Nocturnal Bruxism: Teeth Grinding or Clenching

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

Nocturnal Bruxism or Sleep Bruxism, the clenching and grinding of the teeth during sleep, is becoming a more prevalent problem in the United States, and is still not seriously addressed in standard medicine despite numerous studies indicating that this symptom is related to an array of serious health problems. While the majority of the population will at some time in their life grind or clench their teeth, this is generally normal, not pathological, behavior. Bruxism becomes pathological and needs treatment when it presents problems of tooth damage or non-restorative sleep, which often indicates that associated neurological and perhaps metabolic health problems are present. Sleep studies indicate that over 8 percent of the population may experience a pathological nocturnal, or sleep-related bruxism. The underlying pathophysiology of this problem is complex enough that standard medicine is still largely ignoring it, with no clearly effective treatment, and patients are often depending upon advice from the dentist to treat and understand this symptom. Understanding of Sleep-related Bruxism clearly shows that this a health problems related to a dysfunction of the CNS, not a simple case of jaw misalignment, and that when jaw misalignment is found, that most often this is a functional disorder related to the deep muscles of the temporomandibular joint (TMJ), not an inherited malformation or misalignment of the jaw. We should realize, of course, that the advice from dentistry may be limited, and more geared toward dental work and devices than to actual understanding and treatment of the underlying causes of sleep-related bruxism. Sleep Bruxism is a symptom with a wide range of severity and presentation, and may manifest as a mild to severe movement disorder, with alarm generally occurring when tooth damage is presented, or when quality of sleep is poor, resulting in easy fatigue or daytime sleepiness, but the obvious signs and symptoms may only represent the tip of the iceberg if more serious associated disorders are present as well. Modern medical research is still somewhat unclear on the subject of bruxism, with very few clinical studies performed concerning the sparse treatment options, but we have learned some important facts, which indicate that a more holistic approach is needed to really address this cycle of dysfunction related to pathological bruxism.

Currently, standard medicine has no effective cure for nocturnal bruxism when these more severe episodes of teeth grinding and clenching create tooth damage and sleep depriving fatique. Bruxism may be a sign of more serious underlying health problems, though, and a holistic approach to treatment in Complementary and Integrative Medicine (CIM) may help eliminate the moderate to severe bruxism and address the associated health problems as well, such as TMJ disorder, chronic neck and back pain, snoring and sleep apnea, ADHD, parasomnias, poor quality of sleep, anxiety disorder, adrenal stress syndrome, and metabolic imbalance.

Study of bruxism finds that this is a neurological symptom related to tardive dyskinesia, or delayed onset dysfunction of neuromuscular control, focal to the basal ganglia in the brain, an area near the thalamus at the top of the brainstem that is involved in movement coordination. Evidence indicates a multifactorial perpetuating cycle of dysfunction affecting the normal degree of neuromuscular spasticity, rhythmic movements, and jaw reflexes in deep sleep, especially early REM phases, which we go through a number of times each night during sleep. The factors identified as either associative or causative include chronic myofascial syndromes of contracture and shortening of masticatory muscles, especially the pterygoids, masseters, and scalenes, temporomandibular joint syndrome (TMJ), stress and anxiety, side effects of drugs, especially antidepressant SSRI medications, GABA dysfunction, hypersensitivity of presynaptic dopamine receptors, neurodegeneration, arousal phenomenon or sleep parasomnias, sleep apnea, increased excretion of adrenal norepinephrine (adrenaline), and autonomic stress disorders. The modulation of response to pain and temperature signals, balance of neurotransmitters, hypothalamic function, and transitions between phases of the sleep cycle, especially concerning parodoxical sleep, are all important in the treatment protocol, which may be individualized for each patient. This complex array of potential underlying causes, aggravating factors, and restorative needs demands much more than a dental mouth guard, and a persistent, individualized holistic approach to care is needed.

Assessing and addressing these issues may be complicated, but a thorough and comprehensive treatment protocol may be devised by a competent and knowledgeable practitioner of Traditional Chinese Medicine (Licensed Acupuncturist). Of course, utilizing a well fitted mouthpiece, hopefully individually fitted and molded, by a good dentist, may be a part of this protocol, when needed, to decrease damage to the teeth. It must be realized, though, that this will not address these important underlying health problems and mechanisms that contribute to, perpetuate, or cause nocturnal bruxism, or sleep-related bruxism. The dentist does not have the therapeutic tools and specialized knowledge to treat the underlying pathologies, and the Medical Doctor has no effective pharmacological therapy. If chronic drug side effects are suspected in the array of causative factors, this should be discussed with the prescribing physician, though. An integrated approach to therapy may be needed to cure oneself of this difficult health problem, and the patient would be wise to choose a competent Licensed Acupuncturist and herbalist to integrate into this therapeutic team. CIM/TCM provides an array of therapeutic tools, especially if the TCM physician is trained in myofascial release and neuromuscular reeducation, soft tissue mobilization (Tui na), and applies current research concerning herbal nutrient chemistry.

Perhaps the most important area of concern with nocturnal bruxism is the wide array of health problems and diseases associated with nocturnal bruxism. Potential consequences beyond dental damage and muscular or TMJ pain are numerous. For too long this has been treated with a dismissive attitude despite the extensive scientific study of bruxism and sleep disorder. If the dentist or MD notes signs of Sleep Bruxism he should recommend integration of treatment from a knowledgeable TCM physician to provide an holistic and thorough approach to treatment, addressing the many health factors that are clearly associated.

Experts in this field now state that standard treatment of nocturnal bruxism should include four categories of therapy: physiotherapy, pharmacological, psychological, and myofascial trigger point needling or release (Sherman and Turk 2001; Benoliel et al 2003). Each case may need a different protocol, depending on the identification of important factors related to the syndrome. TCM/CIM may integrate all of these therapeutic protocols, and integrate with various specialists to provide this comprehensive care. Pharmacological treatment has not produced significant results so far, but benzodiazepines, or anxiety relieving medications, are often prescribed, such as Clonazepam, which themselves may produce extrapyramidal side effects, including movement disorders, with chronic use. Study of the pharmacodynamics of herbal and nutrient medicines has supported the use of magnesium, pantothenic acid, calcium AEP, phosphatidylcholine, Kava kava, St. Johns Wort, and various anxiolytic and neuromodulating herbs and supplements. Of course, the array of therapies in the specialty of CIM/TCM that could help with bruxism is much broader than these treatments. Physiotherapies may focus on chronic muscle tension in the neck and back, as well as myofascial trigger point dysfunctions, which may be relieved with trigger point needling, manual release techniques, and neuromuscular reeducation. These therapies may also address TMJ syndromes, which are often associated with bruxism. Stress reduction and anxiety syndromes may need to be addressed as well, and acupuncture and herbal/nutrient medicine may also help treat this aspect of the pathology (see a separate article on anxiety on this website). If esophageal irritation and regurgitaton are involved, or vagal excitability with episodes of tachycardia during sleep, these triggers associated with bruxism and sleep disorder are often related and can be addressd in TCM therapy as well. First treating the more tangible factors, such as the TMJ (TMD) and myofascial syndromes, is sensible, with progression to the more complex effects on the neuromuscular control if needed. The course of therapy may thus be short and simple, or may need a more complex and prolonged series of short courses of therapy.

Parasomnias, or sleep disorders, are also highly associated with nocturnal bruxism, and many experts think that bruxism is a type of parasomnia. What separates this movement disorder from other parasomnias is that bruxism also is seen in some patients during the waking state, although diurnal bruxism almost always produces milder muscle activity than daytime bruxism. Studies of patients with sleep disorders, using electromyogram (EMG), show that about 60 percent of patients with a sleep disorder exhibited bruxism, but only a small percentage had a clinical pathology that involved waking, waking the sleep partner, or fracturing tooth enamel. Parasomnias, often unnoticed until severe, include arousal disorders, REM disorders, sleep behavior disorders, nocturnal seizures, rhythmic movement disorders, and bruxism. Restless leg syndrome would fall into this category, as well as sleep walking, talking in the sleep, rhythmic body rocking, sleep terrors, and emotional agitation during the sleep. Parasomnias are also often associated with sleep deprivation, and sometimes with sleep apnea, as metabolic problems associated with airway hypertrophy may also be associated with elevated stress and adrenal hormones, elevated dopamine, and oxidative stress. There is evidence that successful treatment of sleep apnea (OSA) may decrease sleep-related bruxism, but even if a problematic CPAP machine is used, the underlying health dysfunctions are not addressed by the use of a device to pump more oxygen into the respiratory system during sleep (see the article on this website entitled Sleep Apnea, Adrenal Fatigue and Insulin Resistance). Of course, sleep disorders would directly affect the flow of sleep states, non-REM through the REM cycles, and the abnormal transitions of these sleep cycle phases are at the heart of the bruxism pathology. To fully treat this type of sleep-related bruxism, though, the cycle of underlying dysfunctions should be addressed, which may be different from patient to patient.

Metabolic concerns are also a concern with nocturnal or sleep-related bruxism. Studies show a high correlation between sleep deprivation and deficiency of leptin, as well as elevated ghrelin, another metabolic hormone, which has been shown to affect mental function, memory and dopamine receptors in the basal ganglia that control fine motor movements. Ghrelin is considered a counterpart to leptin, both of which are associated with Metabolic Syndrome, but both of which have a variety of hormonal effects in the body. Ghrelin, produced mainly in the stomach and pancreas, and associated with satiety and appetite regulation, affects the lateral hypothalamus, a focal source of central neurological signals that stimulate the rhythmic movements of the masticatory muscles in nocturnal bruxism. Ghrelin also affects the vagal component of the autonomic nervous system, which too is involved in the phenomenon of episodic nocturnal bruxism of greater intensity, which stimulates a more rapid heart rate. Ghrelin also stimulates secretion of growth hormone from the anterior pituitary, the secretory gland of the hypothalamus, and could have a connection with the association of sleep apnea with nocturnal bruxism, since sleep apnea almost always involves excessive tissue growth of the upper airway. This syndrome of metabolic and neurohormonal imbalance cannot be corrected by simply taking some leptin, but demands a more thorough and holistic approach to treatment.

Sleep disorder must be corrected in sleep-related bruxism syndromes. REM (rapid eye movement) states in deep sleep involve high levels of brain activity and decreased muscle motor responses. Normally, in this deep sleep phase, the body is atonic, or unable to move, except for certain movements, such as the rapid rhythmic shifting in the eyes. In non-REM states of deep sleep, though, limbs may often move rhythmically, and anyone with a pet dog may be familiar with this phenomenon. Restless leg syndrome is such a movement phenomenon associated with deep sleep cycles. Bruxism is often seen in studies occurring during various phases of the deep sleep cycle, and is seen when the normal progression of sleep stages does not progress as expected, with the body reverting to a non-REM state instead of entering the REM, or dreaming phase of deep sleep. The term paradoxical sleep is used to describe the state of sleep where intense brain activity in the forebrain and midbrain paradoxically mimics the brain activity of waking states, and involves REM as well. Studies indicate that sleep deprivation associated with paradoxical sleep, sleep arousals, and sleep instability during the stage 3, or first stage of deep sleep, in the cycles of sleep that take from about 90 to 110 minutes normally, are involved in the phenomenon of nocturnal sleep-related bruxism. Fragmentation is the term given to the interruption of a sleep stage due to transition to a lighter stage, sometimes to wakefulness with insomnia. Fragmentation that does not result in waking, but in milder arousals and paradoxical sleep, is believed to result in the phenomena of nocturnal sleep-related bruxism. Bruxism may occur a number of times during the night, and differing degrees of intensity are noted with occurence during different sleep phases. Restoring the sleep homeostasis is therefore important to finally stop bruxism. Sleep medications are problematic and do not actually restore sleep homeostasis, and a more holistic approach is needed with restorative medicine such as CIM/TCM.

