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Vol	
  3,	
  No	
  1	
  (2015)	
  
ISSN	
  2167-­‐8677	
  (online)	
  

DOI	
  10.5195/d3000.2015.34	
  	
  

	
  

	
  

	
  

http://dentistry3000.pitt.edu	
  

	
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by	
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  University	
  of	
  Pittsburgh	
  Press.	
  

Familial	
  aggregation	
  of	
  anxiety	
  associated	
  with	
  bruxism	
  
David	
  Gorski1	
  	
  
	
  
1	
  University	
  of	
  Pittsburgh	
  School	
  of	
  Dental	
  Medicine,	
  Pittsburgh	
  PA,	
  USA	
  

Abstract	
  

Background:	
   This	
   paper	
   reports	
   the	
   co-­‐occurrence	
   of	
   heritable	
   anxiety-­‐related	
   disorders	
  
and	
  awake	
  bruxism	
  in	
  a	
  family	
  and	
  discusses	
  the	
  heritability	
  of	
  anxiety	
  and	
  implica7ons	
  of	
  
awake	
  bruxism	
  as	
  comorbidity	
  to	
  anxiety	
  disorders.	
  

Subjects:	
  Ten	
  out	
  of	
  14	
  members	
  of	
  an	
  extended	
  family	
  reported	
  having	
  a	
  professionally	
  di-­‐
agnosed	
   anxiety-­‐related	
   disorder.	
   All	
   individuals	
   with	
   anxiety	
   disorders	
   also	
   showed	
   in-­‐
traoral	
  signs	
  of	
  wear	
  from	
  bruxism	
  and	
  reported	
  being	
  aware	
  of	
  grinding	
  their	
  teeth	
  while	
  
awake.	
  Addi*onally,	
  three	
  out	
  of	
  the	
  four	
  family	
  members	
  without	
  an	
  anxiety-­‐related	
  dis-­‐
order	
  did	
  not	
  report	
  grinding	
  their	
  teeth	
  and	
  showed	
  no	
  occlusal	
  wear	
  from	
  bruxism.	
  All	
  of	
  
the	
   individuals	
   that	
   were	
   examined	
   were	
   educated	
   about	
   the	
   short-­‐term	
   and	
   long-­‐term	
  
complica(ons	
  associated	
  with	
  bruxism,	
  but	
  all	
  of	
  them	
  elected	
  to	
  not	
  have	
  treatment	
  per-­‐
formed.	
  
Prac%cal	
  Implica%ons:	
  Anxiety	
  disorders	
  are	
  highly	
  related	
  to	
  suicidal	
  behaviors,	
  par7cular-­‐
ly	
  in	
  children	
  and	
  adolescents.	
  Addi-onally,	
  awake	
  bruxism	
  can	
  o-en	
  serve	
  as	
  an	
  indicator	
  
of	
  anxiety	
  or	
  stress.	
  By	
  recognizing	
  bruxism	
  as	
  a	
  possible	
  manifesta+on	
  of	
  psychological	
  dis-­‐
tress,	
  the	
  dental	
  prac..oner	
  may	
  be	
  able	
  to	
  direct	
  pa.ents	
  to	
  life-­‐saving	
  services	
  like	
  psy-­‐
chologists	
  and	
  crisis	
  hotlines	
  when	
  appropriate.	
  

	
  

Cita%on:	
  Gorski	
  D.	
  (2015)	
  Familial	
  aggrega*on	
  of	
  
anxiety	
  associated	
  with	
  bruxism.	
  Den$stry	
  3000.	
  
1:a001	
  doi:10.5195/d3000.2015.34	
  
Received:	
  June	
  2,	
  2015	
  
Accepted:	
  	
  June	
  26,	
  2015	
  
Published:	
  	
  July	
  20,	
  2015	
  
Copyright:	
  ©2015	
  Gorski	
  D.	
   This	
   is	
   an	
  open	
  ac-­‐
cess	
  ar!cle	
   licensed	
  under	
  a	
  Crea!ve	
  Commons	
  
A"ribu%on	
  Work	
  4.0	
  United	
  States	
  License.	
  
