My Dentist Says I Grind My Teeth: Do I actually need a night guard?
Did you know koalas sleep 18-22 hours a day? Depending on how you look at it, that’s a lot of time for tooth grinding, or maybe it’s the recipe for a simpler, stress free, jaw clenching free, way of life.
Disclaimer: The information presented in this article is for educational purposes only and is NOT intended or implied as a substitute for professional medical advice, diagnosis, or treatment from your dentist, physician, or any other healthcare professional. You should NOT use the information presented here for diagnosing or treating any health problem or disease. Never disregard advice from your personal medical care provider(s) or delay contacting your dentist/other healthcare providers because of anything you read or heard here. Reading this article and/or utilizing any of the information presented in any way does NOT create a doctor-patient relationship between you and the article creator or with any of the healthcare professionals in any way affiliated with this article. You use this information at your own risk. You should contact your dentist/healthcare professionals before beginning any new treatment or practice to address a health problem or improve your health. The author is not responsible for information on external websites linked to from this article or for the information on external websites that link to this article.
Night guards. This might be the most confusing topic in all of dentistry. I know how to place a lovely little filling in a tooth. I can cut a crown prep that’s pretty as a peach. I look at my crown preps sometimes (that’s the thing we dental folk do where we whittle your teeth into little nubs so we can pop a cap¹ over top of it) and I think, “Now that? That’s a pretty Peach. Bowser his-self would try to steal that Peach if he got the chance.”
If I told you I fully understand night guards and their place in dentistry, I would be lying to you. No one does. It’s a topic I’ve been studying for years. We’re getting closer to understanding. I’m WAY more knowledgeable than I was eight years ago. Still, it’s a murky topic and there’s a lot of research out there to filter through. Dentists argue about this stuff on Facebook all day and all night. I’m confident it has led to some clenching and gnashing of teeth by many dentists themselves over the years.
Despite all that uncertainty, I’m going to, perhaps very hubristically, attempt to teach all of you what I can about night guards. Why? Because if it’s confusing for me as a dentist I can’t imagine how confusing it is for you all as patients. There are a lot of factors in play. I want to make things less confusing. I want to demystify the esoteric world of dentistry for the common man. Step one is that I should probably stop using words like “demystify” and “esoteric.” Then again, maybe that’s being presumptuous and I just insulted you. I’m sorry. This isn’t starting well. Here’s to hoping it gets better.
Here’s a seemingly simple question: Why wear a night guard/oral appliance? That’s the first thing to determine: WHY are you putting this in your mouth? What is the goal?
There are LOTS of potential reasons to use a night guard. There are TONS of options for what night guard to use and how long to use it. Every patient is unique and different.
When you put a guard in your mouth, it can influence four primary structures:
Your Teeth
Your Jaw Muscles
Your Jaw Joint
Your Airway
The other important question to answer when considering wearing a night guard is whether you are dealing with an acute (short term) or chronic (long term) problem. Sometimes patients come to me with acute pain. They may only need a night guard for a few days or weeks the same way you would wear a wrist splint or use crutches. Other times I see patients who are pain free, but they are clearly grinding away their teeth. To stop that wearing down process, we should consider a night guard long-term as one treatment option.
I was fortunate enough to have the opportunity to attend a lecture series from one of the highly intelligent, experienced, and wise dentists I admire and he made two excellent points:
Occlusal appliance therapy [ie night guards] should ALWAYS be accompanied by patient education because…
Doctors DON’T heal patients. Patients heal patients!
Truer words have never been spoken. Admittedly, I’ve only been in this dentisting business for a little over eight years. I’m a young pup in the dentistry world. Nevertheless, the endlessly repeating pattern I’ve observed is that no matter what a dentist does to “fix” a patient’s teeth, if the original broke down, then the “fix” can break down. We have to educate our patients so they can confidently maintain their health.
I’ve struggled with that mission in my work as a dentist. It’s hard to have these conversations with patients in a busy dental practice. It can be viewed as unconventional when I start asking patients about things like stress in their life and the quality of their sleep. Sometimes jaw muscle aches feel like toothaches and patients get confused that I’m not going to “fix” their “broken” tooth, but instead recommend dietary and behavioral changes for a period of time. Sometimes you do need a root canal to alleviate the pain you’re having, but that’s not always the case. Even if you need a root canal, I’m trying to figure out why that tooth went bad and how we can prevent another one from doing the same thing in the future.
Other patients have been quite happy to hear that they don’t need a root canal or crown to solve their problem, which I’m thankful for. I think plenty of the confusion patients experience when I try to talk to them about dental health can be laid at my own feet. I’ll readily admit I’m not all that skilled at having these conversations. That’s led me to read a fair bit about emotional intelligence and behavioral psychology. I’m trying to get better at communicating effectively.
Part of the reason I’m trying to write and make videos online is that that way you can access the information as you’re comfortable doing so. One of the rock-solid principles I’ve learned from my limited studies on psychotherapy, and maybe it’s just plain common sense, is that it is absolutely impossible to help anyone who isn’t ready to admit they have a problem and wants to be helped (or help themselves). It’s the old adage, “You can lead a horse to water, but you can’t make it drink.”
I encounter lots of patients who don’t trust what I’m saying and think I’m full of bull hockey. That’s fine. I get it. Maybe I am. But I’ve studied these problems from a variety of angles through experience with patients, research, various books, and my own personal health struggles and lots of the same factors keep coming up for many chronic problems. I’m not saying you can cure cancer by getting proper sleep, nutrition, and exercise, but there are an awful lot of things you can cure with those things. That includes a lot of dental problems.
I wear a guard every night because I know every once in a while I grind and clench my teeth when I’m sleeping. Trouble is, I’ve never been able to predict the nights when I’m going to clench and grind. I ain’t got no crystal ball.
Is this post still about night guards? Yes. Sort of. I’m going to talk about when you might need a guard or oral appliance, but it’s less often than you think if you follow some other guidelines. Even by following those guidelines, some patients can definitely benefit from a guard. The goal of the content I’m making online is to assist patients in maintaining and improving their health at home while simultaneously improving their relationships with their healthcare providers. I think the best health care is both preventative and individualized. Hopefully this article accomplishes those goals in some small ways.
Have I got you all fired up and excited about the future of your teeth? I sure hope so. Alright, let’s go through each of the four structures night guards affect and address both potential acute and chronic issues.
1. Teeth
Common Acute Issue: Cracked Teeth Leading to Pain and Tooth Loss
I see patients that crack or fracture teeth in their sleep all the time.
Sometimes they wake up in the middle of the night and all of the sudden their tooth hurts in a way that makes them want to punch a small child or punt an animal into the next zip code. That usually means they have fractured the tooth down into the nerve chamber. Sometimes these teeth can be saved. Oftentimes they need to be removed.
Sometimes they wake up in the morning and their curious tongue discovers a sharp spot or a hole where there didn’t used to be one, but they don’t have any pain. That typically means they chipped off a piece of a tooth, but that there is not a deep crack.
Sometimes they notice that a tooth has become bite and/or cold-sensitive, but as long as they don’t let anything touch it they are pain free. That means that the tooth has been under some serious pressure and in some cases that a crack is starting in the tooth. It may be at a point where the tooth needs a crown, but sometimes starting wear of a night guard can make these symptoms go away entirely. I’ve had that experience myself. There are tests a dentist can do to check how significant a beginning crack may be.
What can you do about any of that? Well, if you can tolerate wearing a night guard, it will minimize the possibility that you will ever crack any teeth. It distributes the clenching or grinding forces through the guard and you don’t get any pinpoint hard contacts of one tooth against another that could cause damage.
For this particular problem, wearing a night guard is like wearing a helmet when you ride a bike. Maybe it’s not highly likely that you’ll flip over your handlebars and crack your skull open, but it’s nice to have a helmet to prevent that just in case.
I wear a guard every night because I know every once in a while I grind and clench my teeth when I’m sleeping. I’ve had jaw muscle pain as a result of this. I’ve had bite and cold sensitivity on my back teeth that lasted for several weeks because of this (and went away after I started wearing a guard).
Trouble is, I’ve never been able to predict the nights when I’m going to clench and grind. I ain’t got no crystal ball. I’m never snuggling up to doze off and I get a warning from my phone that tonight’s the night, best pop in the guard. If anyone wants to invent that tech and make that app I’m sure you could make a lot of money.
If you’re the type of person who wears seatbelts with gusto and you have some history of issues with your teeth, consider a night guard. It’s also worth noting that teeth are more likely to fracture if they have larger fillings in them. If your teeth have never had any work done on them, they are much more durable — which is a reason to check out my videos and articles on avoiding cavities. Still, I have seen people break virgin teeth (meaning they never had any previous damage or dental work) clean in half by clenching hard enough. Nothing’s impossible, but that’s rare.