It has been surmised that there are triggers that create the phenomenon of strong bruxism, but this is difficult to clearly identify as the condition is considered a tardive dyskinesia, with the triggers perhaps preceding the manifestation by some number of minutes or even days, hence the term tardive. Since the evidence in studies indicates a multifactorial perpetuating cycle is involved, treatment should focus on the array of factors that perpetuate this strong movement disorder. The holistic approach is now highly recommended, and has shown considerable success clinically for many physicians. The clearing of nocturnal bruxism may also occur slowly, just like the onset, and a treatment protocol should address all of the potential triggers, causative factors, and perpetuating factors, with persistence of treatment until the symptom is showing a decline in frequency and intensity. Often, though, this is somewhat difficult to judge, as most patients with nocturnal bruxism do not recall waking or experiencing the teeth grinding and clenching. A sleep partner may notice an improvement, and the jaw discomfort and cracking of tooth enamel may subside, indicating the effectiveness of the therapy. Like most health problems, we need to persist with the right therapeutic protocols, and trust that this will solve the problem. When utilizing a more holistic approach that incorporates CIM/TCM, the patient may utilize short courses of specific acupuncture and electroacupuncture stimulation, while taking a step-by-step approach with persistent herbal and nutrient medicines, and if needed, soft tissue physiotherapy and myofascial release to address TMJ and other concerns.

Risk factors for nocturnal bruxism

Study at the Stanford University School of Medicine, Sleep Disorders Center (Dr. Maurice M. Ohayon et al), found that associated risk factors for nocturnal bruxism included obstructive sleep apnea, loud snoring, moderate daytime sleepiness, heavy alcohol drinking, heavy caffeine consumption, cigarette smoking, highly stressful life, and anxiety. Use of methamphetamines and cocaine stimulants also appear to be risk factors for bruxism in general, as well. The Stanford study found that subjects with sleep bruxism diagnosed, and teeth grinding alone, both were found to drink alcohol at bedtime more frequently than the control subjects. The study found that sleep bruxism rarely occurs alone as a pathology as well. The researchers found that obstructive sleep apnea (OSA) was the highest risk factor for tooth grinding during sleep among the various associated sleep symptoms and disorders, and is probably related to an arousal response. Sleep bruxism, as well as snoring, gasping, and mumbling in the sleep, was seen most often as the episode of sleep apnea terminated. While about 70 percent of subjects diagnosed with sleep bruxism attributed their episodes to stress and anxiety, numerous studies have produced conflicting information on this subject, which is further explored later in this article. Sleep studies at the Sleep Disorders Unit of the Loewenstein Hospital in Israel in 2002 also noted that sleep apnea rarely occurs in isolation, and that when nocturnal bruxism was identified as associated with sleep disorders, that sleep apnea was seen as the most associated and highest risk factor for bruxism during sleep (PMID: 14592147). Treatment of sleep disorders, such as sleep apnea, demand a more thorough and holistic approach, just like the treatment of nocturnal bruxism, and like bruxism, standard medicine still relies on a simple allopathic device that does not resolve the underlying causes of sleep apnea, but simply decreases the severity by use of a cumbersome device called a CPAP (continuous positive airway device). Use of a mouth appliance and a CPAP is not ineffective in therapy, but also is not restorative, and are poorly tolerated by a high percentage of patients. Integrating Complementary Medicine and TCM into the overall protocol allows the patient to actually address the array of factors that are causative and associated with nocturnal or sleep-related bruxism. This approach is sensible and the only side effect is better overall health and quality of life.

Pathophysiology of nocturnal bruxism

Bruxism is still a poorly understood symptom, despite a large number of sleep studies evaluating the phenomenon. Sleep disorders and neurological disorders are highly associated with incidence of nocturnal bruxism, though, and this guides theories related to the etiopathology. Impairment of sleep quality is a common characteristic of neurological diseases such as Parkinsonism and Dystonia, and associated with symptoms of nocturnal bruxism, depression, and restless leg syndrome. Studies have identified increased sympathetic activity preceding episodes of nocturnal bruxism with increase heart rate, and an association with transient sleep arousals and rhythmic masticatory muscle activity. The neural pathways explored reveal that mandibular movements occur through the triggering of trigeminal motor neurons, and that brain activity from the lateral hypothalamic area and central nucleus of the amygdala are associated with this trigeminal activity. The amygdala is an area of the central brain that contains cell nuclei that research shows is associated with processing and memory of emotional reactions, and is part of the limbic system. These areas of the brain are also well known for regulation of the autonomic nervous system, especially the hypothalamus, or neural command center for the endocrine system. Hypothalamic dysfunction may therefore play a significant role in the etiopathogenesis of nocturnal bruxism. Irritation of the trigeminal nerve pathway may also play a part in the pathology, though, and the high association of TMJ disorders and myofascial syndromes of the neck, which may cause irritation of the trigeminal nerve, indicate that this may be an important part of the array factors that perpetuate nocturnal bruxism. Chronic irritation of the trigeminal nerve may also lead to an irritating feedback to a more central nerve pathway, and be associated with altered pain thresholds. The unique characteristics of the trigeminal nucleus in the reticular system of the brainstem is of particular interest to researchers. Holistic treatment approaches may need to address these various problems, aiding hypothalamic function with Calcium AEP and Vitex, autonomic and vagal dysfunction with Taurine, various enzymes and herbal formula, and the trigeminal nerve irritation by using myofascial release of the pterygoid muscles of the jaw and resolution of TMJ. Of course, short courses of acupuncture stimulation will aid all of these treatment approaches. The beauty of CIM/TCM is that all of these therapeutic approaches may be included in the same treatment course, addressing the whole cycle of dysfunction, not just one aspect of the cycle.

Other studies recently in Japan showed that induced esophageal acidity resulted in a higher incidence of sleep bruxism in patients being studied. Transient lower esophageal relaxations are a common cause of esophageal acidity with reflux, and this may occur at night in patients with bruxism. Patients with gastroesophageal reflux episodes involving a lower pH (higher acidity) showed more frequency of bruxism, as well as nighttime GER episodes. The normalizing of esophageal reflux and acidity had a higher rate of success reducing episodes of nocturnal bruxism than any other type of medication therapy. The subject of GERD is not as clear as we believed in the past, though, and many studies now show that gastric hypofunction and transient lower esophageal relaxations are more important in a majority of cases than simple excess acidity. A separate article on this website, entitled Acid Reflux and GERD, explores the subject of GERD and treatment approaches in CIM/TCM. Studies show that electroacupuncture at specific points (P6/ST36) dramatically reduces transient lower esophageal relaxations, and formulas of herbs and nutrient medicines have been found to be very effective in restoring gastric function to eliminate GERD. Once again, there may be a need to address a number of health concerns with pathological nocturnal and sleep-related bruxism, and only a thorough and persistent holistic approach may achieve the desired results.

Studies in Taiwan showed the high incidence of bruxism and sleep disorder in ADHD patients as well, with snoring, bruxism, insomnia, sleep terrors, sleep talking, longer nocturnal sleep, earlier bedtime and later rise times associated with ADHD. Studies also reveal a higher level of catecholamines (dopamine, adrenaline) excreted in the urine of patients with sleep bruxism, which points to an objective connection between nocturnal bruxism, stress disorders, ADHD, and hypothalamic dysfunction. Reports of nocturnal bruxism occurring as a side effect of medication are numerous, with SSRI antidepressants accounting for the majority of reports. Since selective serotonin reuptake inhibitors would eventually affect the dopamine metabolism, this makes sense. A prominent proposed mechanism for diurnal/nocturnal bruxism (symptoms occurring both day and night) involves hypersensitivity of presynaptic dopamine receptors in the frontal lobe. This dopamine receptor dysfunction is also central to ADHD disorders, and to hypothalamic dysfunction. Addressing neurotransmitter balance and homeostasis, adrenal stress syndrome, transient lower esophageal sphincter relaxations, autonomic balance, and hypothalamic function with acupuncture, herbal and nutrient medicine will help correct the underlying causes of nocturnal bruxism. Simply taking ADHD medications, which are amphetamines used to stimulate brain activity, not restore it, and SSNRI medications, will not address the problems associated with bruxism, and in the long run will probably cause a worsening of the CNS dysfunction with neurotransmitter imbalance and increased CNS excitotoxicity. Attention deficit and hyperactivity disorder (ADHD) is unfortunately another difficult health problem to treat that standard medicine has largely failed to deliver a safe and effective restorative treatment protocol to actually resolve. Overuse of ADHD medications has created a public health crisis instead of better quality of life, and CIM/TCM here too offers valuable restorative medicine to help resolve. An article on the website, entitled ADD/ADHD Attention Hyperactivity Disorders, provides research and understanding of this difficult problem as well. There is no claim that simple acupuncture therapy will magically resolve these difficult health problems with just a few treatments, but CIM/TCM provides sensible treatment protocols that may be integrated easily into the overall approach to treatment, and if these short courses of TCM therapy are based on scientific evidence and clinical studies, the outcomes are assured. Patients should understand that a more holistic and intensive approach is needed for more difficult health problems, though, and opting for the simplest acupuncture approach, and trying just a few treatments, may not be the most realistic approach by the patient.

The connection between nocturnal bruxism, sleep disorders, and attention deficit and hyperactivity disorders (ADHD) may be particularly revealing in terms of etiolpathology of nocturnal bruxism. A large study in 2008, cited below in Additional Information, showed a clear relationship in children with a diagnosed ADHD between sleep disturbances in ADHD and rhythmic movement disturbances, snoring, night awakenings, enuresis (bedwetting), and bedtime resistance. You may read more about the pathophysiology of ADHD on another article on this website. Dysfunction of the dopamine receptor system lies at the heart of this disorder, and an array of factors may contribute to this dysfunction, including oxidative stress, neurohormonal imbalance, metabolic deficiencies, and food and environmental chemicals. An array of therapeutic protocols may address these various concerns and contribute to the relief of nocturnal bruxism, and some of these herbs and nutrient supplements are explained in the article on ADHD on this website. While this is a long list of potential treatment aids, these natural medicines are all beneficial to CNS and metabolic health and come with no side effects. A knowledgeable Complementary and Integrative Medicine (CIM) physician, such as a Licensed Acupuncturist and herbalist may best guide the individual patient with the most important of these medicines for each individual. Since the underlying dysfunctions in these disorders are clearly the same, holistic treatment will address all of these difficult problems with the same array of therapeutic protocols.