Email:	
  deg32@pi$.edu

	
  

Introduction	
  

Bruxism	
  is	
  defined	
  as	
  “a	
  repetitive	
  
jaw-­‐muscle	
  activity	
  characterized	
  
by	
  clenching	
  or	
  grinding	
  of	
  the	
  teeth	
  
and/or	
  by	
  bracing	
  or	
  thrusting	
  of	
  
the	
  mandible”	
  that	
  can	
  occur	
  while	
  
asleep	
  (sleep	
  bruxism)	
  or	
  while	
  
awake	
  (awake	
  bruxism)	
  [1].	
  Awake	
  
bruxism	
  is	
  reported	
  in	
  20%	
  of	
  the	
  
adult	
  population	
  in	
  the	
  US	
  [2],	
  but	
  
researchers	
  have	
  only	
  recently	
  
linked	
  its	
  occurrence	
  to	
  anxiety	
  dis-­‐
orders	
  [3].	
  

The	
  heritability	
  estimates	
  for	
  anxie-­‐
ty	
  disorders	
  range	
  from	
  20%	
  to	
  
65%	
  [4].	
  From	
  family	
  and	
  twin	
  
studies,	
  the	
  heritability	
  of	
  General-­‐
ized	
  Anxiety	
  Disorder	
  (GAD)	
  has	
  

been	
  measured	
  at	
  32%,	
  indicating	
  
significant	
  heritability	
  for	
  this	
  anxi-­‐
ety-­‐based	
  condition	
  [5].	
  	
  

Awake	
  bruxism	
  and	
  anxiety	
  are	
  of-­‐
ten	
  only	
  considered	
  in	
  their	
  respec-­‐
tive	
  fields	
  of	
  dentistry	
  and	
  psychol-­‐
ogy.	
  This	
  report	
  describes	
  the	
  co-­‐
occurrence	
  of	
  anxiety	
  disorders	
  and	
  
their	
  manifestation	
  as	
  
awake	
  bruxism	
  in	
  family,	
  
and	
  it	
  discusses	
  the	
  clin-­‐
ical	
  implications	
  of	
  these	
  
findings.	
  

Subjects	
  

A	
  28	
  year-­‐old	
  male	
  was	
  
complaining	
  of	
  “jaw	
  
pain”	
  and	
  “headaches”	
  

that	
  had	
  been	
  worsening	
  in	
  the	
  past	
  
two	
  years.	
  The	
  patient	
  had	
  a	
  rela-­‐
tively	
  unremarkable	
  medical	
  histo-­‐
ry.	
  Other	
  than	
  minor	
  seasonal	
  aller-­‐
gies	
  for	
  which	
  he	
  was	
  taking	
  no	
  
medications,	
  his	
  only	
  notable	
  condi-­‐
tions	
  were	
  Generalized	
  Anxiety	
  Dis-­‐
order	
  and	
  Major	
  Depressive	
  Disor-­‐
der.	
  For	
  these	
  conditions,	
  he	
  was	
  



	
  	
  Familial	
  aggrega*on	
  of	
  anxiety	
  associated	
  with	
  bruxism	
  

Vol	
  3,	
  No	
  1	
  (2015)	
  	
  	
  	
  DOI	
  10.5195/d3000.2015.34	
  

	
  http://dentistry3000.pitt.edu	
  
2	
  

taking	
  Pristiq,	
  a	
  selective	
  serotonin	
  
and	
  norepinephrine	
  reuptake	
  inhib-­‐
itor,	
  and	
  Lithium	
  Carbonate,	
  a	
  
pharmaceutical	
  typically	
  used	
  to	
  

treat	
  bipolar	
  disorder.	
  A	
  thorough	
  
head	
  and	
  neck	
  exam	
  with	
  inspection	
  
of	
  hard	
  and	
  soft	
  tissues	
  showed	
  bi-­‐
lateral	
  sensitivity	
  of	
  the	
  masseter	
  
and	
  medial	
  pterygoid	
  muscles,	
  with	
  
well-­‐defined	
  wear	
  facets	
  on	
  the	
  in-­‐
cisal	
  and	
  lingual	
  surfaces	
  of	
  his	
  
maxillary	
  canines	
  (Figure	
  1).	
  Addi-­‐
tionally,	
  trauma	
  from	
  occlusal	
  wear	
  
was	
  noted	
  on	
  his	
  single	
  mandibular	
  
incisor	
  (Figure	
  2).	
  When	
  ques-­‐
tioned,	
  the	
  patient	
  stated	
  that	
  he	
  
was	
  aware	
  that	
  he	
  had	
  been	
  grind-­‐
ing	
  his	
  teeth	
  during	
  the	
  day.	
  He	
  re-­‐
called	
  that	
  his	
  sister	
  had	
  recently	
  
been	
  having	
  similar	
  symptoms	
  and	
  
had	
  received	
  a	
  “night	
  guard”	
  that	
  

had	
  provided	
  some	
  
relief	
  from	
  the	
  head-­‐
aches	
  and	
  jaw	
  pain.	
  	
