Bruxism as an Emotional
Reactive Disturbance
SHLOMO SHAPmo, D.D.S. AND JACOB SHANON,
• Bruxism means grinding, clenching or click-
ing of the teeth during the daytime or at
night. It exists when there is forceful rubbing
together or application of pressure by oppos-
ing teeth. These are activities which do not
fulfill any physiological purpose of the masti-
catory apparatus such as mastication, degluti-
tion, speech or respiration. 1
Prolonged bruxism may cause lesions in the
hard tissues of the teeth, in their supporting
structures or in the temporomandibular joint.~
It has been proved, experimentally, that oc-
clusal trauma may cause thrombosis of the
blood vessels of the periodontal membrane,
necrosis of the periodontal fibres and resorp-
tion of the alveolar bone. 3 Bruxism is there-
fore an important etiological factor in chronic
destructive periodontal disease. It is char-
acterized by the following signs and symp-
toms: Excessive occlusal wear of the teeth, in-
creased tonus of the masticatory muscles, tired
feeling of the muscles of the jaws when wak-
ing in the morning, tenderness of the muscles
to palpation, increased tooth mobility, sore-
ness of teeth during mastication and audible
sounds from bruxism. 4
The relation of some pathological condi-
tions of the oral cavity to emotional factors
has been discussed in dental literature. 5 S 0
The teeth have served as a weapon since
prehistoric times. It is not surprising that
civilized men might in time of stress or frus-
tration revert to primitive tendencies and
express their emotions by grinding or
gnashing of teeth. Slight grinding of oppos-
Doctor Shapiro is Head of Department of Perio-
dontics and Endodontics, Hebrew University-Hadas-
sah School of Dental Medicine founded by Alpha
Omega Fraternity, Jerusalem, Israel.
Doctor Shanon is Chief Physician of the Depart-
ment of Dermatology and Venereology and Head of
the Psychosomatic Skin Clinic, Hadassah University
Hospital, Jerusalem, Israel.
November-December, 1965
M.D.
ing teeth might not be pathologic in itself. It
seems that the intensity and continuity of this
habit makes it pathologic. 9
Although the importance of emotional fac-
tors in bruxism have been mentioned in the
dental literature, the psychosomatic approach
to this problem is still neglected and the treat-
ment of this condition is mainly based on
mechanical measures. 10 ,1l
The aim of the present study was to de-
termine the psychodynamics of patients suf-
fering from severe bruxism.
MATERIALS AND METIIODS
Patients were selected from among those
undergoing treatment at the Department of
Periodontics, Hebrew University-Hadassah
School of Dental Medicine, Jerusalem, Israel.
During examination of the oral cavity special
attention was paid to dermatological changes
in the oral mucosa. The periodontal condition
of each patient was ascertained. Etiological
factors of periodontal disease such as calculus
and other irritants, malocclusion and bad oral
hygiene were registered. Past medical history
was taken and a periodontal diagnosis was
made. 'Vhen examination revealed abnormal
wear of teeth, tooth mobility or hypertonicity
of the masticatory muscles which lead to the
diagnosis of severe bruxism, the patient was
invited for an interview to study his per-
sonality make-up.
The patients were then referred for further
evaluation to the Psychosomatic Dermatology
Clinic of the Hebrew University-Hadassah
School of Medicine. The psychosomatic evalu-
ation was based on a series of interviews and
the relationship between bruxism and emo-
tional factors was established by the following
criteria:
( 1) Clinical diagnosis, (2) Constitutional
factors, (3) Genesis of trauma (organic and/or
427
 PSYCHOSOMATICS
emotional), (4) Main conflict, (5) Dynamic
diagnosis, (6) The precipitating factor, (7)
Periodicity.l~
Projective tests, including T.A.T. and
Rosenzweig Frustration Test, were carried out
systematically, while Rorschach was applied
occasionally.
Ten patients were examined in this study.