What about daytime clenching?
Patients can also crack their teeth from clenching them during the day. We often clench when we are focused intently on something (I know I tend to do it when I’m cutting one of my pretty as a peach crown preps) or are stressed (pay attention to your teeth the next time someone pisses you off). Many people clench while exercising too. If you like to hulk weight in the gym, pay attention to whether your jaw muscles tense while you’re getting jacked.
Most people don’t like wearing night guards during the day. It’s even in the name. Typically, we’re not into day guards. There’s this whole talking business we do that gets to be challenging with a plastic disk in your clap trapper. So what then? We just let our teeth get pulverized during the day? No. We get innovative. We stick our tongue to the roof of our mouth OR we blow little baby puffs of air out of our mouths.
Say what? Come again?
Option 1: Place the tip of your tongue gently to the roof of your mouth. If you don’t know what I mean, make an “N” or “NNN” sound. See how your tongue goes up to the roof of your mouth? Placing it there will reflexively drop your lower jaw down. Your teeth will separate. You can’t clench your teeth and crack them if they aren’t touching. Victory is ours!
Sort of. One very impressive dentist who specializes in treating orofacial pain disorders explained during a lecture I attended that this “tongue trick” can actually increase muscle tonicity in the jaw muscles. Why does that matter? Well, if you have jaw muscle soreness and the tongue trick tenses the jaw muscles more, you could wind up with more jaw muscle pain and dysfunction.
That won’t be the case with every patient. I personally practice this cute little tongue yoga move on the reg (It’s like Baby Cobra pose in your mouth!) and haven’t had any problems. Still, something to consider.
If Tongue Baby Cobra has your jaw muscles aching still, you could try…
Option 2: Blowing little puffs of air out of your mouth as a reminder to relax your jaw muscles! Is this a rather strange ritual? I think so. But, apparently, it is more effective at relaxing the jaw muscles. For this one, think about making “Ba” or “Pa” sounds as you puff air out your lips.²
Also, when doing these little muscle relaxation exercises, you don’t actually have to make the “N,” “B,” or “P” noises to go along. Feel free to do so if that’s your jam. The world could use more beatboxing. It’s an underappreciated art form as far as I’m concerned.
The pain associated with inflamed and overworked jaw muscles is different from what you’ll see with various types of toothaches. A few careful tests and questions from your dentist can typically distinguish what you’re dealing with (Although, sometimes you do have both problems at the same time. Sorry ‘bout your luck).
Common Chronic Issue: Teeth Wearing Down Leading to Loss of the Smile
This is a common way people lose their smiles over time. Teeth get flat, worn, and short. What us dental folk call “incisal embrasures” — something that adds distinction to a smile — those disappear. The enamel can look flaky at the edges and get little crack lines in it. It sneaks up on you because it is gradual and it very often doesn’t hurt at all.
When I see this problem with patients’ teeth, I bring it up with them. I try to explain what is likely going on. I would say 90% of the time they don’t want to do anything about it because it doesn’t seem like a big deal. I give my little spiel about the fact that the teeth can break down slowly over time. They usually just want to watch it. I explain that if it gets worse it can be much harder to repair in the future (and significantly more expensive). They usually just want to watch it.
That’s fine. I’m not a pushy guy. Maybe I should be because I think many of these patients are going to be annoyed by the changes in their smiles as they age? Maybe I suck at my job. I’m still not sure. That’s part of why I’m writing online. I see this as a way to learn more so I can suck less at my job.
The other thing you can do if you see wear on the front teeth from grinding is that you can place bonding material to repair the teeth. That bonding material may need to be replaced every 5 years or so, but in my opinion, that’s a better solution than letting the patient’s teeth wear away more and more every 5 years.
As teeth wear away they actually erupt out of the bone more. So you end up with these flat, weirdly shaped teeth and the patient wants to fix them, but now you’re in a position where you have to put crowns (or some really impressive fillings) on every tooth in the mouth to get something that looks natural. You might also have to do orthodontics to position teeth appropriately. You might have to have a gum tissue specialist reshape the gums and bone for you to place the crowns where you want them. While the results of these procedures can be spectacular and I’m in awe of the work many dentists do to rehabilitate patient’s smiles, none of that is cheap, fast, or easy.
Assuming you can comfortably wear a night guard, you might prevent the whole business. What will dentists do if there are no smiles left to repair? I don’t know. We tend to be industrious folk though. I’m sure we’ll find something worthwhile.
It can also be the case that the wear on the front teeth is happening because your front teeth bump into each other when you chew on your back teeth. Sometimes that can be corrected with help from an orthodontist.
There are a number of factors that go into protecting your smile for a lifetime. I hope I’m making things a little clearer for you so you can have a more informed discussion with your dentist about your specific goals.
Each of the next sections dealing with the remaining 3 structures affected by night guards (jaw muscles, jaw joint, airway) get a little more complex. For each problem category, I will discuss causes, signs and symptoms, and potential treatment options. The treatment options will include how a nightguard may play into things.
2. Jaw Muscles
As discussed above, reason #1 you might consider a night guard is to protect the teeth from cracking or breaking down over time. Let’s consider what might be causing all that clenching and grinding that is damaging the teeth in the first place. Time to talk about the jaw muscles and how night guards affect them.
Be confident you can improve your life! Like this guy.
Common Acute Issue: A “Toothache” that is actually a Muscle Ache
I frequently see patients who think that they have a toothache because of a cavity and it turns out that they actually have jaw muscle pain masquerading as a toothache. The pain associated with inflamed and overworked jaw muscles is different from what you’ll see with various types of toothaches. A few careful tests and questions from your dentist can typically distinguish what you’re dealing with (Although, sometimes you do have both problems at the same time. Sorry ‘bout your luck).
To understand what can go wrong, it’s helpful to think of your lower jaw bone as resting in or suspended by a “sling” of muscles, tendons, and ligaments. When we close the jaw so that the teeth fit together, a knob in the back on the left and right called the condyle rests against a disk of cartilage up against our skull. So there is a “tripod of stability” with the two back “knobs” of the jaw resting in the two skull sockets (located toward your ears) and the teeth of the lower jaw resting against the teeth of the upper jaw in the front.
As long as that sling can comfortably get the jaw into that rest position and all the soft tissue is healthy, you usually have nice, calm, quiet muscles. However, if something throws off that stability either with the joints or the teeth, then your muscles have to work extra hard to hold your jaw in a new position all the time. Think about how your arms would feel if you had to hold a lightweight book in front of you at shoulder height all day long. Not very good. That’s what can happen with our jaw muscles for a variety of reasons.
Causes of Acute Jaw Muscle Pain
Trauma to either the jaw joint or the teeth can cause instability. This can happen if you bite into a piece of food that’s too hard, if you get hit in the jaw, from oral intubation during surgery, from having your mouth open wide at the dentist for too long, if you’re in a car accident, if you yawn a tad too aggressively, or as a result of various more intimate activities. You don’t need to get too detailed when filling out your health history. Just say you bit a large apple or something, leave it at that.
If you were paying attention to that last paragraph you’ll realize that one of the ironies of working as a dentist is that in our attempts to treat existing problems for patients, we can sometimes cause other problems. If you’ve had discomfort after dental procedures in the past, be sure to let your dentist know about that. There are precautions you can take to try to minimize jaw muscle and joint discomfort.
If you have a more limited ability to open your mouth (Try the “three-finger test.” Can you comfortably stack three of your fingers vertically between your teeth or not?), are having work done on your 2nd or 3rd molars farther in the back of the mouth, or have a history of clenching/grinding with symptoms in the jaw joint or muscles, it may be smart for you to do one or more of the following before and during dental procedures:
If available, be sure to wear a night guard for a few nights before the procedure
Maintain a soft food diet for several days before and after a dental procedure
Take an NSAID medication such as ibuprofen prior to and after your dental appointment for a couple of days (follow appropriate dosing and make sure you don’t have any conditions that would contraindicate the use of this medication)
Use a bite block during dental treatment (This is a rest the dentist puts between your teeth so you don’t have to use your jaw muscles to hold your jaw open. Be sure to let your dentist know if the bite block they are using doesn’t feel like a comfortable size.)
Take periodic breaks throughout any long dental procedures. Discuss this with your dentist ahead of time and don’t be hesitant to raise your hand whenever you need a break for a few minutes.
