The approach and management of bruxism in Alzheimer’s disease: An under-recognized habit that concerns caregivers (innovative practice)

Bruxism (teeth grinding) is the involuntary gnashing, grinding, or clenching of teeth which results in damage to teeth, temporomandibular disorders, and induction of temporal headaches (Kwak, Han, Lee, Yoon, & Suk, 2009). Bruxism can be a cause of caregiver concern in Alzheimer’s disease (AD) as it is not well recognized. Here, we report two cases of AD with bruxism that caused distress to the caregivers.

The first patient was a 62-year-old man with early onset AD who developed bruxism eight months after the diagnosis of AD. He was on donepezil 10 mg for seven months prior to the development of bruxism. His wife complained of severe grinding of teeth by her husband during day and night. She said that the sound was unbearably annoying to her. She was distressed and alarmed by the continuous grinding of teeth. The patient was treated with 50 units of botulinum toxin type A; 15 units of botulinum toxin was injected in each masseter and 10 units in each temporalis muscle. After one week of injection, his bruxism subsided completely and was free of bruxism for the next four months. When the bruxism resurfaced, his wife and his son wanted a second injection of the toxin, but the patient refused treatment as he was not disturbed by it.

The second patient of AD was a 69-year-old man who had been under our care for the past eight years. He was on donepezil and memantine for the past six years, and there were no recent changes to his medications. His wife reported that the patient was grinding his teeth both during day and night for the past six months. She was disturbed by this noise. She was curious to know what the cause of this grinding was. She was satisfied when we explained the nature of the illness. However, she did not want any medications or interventions for the same, as the patient was in advanced stages of AD.

The pathophysiology of bruxism in AD is unknown but may be due to dysfunction of cholinergic and dopaminergic pathways (Kwak et al., 2009). Both of our patients suffered from bruxism during the day and at night. Although bruxism at night (sleep bruxism) is a sleep disorder, bruxism during daytime (diurnal bruxism) is always pathological. In a study from Korea, 4 out of 125 patients of AD had bruxism (Lai, 2013). All of these patients, however, had advanced AD (Lai, 2013). In one of our cases, bruxism started few months after the diagnosis of AD highlighting the fact that bruxism can occur even during early stages of AD. In both patients, bruxism was a cause of caregiver concern. Botulinum toxin injection completely relieved the bruxism in one patient who agreed to be treated. Repetitive behaviors such as teeth grinding could be a form of expressing an underlying unmet need of these patients. An attempt to understand such behaviors and dealing with them in an appropriate and timely manner can help these patients to live more comfortably. Whether bruxism is rare in AD or is under-reported is to be evaluated in future studies.