In two of them, no relationship between
bruxism and their emotional conflict was
found. In eight patients, a definite correla-
tion between their oral symptoms and emo-
tional conflicts could be established. Three
analytical case histories are reported here.
Case 1.-The patient, a 25-year-old law student,
I:orn in Israel of Polish parents, presented himself
for dental treatment.
Dental and oral examination revealed several
<:arious teeth but no clinical or radiologic evidence of
periodontal disease. Marked abrasion was present
on all teeth. On questioning whether he was aware
of the habit of grinding his teeth, the patient said
that his room-mates complained that he kept them
awake by making strong noises with his teeth during
sleep. The marked wear of his teeth and the history
of audible nocturnal grinding led to the diagnosis of
bruxism. Tbe patient was referred for psychosomatic
evaluation.
The patient is a handsome and intelligent young
man. Besides his studies, he is active in cultural
activities. He likes the theatre, painting and singing.
As a child he liked to perform. He suffered from
his teeth since childhood and he remembers that his
mother forbade him to cry during dental treatment.
His father, by profession a civil servant, was a
respected figure. His opinions were highly regarded
by the family. His mother was active and enterpris-
ing, but domineering.
The patient was in love with his mother and she
was his ideal image, full of the highest traits. As
time went by, the patient noticed that his mother
was taking over his father's place as head of the
family, making all the important decisions herself.
The father's behavior became mysterious and
frightening. At night, during his sleep, he suffered
from attacks of shouting which used to wake up the
whole family. Although the patient was still a
child, the image of his father, during these attacks,
remained quite vivid in his mind. His father's con-
gested face expressed fear and his lips were foaming.
The attacks, which occurred quite often, were ac-
companied by strong snoring. His mother used to
wake his father up and then he would tell of his
nightmares, which were related to Nazi persecutions.
Often a doctor was summoned. When the patient
learned that none of his father's family were victims
of the Nazis, he was utterly puzzled by his father's
behaviour. He remembers having complained once
about his father's snoring, to which his mother re-
plied: "You grind your teeth and that is even worse."
428
On questioning, he was unable to answer when he
started to grind his teeth. He was surprised to find
out frem his mother that this started at the age of
nine years, approximately. At that period a change
came about in the patient's behaviour. He started to
hate his mother, although he did not know why. He
became introverted and did not show his feelings.
When asked about his feelings towards his parents,
he answered, "I hate and despise my mother and
pity my father who is a human rag." He avoids
company, is incapable of enjoying life. He is un-
able to form emotional or physical ties with women.
His relationship towards his girl friends is on a
spiritual level only and he is not attracted by them
sexually. The patient made a serious attempt to study
singing but he discontinued his studies for fear of
disappointment. He works intensively. He is un-
able, however, to take upon himself work which
needs perseverance and continuity, because he is
afraid of becoming a clerk like his father. When
asked about two memories that came to his mind,
he gave the following accounts:
1. "In 1947 father took my brother to the Old
City of Jerusalem but mother did not allow me to
join them. Shortly after, the War of Independence
broke out and I have never seen the Old City."
2. "I see myself as a little boy locked up by my
mother in the bathroom. This kind of punishment
was habitual. I used to cry silently-a voiceless
weeping-careful to obey my mother's orders: 'You
may shout, you may cry, but nobody must hear you.'''
What is the relation between the life history of the
patient and his bruxism? The patient was an extro-
vert and in the Oedipus stage; his mother was his
ideal image. His father's behaviour during attacks,
which were probably of an epileptic nature, and the
domineering personality of his mother caused a com-
plete disenchantment with her. He saw his father
as the victim of his mother who made a human rag of
him. The patient's subconscious fear of his mother
can thus be explained. His mother castrated his
father and himself. This brought about his intro-
version, his tendency to isolation, and withdrawal
from women to avoid further disappointment. There
is reason to believe that his choice of law as a pro-
fession was motivated by his search for justice, to
compensate for the injustice caused to his father and
himself. His fear of becoming a clerk is also related
to his identification with his father, who, besides
being a clerk, became also his wife's servant. How
should he show his bitterness and hostility? Hostility
can be expressed by banging or shouting, but the
mother still dominates the subconscious of the
patient, and therefore he is unable to free himself
from her warning: "Shout, cry, but nobody must
hear you." In this case, bruxism expresses hostility
and strangulated aggression towards his mother.