Basically, something (hopefully not a dentist like me) injures either one (or both) of the jaw joints or one (or several) of the teeth. One of the support beams in our “tripod of stability” has been jacked up. Then your muscles jump into action to try to stabilize things that were previously stabilized by the joints resting in the skull socket and the teeth resting against each other. Our jaw muscles aren’t built to brace and stabilize the jaw long term. Our jaw muscles aren’t meant to function 24/7. You want to use them to chew, swallow, talk, etc., and then give them a break. With an unstable joint or a tooth that is causing pain or disturbing your bite the muscles never get a break. That starts to hurt.
Lots of people lock up when you try to talk to them about stress, anxiety, and depression, or even just exercise or work habits. People don’t like talking about how their behavior patterns could be contributing to an adverse health outcome. I get it. It can seem like I’m being judgmental. I try very hard not to come across that way. I see it as my job to help patients understand what is happening with their health so a problem is less mysterious to them. What you want to do with that information is completely up to you. No judgment.
Signs/Symptoms of Acute Jaw Muscle Pain
If you have jaw muscle pain, it will usually ache at a low-grade level relatively consistently throughout the day and/or night. When you do try to eat or use the muscles more, it will hurt more. Sometimes it hurts more seemingly out of nowhere. That pain may feel sharp. You may experience headaches. Pressing on your teeth with a finger or lightly tapping on your teeth with an object (a test your dentist will do — please don’t hit your teeth with any objects at home) WON’T cause pain (if it is purely a muscle issue and not a tooth issue). Pushing on the jaw muscles themselves will often be uncomfortable/sore. There may be tense “trigger points” in the jaw muscles. Think about it: it shouldn’t normally hurt to push on a muscle. Try pushing on your thigh. Unless yesterday was leg day, that shouldn’t be painful.
The good news is that resolving this problem typically only requires a temporary intervention. If we can get you comfortable for a few weeks while your injuries heal up we should be good to go. We just need to help your body adapt and heal.
Sometimes it can get tricky and the cause of an acute jaw muscle pain is actually a toothache. If you crack a tooth or a nerve in a tooth dies and you get an infection it can be very painful to bite down on that tooth. Your jaw muscles reflexively hold the jaw away from that tooth to avoid hitting it. So you have the pain of the toothache combined with the pain of the jaw muscles fatiguing from holding the jaw in an unnatural posture. First, you have to fix the toothache, but then you have to make sure you’re helping the jaw muscles recover and relax too.
If you’re having pain in your jaw and/or teeth (or you can’t tell exactly where it is coming from), consider having answers to these questions ready when you go to your dentist:
Headaches?
Difficulty opening (can you only open slowly and/or not as wide)?
Hard to chew?
History of pain after dental work?
Jaw and temple muscles hurt to press on?
Temperature sensitivity when eating/drinking?
How long does the pain last after you’ve had something cold to drink and swallowed it?
Does the pain come on spontaneously/randomly or only if you do certain things? Are you pain free while sitting doing nothing?
Is the pain dull/achy or sharp/stabbing or both?
Does the character of the pain change throughout the day?
How intense is the pain on a scale of 1–10?
Teeth clenching history?
Potentially damaging oral habits (frequent gum chewing, ice or hard candy chewing).
Exercise/work habits that require intense focus/concentration?
Recent level of psychological stress?
Depression (current and history)?
Anxiety (current and history)?
Lots of people lock up when you try to talk to them about stress, anxiety, and depression, or even just exercise or work habits. People don’t like talking about how their behavior patterns could be contributing to an adverse health outcome. I get it. It can seem like I’m being judgmental. I try very hard not to come across that way. I see it as my job to help patients understand what is happening with their health so a problem is less mysterious to them. What you want to do with that information is completely up to you. No judgment.
I’m not a psychologist or a mental health therapist of any kind, but I also see it as impossible to do my job effectively if I can’t address the underlying causes of the problems I’m trying to “fix” or repair. If it makes you feel any better I have struggled with anxiety and depression issues for long stretches at various points in my life and I 100% understand why you don’t trust me when I say things that run counter to your current worldview. There was a younger version of me who would have told this version of me to go kick rocks. I fully understand that version of me. He was right in some ways, but he wasn’t 100% right. Neither am I now. Still, I think I’ve managed to get a little better. I’d like to help you do the same, one sore jaw at a time. Rome wasn’t built in a day.
Treatment of Acute Jaw Muscle Pain
If you have a toothache issue combined with a muscle pain issue, you need to resolve the toothache issue first and then work on healing the muscle. The toothache is causing instability in the “tripod of stability” (mentioned above) that keeps the jaw in the right position and the muscles are struggling to stabilize the jaw instead. Issues of instability of the jaw joint that can cause jaw muscle problems will be addressed later in this article.
Once your teeth are definitely not the source of any remaining pain we can work on helping your jaw muscles recover. You want to decrease the use of your jaw so that it is functioning within painless limits. Ready for a cute acronym borrowed from physical therapy land? If you have a mild to moderate jaw muscle pain and function problem, you want to follow the MEAT protocol. MEAT stands for movement, exercise, analgesics, and treatment.
Speaking of meat, you want to eat softer food, take smaller bites, and chew more slowly — don’t let it hurt.
What does a “soft food” diet actually look like, practically speaking?
Fruits — peel and chop into small bites, puree or make smoothies
Vegetables — chop/mince raw vegetables into small bites, even better to bake/boil to a softer consistency, or use a juice processor
Meats — make sure they are tender and cut into small bites
Grains — hot cereals, couscous, quinoa, rice, pasta, thin whole grain toast is better than soft/chewy rolls/bread.
Avoid sticky/chewy foods.
Rule of Thumb — Anything you can cut with the side of a plastic fork (NOT what you can stab with the prongs) is generally ok.
While we do want to be cautious and decrease activity with the jaw muscles while they are healing, we don’t want to stop activity altogether. You can perform some light stretching and jaw muscle exercises to get things back in tip-top shape.
Stretching is performed by placing two fingers vertically stacked between the front teeth. You can work your way up to three fingers. Don’t try to be a hero and shove your whole hand in your mouth. You want to feel a slight stretch, not any pain. You can also do this same exercise with tongue depressors stacked on top of each other between your teeth and that will give you a way to more gradually increase the stretch.
Secondly, you can perform a light jaw rotation exercise. This involves placing your tongue to the roof of your mouth and slowly opening the mouth to a comfortable stretch position and then closing again. Don’t go too wide; you want to be at the point of a slight stretch/very mild discomfort.
The combination of stretching and jaw rotation exercises should each be done for 10–20 seconds 6 times each day.
Cool beans. You don’t have any teeth that are hurting. You are being cautious with your eating habits. We’re doing some light jaw exercises to slowly gain back full function. We’re on the right track. Let’s keep going.
In order to keep the jaw muscles relaxed throughout the day, we need to keep you relaxed throughout the day. We have to deal with the stress in your life (That’ll be soooo easy, right?). We need to promote cognitive awareness throughout the day so that when you are stressed, you don’t clench your teeth (see the “What about daytime clenching?” section above for the “N, B, P” sound tricks). We need to learn how to breathe.
Learn how to breathe? Yep. You need to relearn how to breathe properly. We want slow, calm, abdominal/diaphragmatic breathing through the nose (not the mouth). We want to be taking 6–8 breaths per minute. Lots of people in pain will be taking more like 15–20 breaths per minute. This is no bueno. We are trying to relax over here.
Various forms of exercise, especially cardio (walking, running, swimming, rowing, biking, spinning, hiking, etc.) can be excellent stress relievers. Remember, exercise is for you and your health. It has nothing to do with anyone else’s expectations or sense of vanity. You don’t have to apologize to anyone for wanting to be healthy and excited about life.
If you’re feeling overwhelmed by any of this right now, it’s also cool to break down and cry. Let it all out. No need to keep the frustration bottled up inside. A good cry can be therapeutic. People do it in front of me at the dental office plenty once they start unpacking the problems in their lives that have led to their teeth breaking down. I get it. There is a lot of emotional baggage behind the physical damage that manifests on the surface of our bodies. No shame in that. It’s very real and justified. Let it out. Once we have seen the problem we can start dealing with it. You’re on the right track.
The above behavioral modifications are better than pills, but what about pills as something helpful to add on top of behavior change? For acute jaw muscle soreness and pain, you should consider the use of mild analgesics like NSAIDs and acetaminophen. NSAIDs like ibuprofen and naproxen are particularly useful because they are anti-inflammatory meds and muscle pain is inflammatory pain. Taking 400 mg ibuprofen three times daily (once with each meal of the day) is a reasonable recommendation for most patients. Be sure to read the drug warning labels and inserts to make sure any medication is safe for you before you start taking it.