The study of brain function, neural pathways regulating the masticatory muscles, and regulation of transitions in deep sleep has led researchers to focus on the reticular system of the brainstem as the source of dysfunction creating strong nocturnal bruxism. The reticular formation is a part of the brain involved in such actions as regulation of the sleep/wake cycle, as well as filtering incoming stimuli, maintaining motor muscle control, postural balance, motor reaction to stimuli, rhythmic signals to the muscles related to breathing and swallowing, cardiovascular control, pain modulation, and habituation to repetitive stimuli. One example of this last function is to allow a person to sleep through sound stimuli during deep sleep, but awake to a set of sounds that are more meaningful, such as a cry of a baby. The reticular formation projects to the thalamus and cortex to exert control over which sensory signals reach the cerebrum and come to our conscious attention, and plays a central role in regulating alertness and sleep cycles. The brain nucleus reticularis pontis oralis tapers into the reticular formation, and in different subjects has displayed discharge patterns which coordinate with phasic movements to and from paradoxical sleep, which is a sleep cycle that produces brain wave patterns similar to wakefulness, REM, and heavier breathing. Paradoxical sleep is sometimes equated with REM sleep. The pontis oralis is thought to be involved in the mediation of changes to and from REM sleep. The pontis caudalis is a brain nucleus located next to the pontis oralis, and innervates the trigeminal nucleus and surrounding area, as well as projecting to the facial, hypoglossal and parabrachial nuclei, which regulate jaw movements and upper airway control. Studies in recent years clearly show that specific acupuncture and electroacupuncture stimulations modulate these specific areas of the brain and improve cross-talk, or interaction, between these key areas of neural control. To see these study summaries and links to studies, refer to the section entitled Additional Information in this article.

These nuclei of cells in the brainstem, involved in both innervation of the muscles of the jaw and in the complex transitions of brain activity during the sleep cycle, innervate the mesencephalic nucleus of the trigeminal nerve via the parvocellular reticular nucleus. Unlike many nuclei of cells in the central brain, the mesencephalic nucleus contains no chemical synapses, but are electrically coupled, receiving electrical signals concerning proprioception from the jaw muscles, and sending projecting signals to the motor trigeminal nucleus to control the jaw reflexes. The mesencephalic nucleus to the trigeminal nerve is the only structure in the brain and spinal cord to contain the cell bodies of a primary afferent, or incoming neurological signals, which are usually contained in the cranial nerve ganglions. This explains why the movements of the jaw in bruxism is unique to dysfunctions related to the transitions in the sleep cycle. It also explains why myofascial dysfunction may trigger bruxism, as the sensory signals directly affect the brain nuclei that regulates the reflexes and rhythmic movments of the jaw. These brain nuclei are also involved in regulation of expiration in breathing, along with the gigantocellular nucleus, a brain nucleus composed of mainly giant neuronal cells, which are also seen in the pontis oralis and caudalis. The gigantocellular reticular nucleus receives connections from the hypothalamic nucleus, the lateral hypothalamic area, the amygdala nucleus, and the parvocellular nucleus, as well as the periaqueductal gray, a part of the brain that plays a part in modulating signals of pain and temperature, and in defensive behavior. This may explain why, in psychological studies, states of anticipatory anxiety are most related to nocturnal bruxism, while other types of anxiety do not appear to have a connection. All of these connections in the brain are well studied, and explain the various factors that trigger nocturnal bruxism. Unfortunately, this does not simplify the pathology. It only explains how a complex array of signals, or information, could be connected in the phenomenon of nocturnal bruxism.

The amygdala is a part of the brain located in the frontal temporal lobes, which sends impulses to the hypothalamus for activation of the sympathetic nervous system, to the thalamic reticular formation for increased reflex responses, to the nuclei of the trigeminal nerve and the facial nerve, and to various regulatory nuclei for activation of dopamine, norepinephrine, and epinephrine (adrenaline). This area of the brain is of particular interest in research concerning the etiopathology and pathophysiology of nocturnal bruxism, since it plays a role in so many of the observed dysfunctions and physiological abnormalities. Increased excretion of dopamine and norepinephrine with nocturnal bruxism could be directly linked to excess stimulation from the amygdala. The amygdala also receives sensory input from the sense of smell, and the pheromone system, as well as other sensory systems, and could play a central role in triggering of bruxism. Emotional arousal, memory of emotional responses, fear conditioning, association of sounds and smells with emotional responses, triggering of a fast breath and heart rate (tachycardia), and stress hormone release are all linked to the function of the amygdala. The amygdala may show dysfunctional activity with binge drinking, perceptional threat, social phobias, and bipolar disorders. Pathological changes to the amygdala, such as reduction in size and neurodegenerative lesions, are seen in Parkinsonism, Alzheimer's disease, epilepsy, and cognitive decline. Restoration of neural health and function, as well as cognitive and behavioral therapies to address these various emotional, memory, and sensory hyperstimulations of the amygdala could play a significant role in a multidisciplinary approach to nocturnal bruxism. Herbal research is finding a role for specific phytochemical therapies to support this aspect of the treatment protocol. For example, rhynchopylline, the main active alkaloid chemical in the Chinese herb, Uncaria rhyschophylla (Gou teng), which is related closely to the South American Cat's Claw, or Uncaria tomentosa, has been found to reduce the dopamine concentrations in the amygdala, cortex, and spinal cord, while increasing the 5-HT content in the hypothalamus and cortex, and decreasing the release of 5-HT from the hypothalamus. Rhyncophylline also inhibited excess release of both dopamine and 5-HT evoked by high potassium (see study citation below). Such research demonstrates the effective modulation of evolved phytochemicals in medicinal herbs, and the potential for modulation of unwanted motor effects in such pathologies as nocturnal bruxism.

Various neurotransmitters are important, both in modulation of the regulatory centers in the brain, such as the hypothalamus and amygdala, which may affect the nuclei controlling jaw movements, and in the modulation of pain and temperature signals from the spinal cord. Dopamine is very important in the modulation of hypothalamic regulation, and serotonin (5-HT), as well as enkaphlins, such as dynorphins and endorphins, regulate the pain signals and inhibition carried from the peripheral nervous system, such as the pain sensors, or nociceptors, in the muscles related to TMJ disorders. All of this neuroanatomy and physiology explains how so many factors could be involved in the symptom or phenomenon of nocturnal bruxism. This information suggests that there will never be a simple pharmacological solution to nocturnal bruxism, and that a holistic approach, addressing these many factors, is the best solution to restoring the homeostatic mechanisms involved in the pathology. Acupuncture stimulation is well known for its effects on enkaphlins, as well as its neuromodulating effects, and various herbal chemicals have been long proven to effect the production, modulation, and receptor functions of dopamine and 5-HT, or serotonin. Bioavailability of these neurotransmitters may also allow an eventual restoration of normal homeostatic mechanisms. Utilizing a professional herbalist, or TCM physician, to guide this type of restorative medicine is essential, as the unregulated herbal and nutrient medicine industry in the United States has been proven to provide poor quality and fake products when bought off the shelf or from the internet, and there is no actual laws yet to punish companies for such misleading and unethical behavior. Quality assurance and sound guidance is obtained by utilizing a professional TCM physician or Naturopathic Doctor.

Somnographic studies in recent years have also noted that episodes of nocturnal bruxism are preceded by sudden shifts in autonomic cardiac activity. This association is so strong that experts have suggested that a simple device to record heart rate and vagal activity may be the best way to record the prevalence of nocturnal bruxism, rather than the expensive and time-intensive polysomnographic studies in sleep clinics. For instance, a 2013 study at Osaka University in Japan noted that over 90 percent of nocturnal bruxism episodes may be preceded by an increase in the heart rate of 100 percent (PMID: 23626977). Treatment to improve modulation of the autonomic and vagal modulation and regulation of heart rate and cardiac activity could be an important part of holistic therapy in the treatment of nocturnal bruxism. Many studies have noted that bruxism and tachycardia are common adverse reactions of excess use of the common recreational drug Ecstasy, or MDMA, and have noted that this is due to the effects on the 5-HT/serotonin metabolism, the adrenal regulation, and the regulation of release of oxytocin. Such studies offer novel pathways to both increase understanding of the pathology, and to improve the holistic therapeutic protocol. Utilizing a combination of specific acupuncture stimulations and a formula with Taurine, enzymes and herbs that address this vagal and autonomic dysfunction in nocturnal bruxism could help dramatically to to reduce sleep bruxism and achieve a better quality of sleep.

The importance of homeostatic balance of neurotransmitters and brain health

Restoration of homeostatic balance is very important to the resolution of central neurological diseases and dysfunctions, and allopathic chemicals that block reuptake of various neurotransmitters and exert other inhibitory effects are unlikely to restore such balance. Research is finding the complexity of neuromodulation to be daunting, with each type of neurotransmitter exerting either inhibitory or excitatory effects in different parts of the brain, modulated by the concentration of other neurotransmitters, and producing different effects at different types of receptors. A holistic perspective is needed to judge the quantum effects of neurotransmitters, not a perspective which seeks to statically view each chemical alone and isolated in a laboratory setting. Modern scientific method shows its drawbacks in this regard. The body has evolved elaborate fields of effects with differing concentrations of a mix of neurotransmitters creating desired effects at different cells and at different receptors. The same is true of hormonal balance and homeostatic mechanisms in the body. Affecting just one neurotransmitter or hormone without restoring the elaborate balance will not bring about the most desirable and healthy end result.

Not only the balance of a changing quantum field of neurotransmitters, and the homeostatic balance of these neurotransmitters, which varies in distinct parts of the brain and brainstem, but also the homeostatic balance of the neurotransmitter receptor types must be maintained to insure proper brain and brainstem function. For instance, a number of medications in a class called antipsychotics, which are now used to treat many common health problems, such as anxiety, depression, hyperactivity, etc. work primarily by antagonizing specific neurotransmitter receptor types, especially dopamine type 2 receptors, which induces movement disorders as an adverse side effect. A high percentage of parkinsonism, dystonias, akasthesias and dyskinesia are attributed to these medication and their adverse effects. Such imbalances may be induced by a variety of other causes as well. Scientists have been looking for safe and effective integrative Complementary therapy to alleviate these problems, and in 2012, experts at the Federal University of Santa Maria, in Brazil, found that the herbal chemical Resveratrol reduced such induced tardive dyskinesia, or bruxism, in laboratory animals, from effecting 70 percent of the study animals, to just 30 percent. The bruxism was induced by giving Fluphenazine (Prolixin), a common antipsychotic medication that inhibits dopamine type 2 receptors. While the intensity of the bruxism was not reduced in the remaining animals not relieved by the Resveratrol, this study proves that attention to brain health, with natural antioxidants and inflammation modulating herbal chemicals may both prevent and resolve bruxism and other movement disorders in many patients. The combination of Resveratrol and Quercetin, a related herbal chemical, both derived from Chinese herbs, and pterostilbene, another herbal nutrient molecule, is proven to have an increased effect.

Complex dysfunctions such as nocturnal bruxism are prime examples of the need to restore homeostatic balance. In this review of scientific literature by the University of Palermo in Italy, in 2008, we see that a reciprocol modulation occurs in the brainstem and nuclei of the basal ganglia between serotonin (5-HT) and dopamine, with a variety of potential modulatory effects possible, either directly, or indirectly via the GABA inhibitory system. To see a summary of this study, click here: http://www.ncbi.nlm.nih.gov/pubmed/18772027. Holistic medicine and both herbal chemicals and acupuncture provide the means to restore homeostatic balance to correct such health dysfunctions as nocturnal bruxism, and should be integrated into standard care. Studies of acupuncture with fMRI also show the potential for specific acupuncture stimulations to modulate brain acitivity and restore homeostatic neural responses over time. This study at the Chiness Academy of Sciences in Beijing, in 2010, demonstrated that stimulation at a single acupuncture point, ST36, increased or modulated activities of the amygdala, hypothalamus, and periaqueductal gray area of the brain. To see this study, click here: http://www.ncbi.nlm.nih.gov/pubmed/21044291. Combining such evidence-based therapies effectively offers much progress in treating difficult neurological dysfunctions.

