Bruxism vs Bracing

Bruxism vs. Bracing, which might be the larger culprit contributing to TMD-related issues. For those of you who attended the 2025 AAOP conference, you may have had the pleasure of hearing Dr. Daniele Manfredini, DDS, MSc, PhD, Full Professor at the University of Siena, lecture several times. I was most intrigued by his lecture on May 4, 2025, entitled An Update on Bruxism: From the Definition to Management. If you missed it and you are a member of the American Academy of Orofacial Pain (AAOP), I encourage you to listen to it; if not, I believe you can pay for it. In addition, check out the short article entitled, Bracing: The hidden side of the moon, March 2025.

I felt he offered several “drop the mic” moments, one was regarding why we are still using ARA’s, Anterior repositioning appliances for the treatment of TMD, at least when it comes to long-term use, and that over time he is using appliances less and less, and suggested they were “crutches”.

Another topic I am fascinated by is tooth wear, so many potential reasons this can occur, sure bruxism is one, but in my humble opinion, unless the bruxism is excessive, alone I am not convinced it does all the damage we think, but we also know from many other researchers that a high oral PH, due to possibly acid reflux, Gerd, etc. can contribute to tooth wear, but what he said and resonates with me as I have been asking the same questions, what damage can an appliance due when you wear one many hours a day, with a high oral ph.?? Does the appliance just hold all that acid around those teeth now and contribute further to enamel wear, etc? I think those of us who truly treat TMD and orofacial pain try to do the best we can to view the “WHOLE” person, and what unique set of issues does this person/patient bring to the table that we need to factor in when coming up with a successful treatment plan.

But I digress, today’s topic I want to focus on is “BRUXISM”, really the problem, or “BRACING”

Based on the latest 2018 definition of Bruxism from the International consensus on the assessment of Bruxism: Report of a Work in Progress. SLEEP BRUXISM is a masticatory muscle activity during sleep that is characterized as rhythmic (phasic) or non-rhythmic (tonic) and is NOT a movement disorder or a sleep disorder in otherwise healthy individuals.

AWAKE BRUXISM is a masticatory muscle activity during wakefulness that is characterized by repetitive or sustained tooth contact and/or by bracing or thrusting of the mandible and is NOT a movement disorder in otherwise healthy individuals.

An increasing number of papers are being published in Journals that deal with conditions that are associated with bruxism, like obstructive sleep apnea, oral moistening disorders, orofacial pain, and gastroesophageal reflux. There is increasing awareness that these (and other) conditions are closely associated with each other, thus forming a complex comorbid network, or the term I like to use when I lecture is chronic overlapping pain conditions. But Dr. Manfredini goes on to say that BRUXISM IS A SIGN OF SOMETHING! BRUXISM IS NOT THE DISORDER. Bruxism can be a symptom of Physiological phenomena, sleep architecture,  signs of other underlying conditions like psychological issues, Obstructive sleep Apnea, GERD, consequences of drugs or substances, SSRIs, Caffeine, Nicotine, and Alcohol, and finally manifestations of other primary motor disorders.

This led him to start sharing this concept of BRACING, with or without tooth contact. This is not necessarily new; many of us in the Physical Therapy world share this concept all the time with our patients as to what they need to be aware of during the day to control this Bracing concept. But interesting that this new to the dental community and that there are no real great studies that have looked at prolonged tonic muscle contraction with regards to the muscles of mastication or TMD, which I find fascinating given if you have ever worked in sports medicine this is something we talk about all the time and how it can cause muscle fatigue, lactic acid build up, pain, etc.

If you have ever heard me lecture, for some time I have used the concept of “flexing your biceps” even without weights in your hands, if you contract and hold your biceps for an extended period, it will fatigue, start to ache and possibly lead to pain, so I use the analogy when teaching and with our patients to be MINDFUL, COGNITIVELY AWARE of what are you doing with your muscles of mastication with or without tooth contact. Are you bracing your chin forward during a stressful time? Are your teeth in contact with anything other than when you swallow or chew, etc? These are all things that Physical Therapists and other non-dental professionals help our patients focus on. Many of us truly believe during our awake hours, when we have the greatest ability to make a behavioral change and reduce pain associated with the muscles of mastication and/or the temporomandibular joint.

I could go on, but I know I am already getting long-winded here. I suspect in due time we will start to see more research on this Bracing Concept. In the meantime, Behavioral modification during the day is key, and there is an app for Bruxism. Isn’t there an app for everything!! So, on your smartphone, you can download the  Bruxapp. See if that can be a tool to help our patients. Dr. Manfredini concluded by suggesting less and less use of appliances because in patients with isometric activity or bracing, it is more than double in TMD patients than healthy individuals,  and it has been found that females brace 2x as much as males, so possibly another explanation is that TMD is more common in females vs. males. Muscle tension is the key to TMD physiopathology. Who is better than Physical Therapists and other non-dental professionals to treat the muscles!!  But remember, we also treat the joints when needed!

In good Health!

Sincerely,

Mike