Lots of dentists (including myself) have been taught at one point or another to give patients muscle relaxers when they are dealing with acute muscle pain. After learning more from continuing education courses and research since I’ve been out of dental school, I no longer consider this sound advice. I don’t recommend the use of muscle relaxers for jaw muscle pain.
What about opioid narcotic meds? This is a MAJOR NO NO when dealing with acute jaw muscle pain. Opioids will just cover up the symptoms of jaw pain. They won’t resolve the underlying problem. Early management of acute jaw pain is critical if you want to prevent long-term chronic pain! If jaw pain persists for more than one month, most patients will continue to have that same jaw pain for years to come. Why is that?
If you only cover up the pain symptoms, you set yourself up for the rather nasty processes of peripheral and central nervous sensitization. This is a restructuring of the nervous system that leads to chronic pain. Essentially, the extensions of the nervous system in your jaw start sending pain signals to your brain that you’re in pain even when there is nothing to trigger the pain. You “rewire” the nervous system to hurt even when there is nothing wrong at all.
Additionally, if we are just masking symptoms with opioids, then we aren’t doing anything to help the jaw muscles heal. The muscles will keep working harder and harder and get more and more strained. Additional muscles up the side of your face and down your neck and even into your shoulders may get activated and start to suffer as well.
If this turns into a chronic pain situation, now you start suffering more adverse consequences in your life. It’s not fun when your face hurts all the time. This can and will interfere with your ability to eat comfortably and communicate well. Think about how important our facial expressions are for social interaction. Resting jaw muscle pain face is worse than the worst cases of RBF. We’re talking dings to our appearance, self-esteem, and self-expression. We need our face, y’all.
And let’s not forget that we are dealing with an opioid epidemic in this country and it’s not going great. The last thing we want to be doing is giving out more of these drugs unnecessarily. I don’t blame patients for this phenomenon in the least either. They have been educated to think that pain meds were good for them. That’s a failure on the part of leaders in the healthcare industry, myself included. We have to do better and that may mean having some uncomfortable conversations with angry patients who leave bad reviews online or ding you with a negative review if you’re trapped in a hospital system overseen by various healthcare administrators. That’s better than the alternative of getting a confused person hooked on unnecessary meds. There are deeper problems we need to address in our culture. The status quo isn’t serving us or our patients very well.
So, yea. Opioids aren’t the answer. We gotta heal those muscles. Follow the rest of the advice above, and I’m confident you’ll make some progress in feeling better. If you don’t, you’ll need to talk with your dentist to try to figure out if there is more than a simple muscle strain problem at the bottom of your pain.
Various forms of exercise, especially cardio (walking, running, swimming, rowing, biking, spinning, hiking, etc.) can be excellent stress relievers. Remember, exercise is for you and your health. It has nothing to do with anyone else’s expectations or sense of vanity. You don’t have to apologize to anyone for wanting to be healthy and excited about life.
Wasn’t this an article about night guards or something? Oh, yea. That’s right. How might a night guard assist with acute muscle pain? Well, a properly made night guard can help ease muscle discomfort. There are lots of arguments about why this is the case. Those arguments fill up textbooks and Facebook forums. I’ll give you the basics of the ideas that make the most sense to me after filtering through much information on the subject.
For one, when you put a night guard in between the teeth, it stretches out the jaw muscles (your teeth come together sooner because you’re hitting on the guard). Stretching muscles can reduce pain temporarily. Muscles enjoy a nice dynamic stretch, but you don’t want to hold a stretched-out position forever because the muscles fatigue. Hence, wearing a night guard at night (not during the day) for a period of a few weeks gives a dynamic stretch to the jaw musculature and can relieve some pain.
There are specific ways that dentists have been taught to make night guards so that they will be comfortable for patients and not cause any long-term problems such as changes in the bite of the teeth, changes in the jaw joint stability, or problems with our airway. That being said, I have had success in patients resolving acute jaw muscle pain issues with over-the-counter night guards that they mold to their teeth at home.
If you are only going to be wearing the guard for a short period of time, this may be part of a solution for you. It won’t work for everyone, and you wouldn’t want to wear an over-the-counter appliance long-term without it at least being inspected by your dentist, but I understand that not all patients can afford custom-made night guards. I also think it can be helpful to find out if you can tolerate wearing a night guard with a $20 experiment before you invest in a custom guard from your dentist. Some patients can’t wear guards from a comfort standpoint.
I will say that before you give up on wearing a guard, do give your dentist the opportunity to adjust it for you. Guards don’t always fit perfectly right when we get them back from a dental lab. They can require some small (or big) tweaks to make them fit and function optimally.
So night guards can sometimes make the muscles feel better by giving them a temporary stretch. Night guards can also quiet down the muscles if they help position the jaw in a resting posture that is more stable for the teeth to rest in or more stable for the jaw joint to rest in. Those are really the only three reasons a night guard will relieve muscle pain.
Now, there are a few other “reasons” a night guard might “heal” a patient. For one, a night guard can make a patient pay more attention to what is going on with their jaw muscles. If you’re more aware of what is going on with your jaw muscles, you might be more successful in decreasing muscle activation. So, it’s not technically the guard that’s fixing anything, but it is serving as a reminder to you not to clench the same way a note on the kitchen fridge might.
Another “reason” has to do with placebo effects. If I’ve done a solid job of instilling confidence in you as your healthcare provider and you trust me, we have evidence that your body releases enkephalins (basically natural opioids) that can help reduce your pain. Believing the night guard is effective can sort of make it so. It doesn’t heal the muscle per se, but it does reduce the pain perception in your brain.
There’s also the possibility that you were on your way toward recovery and you pop the night guard in and that just happens to coincide with when you were going to feel better anyway. I’m not going to complain about that either. Yay! I get to play the hero. You’re welcome!
Once you’ve been wearing your night guard and following the other muscle-healthy protocols above, if you start to feel better you should phase out the use of the night guard and see if you continue to feel good. If everything still feels great, then, well, awesome! You’re better! The splint worked. It gave your muscles the break they needed to calm down and heal. If you start feeling worse again, you should probably check back in with your dentist (after an honest appraisal of how your behavior modification implementation is going).
Bottom line on night guards for acute muscle pain? It can be part of a combo of behavior changes that resolve the pain. A night guard might also be smart because if you are activating these muscles, it means your teeth are under pressure. Night guards also keep you from cracking teeth while the jaw muscles are being activated. However, a night guard will NOT calm down or relax the muscles over the long term. Night guards do NOT stop muscle activation/grinding. They can decrease it in the short term, but not in the long term. One interesting study actually suggested that alternating night guard wear so that it is sporadic every few weeks may be the best way to decrease jaw muscle activity at night.
If we don’t resolve (or at least improve) the problem with our MEAT protocol in a week or two, we need to figure out what else may be going on. This is headed toward becoming a chronic problem and we should consider coordinated care with other healthcare professionals.
Who needs a chiropractor when you can get a tree massage?
Common Chronic Issue: Chronic Muscle Pain (that may radiate throughout or refer to the Face, Ear, Jaw, Neck, and/or Shoulders)
Chronic jaw muscle pain can often be beyond my ability to manage as a run-of-the-mill dentist. Sure I can make you a night guard and offer some basic counseling, but if this has been an ongoing issue for you for a longer period of time we often need to consider a team approach to your care. That may involve having you see a dentist who specializes in orofacial pain disorders, as well as consulting with a physical therapist and/or health psychologist with expertise in treating chronic pain. You need a different level of attention than most standard dental offices can offer, and that’s perfectly ok. There are still ways to help you treat your pain.
Causes of Chronic Jaw Muscle Pain
As was discussed in the acute jaw muscle pain section above, the cause of chronic jaw muscle pain is often rooted in an acute episode that was never properly controlled. We are past the point where that triggering event is all that relevant. Even if we resolve the toothache or jaw ache that started the whole mess, we can be dealing with changes to the patient’s nervous system (ie your nervous system) that will not resolve simply by fixing the original bad tooth or injured jaw joint. We need to look at the bigger picture as to what is happening in your life that is chronically straining your jaw muscles and repeatedly cycling you through pain.
What could be some contributing factors to your chronic pain?
I know that some people reading this will think I’m a total quack for bringing up seemingly vague advice related to diet, exercise, habitual movements/posture, and (egad!) the vaguest and most ridiculous medical quackery concept of all time — stress. I’d just invite you to think about the fact that I’m not selling you any expensive procedures or products in relation to any of these recommendations. I’m only selling you information, and the “only” cost you incur is the time it takes to read, understand, and implement that information (Not to say time isn’t the most valuable resource we have, because, well, it is. Live your life accordingly.).
