Bruxism and PTSD: The Teeth Keep the Score

How PTSD Can Lead to Bruxism and Dental Issues: The Teeth Keep the Score

By Dr Al Griskaitis, Psychiatrist

Bessel van der Kolk noted in PTSD that "The body keeps the score".

Bruxism "the gnashing of teeth" is a literal example of that.

What is Bruxism?

Bruxism is the involuntary grinding or clenching of teeth. It can occur during waking hours (awake bruxism) or during sleep (sleep bruxism). Common signs include worn-down biting surfaces of teeth, erosion of teeth at the gumline (abfraction), jaw pain, headaches, and increased tooth sensitivity. While bruxism is often associated with transient stress, its common connection to PTSD highlights a bodily impact of feeling endangered. Bruxism likely relates to this chronic state of increased arousal from PTSD which can be further exacerbated by alcohol and some medications.

What is PTSD?

I posit that it is more than a reaction to trauma with a syndrome of symptoms, that's too low resolution.  Post-Traumatic Stress Disorder (PTSD) occurs when a very serious adversity leads to a "alarm state" which is a chronic state of increased arousal. The alarm never stops because the subconscious perceives an ongoing susceptibility to further danger. PTSD also entails intrusive memories/nightmares which can serve as clues to resolve the susceptibility. The longer the trauma susceptibility goes on, the deeper the impacts of cumulative mental, emotional, and physical fatigue. That fatigue brings irritability, anhedonia and depression.

The Link Between PTSD and Bruxism

PTSD can contribute to the development or exacerbation of bruxism through several interconnected mechanisms:

• Physiological Response: The ongoing sense of danger causes heightened physical arousal and chronic stress, leading to increased muscle tension throughout the body, including the jaw muscles involved in bruxism.
• Neurological tone: The ongoing perception of danger ramps up autonomic nervous system, specifically a tonal shift to the sympathetic (arousal) system and away from the parasympathetic (calming) system. 
• Hypertrophy: Constant muscle tension from bruxism can lead to hypertrophy (muscle growth) of the jaw muscles. The stronger they get the more potential for wear on teeth surfaces and abfraction near the gums.
• Endocrine Factors: Increased adrenaline (epinephrine) secretion because of the acute "triggers" over and above the chronic alarm state of PTSD further contributes to muscle tension and bruxism.

Clinical Implications

Chronic teeth grinding can exacerbate existing dental problems, it can cause tooth wear, fractures, jaw pain and temporomandibular joint (TMJ) dysfunction. Here's a recent study.  Recognizing bruxism as a potential symptom of PTSD is crucial to prevent dental damage among people with PTSD.

Treatment Approaches

Managing bruxism in the context of PTSD requires a comprehensive approach that addresses both the psychological and physiological aspects and root cause:

• Root cause Interventions: Treatment of underlying PTSD symptoms through distress tolerance skills, Eye Movement Desensitization and Reprocessing (EMDR), and trauma susceptibility work can reduce bruxism over time.
• Dental Interventions: Custom-fitted occlusal splints (bite guards) can protect teeth from further damage during sleep and periods of heightened stress.
• Botulinum Toxin A Injections: Injections into the masseter muscles can weaken muscle strength, reducing hypertrophy and the severity of bruxism. Initial treatments may require quarterly sessions, reducing in frequency as muscle hypertrophy resolves.
• Combination of approaches are the best mitigation for dental damage.
• Acceptance-Commitment Therapy (ACT Therapy) can help address the underlying psychological causes (see next section).

Patient Stories and Moral Injury

I mostly work with police and military PTSD and most of my patients have bruxism. Real-life examples underscore the connection between PTSD and bruxism, highlighting the need for integrated treatment approaches in improving symptoms and overall quality of life for individuals affected by PTSD complicated by bruxism. It's very common. Clinically there seems to be a strong relationship between Moral Injury and bruxism, which resonates with the biblical idea of one's actions/inactions leading to despair and the "weeping and gnashing of teeth". Moral Injury can benefit from moral solutions. A type of therapy called Acceptance-Commitment Therapy (ACT Therapy) can be most useful. This therapy usually entails a painful acceptance of difficult truths of the events(s), such as the revelation of self-betrayal of one's values or recognising the results of misplaced trust (another form of self-betrayal). A careful exploration of one's "gut" values so that one can crystallise them and make a commitment to follow one's values in the face of morally challenging predicaments is undertaken. Undertaking ACT therapy is an challenging act of self-compassion, forgiveness and atonement. 

Preventive Measures and Self-Care

In addition to professional treatment, individuals can adopt self-care practices to manage bruxism and support overall well-being:

• Tension-Release Exercises (TRE): These exercises allow the body to mimic the "post-traumatic shaking reflex" seen after acute trauma. That shaking reflex is what you observe if you've ever seen an acutely traumatised person. The reflex probably promotes parasympathetic down-regulation to alleviate jaw tension. That can give relief for several hours.
• Distress and stress skills: Learning the skills to manage, prevent and recover from states of Distress can be a game-changer, here's our online course for that: Surviving Distress.
• Regular Dental Check-ups: Routine visits enable early detection of bruxism-related dental issues and prompt intervention.

Conclusion

If you have PTSD, ask your ask your partner to listen out for dental grinding at night and ask your dentist to assess and monitor for signs of bruxism.  If you get jaw tension during the day or wake up with jaw soreness, get checked out ASAP. People can be bruxing for years and accumulate a lot of expensive and permanent damage. Early intervention and a holistic treatment approach can mitigate the impact of bruxism on dental health and overall quality of life.

Don't let your teeth keep the score.