The chosen symptom and its manifestation at night
are in accordance with his mother's orders. This is a
terrible and almost silent cry.
Case 2.-The patient is a 25-year-old married
woman, born in Israel. She has a brother eight years
older than herself. She complains of bleeding gums
Volume VI
 BRUXISM-SHAPIRO AND SHANON
since the age of eighteen and suffers from increased
salivation and recurrent aphthae. On examination,
the diagnosis of advanced periodontitis, bruxism and
onycophagia was made.
The patient is a well-groomed, soft-spoken young
woman. She suffers from headaches and frequent
indigestion. She is very nervous and easily upset.
The father is a successful industrialist born in
Bulgaria. He is very dedicated to his family and
takes a keen interest in the education of his
children. He would spend a great deal of time at
their bedside when they were ill. He never punished
them physically or by depriving them of their free-
dom when they misbehaved.
The mother was born in Austria and was known
in society for her unusual beauty. She has a pedantic
and aggressive nature. Shortly after her marriage, she
began to show signs of restlessness and jealousy
towards her husband. Her emotional condition was
aggravated after her daughter was born. She started
to suffer from nervous attacks during which she
would physically attack the child and her husband.
She accused him of neglecting her because of his
excessive love for their daughter. The mother re-
fused to receive psychiatric treatment. The girl
showed open hostility to her mother from childhood,
and looked to her father for protection. In difficult
situations, when she was attacked by her mother,
she used to run and lock herself up in her room.
Covered with a blanket, she would huddle in the
bed with her face buried in the pillo~ her whole
body shaking, teeth chattering and saliva flowing
from her mouth. She became very shy and could not
make up her mind about anything. Lacking any con-
structive occupation, she started to collect useless
objects, such as discarded bus tickets. She sucked
her thumb at night, but her mother used to wake her
up and admonish her not to do so. She stopped the
habit at the age of five, but by a mechanism of dis-
placement began to bite her nails. Since then she has
been unable to break away from this habit. The
compulsion comes to its climax when the door bell
rings. She gives herself a few seconds before open-
ing the door in order to bite off her nails quickly.
When in society, she hides her nails. Since early
childhood she has looked to her father for protec-
tion and he still plays the role of protector. Any
frustration ends in tears. She did not succeed in her
studies for lack of ability to concentrate. She tried
her hand at ceramics, but this attempt aLa ended
unsuccessfully, although her manual ability was
recognized by her teacher. A drastic change in her
life occurred during her military service. Being an
attractive girl, she found herself the center of at-
tention of her comrades. She met a soldier, also of
Bulgarian origin, whom she married shortly after
his discharge from the army. Her husband entered
the University to study economics, while she took
on a government job. The couple, however, are sup-
ported by her father.
From the personal life history of the patient, it
could be concluded that a relationship exists be-
tween her bruxism and the permanent fear in which
she lived since childhood.
In contrast to Case 1 where the patient was
November-December, 1965
unable to show his aggressive feelings, this patient
openly expressed her hostility towards her mother.
The bruxism, in the form of tapping, and the
sialorrhea represent a reaction to fear analogous to
other psychophysiological reactions such as hyper-
hidrosis, hyperacidity, cutis anserina and high blood
pressure, etc.
While periodontal treatment was being carried out,
the patient underwent psychotherapy by one of us.
(J .S.). The main purpose of the psychiatric treat-
ment, which was to give the patient insight into the
genesis of her inhibitions and thus free her from her
over-dependence on her father, was achieved. Psycho-
therapy resulted in her active participation in and
constructive approach to family life.
