A case of sleep bruxism treated through behavioural change using hypnosis
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0975-2870.103348
The mouth has been a natural site for release of stress. Right from the time of birth, a new born child cries and attracts attention of parents during stress. As the child grows, they spit and bite to release stress and frustration. As an adult, the same child uses abusive language, alcohol, smokes, and uses drugs (all orally) to release stress. Clenching, grinding, and bruxism are also a form of stress release using the oral route. Dentist is the first to detect such habit, and treat such cases with habit breaking appliances, which usually fail. This article highlights the need to refer cases for psychiatric treatment and hypnotherapy may be a choice of treatment. A female aged 26 year, reported with pain in all her teeth due to bruxism. All conventional dental treatments failed. This outlined a strong psychological component, hence hypnosis was tried. A 5-year follow-up showed no relapse. Keywords: Bruxism, Hypnosis, myofascial pain dysfunction syndrome, subconscious, suggestion
Bruxism is clenching or grinding of the teeth when the individual is not swallowing or chewing. Clenching is the continuous or intermittent closure of the jaws under vertical pressure. [1] Bruxists are classified into two categories: 1) those whose bruxism was associated with stressful events and 2) those whose bruxism had no such association. [2] "Stress" bruxists have more muscular symptoms and are seen more in emotionally disturbed individuals. Some other causes are tension, habit, interference with occlusion, occupation, marital status, job problems, worry and hurry, and so on. [3],[4],[5] Various investigators have recommended varied treatment procedures for bruxism. Treatment modalities involve occlusal correction, behavioral change, and pharmacological approach. [6],[7] However, there is no definitive treatment to stop bruxism, including prosthetic treatment. [4],[8] In this case, bruxism was treated through behavioral change using hypnosis. Hypnosis is essentially a particular state of mind which is usually induced in one person by another. It is a state of mind in which suggestions are not only more readily accepted than in the waking state, but are also acted upon much more powerfully than would be possible under normal conditions. In other words, there is an increase in the suggestibility of the subjects. [9] In the hypnotic state, the power of criticism is either fully or partially suppressed. To understand how this occurs, we must accept the concept of the conscious and the subconscious mind. The conscious mind is part of the mind which thinks and feels the facts in the present. [9] The subconscious or unconscious part is the greater part of the mind and normally we are quite unaware of its existence. It is the seat of all our memories, all our past experiences. The power of suggestion is tremendously enhanced when it acts upon the unconscious rather than the conscious mind. Suggestion is the process whereby an individual accepts a proposition put to him by another. In a different sense, the term is also used to describe an idea which is presented to an individual for its uncritical acceptance. [10]
A 26-year-old housewife and a resident of Mumbai reported with pain in all her teeth since a few months. Pain was of recent onset and severe in nature. The patient complained of restless nights, heaviness, and tightness in the temporomandibular joint (TMJ). The pain was intense in the morning and used to decrease toward evening. She was not aware of any forceful biting and grinding of her teeth. No family member had heard any teeth grinding noise at night either. The patient had no history of tobacco or pan chewing and brushes her teeth twice a day with toothbrush and paste, with correct method of brushing. Both her parents had recently died of malignancy. On intraoral examination, the periodontium showed normal, healthy clinical features. There were neither caries nor any fillings in her mouth. The occlusal surfaces did show mild attrition. The X-ray picture showed generalized thickening of the periodontal ligament space, with normal alveolar bone height. Extraorally, the patient exhibited mild tenderness in the region of TMJ and masseter muscle. No clicking or subluxation of TMJ was observed during its movement. Diagnosis In this case, a differential diagnosis was made of traumatic occlusion due to premature contacts, TMJ disturbance, and a case of bruxism. After eliminating the different causes, finally the case was diagnosed as a case of bruxism. Treatment Occlusal prematurity were detected and corrected. The patient was put on anti-inflammatory drugs, but reported a week later without any relief of pain. In the next phase, the patient was prescribed Diazepam 2 mg TDS (Valium) for 1 month along with anti-inflammatory tablets. [11] She reported a week later without any relief. In the third phase, Hawley's bite plates were made for the patient to be worn at night, but the symptoms continued. [12] It was therefore concluded that a psychological component was involved in the disorder. Hence, hypnosis was tried. The patient was taken into a hypnotic trance on the very first day and was given a post-hypnotic suggestion that she would go to sleep at a word command. She was questioned for cancer