  	
  

Figures	
  3	
  and	
  4	
  
show	
  the	
  phenotypi-­‐
cal	
  distribution	
  in	
  
the	
  family	
  after	
  oral	
  
examinations	
  and	
  
medical	
  history	
  in-­‐
terviewing	
  of	
  the	
  
proband’s	
  family.	
  

Out	
  of	
  13	
  individuals	
  examined,	
  ten	
  
had	
  professional	
  diagnoses	
  of	
  anxie-­‐
ty-­‐related	
  conditions	
  and	
  also	
  
showed	
  intraoral	
  signs	
  of	
  bruxism	
  

(Figures	
  5,	
  6,	
  and	
  
7).	
  Additionally,	
  
out	
  of	
  the	
  four	
  
family	
  members	
  
who	
  did	
  not	
  have	
  
an	
  anxiety-­‐related	
  
condition,	
  only	
  in-­‐
dividual	
  II.1	
  
showed	
  any	
  in-­‐
traoral	
  signs	
  of	
  
bruxism	
  or	
  admit-­‐
ted	
  to	
  “grinding	
  or	
  
clenching	
  their	
  

teeth”	
  (Figure	
  8).	
  	
  

None	
  of	
  the	
  family	
  members	
  that	
  
were	
  inspected	
  wished	
  to	
  have	
  
treatment	
  performed.	
  
Individuals	
  III.1	
  and	
  
II.4	
  already	
  had	
  occlu-­‐
sal	
  splints	
  that	
  they	
  
wore	
  at	
  night.	
  They	
  
both	
  rated	
  their	
  
symptom	
  relief	
  from	
  
their	
  occlusal	
  splints	
  
as	
  “moderate.”	
  Indi-­‐
vidual	
  II.4	
  said	
  that	
  
his	
  occlusal	
  splint	
  was	
  
“uncomfortable	
  and	
  
awkward”	
  to	
  wear	
  but	
  did	
  not	
  wish	
  

to	
  have	
  it	
  remade.	
  All	
  members	
  of	
  
the	
  family,	
  regardless	
  of	
  whether	
  
they	
  presented	
  with	
  signs	
  of	
  brux-­‐
ism,	
  were	
  educated	
  on	
  bruxism	
  and	
  
the	
  short-­‐term	
  and	
  long-­‐term	
  com-­‐
plications	
  associated	
  with	
  the	
  con-­‐
dition.	
  

Discussion	
  

Recent	
  studies	
  on	
  twins	
  have	
  found	
  
a	
  significant	
  degree	
  of	
  heritability	
  
for	
  anxiety	
  disorders.	
  But,	
  these	
  
studies	
  have	
  been	
  unable	
  to	
  pin-­‐
point	
  any	
  single	
  genes	
  that	
  are	
  re-­‐
sponsible	
  for	
  the	
  occurrence	
  of	
  anx-­‐
iety	
  [6].	
  Instead,	
  it	
  has	
  been	
  sug-­‐
gested	
  that	
  anxiety	
  has	
  a	
  highly	
  
multifactorial	
  pattern	
  of	
  inher-­‐
itance,	
  with	
  the	
  environment	
  play-­‐
ing	
  a	
  role	
  and	
  a	
  large	
  number	
  of	
  
genes	
  contributing	
  a	
  small	
  individ-­‐
ual	
  effect	
  [7].	
  That	
  being	
  said,	
  based	
  
on	
  the	
  pedigrees	
  for	
  anxiety	
  (Figure	
  
3)	
  and	
  associated	
  bruxism	
  (Figure	
  
4),	
  it	
  would	
  appear	
  that	
  at	
  least	
  
some	
  of	
  the	
  genes	
  that	
  contribute	
  to	
  
anxiety	
  in	
  the	
  proband’s	
  family	
  are	
  
inherited	
  in	
  an	
  autosomal	
  dominant	
  
fashion,	
  with	
  all	
  three	
  noted	
  genera	
  
tions	
  affected	
  by	
  the	
  condition.	
  