Psychological and psychosocial parameters related to nocturnal bruxism and temporomandibular pain and dysfunction syndrome (TMPDS)

Study of psychosocial parameters and pyschological problems related to nocturnal bruxism have been extensive. TMJ disorders have long been associated with triggering of nocturnal bruxism, and are perhaps the most closely allied health problems associated with sleep bruxism. In 1987, the Columbia University School of Public Health in New York published findings that showed that "TMPDS (temporomandibular pain and dysfunction syndrome) patients appear to be unusually distressed individuals who are beleaguered by physical illness and injuries as well as by pain, who tend to attribute their fate to external factors, and who have fewer sources of emotional support." Subsequent studies have tried to correlate anxiety disorders with nocturnal bruxism, but have shown only that anticipatory anxiety and unusual anxiety generated at work could be clearly correlated. The Stanford University study cited above also found that there was some correlation between mood adjustment disorders, bipolar disorders, anxiety disorders, and depressive disorders, with higher incidence in the sleep bruxism diagnosed group than in the control group.

While psychological and psychosocial factors are important in syndromes of nocturnal and Sleep Bruxism, as well as TMJ syndromes (TMD), this is again just one aspect of this confusing and complex array of disorders that manifest with the symptom of bruxism and TMJ. The best treatment approach is to approach each case individually and holistically and address of the health concerns. Standard medicine today instead guides patients to specialistst that address just one part of the cycle of dysfunction, and tend to treat all patients with the symptom the same way, not with an individualized approach. Integrating Complementary Medicine and the TCM physician into your treatment protocol with a persistent approach is truly the sensible and intelligent approach. Utilizing Cognitive and Behavioral Psychologists and other health professionals to address these concerns is also very sensible to achieve the best outcome.

The Temporomandibular Joint (TMJ), often painful or uncomfortable with chronic bruxism, may be a result of bruxism or a causative factor for it

Studies in 2009 at Johns Hopkins University School of Medicine in Baltimore, Maryland, found that there is a clear association between sleep disorders, nocturnal bruxism, and chronic pain sensitivity (hyperalgesia) of a central neural focus, seen in a majority of patients with temporomandibular joint disorders (TMJ). This study is cited below. Hyperalgesia is a key component of most chronic myofascial pain syndromes, with reduced pain and thermal thresholds developed because of chronic autonomic irritation from constant nerve stimulation associated both with constantly firing muscles, and with the irritation of the nerves from accumulations of irritating calcium ions and other chemicals around the myofascial trigger points. Hypoalgesia, or insensitivity to pain of a central neurological focus, was associated with breathing disorders during sleep, such as apnea. These studies indicate that chronic myofascial pain syndromes such as TMJ disorder may be central to the etiology of nocturnal bruxism.

The temporomandibular joint (TMJ) is a complex joint shaped like an S, and a fibrocartilaginous disc divides the joint into two cavities. The joint actually joins three separate structures, the mandible with the mandibular fossa, and the mandible with the temporal tubercle, making this a complex joint compared to all others in the body. The mandible is the jawbone, and of course, is used a lot, both for eating and speaking, so pathology of this joint can be a nagging constant irritation, even without overt pain. Problems with TMJ can become severe and episodic, and a number of contributing factors can irritate the joint, with neuromuscular factors contributing to worsening symptoms. The relatively mild overt symptoms in most cases of developing TMJ pathology cause us to overlook the serious underlying health problems that can be caused by, or are the cause of TMJ disorders.

TMJ is a term that has been given in the last 30 years to a medical syndrome that is increasing in frequency as a health problem and now proven to be associated with a number of other difficult health problems, including sleep apnea, migraine headache, tension headache, tinnitus, nocturnal bruxism, chronic neck and back pain, and even depression and anxiety disorders. This musculoskeletal and neuroorthopedic pathology was called Costen's Syndrome, and then Temporomandibular Pain and Dysfunction Syndrome (TMPD), for many years, until the medical field relegated it to a dental concern and just called it TMJ. Finally, with more patients demanding medical attention due to nagging problems with this chronic disorder, and more patient awareness of the scope of their syndrome, research has demonstrated how a comprehensive holistic treatment protocol is necessary to correct this neuromuscular condition. The Licensed Acupuncturist and herbalist with skills in myofascial release is the ideal physician to manage this type of care.

Pathology of the TMJ is referred to as a TMD, or a temporomandibular disorder. To show you how lightly standard medicine treats this common health problem with serious long-term consequences, we still have not given it a real medical name, and continue to just call it TMJ. A wealth of research on this problem has been driven not by public health concerns, but by new expensive technology and treatment, and finally standard medicine is referring to the problem as TJS, or temporomandibular joint syndrome, expressing the fact that the problem is not so simple, and may include quite the variation and complexity of associated health problems within a syndrome. It is conservatively estimated now that over 11 million U.S. citizens have a temporomandibular joint syndrome of some severity, and over 35 million suffer from some TMJ problems.

Experts in the field now prefer to call these TMJ problems Craniomandibular Disorders, and some would expand the diagnostic terminology to Trigeminal Mandibular Disorders to describe the fact that the fifth cranial nerve (CN5) is involved in this pathology, and the elusive origin of the problem may actually lie in a neuropathy of this combined sensory and motor facial nerve. This more accurately describes the focus of dysfunction in the pathology, namely, the dysfunction of the medial pterygoid muscle, which unlike the other muscles of mastication, is innervated not by the facial nerve (CN7), but by the trigeminal. The term Trigeminal Mandibular Disorder (also termed TMD) elucidates this key aspect of the TMJ disorder and syndrome. While the treatment in this disorder or syndrome needs to be individualized and sometimes comprehensive to fully cure, myofascial release of the medial pterygoid muscle is most important in the protocol.

The medial pterygoid muscle is not the only muscle involved in this neuromuscular disorder, though. Muscles of the temple as well as muscles of the neck can also add strain to the joint. While the medical establishment has pushed theories of dental problems and inherited joint abnormalities in recent years, the truthful conclusion is that TMJ is a multifactorial problem that requires treatment of a variety of muscles as well as reeducation of the patient to avoid habitual aggravation of the TMJ. For some patients, underlying health problems should also be addressed. To see a recent synopsis of scientific findings in the New York Times, click here: http://www.nytimes.com/2009/02/03/health/03brod.html?_r=1&ref=health. While the headline implies that nothing can be done for TMJ, careful reading of the article shows that it is oral and maxofacial surgery that should be avoided, and that a treatment protocol of intelligently applied physiotherapies and stress management, which should include acupuncture, is the preferred course.

A comprehensive approach to TMJ pathology includes myofascial release of the local muscles, or pterygoids, as well as the release of the scalenes and neck extensors, and possibly the temporalis. In addition, stress reduction, instruction in postural mechanics and targeted stretch of the TMJ, and assessment of the joint inflammation and potential contributors and cures should be included. Acupuncture, herbal medicine, and nutriceutical aids to tissue health and nerve function can all contribute to overall success of treatment. Individually, no one specific treatment approach has given proof of great success, but combining all of these therapies, each having shown limited success in treatment, adds up to a cumulative protocol that guarantees a successful outcome.

Standard medicine has also adopted a holistic and comprehensive protocol to treat TMJ now, utilizing soft tissue mobilization with electrical stimulation, ultrasound, heat and cold therapies, active release techniques, and joint manipulation to restore myofascial function and clear tissue toxins and irritants. A small number of specialized clinics now offer this treatment protocol in hospitals and clinics. Description of this protocol, which is very similar to the TCM protocol, and may be integrated with TCM, acupuncture, physiotherapy, postural correction and herbal/nutrient therapy, can be seen at this website: http://www.tinnitusformula.com/infocenter/articles/conditions/tmj.aspx

The many health problems found to be associated with TMJ disorders

A variety of health problems are associated with TMJ disorders. Tinnitus is a persistent and often complex pathology that is associated with TMJ in a percentage of patients. If the mechanical irritation of TMJ is one of the causes of this persistent symptom, relief of TMJ may be a very important part of the treatment protocol to finally reduce or eliminate tinnitus. TMJ is also associated with sleep apnea, and may be an important factor in this multifactorial syndrome as well, which is primarily caused by tissue hypertrophy in the nasopharyngeal area. Biomarkers for TMJ include vascular endotherlial growth factor (VEGF) that is also seen in excess in hypertrophied tissues of the mouth and throat in sleep apnea. Nocturnal bruxism, or grinding of the teeth, a tardive dyskinesia that apparently is stimulated when the patient is in deep sleep, and does not smoothly transition from the first or second stage of deep, or REM, sleep, is also associated with TMJ pathology. This nightly grinding of the teeth may not only cause dental fractures, but irritate the scalene muscles, which play a role in mastication. A vicious cycle may evolve in this case. Both the myofascial syndromes, which eventually result in a denervated supersensitivity, and the central nervous system dyskinesia of bruxism, potentially contribute to autonomic nervous dysfunction. TMJ is also indirectly associated with Raynaud's Syndrome, a vasospastic autonomic nervous disorder, in which the extremities may be triggered into a state of sudden loss of circulation with cold and purplish coloring, and often pain. The involvement of the scalenes in TMJ disorders and concurrently in thoracic outlet syndrome (TOS), as well as the eventual autonomic stress, link TMJ potentially to TOS and Raynaud's Phenomenon, another poorly understood, but common and annoying pathology. Various problems that are associated may need to be resolved together to effect a sufficient cure. To gain a more thorough understanding of tinnitus and sleep apnea you may go to the articles devoted to these conditions on this website.

Of course, various types of headache are associated with TMJ pathology as well, as well as chronic neck, upper back, and even shoulder pain. The problematic muscles that contribute to TMJ disorder may also be causing tension headaches, referred myofascial pain, and affecting the mobility of the cervical spine. Migraine headaches, which are now recognized as a disorder frequently driven by temporal ateritis, or inflammatory problems affecting the ateries in the temple, is also associated with TMJ disorder, or TMD, because these temporal arteries travel alongside the trigeminal nerve and are innervated with offshoots of this cranial nerve. Dizziness and ear problems have also been found to be associated with TMJ in some instances, and here too, an anatomical relationship between the trigeminal nerve and arteries explains how this is possible. A thorough and intelligent assessment should be performed to evaluate relationships between these problems, and assess the whole health history to see if underlying health problems are potentially contributing. In standard medicine this could mean trips to a number of specialists, a variety of expensive tests, and elaborate specialty clinics that just address one aspect of the whole problem. With holistic medicine, and a Licensed Acupuncturist with a number of therapeutic skills, these problems may be addressed together and more directly. Integrating the holistic perspective and the various practical treatment modalities of Traditional Chinese Medicine is a smart choice.

