Nightguards May Not Be Best for Bruxism

An Expert Interview With Steve Carstensen, DDS

Laird Harrison

October 17, 2011

October 17, 2011 (Las Vega, Nevada) — Editor's note: Most dentists recognize the signs of bruxism and prescribe a nightguard to treat it, but few make the connection between teeth grinding and breathing problems.

A presentation on bruxism was featured here at the American Dental Association (ADA) 2011 Annual Session. Medscape Medical News interviewed presenter Steve Carstensen, DDS, a general practitioner in Bellevue, Washington, who is certified by the American Board of Dental Sleep Medicine.

Medscape: How can dentists determine the best treatment for bruxism?

Dr. Carstensen: Most dentists have been trained to recognize the signs and symptoms of bruxism in wear and perhaps joint pain. Most dentists don't think they can stop bruxism, but they can make their patients more comfortable by making them a nightguard. But many patients who grind their teeth don't breathe very well, and we can treat both at the same time. So the dentist who sees worn-out teeth, prescribes a nightguard, and stops there is not as complete as the dentist who asks what else is going on.

Medscape: Does bruxism cause breathing problems, or is it the other way around?

Dr. Carstensen: People who grind their teeth at night are twice as likely to have problems breathing. And people who have trouble breathing at night are twice as likely to grind their teeth. But we don't know exactly what causes bruxism. Some risk factors have been identified, but there are too many exceptions to generalize. One theory is that your muscles clench when you don't get enough oxygen, and that may cause people to grind their teeth.

Medscape: What sort of breathing problems are you talking about?

Dr. Carstensen: Snoring and sleep apnea. In sleep apnea, breathing stops periodically during sleep, as many as 100 times per hour. When breathing stops, the lack of oxygen wakes patients up to breathe. Because they wake up so briefly, they may not be aware of the problem. But constantly waking up interrupts the normal sleep cycle, so people with this condition often feel sleepy during the day.

Medscape: How can dentists diagnose these problems?

Dr. Carstensen: They can use the Epworth Sleepiness Scale or the STOP-Bang Questionnaire. They are simple screening tools with 8 questions. They will come right up if you Google them. With a proper diagnosis, dentists will know whether to make their patients nightguards or an oral appliance to help them breathe.

Medscape: What kind of appliances help with breathing?

Dr. Carstensen: There are so many kinds I can't describe them all. Different manufacturers and laboratories have come up with different designs. The US Food and Drug Administration has approved over 90. All of them are intended to keep the patient's airway open, but they do this in subtly different ways. Some come off the shelf in different sizes. Some can be molded to the patient's mouth. And some are custom made by laboratories from an impression taken by the dentist. They range in cost up to several hundred dollars.

Medscape: How can a dentist choose which to prescribe?

Dr. Carstensen: What you do is check the research. Has it been tested well? Evaluate the company. Is it a company you want to do business with? Then you have to evaluate what works well in your hands. Dentists are used to doing this; we do it all the time with other appliances.

Medscape: Are they hard to prescribe?

Dr. Carstensen: They are not hard to prescribe, but it takes some training. One place you can learn is the American Academy of Dental Sleep Medicine.

Medscape: Will the oral appliances protect patients' teeth?

Dr. Carstensen: Most people who improve their breathing will stop their grinding. But if they don't, the appliance can protect their teeth. The key is to understand the whole diagnosis before you make them a nightguard.

Medscape: What about the reverse? Will a nightguard improve breathing?

Dr. Carstensen: No. In fact, some people get much worse in their breathing with a normal nightguard.

Medscape: There are also devices that beep when a patient clenches. Do they work?

Dr. Carstensen: I would be very worried about something that makes a beep because that would disturb the patient's sleep. Biofeedback is very helpful with daytime bruxism, but not nighttime bruxism.

Medscape: What about medication?

Dr. Carstensen: There is medication for bruxism, but it is very hard to use.

Medscape: Do hypnotism or meditation help?

Dr. Carstensen: There is no scientific evidence of a benefit.

Medscape: When patients have no symptoms, how do you get compliance?

Dr. Carstensen: The body is very adaptable, so patients may not experience what other people are experiencing. There is no way of testing to see if patients are wearing their appliances. What you can do is try to ask enough questions. We might ask how they breath when they sleep or whether they have ever had any tooth pain.

Medscape: Do dentists need to get certified by the American Board of Dental Sleep Medicine to treat these problems?

Dr. Carstensen: No, any dentist can do it. I got certified because I wanted to declare that this is an important part of what I do.

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