What do I get out of the deal?³ Hopefully, you start to get better and heal. Then, you’re able to better engage in the world and do the work of improving things to the best of your ability being unhampered by chronic pain. That sounds pretty good to me. I’d like to empower lots of people to do that. I’m excited to see what we might all accomplish if we weren’t burdened by so much chronic preventable pain and disease. I think humanity has more to give to each other and the world. Is that too lofty for an article about night guards? I don’t care. It’s what I think, so chew on that (Slowly and carefully now — we don’t want to strain those jaw muscles too much!).
I’d also like to make the argument that this isn’t quackery either. It’s sort of common sense that we’re now starting to back up with some reasonable scientific evidence. For example, if someone gets stressed out, they are more likely to tense their jaw muscles. It’s one of the things that can happen when you turn on the freeze, fight, or flight sympathetic nervous system response. If you keep turning that anxiety system on over and over all the time (from a stressful job, difficult home life, uncertain future of whatever kind) you can very easily cause chronic pain as a physical manifestation of muscle fatigue.
The triggering event isn’t that you got hit in the jaw, clenched your teeth too hard, or had too much fun with your mouth rolling around in the hay last night. The triggering event is an ever-present overactive muscle tone you aren’t even consciously aware of. You’re too busy struggling to deal with other problems to notice how tight your jaw is all the time.
Also, there is plenty of research to demonstrate that anxiety and stress increase pain perception. That means if you’re having a rough time in life, everything can and will hurt more because your nervous system is very literally functioning differently than when you are calm and everything in life is going according to plan. When life’s good and we feel in control, the brain can release chemicals that help inhibit pain signals trying to work their way up into our conscious mind. Trippy but true.
Chronic stress and anxiety can do the opposite. And the real bummer is that these effects can snowball together. Ever tried to fall asleep when you’re anxious and in pain? How well rested and prepared to take on the day do you feel when you didn’t get much sleep? Looks like another day full of irritation and anxiety and pain, another restless night, and the cycle repeats.
I’ve had this experience myself. Less frequently with my jaw (although I have had significant episodes of jaw muscle pain and tooth sensitivity from clenching in my sleep and during the day in the past — guess who wears a night guard every night?) and more so with my digestive system. I’ll spare you the details, but my digestive system was an absolute train wreck for almost ten years. My twenties were not a fun time. My stress levels were through the roof and I didn’t cope well.
After some very serious life changes (dietary for sure, but also behavioral in terms of sleep hygiene, exercise, and mindset) I can happily report that my abdomen doesn’t hurt all day every day sprinkled with random sharp stabbing electric-like pains that make me bend over involuntarily or scream in frustration in my car. That’s a nice feeling.
I didn’t understand or believe in any of this “voodoo nonsense” 10 years ago either. I was a learned man of science. I didn’t trust quackery. Well, now I’m a little wiser and a little more humble and I realize that just because something hasn’t been verified by a double-blinded clinical trial six different times doesn’t mean that it might not possibly help you.
If someone’s trying to sell you something crazy expensive and you can’t find any real evidence to back it up, then sure, don’t buy it. But if someone tells you to try eating healthier, sleeping more, and exercising in a way that works for you and improves your mental health? Maybe don’t tell that person to eff off immediately. Or do. It’s your life. We’re all ultimately the captain of our own ship and get to do what we want. Believe me, I’ve been a dick who pushed people away when they were trying to be helpful plenty of times. Hurt people hurt people. I gets it.
I think it’s quite possible that I’ve confused everyone reading this at this point. What am I trying to get across exactly?
Signs/Symptoms of Chronic Jaw Muscle Pain
If you’ve read this whole article so far, you probably have a pretty good idea what chronic jaw muscle pain might look like. It’s basically the same as acute jaw muscle pain, except it keeps getting worse and becoming more widespread, or at least it never seems to improve. That being said, I’m just going to give you a series of questions to consider when evaluating what might be going on with your chronic jaw pain.
Risk Assessment for Chronic Pain:
Behavioral — What might you be doing on a regular basis (consciously or unconsciously) that may be contributing to your pain?
Repetitive oral habits?
Muscle tension?
Jaw postural habits?
Diet (gum chewing, hard foods)?
Sleep issues/teeth clenching/grinding?
Cognitive — This is where you may need help from a health psychologist to sort out how your approach to certain problems you are facing in life could be modified to improve your overall health.
Is it possible you have a limited understanding of the source of your pain?
Might you have unrealistic expectations about how your pain can be resolved with an interventional treatment?
What coping strategies have you been taught to use in your life when you face a new challenge?
How is your level of anxiety?
Do you tend to catastrophize (think of the worst possible outcome)?
Social — This is a whole can of worms I’m not prepared to address appropriately, but for real, if you have chronic pain issues that may be related to stress and anxiety it could be time to reassess the people you’re closest to in your life. That can involve work, family, friends. Nothing easy to change. Still, sometimes it has to change.
Lack of social support?
Conflict?
Abuse?
Comorbid Conditions — Again, these are conditions I can’t address as a dentist, but they can contribute to chronic jaw pain manifesting. I should at least make you aware of that in writing this article, right?
Fibromyalgia?
Migraines?
Back pain?
Treatment of Chronic Jaw Muscle Pain
If chronic pain is treatable (if any chronic condition is treatable), then almost by definition the best treatment is a change in behavior. Chronic conditions are frequently the result of our everyday habits and behaviors.⁴ How to possibly cure such maladies? A good start may be incrementally altering those everyday habits and behaviors. Behavior change isn’t easy, but it can be wildly effective.
If you’re chronically anxious and stressed, your nervous system is all jacked up and that messes with your body in all kinds of ways. A regular habit of aerobic exercise can combat that problem. Aerobic exercise is great for humans. It reduces pain, helps you sleep better, lowers your heart rate, and blood pressure goes down. All of these things counteract the negative effects of a nervous system upregulated by stress and anxiety.
Like it or not, when we’re dealing with chronic pain, you are part of the team that is going to heal you. We need you to be able to cope and adapt. Your care team can’t cure you on their own. It’s a team endeavor.
Non-invasive treatment modalities should be used as front-line treatment for any chronic pain. You don’t want to consider surgical/interventional options before you’ve thoroughly considered less invasive treatments. Interventional surgery is often not the solution for chronic problems. Non-invasive therapies can include:
splint therapy
massage
physical therapy
biofeedback
stress relief
exercise
adjustments to eating/oral habits
acupuncture
chiropractic therapy
spray and stretch with ethyl chloride
NSAIDs
anti-depressants⁵
botulinum toxin injections into muscles to decrease contraction
I think it’s quite possible that I’ve confused everyone reading this at this point. What am I trying to get across exactly? The basic idea is that not all dentists (myself included) are experts in dealing with every pain condition that affects the jaws. These things can get complex.
That doesn’t mean there’s no hope if you have a chronic pain condition. It just means we need to be looking for answers in the right places and presenting health experts with a thorough and comprehensive history of your problem to give them the best chance possible of figuring out what is going wrong.
I also hope I’m opening you up to the possibility and necessity of you being a partner with your healthcare providers in improving your health. You are so much stronger and more capable than you think. I know healthcare can feel intimidating. It’s always scary when your body isn’t functioning how you would expect it to. Still, you know more than you think.
As healthcare workers, we do our best to care for patients, but we will always come up short if communication between us and patients isn’t honest, open, and respectful. We both have to do our part, especially when combating stubborn chronic problems. For the acute stuff, sure, the onus is on the provider. I don’t expect you to fix your jaw if some bozo breaks it in a useless fight. It’s not exactly fair to expect you to be capable of performing reconstructive surgery on yourself.
3. Jaw Joint
Hamlet! Existentialism!
Common Acute Issue: Joint Inflammation following an Injury
As was mentioned earlier, your jaw muscles sort of suspend your lower jaw in a sling that is stabilized by stop points against the skull in the back on the left and right and the teeth up front. Injuries (a single event like getting hit in the jaw or slow repetitive use injuries that worsen over time) that affect the jaw muscles and teeth can also damage the jaw joints in the back.
The jaw muscles connect to the jaw and skull to help stabilize the jaw. Ligaments from bones surrounding the joint connect to a fibrocartilage disc/capsule of the joint to help keep the disc cushioning things between the jaw bone and skull. If you have an injury or pain that involves the jaw muscles, that can also result in strain on the disc that is positioned in the jaw joint.
If the disc in the jaw joint gets pulled out of position due to injury (which can stretch the ligaments and destabilize the joint), irregular muscle activity, or an unstable bite, you may experience symptoms in the joint such as clicking, popping, grating/crepitus or pain. A click or a pop can be a sign of the disc slipping out of its normal position. The unusual sounds, sensations, and discomfort you may feel in the joint are a result of the jaw bone rubbing against tissues other than the disc of cartilage it is meant to surf on when you open, close, or shift your jaw.