More recent studies have also found a potential relationship between TMJ disorders and related health problems and increased incidence of depression and anxiety disorders. Since chronic TMJ (TMD) may be caused by myofascial syndromes that eventually cause autonomic dysfunction, as well as sleep disturbance and bruxism, a plausible relationship between TMJ disorders and neurological dysfunction and stress is not out of the question. Of course, relieving TMJ (TMD) will not cause these various other serious health problems to instantly disappear, but it may be a key part of the overall treatment and help resolve other serious health problems down the road.

Temporal mandibular joint disorders relegated to the dental profession, and the common use of cone-beam computed tomography to diagnose, despite the risks of accumulated radiation and the lack of training in musculoskeletal medicine

NOTE: The leading experts in the musculoskeletal disorders in the last few decades, Drs. Janet Travell M.D and David Simons M.D., state in their definitive text, Myofascial Pain and Dysfunction that: "Historically the dental profession has considered occlusal disharmony and variation as a potentially primary etiologic factor in TM (temporomandibular) disorders. However, literature reviews and data from recent studies do not support occlusion as a significant etiologic component of TM disorders (TMD)." (Magnusson et al; Orafacial Pain 8:207-15;1994)(Pullinger et al; Oral Surg Oral Med Oral Pathology 71;529-34;1991)(Pullinger AG; J Dent Res 72;968-979;1993)(Verdonck et al;J Oral Rehabil 21;687-97,1994). Further scientific studies since 1994 confirm these findings and reveal the multifactorial causative etiology in TMJ (TMD) disorders. Still, for lack of appropriate treatment protocol in standard medicine, the dental profession has hit upon this pathology as a new area of treatment promotion in dentistry, and the insurance industry has promoted this approach, despite decades of scientific study citing the inappropriateness of a dental or oral surgery approach. This resort to the dental specialty to treat TMD has now expanded to the treatment of nocturnal or sleep-related bruxism, apparently only because standard medicine has no effective treatment strategy and is reluctant to integrate Complementary Medicine.

While oral occlusion, or the misalignment of the upper and lower jaw during use of the jaw, or mandibular action, occurs due to TMJ disorder and contracture of the medial pterygoid and other muscles, this occlusion is not the cause of the problem, and an allopathic realignment does not resolve the underlying causative problems. Appropriate holistic treatment will resolve the myofascial dysfunction, and if needed, the problems with joint arthritis, and neuromuscular pathology. The only reason for insurers to deny coverage for treatment of TMJ disorders from the appropriate treaters, utilizing a comprehensive approach and integrative multidisciplinary diagnostic assessment, is that it costs less to let the profession of dentistry treat this pathology. Considering the number of serious health problems proven to be associated with TMJ disorders, this is not even a medical cost saving strategy in the long run.

TMJ therapy is now described as dentistry's "hottest" area of business, heavily promoted in dental colleges, and promoted by both the insurance and medical equipment industries. Today, many prominent dentistry experts are warning that most of the testing protocols and treatments routinely prescribed for TMJ disorders by dentists are not supported by scientific studies of medical efficacy, create negative long-term consequences, and sometimes come with considerable risks down the road. Dental surgeons are also promoting orofacial surgery in many cases, despite the poor outcomes and risks present in surgical correction of TMJ disorders. Dr. Joseph Marbach, an expert in the diagnosis and treatment of chronic jaw and facial pain, a professor at the University of Medicine and Dentistry in New Jersey, the late director of a facial pain clinic at Harvard, and a prominent researcher at the University's School of Public Health, stated that surgical options for correction of TMJ disorders should not be considered. Despite such expert advice, the dental industry is heavily promoting surgical correction, and the public is led to believe that any dental surgery is different and more benign than surgery performed by a MD surgical specialist.

Patients should also be aware that a particular dentist should present the proper credentials of dental specialty, which indicate a more than two year advanced training after completing a standard dental degree, before proceeding with various testing and treatments for TMJ disorders. These include Orthodontics (diagnosis and correction facial deformities), Oral Pathology (diagnosis of diseases of the head and neck), Oral and Maxillofacial Surgery (diagnosis and surgical treatment of diseases and defects of the jaw), and Oral and Maxillofacial Radiology (expertise in safely performing advanced radiological diagnostic tests and interpreting them). The X-ray and CT diagnostics in dentistry are often described as harmless tests that you shouldn't worry about. The fact is that these tests need to be performed expertly and with the right equipment and settings to minimize harm and risk. Many dentists performing radiological testing with cone-beam computed tomography have no advanced training in radiology, and the tissue injuries from these procedures, which involve focused arrays of high-speed X-ray slices (typically 60 to 300 X-ray slices in a single CT), sometimes appear weeks after the CT testing, when the test was not performed properly. The safety of these CT devices are promoted by the manufacturers, and insufficiently regulated by health authorities. Dentists with older X-ray equipment may also be using outdated equipment with excessive radiation, and many dentists are taught to take these radiation exposure problems lightly. A good dentist will only use radiology when absolutely necessary, not just to sell the dental work. Since radiology is a complex medical specialty, the patient population that thinks that anyone with little or no training can expertly interpret even simple X-ray films is naive. Long ago, we assumed that X-rays were harmless, but with decades of data, we now know that they aren't.

The percentage of cancers directly attributed to CT scans in the United States quadrupled between the late 1990s and 2007, with government estimates that up to 2% of all cancers in the United States may be directly attributed to CT scans with the dramatic increase in their use. Low level radiation is accumulative, and while these accumulations are not as serious as radioactive isotopes with long half-lifes, there are now so many sources of man-made low level radiation in the United States that an alarming number of cancers are not attributed to radiation. The 2009 Annual Report by the President's Cancer Panel stated that nearly half of American's radiation exposure now comes from medical imaging, compared to only 18% 30 years ago, and warned that this dramatic rise in radioactive testing now is a predominant cause of radiation induced cancer, and a significant contributor to most cancers, which have a multifactorial cause. Radiation, which to some extent is normal in our natural environment, has always been considered the primary cause of cancer, but the cavalier use of radiological testing, despite the development of other benign forms of testing, such as advanced portable MRI and ultrasound, presents an unnecessary cancer risk that the public should be aware of and refuse unless it is absolutely necessary to diagnose a health problem.

The widespread use of "night guards" in the treatment of TMJ disorders also have come with misinformation and health risks, and are not supported by sound scientific studies. While modest benefit has been proven in some small studies, the evident risks and potential long-term harm revealed in these studies should prompt patients to more closely consider the benefit-risk ratio, and utilize these devices for short term relief of symptoms while pursuing more effective comprehensive and holistic therapy. Most of these devices are not the same as simple mouth devices used to prevent teeth grinding injury from nocturnal bruxism, but instead are mandibular orthopedic repositioning appliances (MORAs) that require proper fitting from a dentist with advanced training. These occlusal devices have been shown to be nonspecific in their action, and modest benefits from properly fitted MORAs are derived from mild decrease in muscle fatique when excess nighttime teeth grinding, or bruxism, is present. They do not resolve the essential myofascial dysfunctions, arthritic degeneration, or neuromuscular problems. When worn too much, these MORAs can affect the proper position of the teeth at the base, eventually causing pain or discomfort, and sometimes requiring orthodontic or surgical correction later in life. Despite the long-term possible negative consequences, many dentists without advanced specialist training are fitting these oral devices to supposedly correct TMJ problems. The prescription of more benign night guards whenever there is a report of jaw clicking or grinding is also unwarranted, and in some cases, these devices, which cover all the teeth to prevent wearing down of tooth enamel, may irritate actual TMJ disorders. While these night guards are proven to not cause teeth to become misaligned, they may increase myofascial strain in some patients, and should only be prescribed when tooth enamel wear is an obvious problem, and not overprescribed whenever a patient reports nocturnal grinding and benign jaw clicking. Patients with TMJ disorders and nocturnal bruxism should seek a comprehensive treatment to resolve these health problems instead of just relying on night guards and excessive use of MORAs to reduce symptoms.

Obviously, TMJ disorders are not a simple dental problem, but rather, dental problems occur due to TMJ disorders. It is a big mistake to relegate TMJ disorders, considering the complexity of this pathology, to dentistry. Many insurance plans will not pay for treatment and diagnostic workup of TMJ disorders outside of a dental plan. This is unbelievably ridiculous. Patients are often shunted to dentists, who have little or no training in musculoskeletal medicine and neurological health, and the standard guidelines now are pushing many unnecessary specialized CT scans of the mouth. A series of article in 2010 in the New York Times (cited below with easy links) explains the dangers and harm from all of this excess radiation in medicine. Simple physical exam diagnoses TMJ disorders, and exposing onself to multiple X-rays in cone-beam CT is preposterous. Many patients are led to believe that since these tests are conducted in a dental office, that they must be benign. This is far from the truth. The truth is, that many medical experts around the world are now calling for the industry to give up radiation in testing almost entirely. With new technology, this old technique of imaging is no longer necessary, especially as we are now exposed to numerous sources of environmental radiation. Radiation, even at a low dose, is accumulative in most cases, and exceeding an accumulative level is more than our bodies can handle in repair of cellular mutations. Hence, we get cancer. It appears that only when the public shows awareness of these risks of X-ray and CT that the medical device industry will actually utilize the technological know-how that they already possess to create testing devices that cause no harm. The only reason that this industry has not done this is due to the question of profits, and public health regulation may need to step in if the public does not demand a positive change.

Now, many experts associated with the growing industry of advanced radiological testing tell us that they can find hardly any cases of direct causing of cancer or tissue injury by these procedures. Obviously, since radiation is ubiquitous in the natural environment, and causes an accumulative effect, a single low-dose radiation exposure cannot be blamed by itself for a specific cancer in most cases. The same argument was given for atomic bomb tests, leaking nuclear wastes, radioactive water dumped into rivers from power plants, radioactive material in armaments, and even nuclear power plant meltdowns in the past. Does the public never learn? Are we such fools? Anyway, this just diverts a patient from the real issue, which is that a physician with training in musculoskeletal medicine can easily diagnose TMJ disorders, and a comprehensive package of care can address all of the factors in this multifactorial disorder. The options presented in dentistry should address only dental problems, and the intelligent patient will seek effective medical care from physicians skilled and knowledgeable in musculoskeletal medicine. This is not to say that every Licensed Acupuncturist has these skills and is knowledgeable. Choose wisely. Most acupuncturist can deliver modestly effective needle stimulation in the overall treatment protocol, but for many patients with a TMJ disorder, a more comprehensive package of care is necessary, with myofascial release of the ptyerygoids and scalenes included, as well as effective joint mobilization and neuromuscular reeducation. For individual cases, concurrent treatment of related health problems should also be performed.