	
  	
  Familial	
  aggrega*on	
  of	
  anxiety	
  associated	
  with	
  bruxism	
  

Vol	
  3,	
  No	
  1	
  (2015)	
  	
  	
  	
  DOI	
  10.5195/d3000.2015.34	
  

	
  http://dentistry3000.pitt.edu	
  
3	
  

Awake	
  bruxism	
  has	
  been	
  noted	
  to	
  
have	
  a	
  number	
  of	
  varied	
  associa-­‐
tions—smoking,	
  caffeine	
  intake,	
  and	
  
alcohol	
  consumption	
  [8].	
  However,	
  
in	
  a	
  study	
  of	
  86	
  children	
  by	
  Monaco	
  

et	
  al,	
  72%	
  percent	
  of	
  children	
  that	
  
bruxed	
  showed	
  significant	
  anxiety	
  
scores,	
  while	
  only	
  12%	
  of	
  non-­‐
bruxers	
  had	
  similar	
  psychological	
  
findings	
  [9].	
  This	
  would	
  indicate	
  
that	
  the	
  act	
  of	
  bruxing	
  is	
  highly	
  cor-­‐
related	
  with	
  anxiety	
  disorders.	
  The	
  
results	
  from	
  this	
  study	
  agree	
  with	
  

the	
  findings	
  from	
  the	
  family	
  report-­‐
ed	
  here.	
  Indeed,	
  in	
  this	
  family,	
  brux-­‐
ism	
  and	
  multifactorially	
  inherited	
  
anxiety	
  disorders	
  appear	
  to	
  be	
  in-­‐
tertwined.	
  Each	
  person	
  with	
  a	
  diag-­‐
nosed	
  anxiety-­‐related	
  disorder	
  also	
  
had	
  signs	
  of	
  occlusal	
  wear	
  associat-­‐
ed	
  with	
  bruxism	
  and	
  were	
  aware	
  
that	
  they	
  bruxed	
  while	
  awake.	
  Simi-­‐
larly,	
  three	
  out	
  of	
  four	
  of	
  the	
  indi-­‐

viduals	
  (I.1,	
  
III.4,	
  and	
  III.6)	
  
who	
  did	
  not	
  
have	
  an	
  anxie-­‐
ty	
  disorder	
  

also	
  did	
  
not	
  brux.	
  
Only	
  one	
  
family	
  
member	
  
(individual	
  II.1)	
  showed	
  signs	
  of	
  
occlusal	
  trauma	
  from	
  bruxism,	
  
but	
  was	
  not	
  diagnosed	
  with	
  
anxiety.	
  This	
  family	
  member	
  
attributed	
  the	
  wear	
  patterns	
  to	
  

“occasional	
  grinding”	
  due	
  to	
  stress	
  
in	
  the	
  workplace.	
  

This	
  report	
  highlights	
  the	
  im-­‐
portance	
  for	
  dental	
  health	
  profes-­‐
sionals	
  to	
  understand	
  the	
  signifi-­‐
cance	
  of	
  dental	
  manifestations	
  due	
  
to	
  other	
  conditions.	
  Many	
  dental	
  

professionals	
  are	
  aware	
  of	
  
the	
  evidence	
  linking	
  perio-­‐
dontal	
  disease	
  to	
  heart	
  dis-­‐
ease	
  [10]	
  and	
  diabetes	
  [11].	
  
As	
  a	
  result,	
  many	
  dentists	
  
are	
  able	
  to	
  act	
  as	
  “early	
  
warning	
  indicators”	
  and	
  
counsel	
  their	
  patients	
  about	
  
possible	
  systemic	
  comor-­‐
bidities.	
  Simi-­‐
larly,	
  the	
  dental	
  
field	
  should	
  
become	
  aware	
  

of	
  bruxism	
  as	
  a	
  possible	
  
predictor	
  of	
  heritable	
  
anxiety-­‐related	
  disor-­‐
ders.	
  Anxiety	
  disorders	
  
are	
  highly	
  related	
  to	
  
suicidal	
  behaviors,	
  par-­‐
ticularly	
  in	
  children	
  and	
  
adolescents	
  [12].	
  If	
  
dentists	
  are	
  able	
  to	
  rec-­‐
ognize	
  the	
  oral	
  mani-­‐

festations	
  of	
  anxiety	
  and	
  stress	
  in	
  
their	
  patients,	
  they	
  may	
  be	
  able	
  to	
  
counsel	
  these	
  patients	
  and	
  ultimate-­‐
ly	
  direct	
  them	
  to	
  life-­‐saving	
  services	
  
such	
  as	
  therapists	
  and	
  crisis	
  cen-­‐
ters.	
  



