in anxiety further
reinforce the notion that the patient cannot learn how
to relax, the clinician has several options: using relax-
ation methods that focus very directly on bodily sen-
sations, adding hypnosis into the protocol or referring
the patient to a behavioral medicine specialist.
• Self-monitoring
Both success and compliance with these biobehav-
ioral modalities must ultimately be assessed by the
clinician but to do so detailed progress information is
needed from the patient. Therefore, patients are asked
to maintain a daily log for as long as necessary to
record symptoms and associated behavior, affects and
cognition. Generally, the practice of self-monitoring
is self-explanatory as the individual develops insight
into the situation.
The clinician provides support for the patient
to perform this task. The use of customized forms
is highly recommended because they facilitate the
patient’s activity; however, for simple recording tasks,
index cards also serve well. Patients will be more
responsive when the instructions about what to do are
concrete. Patients should start off with just one or two
things to record at a time and they should be moni-
tored for compliance; i.e. the clinician must evaluate
what the patient did and discuss it so that the patient
will want to continue.
Propositions for a cognitive behavioral approach to bruxism management   9
original article
People who are too busy to record their adher-
ence and progress are generally too busy to perform
at a level necessary for progress to occur. People who
are unable to modify their existing schedule (itself
often an adaptation to the existence of chronic pain)
to adhere to treatment seldom make progress in skill
building. The observation of such behavioral signs
suggests the need for reassessment in terms of a pos-
sible personality disorder that impacts medical care.
• Coaching
Biobehavioral therapies require calendar time for effi-
cacy to emerge, meaning that the patient needs sup-
port and encouragement to pursue such treatments.
In addition, the patient often needs repeated assur-
ances that the diagnosis is correct and that the pro-
vided treatments can ultimately be effective.
• Attention and exercises
Exercises invoke intentional behavior and with atten-
tion to the new behavioral pattern further changes
are possible within the brain’s motor programs, sen-
sory perception and appraisal processes, as well as in
beliefs about the self. The power of sustained atten-
tion to the development of new motor skills, including
physical rehabilitation, has been repeatedly observed
by athletes perfecting their craft. Similarly, patients
need to learn control, self-discipline and healthy pro-
prioception and appraisal. Therapeutic exercises are
also part of a cognitive-behavioral program. To over-
come this concern, the patient is asked to engage in
the exercises with conscious and intentional aware-
ness so that the exercise will help restructure experi-
ence and beliefs.
Cognitive behavioral therapies in oral health
In the field of oral health the therapeutic effect of the
cognitive-behavioral approach in the management of
TMD in adults has been shown in numerous clinical
studies [39]. Although the cognitive-behavioral model
can look deceptively simple, significant specialized
training beyond the typical training of a dentist or physi-
cian is required to use the model with high efficacy. The
cognitive-behavioral model has been empirically imple-
mented at two levels for the treatment of chronic TMD
pain: it is either administered by a trained dental hygien-
ist for patients with only mild pain-related disability or
by a trained psychologist for patients with moderate to
severe pain-related disability. The evidence from these
two studies indicates that both models are more effective
than some of the usual dental treatments (e.g. bite appli-
ance, medication and jaw exercises) for the respective
clinical groups [40].
Relaxation of the muscles can be learnt much quicker
with cognitive-behavioral therapy. This hypothesis is
supported by the results of some studies: for example,
Oakley et al. [41] showed that the cognitive-behavioral
approach had a positive effect on the effects of anxiety.
Restrepo et al. [42, 43] reported a significant effect of psy-
 Author's personal copy
original article
chological approaches to muscle relaxation and reduc-
tion of bruxism in children with primary dentition. For
Casas et al. [44] the attitudes of stress management learnt
while awake might have effects on muscle activities
induced by stress during sleep.
Kato et al. [3] proposed that behavioral-cognitive
strategies be tested to see whether they reduce the prob-
ability of sleep bruxism genesis or decrease oromotor
responsiveness to microarousal.