A variety of TMJ disorders are seen under the umbrella of Craniomandibular Disorders and Trigeminal Mandibular Disorder, and a full assessment of the problem helps to guide therapy more successfully

The national TMJ Association finds that TMJ disorders may be divided basically into three categories: arthritic, joint derangement, and myofascial pain syndromes. A fourth category, neuromuscular disorders, is still under investigation, and will be somewhat controversial until more research is conducted. Arthritic TMJ disorders are often associated with osteoarthritic degeneration, Rheumatoid Arthritis, or some other form of rheumatic arthritis that typically affects the jaw, such as Polymyalgia Rheumatica, which has seen an explosive growth in incidence, and is associated with the autoimmune disease Giant Cell Arteritis. Giant Cell Arteritis is seen in 15% of patients with Polymyalgia Rheumatica, and primarily affects the temporomandibular joint. Joint derangement, such as subluxation or disc degeneration, usually occurs due to an imbalance of stress on the joints from the muscles of mastication. Myofascial pain syndromes involve a muscle firing dysfunction with a syndrome of dysfunction and generation of referred pain. You may learn more about myofascial pain syndromes, rheumatic, or autoimmune disorders, and arthritis on other articles of this website. Another cause to consider is the number of cases of jaw degeneration due to the side effects of biphosphonate drugs, which are used to treat osteoporosis, bone pain in cancer therapy, or in cancer therapy related to estrogen receptor stimulated cancers. FDA warnings have been issued concerning the eventual degeneration of the jawbone, and increased gum infections, loose teeth, numb heavy sensation in the jaw, and increased tooth and gum pain are signs of the degeneration, or osteonecrosis, associated with use of biphosphonate drugs. While cases of severe jaw osteonecrosis are still relatively rare with these drugs, it is believed now that milder degenerative changes are very common.

Osteoarthritis of the cervical spine, a degenerative condition primarily related to poor postural and mechanical habits, may also play a considerable part in the causative etiology of TMJ disorders. When the normal lordotic curve and mobility of the midcervical spine is decreased, abnormal pressures and stress are increased to the various structures that primarily cause TMJ dysfunction, such as the neck extensors (esp the splenius cervicis), the scalenes (attached to the midcervical vertebrae), and the cranial nerves and blood vessels. In these cases, therapy to resolve the cervical osteoarthritic arthrosis should be performed.

The vast majority of TMJ disorders are primarily due to myofascial pain syndrome though, usually involving the pterygoids and scalenes. The temporal muscles, although thin, can also contribute in many cases, especially when chronically tight neck extensors, or splenii muscles, generate frequent tension headaches. The splenius cervicis, or extensor muscle attached to the cervical spine, affects the temporal muscle in cases of tension headache that are felt along the side of the head to the posterior eye orbit. In these cases, joint derangement may eventually occur due to the myofascial syndromes and imbalances of muscular stresses on the complex joint of the jaw during eating and talking. It is important to properly assess each individual case for evidence of these other conditions, though, which would alter the therapuetic protocol. A combination of myofascial release and passive joint mobilization is central to the therapeutic protocol in most cases of TMJ disorder involving myofascial syndromes and joint derangement as the primary cause or manifestation. Knowledgeable professional assessment and individualized and comprehensive approach is obviously important in the treatment of TMJ disorders. For too long, we have taken this syndrome or complex disorder too lightly.

Patient education in neuromuscular control and kinetic habits may be an effective part of a comprehensive protocol to cure or relieve TMJ disorders

An effective treatment protocol for TMJ disorders needs a strong proactive participation by the patient. The patient needs to correct the problems that caused, and are perpetuating, the specific TMJ disorder. A knowledgeable physician is able to assess and point these out to the patient, so that postural correction, stress reduction, and neuromuscular reeducation can be accomplished. The physician is always there to help the patient resolve health problems. The intelligent patient realizes their responsibility to understand and resolve the health problems themselves, with the help of the physicians and therapists.

The most important considerations in resolving TMJ disorders are forward head and neck postures, excessive use of the jaw (e.g. chewing gum, frequent snacking on chewy foods, excessive talking, or habitual movements) especially with postural stress during jaw movement, a slumped shoulder posture, and correct tongue position. The tongue should relax with the tip against the roof of the mouth just behind the upper teeth, but not quite touching the teeth, and most breathing should be through the nose in relaxed states, or in through the nose and out through the mouth, with the lips slightly parted. An exercise to restore neutral tongue position at rest: correct the head and neck posture, say the work Boston and let the tongue end up against the upper palate after enunciating the "N", hum the letter N for a few seconds, and exhale with a relaxed sigh. Try to maintain the tongue position with the tongue tip against the roof of the mouth just behind, but not touching the upper teeth, while in a relaxed state. Many patients with TMJ disorders acquire bad mechanical habits that perpetuate the pathology and go unnoticed. A relaxed posture during meals, rather than eating on the go, may be helpful, unconscious chewing on one side of the mouth may be occurring, perhaps due to tooth and gum irritation, and should be acknowledged. Stess response may be habitual, such as clenching the teeth, and can be resolved with proper conscious attention.

While strength exercises of the masticatory muscles are almost never warranted in TMD patients, because the muscles are constantly working, some neuromuscular reeducation could be very helpful. Experts in the past, such as Schwartz and Bertoft, have recommended a protocol of reflex relaxations of the pterygoids. These neuromuscular exercises can irritate the deranged joint, though, and proper instruction should be utilized to perform them correctly, or the neuromuscular reeducation should be performed with physician guidance. Slow opening of the jaw fully with lateral movement, first in one direction, and then in the other, with resistance applied during slow closing of the jaw is the standard technique. These exercises are best performed after the muscles are released, though, as the usual neuromuscular problem is overfunction, and not underfunction, meaning that the pterygoids and other masticatory muscles, such as the scalenes, are in constant firing mode, rather than insufficient firing. If the muscles are not relaxed before neuromuscular reeducation, stretch movements and resistance may irritate the contracted muscles and tendons. Over time, though, with myofascial syndrome, the muscles are not only continually firing into contracture, but become weak due to this constant neurostimulation. Concurrent contracture and weakness, or a combination of overfunction and underfunction, is what perpetuates TMJ disorders. If attempting to perform neuromuscular retraining without physician guidance, some gentle finger tapping and circular massage are suggested as a relaxing warmup.

Stretch is a patient activity that may both help resolve myofascial trigger points in the elevator muscles of the temporomandibular joint and accomplish some neuromuscular reeducation at the same time. Therapeutic stretch should always be targeted, slow and conducted with a patient approach. Fast hard stretch may be applicable to athletic training, but has no place in therapy. By applying the mind, and focused attention, to the targeted tissues, a neuromuscular retraining may be accomplished. Therapeutic stretch of the jaw is always recommended in TMJ disorders, but should not be overdone. Therapeutic targeted stretch of the neck muscles should also be taught to the patient, and this should be performed daily.

Sleep posture may be very important to the resolution of TMJ disorders. Sleeping face down should be avoided and corrected completely. If this is a problem, lying face down when going to bed for a few minutes, until you are feeling very sleepy, may be allowed, and then turning to a side posture with the neck properly supported at the level of the spine, and the shoulder not tucked under the body or the hand under the head, is the best sleep posture. Neck support is best accomplished with a feather pillow, Japanese quality buckwheat hull pillow, or a Tempurpedic foam (which doesn't jiggle in REM). If the scalenes ar excessively tight at night, a small riser under the legs of head of the bed may tilt the bed just enough to take some pressure off with gravity, but not enough to be noticed. Furniture floor protectors may be thick enough, or a small can stuffed with cloth may be used provide a stable riser with enough height. If the bed is on a hardwood floor with a rug under the legs of the foot of the bed only, or the house is tilted, your bed may be actually tilted slightly with the head below the feet, aggravating the neck muscles with excess tilt stress during the night.

If the patient is spending a lot of time driving, driving posture and stress can be very causative or perpetuating of TMJ disorders. Avoiding driver stress, teeth clenching, excessive talking or singing while driving with postural stress, eating while driving, and excessive turning of the head all may be important factors. A forward head and neck posture during driving should be corrected. Some helpful routines may be to use a low back supporting pillow to help sit more upright, adjusting the car seat so that you are in a more balanced upright position, using the pelvis to stabilize instead of muscles, and trying to move the feet and legs without using upper back and neck muscles. When you are at a stoplight, take a few seconds and deep breathe, and push the head gently against the neck brace cushion to flatten the cervical thoracic joint, tucking the chin to the chest, and then exhale with a sigh. Shift in the car seat occasionally, and stop and take a short walk after an hour in the car on long drives. All of these may may a difference in neck and jaw tension.

Another type of neuromuscular reeducation that may be helpful is patient focus on proper TMJ movements during jaw opening. By placing the index and middle fingers, or the heel of the hand, against the temporomandibular joint, and the other index finger against the chin just below the mouth, the patient can practice repeatedly, for a few minutes per day, the proper motion of the joint. This should be performed sitting, and the tongue pushed against the hard palate, with slow opening of the jaw within a non-painful range, and a slight push against the chin to prevent excess jaw protrusion. Some resistance may be needed against the temporomandibular joint or the jaw if abnormal movements of lateral joint rolling or jaw protrusion are noticed. Strong pressure should be avoided, though, as this could cause joint irritation. Slow, focused jaw movement is the key to neuromuscular retraining, not forceful pressure. Maintaining the pressure with the tongue against the hard palate, or roof of the mouth, prevents one type of unnatural jaw movement that often irritates the TMJ. Taking a deep breath during the jaw opening, and a relaxing outbreath, or sigh, during the closing phase, also neuromuscularly helps with reflexive retraining.

Another technique that may be useful, but in some cases may cause irritation to the joint when self-administered, is bilateral pressure applied at the TMJ with the heels of the palms while slowly opening and closing the mouth fully in a non-painful range of motion, and feeling the movements of the TM joints to try to achieve as smooth of a motion as possible. This technique may be best employed while lying supine, or face up, to decrease active tension on the jaw. This simple procedure allows the patient to focus control of the jaw movement more effectively, and may carry over into unconscious neuromuscular control during eating and talking. Patients who must talk a lot at work, such as those on the phone most of the day, may be particularly helped by neuromuscular reeducation. Of course, better ergonomic habits should also be learned in these cases. Use of headsets, or attached ear phones, are highly recommended. Eliminating the cradling of the phone against the shoulder is absolutely necessary, and better body mechanics in holding the phone and insuring that unnecessary neck rotations are not performed while talking are also very important. Use the chair swivel and your feet to turn when talking on the phone, as well as the gaze of the eyes instead of turning of the neck while talking are habits that should be reinforced. This type of concurrent use of the scalene neck muscles during activities of the jaw, with turning of the head and forward head and neck posture, can be the source of the injury. Of course, professional guidance on targeted ergonomic, or body mechanics, retraining are most effective. Simply changing the workstation does not really address the problems created with ergonomics, though. The term ergonomics actually means body mechanics, and does not mean furniture design.

Another type of kinetic neuromuscular retraining may be accomplished either with the aid of the physician, or at home by the patient alone. By placing the end of the little finger in the ear and presssing on the end of the mandible, or lower jaw, the movement, or lack of, is very evident. Gentle pressure on this part of the bone while engaging in slow and relaxed opening and closing of the mouth, with reflexive activities of breathing and eye movements to aid contraction and relaxation, may be very helpful to reengage the joint with proper relaxed normal movements. Start by placing the tip of the little finger in the ear and gently pressing on the end of the mandible. By opening and closing the mouth, the mandibular movements will become obvious on the tip of the finger. Once the finger is in place, open the mouth as far as is comfortable and relax. Maintain gentle pressure on the mandible while taking a deep breath and looking up, at the same time slowing closing the jaw. When the jaw is closed, maintain gentle pressure, breathe out with a a sigh, and look down. See if the joint can relax into a less tight alignment. Repeat this exercise a few times.