The good news is that for the vast majority of patients the jaw joint will settle down and adapt over time. A click, pop, or crepitus is not a reason to become highly concerned. If you’re not having significant chronic pain and progressive joint degeneration (which is quite rare) you can safely go about your life. Even if you lose all soft tissue support and have bone rubbing on bone in the jaw joint, it will typically adapt to be pain-free within a year without any surgical interventions. Think of how a callus develops on your hands from working. The same sort of thing happens from your jaw bone rubbing against various tissues in the jaw joint. The fibrocartilage that makes up the disc in the jaw joint is also unique compared to the hyaline cartilage that cushions other joints. This fibrocartilaginous disc has more ability to heal and repair itself. It’s much better to manage these injuries with conservative treatments.
Causes of Acute Jaw Joint Pain
Generally, jaw joint injuries are not as painful as jaw muscle injuries. We still have to keep in mind that the jaw joint, jaw muscle, and teeth can all be injured at the same time, so it’s not impossible to have multiple sources of pain stacked on top of each other. Since branches of the same nerves run to various parts of these structures, it’s also possible to get referred pain that tricks you as to the source of your discomfort. However, there are some factors that can help differentiate jaw joint pain from a muscle ache or toothache.
One thing to keep in mind is that the disc your jaw bone is meant to rest on in the joint does not have nerves, so if the jaw is surfing on that disc safely you won’t have pain sourced in the jaw joint. However, the tissues behind the disc do have nerves that can send pain signals. If the jaw bone slips off the disc and starts putting pressure on these tissues further back: ouch.
Normally ligaments hold the disk and condyle (that knob in the back on the left and right) of the jaw in position, but those ligaments can get stretched out and this destabilizes the joint. Sometimes the shape of the disc (it is normally biconconcave like a red blood cell — think of a donut with the hole filled in in the middle — such that the bones tend to stay centered) can also get distorted over time from repetitive use injuries (the jaw bone pushing on the disc in a misaligned position) and this makes it easier for the jaw bone to slip off the disc.
Signs/Symptoms of Acute Jaw Joint Pain
If a jaw joint is injured such that the jaw bone is not resting comfortably on the disc that is attached between it and the skull, you can develop inflammation of the tissues around the disk that the jaw bone is now so rudely rubbing against.
If you’re dealing with a fresh injury and the tissues haven’t had any time to adapt, you can experience severe pain when biting/chewing because this increases the pressure of the jaw bone against tissues it’s not supposed to be pressing against.
You may not be able to open very wide. This can happen because of a limitation on the second stage of opening the mouth. When we first start to open our mouth, the jaw is only rotating in place on the disc. When you go to open wider, the disc actually gets pulled forward down along your skull and the jaw bone comes along for the ride surfing on top of it. If the disc is out of alignment and the jaw bone can’t surf on it, the jaw bone might get a little stuck as you try to open wider. A second reason for limited jaw opening is that your jaw muscles can go into spasm as a protective reaction to stabilize the jaw after an injury.
This misalignment can be temporary. With an acute jaw joint injury, the tissues around the disc can get inflamed and swell which pushes the disc out of position. An injured/inflamed jaw joint will be painful to touch if you press on the joint itself (back by your ear). Your dentist will also often be able to notice that your jaw is shifted toward the opposite side of the inflamed joint, and this actually causes your back teeth to not come all the way together on the side where you have pain.
Another cute little test that can identify an acute jaw joint injury/inflammation is that if you put a tongue depressor between the back teeth on the painful side, you should be able to close together without any pain. It’s a little complicated to explain why this works, but basically, the swollen tissues are pushing the jaw into a position that causes the teeth to hit in a way they shouldn’t when you bite down. The tongue depressor lets the jaw bite in a more appropriate way to avoid kicking the jaw backward where it would press harder on the inflamed joint tissues.
A slightly meaner way to figure out if you have a jaw joint issue (as opposed to a jaw muscle issue) is to have your dentist make you a type of night guard called an “anterior deprogrammer.” These guards only fit over the front teeth and don’t let your back teeth touch at all. These appliances can be very helpful for acute muscle injuries, however, they also load the jaw joints with more pressure. So, if you have jaw joint swelling and you put in an anterior only guard, you’ll push the jaw bone into the injured tissue harder and it won’t feel so good. Still, if it feels better with one of these anterior guards in place, congratulations, you are likely dealing with an acute muscle injury. See the section above on resolving jaw muscle pain at home.
Treatment of Acute Jaw Joint Pain
Once you’ve determined that the pain is from a jaw joint injury, the best way to treat it is to create a nightguard that will take pressure off that joint in the same way that the tongue depressor trick did. Your dentist can make you a night guard that is thicker in the back on the side of the injury to help position the jaw in a comfortable position in the joint.
You should wear this splint at night and then during the day as needed for your comfort. If you can’t get to a dentist or afford a night guard for whatever reason, you could try an athletic mouthguard and see if it improves your comfort. Athletic guards may offer enough posterior support to better position the jaw temporarily, but it’s no guarantee.
Also, sometimes you won’t need a splint. It depends on your tolerance for the level of discomfort you have and the severity of the injury. The inflammation will resolve and once the swelling goes down the jaw bone should be able to reposition on the disc (assuming there wasn’t more severe damage to the other supporting structures in the joint).
If you know you’re dealing with joint inflammation, it’s a good idea to ice the area on and off for the first couple of days to minimize swelling. You can apply moist heat after 48 hours to increase blood flow to the area. You want to stick with the softer food diet described above in the jaw muscle injury section. Avoid habits like gum chewing and any strenuous activities. We want to keep the jaw muscles calm too while the joint is healing up.
If you had a guard made by your dentist, you’ll need to follow up with them in a couple of weeks to have the guard adjusted. The thick side in the back will need to be smoothed down. Why? Because as the joint swelling goes down, the jaw will go back to its normal position and your teeth will come together naturally again. All of the sudden that thick area in the back of the guard will be hitting too heavy in your bite. Your dentist can shave that down and then you have a night guard you can wear for long-term protection of your teeth at night, or, if you’re not worried about that, you can still keep it around in case you have acute pain episodes in the future.
Common Chronic Issue: Gradual Breakdown of the Cartilaginous Disk, Ligaments, Soft Tissues, and Bone that Comprise the Temporomandibular Joint
Causes of Chronic Jaw Joint Pain
If your jaw joint feels better in a couple of weeks, sweet. That means the discomfort was just due to swelling from inflammation. The overall structure of the joint is still in good shape. What if that joint discomfort is lingering?
It’s possible that the ligaments that help stabilize the joint were stretched and the jaw bone is not centered on the disc anymore. You might be getting some popping/clicking.
Over time, this unnatural position of the jaw bone could distort the disc shape more and the position of the disc and jawbone could slip further. As a result, you might notice changes in the types of pops, clicks, and grating sensations you have in the joint over time. Your jaw might get stuck in place occasionally. Your level of discomfort may fluctuate as the joint is shifting over time.
Dentists used to think that the way your teeth come together (your bite or occlusion) could have a significant influence on the development of temporomandibular joint disorders (TMD). This is no longer thought to be the case after extensive reviews of the scientific literature on the topic. I won’t go on a rant about understanding the difference between correlation and causality in statistics here, but that had led the dental profession astray on this topic in the past. It is rare that the dental occlusion (the way the upper and lower teeth fit together) is the primary source for a TMD issue (but it can happen if you’re not careful with orthodontics for instance).
The only way that your dental occlusion (bite/relationship between your upper and lower teeth) could be causing an issue with your jaw joint is if the way your teeth interact makes it difficult for your jaw bone to settle comfortably into the jaw joint. Is the way your bite comes together somehow straining your jaw muscles or destabilizing the jaw joint? Then maybe the occlusion of the teeth is a problem. This is not common though. If you can close your teeth together and squeeze without any pain back in the jaw joint, you likely don’t have a problem with your occlusion.
All of the mobile joints in our bodies (finger, wrist, elbow, shoulder, knee, etc…) are stabilized by muscles pulling across the joint. Our jaw muscles help pull the jaw into position upward and forward against the inside of the skull socket. Generally, the tooth relationship that allows this to happen without interference involves the back teeth contacting harder than the front teeth. Then, when you slide/grind your teeth side to side you want the back teeth to separate because your front teeth are guiding over top of each other.
The separation of the back teeth leads to less activation and strain of the jaw muscles. When your back teeth still hit into each other on the opposite side from the side you are sliding your jaw towards, that can destabilize the joint. Again, this bite relationship is generally rare and it doesn’t always lead to a problem.