	
  	
  Familial	
  aggrega*on	
  of	
  anxiety	
  associated	
  with	
  bruxism	
  

Vol	
  3,	
  No	
  1	
  (2015)	
  	
  	
  	
  DOI	
  10.5195/d3000.2015.34	
  

	
  http://dentistry3000.pitt.edu	
  
4	
  

References	
  

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  de+ined	
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Lavigne	
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23121262	
  

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in	
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  Re-­‐
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  PMID:	
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  and	
  meta-­‐analysis	
  
of	
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  epidemiology	
  
of	
  anxiety	
  disorders.	
  Hette-­‐
ma	
  JM,	
  Neale	
  MC,	
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KS.	
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  Psychiatry.	
  2001	
  
Oct;158(10):1568-­‐78.	
  PMID:	
  
11578982	
  

6. First	
  genome-­‐wide	
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tion	
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  on	
  anxiety-­‐
related	
  behaviours	
  in	
  child-­‐
hood.	
  Trzaskowski	
  M,	
  Eley	
  
TC,	
  Davis	
  OS,	
  Doherty	
  SJ,	
  
Hanscombe	
  KB,	
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EL,	
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  CM,	
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  T,	
  
Plomin	
  R.	
  PLoS	
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2013;8(4):e58676.	
  doi:	
  
10.1371/journal.pone.0058

676.	
  Epub	
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  Apr	
  2.	
  
PMID:	
  23565138	
  

7. Symptoms	
  of	
  anxiety	
  and	
  
depression	
  in	
  a	
  volunteer	
  
twin	
  population.	
  The	
  etio-­‐
logic	
  role	
  of	
  genetic	
  and	
  en-­‐
vironmental	
  factors.	
  
Kendler	
  KS,	
  Heath	
  A,	
  Martin	
  
NG,	
  Eaves	
  LJ.	
  Arch	
  Gen	
  Psy-­‐
chiatry.	
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Mar;43(3):213-­‐21.	
  PMID:	
  
3954540	
  

8. Bruxism:	
  a	
  literature	
  re-­‐
view.	
  Reddy	
  SV,	
  Kumar	
  MP,	
  
Sravanthi	
  D,	
  Mohsin	
  AH,	
  
Anuhya	
  V.	
  J	
  Int	
  Oral	
  Health.	
  
2014	
  Nov-­‐Dec;6(6):105-­‐9.	
  
Review.	
  PMID:	
  25628497	
  

9. The	
  anxiety	
  in	
  bruxer	
  child.	
  
A	
  case-­‐control	
  study.	
  Mona-­‐
co	
  A,	
  Ciammella	
  NM,	
  Marci	
  
MC,	
  Pirro	
  R,	
  Giannoni	
  M.	
  
Minerva	
  Stomatol.	
  2002	
  
Jun;51(6):247-­‐50.	
  PMID:	
  
12147977	
  

10. Periodontal	
  disease	
  and	
  
coronary	
  heart	
  disease	
  inci-­‐
dence:	
  a	
  systematic	
  review	
  
and	
  meta-­‐analysis.	
  Humph-­‐
rey	
  LL,	
  Fu	
  R,	
  Buckley	
  DI,	
  
Freeman	
  M,	
  Helfand	
  M.	
  J	
  
Gen	
  Intern	
  Med.	
  2008	
  
Dec;23(12):2079-­‐86.	
  doi:	
  
10.1007/s11606-­‐008-­‐0787-­‐
6.	
  Epub	
  2008	
  Sep	
  20.	
  Re-­‐
view.	
  PMID:	
  18807098	
  

11. Diabetes	
  mellitus:	
  biochem-­‐
ical,	
  histological	
  and	
  micro-­‐
biological	
  aspects	
  in	
  perio-­‐
dontal	
  disease.	
  Marigo	
  
L,	
  Cerreto	
  R,	
  Giuliani	
  M,	
  
Somma	
  F,	
  Lajolo	
  C,	
  Cordaro	
  
M.	
  Eur	
  Rev	
  Med	
  Pharmacol	
  
Sci.	
  2011	
  Jul;15(7):751-­‐8.	
  
Review.	
  PMID:	
  21780542	
  

12. Suicide-­‐related	
  behaviors	
  
and	
  anxiety	
  in	
  children	
  and	
  
adolescents:	
  a	
  review.	
  Hill	
  
RM,	
  Castellanos	
  D,	
  Pettit	
  JW.	
  
Clin	
  Psychol	
  Rev.	
  2011	
  
Nov;31(7):1133-­‐44.	
  doi:	
  
10.1016/j.cpr.2011.07.008.	
  

Epub	
  2011	
  Jul	
  28.	
  Review.	
  
PMID:	
  21851804