Lastly, many people that work and talk with stress do not breathe diaphragmatically. Each seventh breath is usually a deep diaphragmatic breath. When one is stressed at work and talking, the avoidance of this necessary breathing reflex occurs, and this can contribute a lot to TMJ disorders. The scalene muscles are both masticatory and deep inspiration muscles, and stabilize the neck during active movements. Both diaphragmatic muscles and scalenes may eventually become held in contracture and contribute to improper breathing habits and improper active jaw movements, as well as inhibition of normal cervical range of motion. Nerve impingement, even the irritation of the trigeminal nerve, may occur. Release of these various muscles with myofascial release techniques and trigger point needling may be a key to therapy, but also patient reeducation to normal diaphragmatic breathing with a conscious control, may be very helpful. Patients with allergies and/or asthma, or even simple nasal congestions, are more prone to these problems. By taking a few minutes each day and practicing nasodiaphragmatic breathing, either lying supine or sitting, can be very helpful in the therapeutic protocol. Diaphragmatic breathing is accomplished by sitting upright and balanced, relaxing the shoulders and jutting out the sternum, and breathing consciously and slowly, first expanding the belly, or the muscles below the diaphragm, and then proceeding slowly to inflate the entire chest to the upper rib cage. Hold the full breath for one second and then let the air escape from the mouth in a sigh to reflexively relax the diaphragm. Other techniques touted include placing a soft ball (such as a tennis ball) against the thoracic spine at the level of the lower scapula while performing this breathing reeducation, and keeping the tongue held against the roof of the mouth.

Understanding various symptoms in TMJ disorders and their cause

Clicking of the jaw is caused by the impact of the articular disc complex against the most protruding portion of the upper joint, the eminence. This requires that the disc is moved, with tight jaw movement, forward and medial, as the lower bone of the jaw moves over the eminence to allow the fullest opening of the mouth. With clicking, the lower jawbone, or condyle, must override a too thick portion of the central disc, and then pop into a thinner disc portion. This implies that the disc may be unhealthy, and/or that the medical pterygoid muscle is pulling the mandible, or lower jawbone, medially out of place during jaw opening. If left untreated, this will usually progress toward a jaw locking as it opens, which is quickly resolved, and patients often just get used to this click and lock. Pain comes later. To resolve, the medical pterygoid should be functionally restored with myofascial release, and if this is insufficient, trigger point needling with the jaw propped wide open. Manual release is usually painful, or at least uncomfortable, but is rewarding, and if done properly, will resolve medial and main pyerygoid muscle contracture with just 1-3 treatments. If this is not sufficient to fully release the muscle, a trigger point needling is used, but this approach is difficult until the pterygoid is released, and the jaw is able to open wide enough for the needle position. The patient that may be deficient in ascorbic acid (Vit C) should take a high dose before treatment to facilitate the trigger point releases.

A crunching or rough sound sensed by the patient with jaw movment is most likely creptitus, or the sound of mineral deposits and calcifications in the joint capsule and disc complex. If there is a pathology of disc and capsule degeneration in this complex joint, the full resolution may take some time, as these tissues are avascular. Just as in the degeneration of discs in the cervical and lumbar spine, disc rehydration depends upon some decrease in tension on the disc. Lacking a direct vascular supply, the disc and other joint soft tissues depend upon the relief of muscular contracture and the gentle motions of the joint to rehydrate. If the disc is hardened, either due to arthritic calcification, inflammatory scarring or hypertrophy, or dryness, steps should be taken to resolve these conditions. Sensations of stiffness and swelling may be explained by these problems. Increased circulation, decreased mechanical stresses, herbal formulas to decrease excess inflammatory cytokines and growth factors noted as markers of TMJ pathology (TNFalpha and VEGF especially), and perhaps hyaluronic acid if dry tissues and cells are suspected, all may be combined in a holistic protocol to treat the causes of stiffness and swelling. Expert passive joint mobilization (Tui na in Traditional Chinese Medicine) is essential to clearing mineral deposition in these tissues, but must be combined with a thorough holistic protocol.

Many of the cases of TMJ disorder, or TMD, may not involve pain, or involve pain that comes and goes. If there is pain, an underlying joint inflammation, or arthritis, should be suspected. This type of pain is typically described as an aching pain around the joint, with an occasional spasm of sharp pain and jaw immobility. Three types of pain scenario, or explanation, are presented by Drs. Janet Travell and David Simons, in their definitive text on myofascial disorders. These are 1) true mandibular joint pain, 2) myofascial pain due to trigger points alone, and 3) myofascial pain that is perpetuated by a noninflammatory or intermittently inflammatory joint condition. Treatment should be tailored individually to reflect these considerations. A physician that understands the myofasical syndrome and referred trigger point pain patterns is able to assess this pain properly.