You may be noticing a vibe in the way I’m talking about joint pain compared to muscle pain when it comes to TMD. Muscle pain is usually the scarier beast. Chronic joint issues are rarely progressive, meaning they don’t tend to get worse and worse over time.
Also, lots of the time when patients have teeth that are getting in the way of the jaw bone reaching a comfortable and stable position, they will just end up grinding down their teeth against one another until the jaw bone gets where it wants to be. This can be tricky when deciding when you may or may not need a night guard. Sometimes you can have wear on your teeth from your jaw settling into the joint over time and that wear won’t necessarily get any worse going forward.
If you have teeth that are blocking the jaw bone from settling into the joint, your jaw muscles will compensate by holding your jaw bone in a muscle-stabilized position further down and forward out of the jaw joint. This down and forward bite can be noticed as a shift that happens as you close your teeth together. Your teeth will tap together in an initial spot or two, and then they will have to shift forward slightly in order for the rest of the teeth to come together.
Basically, as long as you don’t have a huge shift that is causing muscle strain to hold the jaw in this position, a little interference from your teeth in the positioning of your jaw doesn’t matter most of the time.
Signs/Symptoms of Chronic Jaw Joint Pain
This was already more or less outlined in the section on acute jaw joint pain above. You’ll have pain in your jaw joint when you try to use your jaw to chew or talk. Your jaw may lock in place if you open wider. You will hear/feel clicking, popping, or grating. These sensations can shift over time. Pressing on the joint itself can be painful. Unless your symptoms are progressively getting worse, you want to stick with conservative treatments.
Treatment of Chronic Jaw Joint Pain
You may be noticing a vibe in the way I’m talking about joint pain compared to muscle pain when it comes to TMD. Muscle pain is usually the scarier beast. Chronic joint issues are rarely progressive, meaning they don’t tend to get worse and worse over time. You may have shifts in your symptoms and signs here and there as the joint tissues continue adapting, but it typically isn’t debilitating or interfering with your life consistently.
You might consider the analogy of a blister as compared to a callus. If you have a swollen, painful blister that won’t heal, then it probably deserves further investigation. If you have a hardened callus that looks and feels a little different, but it’s functioning perfectly well, then we probably don’t need to panic about that.
“What about us blister people reading this?” That’s fair. If you have consistent pain specifically located in the jaw joint itself that is interfering with your life, you should consider an anterior repositioning appliance. This is a special night guard that pulls your jaw forward so that the jaw bone doesn’t compress the irritated tissues back in the joint space.
The downside to using one of these appliances is that the tissues and position of the jaw can adapt such that you develop an open bite over time (if you only wear the appliance at night and not during the day this is less likely to happen, but still can). This means that when you close down on your back teeth your front teeth will no longer come together. That may be ok with you if you are struggling with chronic jaw joint pain. Maybe a change in the appearance and function of your front teeth is preferable to having continual jaw joint pain. This is still a much more conservative therapy than trying to do anything to repair the jaw joint surgically. Eventually, you will not need the anterior repositioning appliance after the joint has adapted to the new position. Using this appliance is like using crutches to keep pressure off a sprained ankle while it heals.
4. Airway
Yawning cat!
Common Acute Issue: You Choke on Something in Your Sleep?
Ok. Jk. This one didn’t really have an acute example I could think of, so I decided to be a little silly. Although, there was this one time when I was in college that I had a dream I was choking on a bag of small rocks I was dumping into my mouth and then I woke up and realized I was choking on my orthodontic retainer that had fallen loose while I was asleep. Probably not the greatest story to be telling in an article that’s trying to get people to consider wearing something on their teeth while they sleep, but it happened, so, take that for what it’s worth (Honestly, not much — night guards are a lot bigger than that retainer was. You’d have a hard time trying to choke on a night guard.).
Common Chronic Issue: Sleep Apnea
I could write a whole ‘nother obnoxiously long blog post about the topic of sleep apnea as it relates to dentistry overall (and maybe I will someday!), but I’m going to try to keep this focused on a discussion relevant to night guards.
You’ll notice I put question marks after all the headings in this section. That’s because the jury is still out on a lot of these issues dealing with sleep apnea and bruxism (clenching/grinding of the teeth at night). Sleep physicians and dentists don’t have all of this figured out by a long shot. I’ll do my best to outline what we do know and how it may be able to help you.
Causes of Sleep Apnea and Nighttime Clenching and Grinding?
This is a difficult thing to study. People who grind their teeth don’t do it every night all night long. If you have a history of clenching and grinding you may only be doing it in 10–15 minute cycles a few nights a week. There can be a lot of variation. So, if you have a sleep study done that tries to look at grinding behavior for a night or two, you may not have a large enough sample size to get data that tell you anything definitive. You also have to consider that sleep studies introduce a weird environment (you have stuff hooked up to you to monitor you). It’s possible that may distort how you would normally sleep.
Considering the above limitations of sleep studies, we do still have some potentially informative data. If we look at TMD patients (not sleep apnea patients), we can see that they do not grind their teeth at night any more than patients with normal muscles and joints do. That’s interesting. If you have jaw muscle and joint pain, it’s not all that likely that it is because you are grinding your teeth at night. It is still likely because your jaw muscles are overactive in some way as discussed in the above sections, but not all that likely due to grinding of the teeth at night specifically.
Another sleep study has shown that there is no relationship between the amount of wear on patients’ teeth and how much they grind and that patients who grind their teeth more do NOT have more pain. In fact, it’s actually people who grind their teeth less who report more muscle pain when they grind.
Why would that be? Think about it. If you work out all the time, your muscles adapt and strengthen and can handle the increased activity level. What happens when you only lift weights once a year? You’re pretty sore the next day.
The weirdest part of the above studies is that they found that people with more wear on their teeth didn’t grind more at night than others. I think it’s entirely possible that this is a sample size error because patients can’t be tracked with sleep studies over long periods of time. Those teeth are wearing down somehow. It’s not magic. It is possible it’s happening during the day. It is also possible that the patients being studied used to grind their teeth more in the past and that’s when the damage occurred. I’m not sure what the answer is, but somehow those teeth rubbed up against each other an excessive amount to produce significant tooth wear.
One of the newest (though it’s been being bounced around for some 20 years or so at least) ideas that is in vogue in the dental world regarding sleep bruxism (grinding of the teeth at night) is that it is related to sleep apnea. The data on how true this is is all over the place.
There is reasonable evidence that sleep apnea is likely a problem for your overall health for lots of other potential reasons, but it is not entirely clear how much it increases the grinding of the teeth.
Signs/Symptoms of Sleep Apnea and Nighttime Clenching and Grinding?
There are two types of sleep apnea: central sleep apnea and obstructive sleep apnea. Central sleep apnea is basically when your brain forgets to tell you to breath (C’mon brain! Get it together up there!). Obstructive sleep apnea is when your throat collapses in and blocks off your airway (What the heck throat? Get it together down there!).
Dentists are taught to look for various signs of potential sleep apnea. Obstructive sleep apnea is more common than central sleep apnea and there are some anatomical landmarks/variations dentists look at because we have some evidence that these can increase the risk of obstructive sleep apnea. At the risk of making you freak out about the way your face and mouth are shaped, I’ll highlight some of those briefly.
Narrow, high arched palate — This means the roof of your mouth is deep and cupped out as opposed to flat. The theory on why this happens is actually pretty interesting and cool if you’re a nerd like me. Basically, if you breathe through your nose, your tongue rests naturally against the roof of your mouth. If you breathe through your mouth, it doesn’t. The pressure from the tongue resting against the roof of your mouth applies pressure to the upper teeth as you grow to push them out toward the cheeks. This widens and flattens the palate. Swallowing also plays a role. Some people place their tongue to the roof of their mouth when they swallow. Others thrust their tongue forward in between their front teeth when they swallow. We swallow somewhere between 2,000 and 3,000 times throughout the day. That’s a lot of tongue pressure on either the upper back teeth to move them and widen the palate or on the front teeth to flare them forward and open the bite up front. Thumb and finger sucking can also play a role because if this is going on as the child is growing then the cheeks get pulled in with more pressure in the back and shove the teeth into a more narrow arch which means you get a more narrow palate. Why does any of this potentially matter for sleep apnea? Well, for one, the nasal sinuses are located directly above the palate. The thinking goes (although I don’t have any scientific studies to prove this to you) that if your palate narrows and your sinus cavities shrink you may be less successful at breathing through your nose. If you can’t breathe through your nose and instead breathe through your mouth, the airflow is more turbulent (in the nose we have turbinate bones that help break up airflow to make it more laminar) and this can increase the likelihood that the soft tissue of the throat collapses when you breathe. So, even if you take in a larger volume of air through your mouth as compared to your nose, you actually get less oxygen to your lungs. Pretty interesting, no?