Justification for dentist involvement in oral
cognitive behavioral rehabilitation
For Ommerborn et al. [40] it was also necessary to
emphasize the disadvantages of cognitive-behavioral
approaches which are time-consuming in the clinic
(requiring several sessions) and the effects tend to fade
with time if there is no real surveillance. This means that
coaching that is structured, easy to install in daily prac-
tice and integrated into standard clinical phases of den-
tistry to avoid overtreatment must be proposed. Dentists
routinely use this type of coaching for the maintenance
of oral hygiene. Why not rely on cognitive behavioral sur-
veillance for bruxism and stress? For example, Dworkin
et al. involved dental hygienists in the coaching of TMD
patients [39] and a pilot study showed that using a modi-
fied model of cognitive-behavioral therapy by keeping a
diary, resulted in increased adherence to oral hygiene
and improved knowledge about gingivitis, compared
with traditional instructions [37].
Dental practitioners can manage the patient treat-
ment by providing sleep hygiene instructions that
include information about weight loss, maintaining a
regular sleep schedule and also avoiding drinking alco-
hol or eating a large meal or both at dinnertime. The
practitioner might recommend that patients with sleep
bruxism accompanied by snoring, upper airway resis-
tance or hypoventilation use a mandibular advancement
appliance [45].
Is it legitimate for the dentist to initiate a cognitive-
behavioral therapy for patients? The answer of the
authors is yes. The dentist is the clinician of mandibular
behavior whether for hygiene or oral parafunctions.
Explaining that self-control is an antidote to the harm-
ful behavioral manducation is within his competence.
In this society, dentists are healthcare practitioners
who meet with millions of compatriots every year. It is
the role of each practitioner to be concerned with the
behavioral and emotional health of patients especially
with regard to the masticatory organ. It is also a role to
screen for psychoemotional difficulties or serious dis-
eases and then refer patients to colleagues with exper-
tise in the related field. If dentists really want to help
patients they need to acquire the relevant psychodiag-
nostic and psychotherapeutic skills. Building on this
principle it is necessary to reinforce the initial educa-
tion of dentists in psychosociology.
10   Propositions for a cognitive behavioral approach to bruxism management
Proposed protocol
Because:
• s evere bruxism generates some major mechanical
risks for the survival of dental elements especially if
they are artificial,
• classical forms of bruxism management are deceiving,
• the central nervous system is directly concerned with
bruxism so the therapeutic approach must be central-
ly mediated by cognitive or sensory inputs,
• the cognitive-behavioral approach has been success-
ful in the field of oral health (oral hygiene, TMD),
• daily mandibular behavioral control could impact
clenching habit, nasal breathing, sleep quality and
sleep bruxism level,
• and because it is a role of the general dentist to be a
behavioral clinician of oral dysfunctions,
the following protocol of a cognitive behavioral approach
to risky bruxism is proposed. As with any kind of care, it
is necessary to follow the precise steps of an established
protocol.
Objectives
The aim is: behavioral control of severe bruxism achieved
by decreasing anxiety and oral parafunctions through
improved stress management, relaxed mandibular func-
tions and nasal breathing.
Practically speaking the intention is not to eliminate
bruxism but to reduce it by decreasing muscular loading
during awakefulness, seeking to reduce the “puff” type of
breathing of sleep bruxism and improving the capability
of stress management to lower the anxiety level.
The first target concerning the infracortical level, aims
to rehabilitate the habitual reflex of mandibular-tongue
rest posture and nasal breathing and to increase aware-
ness of daily clenching by self-management of oral hab-
its. For this first target the method will be the same for all
patients.
The second target more oriented to the supracortical
level, aims to improve self-management of stress through
individualized but simple counseling concerning evalu-
ation of stressors, anxiety level by means of introspec-
tion, quality of life to prepare quality of sleep and sleep
hygiene instructions. For this second target the counsel-
ing must be adapted to each patient.
Diagnosis and indication
Indications: risky bruxism without severe psychological
disorders
It is proposed to identify risky bruxism by combining
the intensity of bruxism and fragility of the dental sys-
 Author's personal copy
Table 1  Diagnosis indicator
Indicator of bruxism management
Level of severity of bruxism
No (0), little (1), mild (2), 0 1 2 3
strong (3), major (4)
L evel of structural risk (teeth,
periodontal, implant, prosthe-
sis, muscles, TMJ)
No (0), little (1), mild (2), 0 1 2 2
strong (3), major (4)
Indicator of care difficulty
Level of compliance
Very strong (0), strong (1), 0 1 2 3
mild (2), low (3), very
low (4)
Level of psychological tension
No (0), little (1), mild (2), 0 1 2 2
strong (3), major (4)
Indicator of bruxism management: a score above 4 could be interpreted as
risky bruxism
Indicator of difficulty a score above 4 could indicate associated care with a
psychological care professional
tem. In dealing with risky bruxism cases, as a first step,
a cognitive-behavioral management approach could be
effective, safe and simple to implement. If a high level
of emotional tension is detected, the cognitive behav-
ioral approach must be conducted in collaboration with
a behavioral medicine specialist. Severe bruxism is not
systematically associated with severe psychological dis-
orders but if dentists detect signs of severe psychological
disorders the patient must be referred to a specialist.
