An Operational Clinical Approach in the Diagnosis and Management of Sleep Bruxism: A First Step Towards Validation

Exacerbation of nighttime sleep-related oromotor activity is often recognized as a relevant clinical entity commonly known as sleep bruxism (SB). Many pragmatic issues about SB diagnosis and management remain controversial. Therefore, within a critical review of the literature, this article proposes an operational clinical approach for SB diagnosis and management, with a focus on three comorbidities frequently occurring in relation to sleep: obstructive sleep apnea (OSA), gastroesophageal reflux disease (GERD), and insomnia. In the absence of any comorbidities, and if clinically justified, short-term medication and/or splints may be considered. If a comorbid condition is suspected, then the patient should be screened for OSA, GERD, and insomnia. For OSA screening, the Epworth Sleepiness Scale, STOP-Bang, and NoSAS questionnaires are available validated tools. For GERD screening, a positive patient report, whether associated or not with clinical signs and symptoms of heartburn and/or regurgitation, can be tested. For insomnia screening, report of difficulties initiating or maintaining sleep or of early morning awakening more than three times a week may be useful for diagnosis clarification. An adequate clinical approach for comorbid SB requires that both SB and the related comorbid condition be properly assessed and managed. Very often, improvement of SB with treatment of the associated condition will confirm the relationship and establish a more precise diagnosis (ie, secondary SB). Clinicians intending to manage SB should be able to identify these possible clinical interactions, and, if needed, perform an integrative multidimensional approach. Some approaches will benefit from a multidisciplinary approach for achieving therapeutic success.

gastroesophageal reflux; insomnia; obstructive sleep apnea; sleep bruxism

1. Lavigne GJ, Kato T, Kolta A, Sessle BJ. Neurobiological mechanisms involved in sleep bruxism. Crit Rev Oral Biol Med 2003; 14:30–46.

2. Lobbezoo F, Ahlberg J, Raphael KG, et al. International consensus on the assessment of bruxism: Report of a work in progress. J Oral Rehabil 2018;45:837–844.

3. Mayer P, Heinzer R, Lavigne G. Sleep bruxism in respiratory medicine practice. Chest 2016;149:262–271.

4. Lavigne G, Palla S. Transient morning headache: Recognizing the role of sleep bruxism and sleep-disordered breathing. J Am Dent Assoc 2010;141:297–299.

5. Maluly M, Andersen ML, Dal-Fabbro C, et al. Polysomnographic study of the prevalence of sleep bruxism in a population sample. J Dent Res 2013;92(7 suppl):s97–s103.

6. Ohmure H, Takada H, Nagayama K, Sakiyama T, Tsubouchi H, Miyawaki S. Mastication suppresses initial gastric emptying by modulating gastric activity. J Dent Res 2012;91:293–298.

7. Manfredini D, Serra-Negra J, Carboncini F, Lobbezoo F. Current concepts of bruxism. Int J Prosthodont 2017;30:437–438.

8. Manfredini D, Ahlberg J, Winocur E, Lobbezoo F. Management of sleep bruxism in adults: A qualitative systematic literature review. J Oral Rehabil 2015;42:862–874.

9. Huynh N, Lavigne GJ, Lanfranchi P, Montplaisir JY, de Champlain J. The effect of 2 sympatholytic medications—propranolol and clonidine—on sleep bruxism: Experimental randomized controlled trials. Sleep 2006;29:307–316.

10. Sakai T, Kato T, Yoshizawa S, et al. Effect of clonazepam and clonidine on primary sleep bruxism: A double-blind, crossover, placebo-controlled trial. J Sleep Res 2017;26:73–83.

11. Shim YJ, Lee MK, Kato T, Park HU, Heo K, Kim ST. Effects of botulinum toxin on jaw motor events during sleep in sleep bruxism patients: A polysomnographic evaluation. J Clin Sleep Med 2014;10:291–298.

12. Johns MW. A new method of measuring daytime sleepiness: The Epworth Sleepiness Scale. Sleep 1991;14:540–545.

13. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: A tool to screen patients for obstructive sleep apnea. Anesthesiology 2008;108:812–821.

14. Marti-Soler H, Hirotsu C, Marques-Vidal P, et al. The NoSAS score for screening of sleep-disordered breathing: A derivation and validation study. Lancet Respir Med 2016;4:742–748.

15. Morin CM, Belleville G, Bélanger L, Ivers H. The Insomnia Severity Index: Psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep 2011;34:601–608.

16. Gagnon Y, Mayer P, Morisson F, Rompré‚ PH, Lavigne GJ. Aggravation of respiratory disturbances by the use of an occlusal splint in apneic patients: A pilot study. Int J Prosthodont 2004;17:447–453.

17. Nikolopoulou M, Ahlberg J, Visscher CM, Hamburger HL, Naeije M, Lobbezoo F. Effects of occlusal stabilization splints on obstructive sleep apnea: A randomized controlled trial. J Orofac Pain 2013;27:199–205.

18. Marshansky S, Mayer P, Rizzo D, Baltzan M, Denis R, Lavigne GJ. Sleep, chronic pain, and opioid risk for apnea. Prog Neuropsychopharmacol Bio Psychiatry 2018;87:234–244.

19. Winocur E, Gavish A, Voikovitch M, Emodi-Perlman A, Eli I. Drugs and bruxism: A critical review. J Orofac Pain 2003; 17:99–111.