Lips Apart at Rest — This can be a sign of mouth breathing as opposed to nasal breathing.
Large Tonsils — This is more of a potential issue for children than it is for adults. If the tonsils and/or adenoids are really big there is some possibility that they can obstruct the airway. Kids don’t present with sleep apnea the way adults do, but there is some evidence that this can disturb their sleep so that it is less restful. There is also some evidence that airway issues may be related to teeth grinding at night in kids (kids grind their teeth at a much higher frequency than adults do). Many of the continuing education courses I have attended have discussed how disturbed sleep can be related to hyperactivity in children and perhaps misdiagnosis of ADHD. This is obviously very controversial. I don’t have a strong opinion on it one way or the other. I need to do more research myself. The theory is interesting and biologically plausible as far as I can tell so far, but I am NOT an expert on this topic. Also, tonsillectomies are not without risks and they are performed with much less frequency than they were in the past because of this. Justifying the removal of the tonsils to resolve airway issues in kids requires coordination between your dentist and your physician/ENT.
Large Tongue — If the tongue is larger (or the arches of the teeth are narrow) you may see scalloped borders imprinted along the sides of the tongue where it is being pressed harder up against the sides of the teeth. A large tongue that is being crowded back toward the throat may be more likely to obstruct the airway.
Wear on the Front Teeth — Again, whether or not sleep apnea is related to teeth grinding is controversial, but one theory is that when a patient is struggling with obstructive sleep apnea the jaw postures forward in an attempt to open the airway. If you jut your jaw out it pulls the tongue with it and can help increase the size of the airway. This is also why some people get relief from sleep apnea by sleeping on their side instead of on their back (gravity isn’t pulling the jaw back/down). If the jaw juts forward throughout the night, then the front teeth can run into each other and wear down. I have commonly seen patients with this wear pattern who have been diagnosed with sleep apnea. Still, that is only anecdotal evidence on my part, which is the lowest form of evidence. I can’t show you any scientific studies that would prove this connection.
Acid Erosion on the Back Teeth — There is evidence that when a patient struggles to breathe during an apnea episode, negative pressure builds in the chest and positive pressure builds in the stomach. This can push acidic fluid in an aerosolized form up into the mouth and onto the teeth. Your teeth get sprinkled with stomach acid. That acid wears the teeth down. I see this pattern fairly commonly with patients.
Screening Tools for Sleep Apnea — Tools like the Epworth Sleepiness Scale and the STOP BANG questionnaire can be used to assess the quality of sleep you may or may not be getting. These are not diagnostic, but they do give an initial idea of your sleep quality baseline. If it looks like you’re getting low-quality sleep based on these screening tools, it can make sense for you to have a sleep study done to confirm or rule out the diagnosis.
Although, there was this one time when I was in college that I had a dream I was choking on a bag of small rocks I was dumping into my mouth and then I woke up and realized I was choking on my orthodontic retainer that had fallen loose while I was asleep.
Treatment of Sleep Apnea and Nighttime Clenching and Grinding?
This is a long article, and I’m going to mostly punt on this topic for now. A few quick points:
You have to be careful about wearing a night guard if you have sleep apnea because night guards can make it worse. That means a store-bought night guard is likely not for you if you have obstructive sleep apnea.
A 2017 Journal of the American Dental Association systemic review discussed how scientific trials using CPAP (continuous positive airway pressure) to treat obstructive sleep apnea have not established whether treatment is associated with reduction in the mortality rate or improvements in most other health outcomes, except for a modest improvement in sleep-related quality of life. There is uncertainty about how accurate or effective screening tools and treatments are for OSA in ultimately improving health outcomes in asymptomatic adults or adults with unrecognized symptoms of OSA. Dental appliances may reduce AHI (Apnea Hypopnea Index) and excessive sleepiness, though with smaller effect sizes than CPAPs.
What does the gobbledygook in the previous paragraph mean? Basically, treating sleep apnea effectively with CPAP is questionable. The results are even more questionable for dental oral appliances to treat sleep apnea.
So, will a night guard of some sort cure your sleep apnea? Often it won’t, but sometimes it will. It could make it worse. There is something called The Seattle Protocol taught by Spear Dental Education (I have no affiliation with this organization and I don’t do this treatment myself) that I think has the best chance by far of creating an oral appliance that could help a patient with their sleep apnea. It involves a number of steps to measure and test that an appliance is effective before making the final product for you. If you don’t do that, it’s basically a shot in the dark.
It also may be more difficult to wear a guard if you have sleep apnea. Then again, you could be a unicorn who actually improves their sleep quality and reduces sleep apnea with a standard night guard. These patients exist. Everyones’ jaw and airway are made different y’all. But it’s a lucky guess if that ends up being you.
Real quick, I’m going to reveal my bias toward preventative medicine again and get up on my soapbox because I can’t help myself.
Risk Factors for Obstructive Sleep Apnea:
Obesity
Large Neck Circumference (greater than 17 inches for men and more than 15 inches for women)
Hypertension
Diabetes
GERD
Use of alcohol and/or sedatives
Smoking
Difficulty breathing through the nose (mouth breathing)
Behavioral modifications to Help Treat Obstructive Sleep Apnea:
Weight control/weight loss,
Not exercising before bed
No food before bed
Reduction of caffeine
Reduction in alcohol
Better sleep hygiene — waking up at the same time each day
Change in sleep position — don’t sleep on your back.
If the idea of improving your health with some new habits in your life appeals to you, I recommend you start by reading the book Atomic Habits by James Clear and listening to Dr. Mark Hyman’s The Doctor’s Farmacy podcast. You got this, champ.
Summary:
If you have sudden cold sensitivity on a tooth, this can be a sign of a crack starting. There are other reasons for cold sensitivity, but if it shows up suddenly it shouldn’t be ignored.
If you are chipping teeth, don’t ignore it.
If you have fillings in your teeth, especially large ones, there is a greater risk that they could fracture. Solution? Learn how to take care of your teeth so you don’t have to get fillings!
If your front teeth are wearing down, flattening, thinning, or chipping and you can’t trace it to a particular accident or event, don’t ignore it.
Just because it doesn’t hurt, that doesn’t mean that you’re not grinding your teeth.
Lots of us clench and grind, but that doesn’t mean it happens every day and night all day and night long. A little bit here and there can still damage the teeth significantly over time.
Over-the-counter guards can be helpful within certain limitations, but they are cheaper for a reason. If it works for you, that’s awesome.
If you have sleep apnea, you need to be much more careful about what type of night guard you use. A standard night guard could very easily make your sleep apnea worse.
If you’re confused as to whether you have a jaw muscle versus a jaw joint issue:
Problems with bringing your teeth together are usually answered by investigating what is going on with the muscles.
Once the teeth are comfortably touching in your normal bite, problems with chewing into something or applying more pressure are typically answered in the joints.
Obviously, talking to your dentist, physical therapist, physician, psychologist, mother, father, children, next door neighbor etc. is going to be more informative than this article, but I figured I’d take a crack at it.
Get well soon.
Thanks for reading.
I really hope you don’t sleep this way.
Footnotes:
¹ How many of you thought I was gonna type “in its ass” after “pop a cap?” I thought I was going to. I had restrain myself. It wasn’t easy. That’s why I’m confessing and venting in this footnote. It’s not easy to say or write “pop a cap” and not immediately follow it up with “in its ass.” That’s like peanut butter and macaroni. Jelly and cheese. You just can’t separate them, ya know?
² Did you know your lips were needed for these sounds? That’s why this game works. There’s certain sounds you can’t form well without your luscious lips. Hint: If you know what those sounds are, you can come up with a sort of code between you and your partner to hack this game. See? Aren’t you glad you read the footnotes now? You can one up the neighbors at your next civilized dinner party where everyone spits all over each other in frustration after the meal.
³ I also get a commission when you spend time reading this article if you’re a Medium member. Then there’s all that sweet, sweet YouTube ad revenue if you watch my videos. And, of course, if you really want to love me (within appropriate legal boundaries and social norms), you could sign up for my email list on my website and come to a future comedy show or purchase a comedy album. So yea, maybe I get all of that juicy selfish stuff out of the deal at the same time. I’m quite the dainty little conman, ain’t I?
⁴ Unless we’re talking about an irreversible acute injury. If you are chronically missing a leg after an accident, well, I’m not going to tell you it will grow back if you just go for enough jogs. There’s a limit to this line of thinking. Hopefully, that’s obvious.
⁵ Although it is questionable in my mind how non-invasive these meds are.