The initial interview phase of listening and observa-
tion helps to identify behaviors that could promote awake
or sleep bruxism: alcohol, tobacco, taking psychostimu-
lants, neuroleptics, emotional tensions, sleep disorders
and oral breathing. A clinical examination will focus on
signs of oral muscular hyperactivity (abrasions, muscle
density, frequent unconscious muscular activities, oral
parafunctions, tongue dysfunctions and oral breathing).
A stomatognathic status grid (Table 1) allows the den-
tist to quantify the level of structural risk (teeth, peri-
odontium, implants, prostheses, muscles, TMJ).
Indicator of bruxism management Using the proposed
bruxism management indicator a score of more than
4, adding the structural risk level and the severity level
of bruxism, could be interpreted as risky bruxism,
and would indicate a cognitive-behavioral approach
(Table 1).
Indicator of care difficulty  Using the proposed care diffi-
culty indicator a score of more than 4, adding the level of
compliance and the level of psychological tension, could
be interpreted as an indication for combining care with
a medical specialist. So the patient could be managed
exclusively in a dental practice if the indicator of diffi-
culty is not over 4 (Table 1).
original article
Method
Building trust
4
The patients are informed of the parasitic effects of some
of their habits and the possible structural risk. Empathy,
simplicity of speech, materialization of signs of overload,
accessible explanations of pathophysiological interre-
4 lationships, setting clear therapeutic goals, establishing
a schedule of visits, explaining the importance of self-
monitoring, all of these factors can win over the neces-
sary patient trust. Without dramatization, there can be no
4
success unless the patient understands the nature of the
problem. Moreover, the duration and conditions of this
empathic explanation are probably decisive parameters.
4
Self-management of awake bruxism and oral
habits
Awareness of awake bruxism is the first step: because
daytime clenching is probably frequently unconscious,
the patient’s consciousness of harmful activities is the
basis for a cognitive approach. To boost this awareness,
the use of sensory alert methods to prompt sudden atten-
tion to oral behavior is essential because it increases
awareness of awake bruxism. Sensory alerting requires
the use of triggers such as conventional colored adhesive
stickers placed on objects frequently within the patient’s
visual field, or something worn on the wrist or hands in
an unusual way (a watch or jewellery). Individualized
types of sensory alert must be placed by the patients
themselves.
Any dental modification, for instance during a new
dental treatment with a prosthesis or during orthodon-
tic treatment, represents a very permanent sensitive
alert located directly in the oral area. For example, a
small piece of composite material, without changing the
intercuspation, could be added on a lingual surface of a
maxillary tooth to reinforce the awareness. Of course all
invasive dental treatments are strictly not recommended
without dental indications.
Rest and swallowing posture  The next step is reprogram-
ming the automatic reflex of swallowing and mandib-
ular-tongue rest posture. Although changing a habit is
essentially a question of motivation (desire plus under-
standing the problem), it also implies multiple daily
repetition of a simple exercise. For these purposes the
sequence includes 4 steps:
1. Sensory triggering: sensory alert starts a new reflex
loop (rest–swallow–rest)
2. Resting posture: lips in slight contact, tongue in slight
contact on the palate, teeth without contact
3. Swallowing: teeth in slight contact, tongue on the pal-
ate, repeat interiorly tooth touching does not mean
tooth clenching
Propositions for a cognitive behavioral approach to bruxism management   11
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original article

Fig. 2  Bruxism: patient information sheet

12   Propositions for a cognitive behavioral approach to bruxism management

 Author's personal copy
4. Resting posture: return to rest posture with the tongue
remaining in slight contact with the palate, teeth
apart.
Self-management of stress
Cognitive therapy techniques help people become more
aware of how they reason and of the kinds of automatic
thought that spring to mind and give meaning to things.