The periodontal treatment, consisting of gingivect-
omy and occlusal equilibration, resulted in complete
normalization of her periodontal condition. In the
course of the treatment, the patient was prevented
from biting her nails by the surgical pack placed
after gingivectomies. Bruxism in the form of tap-
ping and sialorrhea disappeared. It is worthwhile
mentioning that the habit of onycophagia and the
bruxism did not recur in the follow-up period which
lasted two years.
Case 3.-The patient, a 53-year-old man, married
and father of three children, came to the Dental
Clinic of our School complaining of a throbbing
tooth-ache on the lower right side. A diagnosis was
made of pulpitis in the third lower right molar. The
patient was in need of extensive oral rehabilitation.
He did not suffer from periodontal disease, but ad-
vanced abrasion on all his teeth was noticeable.
His nails were bitten off. When asked about the
habit of teeth-grinding and nail biting, he stated
that he was aware of these habits. He said that he
grinds his teeth forcefully during the day and en-
joys it.
Oral rehabilitation was undertaken and the pa-
tient was referred for psychosomatic evaluation.
The patient was born in a village in Russia. As
the youngest of fifteen siblings, he was the favorite
child and very much spoiled by the whole family.
Until the age of six some members of the family
used to chew his food for him, as a special treat.
One of the vivid memories of his childhood is the
anger he used to experience at being deprived of
chewing his own food. Since then, right up to the
present day, he starts chewing on his own teeth
when he sees food which rouses his appetite. The
patient states: "People say that tasty food makes
their mouth water. With me it is different; when I
see good food, I start grinding." The patient grinds
his teeth during the day and at night. He has also
been a habitual nail-biter since childhood. Since he
bought a wrist-watch twelve years ago, he stopped
hiting the nail of the third finger of the right hand,
which he needs for winding his watch. The nail of
the index is also spared for scratching and pointing
at objects. The patient feels that he could easily
break off the habit of nail-biting as well as bruxism,
but he is not willing to do so, since grinding gives
him a lot of satisfaction, amI nail-biting relieves his
tension.
429
 PSYCHOSOMATICS
A great deal of his time is devoted to household
chores like shopping, cleaning the house and cooking.
He is a meddler and likes to gossip. He likes enter-
tainment, but enjoys it specially when it costs him
nothing.
The patient seldom expresses his anger by shout-
ing because he feels it is not worthwhile-his
children do not respect him and call him names like
"sissy," "stingy," "dumb." On the rare occasions
when he does lose his temper, he runs out of the
house banging the door after him. On these oc-
casions, his wife runs after him and brings him back
home.
His wife, who is a nurse by profession, falls fast
asleep from tiredness at the end of the day and was
not aware of his habit of night-grinding. At our
suggestion, she watched him at night and observed
him grinding his teeth, his face expressing complete
happiness. In answer to our inquiry, the patient
reported the frequent joyful dreams in which he
experienced the pleasurable sensation of chewing
a cake.
The present case, compared to the ones described
above, is of a completely different nature. As a
result of overgiving, the patient was deprived of the
pleasure of mastication and developed a conditioned
reHex of bruxism. To the best of our knowledge,
bruxism as an expression of oral gratification has not
been described previously.
SUMMARY AND CONCLUSIONS
Ten patients suffering from severe bruxism
were analyzed. No relationship between
bruxism and their emotional conflicts was
found in two patients. In six cases, bruxism
was motivated by "strangulated aggression."
One of them is reported in detail. Another
case is described in which bruxism manifested
itself as a psychophysiological reaction to
fear. In the third case reported, bruxism
manifests itself as a conditioned reflex and
is an expression of oral gratification.
In three cases of the present series recur-
430
rent aphthous stomatitis was diagnosed. In
order to establish any possible correlation be-
tween bruxism and recurrent aphthous
stomatitis further studies on a large number
of patients are required.
It seems worthwhile mentioning that
onycophagia is a frequent unspecific accomp-
anying neurotic symptom in bruxism.
The importance of a psychosomatic ap-
proach to the diagnosis and treatment of
bruxism in periodontal practice is stressed.
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Volume VI