Information Resources and Additional Information

  1. A 2003 analysis of the neurobiological mechanisms underlying sleep bruxism at the University of Montreal, Canada, (sleep bruxism is related to a central nervous system dysregulation, rather than a periperhal nerve pathology), found that the literature implicates REM sleep disorders, serotonin, dopamine, GABA, and noradrenaline in the genesis of the disorder. : http://www.ncbi.nlm.nih.gov/pubmed/12764018
  2. A 2015 updated meta-review of all published scientific study of standard treatment for nocturnal bruxism, the the University of Padova, in Italy, the University of Helsinki, in Finland, the University of Amsterdam and VU University, in The Netherlands, and Tel Aviv University, in Israel, reported that only 12 randomized controlled studies were found of high quality, and that "it can be concluded that there is not enough evidence to define a standard of reference approach for sleep bruxism treatment, except for the use of oral appliances", showing that benefits of pharmaceuticals such as clonazepam and clonidine, botox injections, biofeedback, and cognitive-behavioral therapy are still unclear: http://www.ncbi.nlm.nih.gov/pubmed/26095208
  3. A 2007 report by the Netherlands Pharmacovigilance Center Lab found that SSRI medications made up the majority of reports on drugs causing nocturnal bruxism as a side effect, and reported that this could be explained by the effect or serotonin reuptake inhibitors on the central dopamine pathway: http://www.ncbi.nlm.nih.gov/pubmed/17937375
  4. A 2006 report from the Dept. of Neurology at Chang Gung Memorial Hospital in Taiwan surmises that hypersensitive presynaptic dopamine receptors may be the underlying pathology responsible for bruxism that occurs both in the waking and sleep times: http://www.ncbi.nlm.nih.gov/pubmed/15749418
  5. A 1997 study at the University of Montreal, Canada, found that the central dopaminergic system may be involved in the modulation of sleep bruxism, as evidenced from fMRI studies and reaction to a dopamine D2 receptor antagonist: http://www.ncbi.nlm.nih.gov/pubmed/9294496
  6. A 2004 study in Saudi Arabia found that in a study of children diagnosed with ADHD, subjects treated with pharmacological medications showed a higher incidence of bruxism compared to those not taking medications, and that CNS stimulants were most associated with this drug side effect: http://www.ncbi.nlm.nih.gov/pubmed/15554406
  7. A 2009 case study at the Neuropsychiatry and Headache Clinic in Pratap Nagar, India, found that the newer ADHD drug atomoxetine (Strattera) exacerbated nocturnal bruxism in children with ADHD, which subsided upon discontinuation of the drug, and returned with retrial, showing a clear association. Atomoxetine is a selective norepinephrine (adrenalin) reuptake inhibitor: http://www.ncbi.nlm.nih.gov/pubmed/19165653
  8. A 2008 study in Spain showed a clear relationship between ADHD in children and sleep disturbances involving rhythmic movement disorders such as nocturnal bruxism, snoring, enuresis (bedwetting, an autonomic response), night awakenings, and bedtime resistance: http://www.ncbi.nlm.nih.gov/pubmed/18775271
  9. A 2012 study at the Federal University of Santa Maria, in Brazil, showed that the herbal chemical Resveratrol significantly lowered the incidence of bruxism, or movement disorder of chewing, induced by an antipsychotic medication fluphenazine, which acts by antagonizing type 2 dopamine receptors. These scientists found that the adverse side effect of bruxism occurred in 70 percent of the animals and that giving them Resveratrol reduced the incidence to 30 percent, a dramatic decrease: http://www.ncbi.nlm.nih.gov/pubmed/22266770
  10. A 2006 study at the University of Hong Kong found that patients with a diagnosis of nocturnal bruxism consistently had higher levels of AGEs (Advanced Glycation Endproducts), which are complex molecules of sugars, fats and proteins that are clearly associated with atherosclerosis and many tissue problems and dysfunctions, as well as Metabolic Syndrome and diabetes: http://www.ncbi.nlm.nih.gov/pubmed/?term=sleep+apnea+advanced+glycation+endproducts
  11. A 2015 study at the University Nove de Julho and the State University of Campinas, in Brazil, found a strong correlation between diurnal cortisol levels and intensity of TMJ or TMD disorders. Such research points to the need for a more holistic approach to treatment and restoration of neurohormonal homeostasis. TCM/CIM presents such an approach to treatment: http://www.ncbi.nlm.nih.gov/pubmed/25995595
  12. A 2009 study at the New York Medical College, in New York, U.S.A. measured the physiological responses from simple downward pressure applied to the front teeth with a toothpick to see if reports that vigorous toothbrushing could possibly work to relieve bruxism and headache. This strange study found that this stimulation did trigger immediate changes in Substance P, DHEA levels, and increased acetylcholine, also acting to preserve gene telomeres. The researchers, amazed at this response, also then noted that prior studies showed that acupuncture at ST36 and the use of the herbal nutrient medicines Astragalus and Boswellia also produced these same biochemical parameters, indicating that TCM therapies could prove to supply an array of beneficial effects to treat both nocturnal bruxism as well as the associated TMJ, headache, and adrenal stress imbalance:http://www.ncbi.nlm.nih.gov/pubmed/20344885
  13. A 2015 meta-review of all studies of manual physiotherapies to treat temporomandibular disorders, by the Federal University of Sao Carlos, in Sao Carlos, Brazil, and Salamanca University, in Spain, concluded that evidence strongly supports manual physiotherapies, but the results vary widely according to the treatment techniques. Myofascial release, deep tissue massage, and joint mobilization were found to be as effective as control treatments such as Botox. Of course, study design, with comparative control placebo treatments, blinded to the patients, is very problematic, and serves to diminish the quality of manual physiotherapy that can be used, yet despite these drawbacks, numerous studies still confirmed efficacy with evidence. All of these manual physiotherapies can be obtained in TCM treatment if the physician is trained in Tuina, the soft tissue mobilization techniques of Traditional Chinese Medicine, and combined with effective acupuncture, herbal and nutrient medicine: http://www.ncbi.nlm.nih.gov/pubmed/26059857
  14. A 2015 study at the University of Brasilia, in Brazil, and the Dental Research Center of Sao Paolo, Brazil, found that there was a strong association between abnormal head and neck posture and TMJ, showing the need for incorporation of patient instruction in body mechanics and postural habits (ergonomics) in treatment: http://www.ncbi.nlm.nih.gov/pubmed/26017489
  15. A 1993 study at the Zunyi Medical College in China demonstrated the effects of a chemical in a Chinese herb (Uncaria rhysochophylla, or Gou teng) used to treat neurological problems with excessive motor response. This herbal chemical reduced the dopamine concentration in the amygdala, while increasing the 5-HT (serotonin) concentration in the hypothalamus and reducing the release. Such modulatory effects on the CNS homeostasis demonstrates the potential of evolved herbal chemistry to effect pathological problems in a complex modulatory fashion, which is the basis of success for natural holistic therapy. Such research and therapeutic potential has been suppressed and underutilized in the U.S., where the pharmcological industry dominates: http://www.ncbi.nlm.nih.gov/pubmed/8352000
  16. A 2009 study at Johns Hopkins University School of Medicine found that pain sensitivity in TMJ had a clear association with sleep disorders and nocturnal bruxism. These acquired hyperalgesia and hypoalgesia states are part of chronic myofascial pain syndromes, which may play a significant role in causing or perpetuating nocturnal bruxism: http://www.ncbi.nlm.nih.gov/pubmed/19544755
  17. A 2014 study at the University of Torino, Torino, Italy, noted that polysomnographic studies show that episodes of nocturnal bruxism are preceded by a sudden shift in autonomic cardiac activity, with increased heart rate and vagal stimulation. This association is so clear that these experts conducted a study confirming that a simple home monitor of heart rate and vagal activity may be the best means of monitoring the frequency of nocturnal bruxism events: http://www.ncbi.nlm.nih.gov/pubmed/24417585
  18. A 2010 study at the New York Medical College found that simple acupuncture, acupressure, and herbal medicine had a significant effect in treating nocturnal bruxism, working to decrease nerve excitability at the hippocampus: http://www.ncbi.nlm.nih.gov/pubmed/20344885
  19. A randomized controlled 2005 study of 80 human subjects at the University of Arkansas for Medical Sciences, in Little Rock, Arkansas, showed that electroacupuncture at specific points (P6, HT3, LV3) could effectively reduce arousal levels or thresholds in patients with sleep disorders. This research found that bilateral stimulation and use of 5 Hz frequency produced the best results: http://www.ncbi.nlm.nih.gov/pubmed/16213248
  20. A 2003 study at the Federazione Italiana Societe de Agropuntura, randomized and placebo controlled, showed that both single acupuncture point stimulation and single ear acupuncture point stimulation reduced muscle hypertonicity in the various muscles associated with nocturnal bruxism, significantly better than the control points used: http://www.ncbi.nlm.nih.gov/pubmed/15108607
  21. A 2014 randomized controlled human clinical trial of electroacupuncture to treat the trigeminal nerve pathology, found that this stimulation at Taiyang and the Sishencong group (around DU20), combined with Ren12, Ren 4 and UB23, followed by a spinal mobilization (Tui na), produced greater relief of pain in trigeminal neuralgia than treatement with carbamazepine (Tegretol). Such study shows that a comprehensive treatment strategy is effective in treatment trigeminal pathology, and could be applied the trigeminal pathology of bruxism: http://www.ncbi.nlm.nih.gov/pubmed/25335251
  22. A 2010 study at the Nagasaki University School of Medicine, in Nagasaki, Japan found that electroacupuncture affects both the spinal cord tracts and the reticular system in the brain in a modulatory manner, with the majority of nucleus raphe magnus neurons inhibited by electroacupuncture stimulation in pain studies, and half of the nucleus reticularis lateralis neurons were inhibited. Such studies clearly show how acupuncture stimulation could be a valuable part of treatment of CNS disorders such as bruxism: http://www.ncbi.nlm.nih.gov/pubmed/20821819
  23. A 2011 meta-review of scientific studies at the Shandong University of Chinese Medicine, in Jinan, China, found that the main point to treat orofacial problems such as TMD and trigeminal neuralgia, LI4, is found with fMRI studies to affect the key areas in the brain associated with these disorders as well, such as the reticular system, thalamus, spinal cord and brainstem, and cortex. Evidence suggests that much of the effect on the facial pathologies stems from the modulating effects on these key areas of the brain and the balance of key neurotransmitter from these areas, such as serotonin, enkaphlin, substance P, and GABA. This single point is just the starting point in point prescriptions used to treat TMD and bruxism: http://www.ncbi.nlm.nih.gov/pubmed/22073895
  24. A 2008 randomized controlled study of the effects of stimulation from the acupuncture point Ren 4, at the Shanghai Medical College of Fudan University, in Shanghai, China, found that electroacupuncture of 2-3 Hz at this point in laboratory animals reduced viral-induced pathological activity in the reticular system and hypothalamus, and in animals with induced endocrine dysfunction by removing the ovaries, improved function in these areas occurred by electrostimulation of Ren 4:http://www.ncbi.nlm.nih.gov/pubmed/18807714
  25. A 2007 randomized controlled study at the Peking University School of Medicine and hospital, in Beijing, China, found that elecroacupuncture stimulation at a single point, P6, significantly reduced the frequency of transent lower esophageal relaxations, the main cause of acidic irritation of the esophagus, which is proven to contribute to nocturnal bruxism in many patients as a trigger, and which may affect the vagal autonomic system: http://www.ncbi.nlm.nih.gov/pubmed/17828819
  26. A 2008 study at the State University of Campinas, in Brazil, noted a high relationship between bruxism, TMJ disorder, and headaches, with MRI studies showing that TMJ disc displacement and swelling (effusion) had a significant association with headache. This study followed patients with nocturnal bruxism, chronic headaches, and joint pain to see if TMJ disorders may be central to this array of symptoms: http://www.ncbi.nlm.nih.gov/pubmed/18784854
  27. A 2010 analysis of over 1500 patient with TMJ disorders at the Medical College of Wisconsin Department of Population Health found that TMJ disorders represent quite an array of complex pathophysiologies and clinical manifestations associated with a number of chronic comorbidities, and predominantly affect females between the ages of 30 and 50: http://www.ncbi.nlm.nih.gov/pubmed/21178593
  28. A comprehensive analysis of TMJD (temporomandibular joint disorder) is found at the TMJ Association: http://docs.google.com/viewer
  29. Although extensive research into the proof of acupuncture outcomes with TMJ disorders (TMD) is yet to come, small studies in Europe have shown consistent improvement in randomized clinical trials. In a real clinical setting, the acupuncture would be just one part of the treatment protocol: http://www.ncbi.nlm.nih.gov/pubmed/16645291?dopt=Abstract
  30. In 2010, a clinical report concerning treatment of TMJ disorders with subluxation at the University of Pennsylvania, physicians found that for most patients, addition of a simple acupuncture regimen increased the success of joint manipulation dramatically: http://www.ncbi.nlm.nih.gov/pubmed/21319604
  31. A 2010 meta-analysis of scientific studies of acupuncture in the treatment of TMJ disorders, by the University Europea of Madrid, Spain, shows that acupuncture is a reasonable and effective part of a holistic treatment protocol in standard medicine: http://www.ncbi.nlm.nih.gov/pubmed/20551730
  32. A 2010 meta-analysis of scientific studies of acupuncture in the treatment of TMJ disorders, at Kyung Hee University Medical Center in Korea also found that systematic review found that acupuncture showed moderate evidence as an effective treatment intervention for TMJ disorders: http://www.ncbi.nlm.nih.gov/pubmed/20401353
  33. A 2009 study at Sao Paolo University in Brazil, found that acupuncture treatment resulted in sustained beneficial changes in a 3-month follow-up study, with improved neuromuscular activity (EMG studies), increased strength of masticatory muscles, and sustained remission of TMJ pain: http://www.ncbi.nlm.nih.gov/pubmed/19958104
  34. A 2008 study at the University of Arizona in Tucson, found that a treatment system that utilized a number of treatment options with Traditional Chinese Medicine and Naturopathic Medicine resulted in significantly greater reduction of pain, and psychosocial interference, than standard medical protocols: http://www.ncbi.nlm.nih.gov/pubmed/18564953
  35. A study at Missouri State University found that polyphenols in grape seed extract, (also found in whole pomegranate extract and some Chinese herbs), may be a beneficial addition to the treatment protocol for TMJ disorders, resolving problems in the trigeminal nerve associated with TMJ pathology: http://www.ncbi.nlm.nih.gov/pubmed/21143976
  36. A 2005 study at Wakayama Medical University in Japan found that serotonin receptors in the trigeminal nerve near the upper cervical spinal cord are involved in mediating both proprioceptive and nociceptive effects in TMJ syndrome, suggesting that perhaps use of a serotonin aid, such as 5HTP, may be beneficial in the treatment protocol. A combination of 5HTP, melatonin (which is a potent antioxidant and neurotransmitter), P5P, and St. John's Wort extract could significantly benefit therapy: http://www.ncbi.nlm.nih.gov/pubmed/16112478
  37. A 2000 randomized controlled study at the University of Hong Kong found that a Chinese herbal ointment, Ping On, significantly reduced TMJ pain symptoms compared to placebo, and improved the ability to fully open the jaws: http://www.ncbi.nlm.nih.gov/pubmed/20001836
  38. A 2010 meta-analysis of studies of the use of mouthguards, or intraoral appliances now routinely prescribed to relieve TMJ disorders show modest benefit but potential for adverse events and irritation, and stabilization appliances should be used that are professionally adjusted, and used with monitoring and caution: http://www.ncbi.nlm.nih.gov/pubmed/20664825
  39. A warning by a prominent dental surgeon concerning the heavily promoted dental diagnostics and treatments for TMJ disorders is presented here: http:/www.dentalwatch.org/questionable/tmj.html
  40. A survey of medical and dental students with TMJ disorders found a variety of associations of other health problems prevalent with persons with TMJ: http://www.ncbi.nlm.nih.gov/pubmed/21206936
  41. Demographic health studies in Brazil found a significant relationship between TMJ disorders and migraines, episodice tension headaches, and chronic daily headaches: http://www.ncbi.nlm.nih.gov/pubmed/19751369
  42. A review of scientific studies, meta-analysis, and systematic reviews in clinical research found significant incidence of TMJ disorders following whiplash injury in motor vehicle accidents. Whiplash injury primarily involves a myofascial strain syndrome of the neck extensors and stabilizers, namely the splenii and scalene muscle sets. This analysis also finds an association with traumatic stress and TMJ disorders: http://www.ncbi.nlm.nih.gov/pubmed/21206925
  43. A 2011 study at Daemen College in Amherst New York found that two biomarkers, an endothelial growth factor (VEGF) and D6 (a heptahelical membrane protein expressed by lymphatic endothelial cells, and associated with specific inflammatory cytokines) were associated with TMJ, potentially linking the underlying pathological processes to other disorders with these biomarkers: http://www.ncbi.nlm.nih.gov/pubmed/21163381
  44. A 2011 review of modern dental training shows that computed tomography, a form of radiological testing that uses a large number of quick X-rays, is now pushed as standard dental practice, much of it to diagnose TMJ. The public must start expressing some alarm to reverse such trends, as excess radiation has accumulative effects and is a primary cause of cancers: http://www.ncbi.nlm.nih.gov/pubmed/21205734
  45. A 2010 article in the New York Times shows that some radiological experts at major universities are concerned about the pushing of unnecessary dental X-rays and cone-beam CT scans due to the risks of excess radiation exposure: http://www.nytimes.com/2010/11/23/us/23scanbox.html
  46. A 2010 article in the New York Times expresses the natural alarm at the pushing of cone-beam CT scans in dental offices and the unbelievable misinformation that is so cavalierly distributed to medical and dental personel to sell them on these scans: http://www.nytimes.com/2010/11/23/us/23scan.html