The patient who is able by training to recognize stress and
anxiety, will improve the stress response by implement-
ing a simplified form of introspection regarding how to
react to emotional tension. This creates a certain lifestyle
which promotes recovery sleep and learning about the
foundations of simple relaxation methods. Patients must
be instructed individually in problem solving, including
a systematic introspection of stress-causing situations
and the proximate behavior, progressive muscle relax-
ation, training in recreation and pleasure, learning to
identify enjoyable activities and to integrate them into
everyday life.
Strengthening of behavioral management
Information sheet, coaching and self-monitoring The
beneficial effects of this self-management will be greatly
strengthened by providing the patient with an explana-
tion sheet about bruxism and how to manage it (Fig. 2)
and by setting up a monitoring schedule: 3 visits at 1
month intervals during the first 3 months then 1 visit
every 3 months for 1 year followed by 1 visit per year to
maintain attention. A self-monitoring system backed up
with a customized form (Table 2) is highly recommended
because it facilitates the patient’s activity and helps
maintain motivation.
Table 2  Bruxism management: self-monitoring form
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original article
After 2 months in case of an initial absence of success
or a high level of dental risk, a full nocturnal mandibular
oral appliance (splint) can be worn for 2-4 months and
then the oral appliance will be discontinuously worn
(only at night) during periods of stress or difficulties in
nasal breathing, for example.
Evaluation of results
Evaluation of the bruxism level probably requires associ-
ating a questionnaire, check of the self-monitoring form,
clinical examination and bruxchecker [46, 47]. Lack of
success after 3–6 months means that reevaluation of
the diagnosis is necessary. For extensive prosthodontic
treatment in a bruxism context, this type of cognitive-
behavioral approach could be indicated during the ini-
tial phases of treatment and the final prosthodontic steps
only carried out if excessive bruxism seems to be under
control.
Conclusions
The practitioner must of course endeavor to under-
stand bruxism well in order to limit the mechanical risks
through an appropriate prosthetic strategy. This means
that the resistance of the prosthesis needs to be adapted
to the constraints it is subjected to but dentists must
also be aware of the capacities of behavioral rehabilita-
tion, which certainly deserve to be put into practice. The
patients may act on the bruxism; however, communica-
tion, explanations, methods and coaching could be key
determinants of success. That is why the practitioner
must first of all be confident in the knowledge of brux-


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Propositions for a cognitive behavioral approach to bruxism management   13

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original article

ism and the results that can be expected from a cognitive- 19. Winocur E, Uziel N, Lisha T, Goldsmith C, Eli I. Self-
behavioral approach. That means education in this field. reported bruxism—associations with perceived stress,
motivation for control, dental anxiety and gagging. J Oral
Rehabil. 2011;38:3–11.
Conflict of interest 20. Endo H, Kanemura K, Tanabe N, Takebe J. Clenching
The authors declare that there is no actual or potential occurring during the day is influenced by psychological
conflict of interest in relation to this article. factors. J Prosthodont Res. 2011;55:159–64.
21. Manfredini D, Landi N, Fantoni F, Segù M, Bosco M. Anxi-
ety symptoms in clinically diagnosed bruxers. J Oral Reha-
References bil. 2005;32:584–8.
22. Manfredini D, Fabbri A, Peretta R, Guarda-Nardini L, Lob-
bezoo F. Influence of psychological symptoms on home-
  1. American Academy of Sleep Medicine. International clas-
recorded sleep-time masticatory muscle activity in healthy
sification of sleep disorders. 2nd ed. Rochester: Allen; 2005.
subjects. J Oral Rehabil. 2011;38:902–11.
  2. De Leeuw R, editor. American Academy of Orofacial Pain.
23. Kail K, Slavicek R. Behandlungserfolg bei Kiefergelenks-
Orofacial pain: guidelines for assessment, diagnosis and
beschwerden in Abhängigkeit von organischen und psy-
management. 4th ed. Chicago: Quintessence; 2008.
chischen Faktoren in Zusammenarbeit mit Slavicek,
  3. Kato T, Thie NMR, Huynh N, Miyawaki S, Lavigne G. Topi-
Fischer, Formann, Keresztesi, Frohner Grund- und Inte-
cal review: sleep bruxism and the role of peripheral sensory
grativwiss. Austria: University of Vienna; 1986.
influences. J Orofac Pain. 2003;17:191–213.