phobia, but it revealed that she was not worried of cancer and death did not frighten her. In the second sitting, she revealed under hypnotic trance that her sleep was disturbed, but she did not know the reason. Relevant questioning brought out the fact that she used to have a frightening dream which was forgotten on awakening. In her dream, she saw herself sitting in an unknown room in an unknown place. The room had one window, one door, and one bulb. There were six women sitting in the room, one of whom was very old. The old woman had flowing white hair and was staring at her venomously, while the other women were whispering among themselves and giving her accusing looks. But it was the old lady who was frightening her, though she did not know the reason. While the patient was relating her dream, she had started shivering and sweating. Her pulse had become rapid and skin was cold and damp. She was also seen grinding her teeth. On suggesting that she make an effort to talk to the ladies, she refused saying she was frightened. No amount of coaxing and persuasion helped. Therefore, a post-hypnotic suggestion was given to her to hold her left forefinger with her right hand and press it and this would give her courage to face the old lady. [13] In the next sitting, under hypnosis, the patient was again frightened and was suggested to follow the post-hypnotic suggestion given to her; she pressed her forefinger and became once more relaxed, as the old lady in the dream had gone to sleep and she was not frightened anymore. On the subsequent visits, the patient's dream was the same with the old lady sleeping. Hence, she started getting peaceful sleep and stopped grinding her teeth, and the pain too had disappeared.
The majority of the population will at some point of time during their lifetime grind or clench their teeth. It becomes a pathological condition when the subject presents severe tooth damage or complains of non-restorative sleep. [4] There is no specific treatment for sleep bruxism. Each subject has to be individually evaluated and treated. Three management alternatives are used: Dental, pharmacological, and psychobehavioral. [4] The most common method of treating bruxism in a dental clinic is by using habit breaking appliances such as Hawley's appliance or occlusal splints. [6] Many studies have reported weak evidence for the occlusal splint. [14],[15],[16],[17] Klasser et al. stated that the role for occlusal splints is to protect the teeth and hopefully to diminish muscle activity during sleep. [18] Early etiologic explanations were generally focused on mechanistic factors, but later, attention was focused on psychological issues such as stress and anxiety; by the end of the 20th century, most opinions combined these two ideas. [18] In this case also, the conventional method of occlusal splint and removal of occlusal prematurity along with pharmacological intervention was performed, but no improvement was observed, hence the treatment plan was focused on the psychological issue. [18] Since the patient had sleep bruxism, hypnosis was used to induce sleep. During sleep, dreams induced her to clench and grind her teeth. This resulted in pain of TMJ, muscles of mastication, and all teeth in the morning. The diagnosis was confirmed at this stage. On further probing, the patient revealed a past history of family dispute. The patient's husband and her mother had a dispute over some financial transactions, which finally resulted in patient being thrown out of the house by her husband along with her two children. The patient's mother also refused to give her shelter. This incidence created a sense of insecurity in her subconscious mind. As the patient was in a hypnotic state, the same was used as a means to give moral and ego boosting suggestion. This objective was achieved when the patient caught her left forefinger and squeezed it during the dream. The patient's mother had long white hair similar to that of the old lady. Thus, the old lady in her dream was her mother. The old lady sleeping after the moral boosting post-hypnotic suggestion was a death wish for her mother. A 5-year follow-up showed that the patient was fully relieved of her problems. The result in this case is consistent with the case reported by Michael B. LaCrosse [19] who reported a 5-year follow-up with no relapse. Alladin [20] states, "One way of promoting the therapeutic standing of hypnotherapy as an adjunctive therapy is to systematically integrate it with a well-established psychotherapy. By blending hypnotherapy with cognitive behavior therapy, clinical hypnosis offers a unified version of clinical practice that fits the assimilative model of integrated psychotherapy, which represents the best integrative psychotherapy approach for merging both theory and empirical findings." Therefore, it is very important to find out the root cause of stress-causing parafunctional habits such as bruxism. At times, the patient is unaware of the factor causing stressful event. For such cases, suggestion through hypnotic trance could be therapeutically used as a nondeceptive placebo. [21] Although there is a dispute about the role of psychological factors in the etiology of bruxism and other parafunctional activities, the contribution of a psychologist in the treatment of individual patient is recommended.
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