24. McEwen BS. Stress, adaptation, and disease. Allostasis and
  4. Huynh N, Manzini C, Rompre PH, Lavigne GJ. Weighing the
allostatic load. Ann N Y Acad Sci. 1998;840:33–44.
potential effectiveness of various treatments for sleep brux-
25. Hori N, Lee MC, Sasaguri K, Ishii H, Kamei M, Kimoto K et
ism. J Can Dent Assoc. 2007;73:727–30.
al. Suppression of stress-induced nNOS expression in the
  5. Manfredini D, Lobbezoo F. Role of psychosocial factors in
rat hypothalamus by biting. J Dent Res. 2005;84(7):624–8.
the etiology of bruxism. J Orofac Pain. 2009;23:153–66.
26. Sato S, Slavicek R. The masticatory organ and stress man-
  6. Manfredini DF, Lobbezoo F. Relationship between bruxism
agement. Int J Stomatol Occl Med. 2008;1:51–7.
and temporomandibular disorders: a systematic review of
27. Yoshimi H, Sasaguri K, Tamaki K, Sato S. Identification of
literature from 1998 to 2008. Oral Surg Oral Med Oral Pathol
the occurrence and pattern of masseter muscle activities
Oral Radiol Endod. 2010;109:e26–e50.
during sleep using EMG and accelerometer systems. Head
 7. Lavigne GJ, Kato T, Kolta A, Sessle BJ. Neurobiological
Face Med. 2009;5:7.
mechanisms involved in sleep bruxism. Crit Rev Oral Biol
28. Sato C, Sato S, Takashina H, Ishii H, Onozuka M, Sasaguri
Med. 2003;14:30–46.
K. Bruxism affects stress responses in stressed rats. Clin
  8. Klineberg I. Bruxism: aetiology, clinical signs and symp-
Oral Investig. 2010;14:153–60.
toms. Aust Prosthodont J. 1994;8:9–17.
29. Ono Y, Yamamoto T, Kobo KY, Onozuka M. Occlusion and
  9. Every RG. The teeth as weapons; their influence on behav-
brain function: mastication as a prevention of cognitive
iour. Lancet. 1965;1(7387):685–8.
dysfunction. J Oral Rehabil. 2010;37:624–40.
10. Kato T, Thie NM, Huynh N, Miyawaki S, Lavigne GJ. Topi-
30. Sugimoto K, Yoshimi H, Sasaguri K, Sato S. Occlusion fac-
cal review: sleep bruxism and the role of peripheral sensory
tors influencing the magnitude of sleep bruxism activity.
influences. J Orofac Pain. 2003;17:191–213.
Cranio. 2011;29(2):127–37.
11. Lopez-Perez R, Lopez-Morales P, Borges-Yanez SA, Mau-
31. Lavigne L, Palla S. Transient morning headache: recogniz-
pome G, Pares-Vidrio G. Prevalence of bruxism among
ing the role of sleep bruxism and sleep-disordered breath-
Mexican children with Down syndrome. Downs Syndr Res
ing. J Am Dent Assoc. 2010;141:297–9.
Pract. 2007;12:45–9.
32. Macedo CR, Silva AB, Machado MA, Saconato H, Prado GF.
12. Peres AC, Ribeiro MO, Juliano Y, Cesar MF, Santos RC.
Occlusal splints for treating sleep bruxism (tooth grinding).
Occurrence of bruxism in a sample of Brazilian children
Cochrane Database Syst Rev. 2007;17(4):CD005514. doi:
with cerebral palsy. Spec Care Dentist. 2007;27:73–6.
10.1002/14651858.CD005514.pub2.
13. Kreulen C, Van’t Spijker A, Rodriguez J, Bronkhorst E,
33. Lobbezoo F, van der Zaag J, van Selms MK, Hamburger HL,
Creugers N, Bartlett D. Systematic review of the prevalence
Naeije M. Principles for the management of bruxism. J Oral
of tooth wear in children and adolescents. Caries Res.
Rehabil. 2008;35:509–23.
2010;44:151–9.
34. Van Der Zaag J, Lobbezoo F, Wicks DJ, Visscher CM, Ham-
14. Restrepo CC, Vasquez LM, Alvarez M, Valencia I. Per-
burger HL, Naeije M Controlled assessment of the efficacy
sonality traits and temporomandibular disorders in a
of occlusal stabilization splints on sleep bruxism. J Orofac
group of children with bruxing behaviour. J Oral Rehabil.
Pain. 2005;19:151–8.
2008;35:585–93.
35. Litt MD, Shafer DM, Ibanez CR, Kreutzer DL, Tawfik-Yon-
15. Olkinuora M. Psychosocial aspects in a series of bruxists
kers Z. Momentary pain and coping in temporomandibular
compared with a group of non-bruxists. Proc Fin Dent Soc.
disorder pain: exploring mechanisms of cognitive behav-
1972;68:200–8.
ioral treatment for chronic pain. Pain. 2009;145:160–8.
16. Ahlberg J, Savolainen A, Rantala M, Lindholm H, Kononen
36. Truelove E, Huggins KH, Mancl L, Dworkin SF. The efficacy
M. Reported bruxism and biopsychosocial symptoms:
of traditional, low-cost and nonsplint therapies for tem-
a longitudinal study. Community Dent Oral Epidemiol.
poromandibular disorder: a randomized controlled trial. J
2004;32:307–11.
Am Dent Assoc. 2006;137:1099–107.
17. Von Onciul J. ABC of work related disorders. Stress at work.
37. Fjellstrom M, Yakob M, Soder B. A modified cognitive
BMJ. 1996;313:745–8.
behavioural model as a method to improve adherence to
18. Lavigne GJ, Kato T, Kolta A, Sessle BJ. Neurobiological
oral hygiene instructions—a pilot study. Int J Dent Hygiene.
mechanisms involved in sleep bruxism. Crit Rev Oral Biol
2010;8:178–82.
Med. 2003;14:30–46.

14   Propositions for a cognitive behavioral approach to bruxism management

 Author's personal copy
38. Ohrbach R. Behavioral therapy in TMDs: an evidence
based approach to diagnosis and treatment. In: Laskin DM,
Greene C, Hylander W, editors. Chicago: Quintessence;
2006. pp. 391–402.
39. Dworkin SF, Turner JA, Mancl L, Wilson L, Massoth D,
Huggins KH, et al. A randomized clinical trial of a tailored
comprehensive care treatment program for temporoman-
dibular disorders. J Orofac Pain. 2002;16:259–76.
40. Ommerborn MA, Schneider C, Giraki M, Schafer R,
Handschel J, Franz M, et al. Effects of an occlusal splint
compared with cognitive-behavioral treatment on sleep
bruxism activity. Eur J Oral Sci. 2007;115:7–14.
41. Oakley ME, McCreary CP, Clark GT, Holston S, Glover D,
Kashima K. A cognitive-behavioral approach to temporo-
mandibular dysfunction treatment failures: a controlled
comparison. J Orofac Pain. 1994;8:397–401.
42. Restrepo C, Gomez S, Manrique R. Treatment of brux-
ism in children: a systematic review. Quintessence Int.
2009;40:849–55.
Propositions for a cognitive behavioral approach to bruxism management   15
View publication stats
original article
43. Restrepo CC, Alvarez E, Jaramillo C, Velez C, Valencia I.
Effects of psychological techniques on bruxism in children
with primary teeth. J Oral Rehabil. 2001;28:354–60.
44. Casas JM, Beemsterboer P, Clark GT. A comparison of
stress-reduction behavioral counseling and contingent
nocturnal EMG feedback for the treatment of bruxism.
Behav Res Ther. 1982;20:9–15.
45. Lavigne L, Palla S. Transient morning headache: recogniz-
ing the role of sleep bruxism and sleep-disordered breath-
ing. J Am Dent Assoc. 2010;141:297–9.
46. Onodera K, Kawagoe T, Protacio-Quismundo C, Sasaguri
K, Sato S. The use of a bruxchecker in the evaluation of dif-
ferent occlusal schemes based on individual grinding pat-
terns. J Craniomandib Pract. 2006;24:292–9.
47. Kawagoe T, Onodera K, Tokiwa O, Sasaguri K, Akimoto S,
Sato S. Relationship between sleeping occlusal contact pat-
terns and temporomandibular disorders in the adult Japa-
nese population. Int J Stomatol Occl Med. 2009;2:11–5.