Contingent electrical lip stimulation for sleep bruxism: A pilot study

Keisuke Nishigawa, DDS, PhD,a Kazuo Kondo DDS, PhD,b Hisahiro Takeuchi DDS, PhD,c and
Glenn T. Clark DDS, MSd
School of Dentistry, Tokushima University, Tokushima, Japan; School of Dentistry, University of
California at Los Angeles, Los Angeles, Calif.
Statement of problem. No effective method has been found to fully control sleep bruxism, although con-
tingent feedback methods show some promise.
Purpose. This demonstration-of-concept study evaluated the effect of contingent electrical lip stimulation on
sleep bruxism.
Material and methods. Recordings of masseter muscle activity were performed over 5 nights in 7 subjects
with acknowledged bruxism and dental attrition (5 men, 2 women). A small electrical switch, activated with light
force clenching, was mounted between 2 occlusal orthotics. This switch triggered a stimulator, which delivered
slightly noxious electrical pulses to the subject’s lip. After a baseline first night recording session, stimulation was
delivered in 1-hour blocks for half of each sleep period during nights 2 through 5. Paired t tests (␣ ⫽ 0.05) were
conducted on 4 recorded bruxism parameters.
Results. With stimulation, the number (⫾SD) of events/hour reduced from a baseline level of 3.9 ⫾ 2.0 to
2.4 ⫾ 0.8 and the mean amplitude (% maximum voluntary contraction) reduced from 28.7 ⫾ 20.0 to 17.6 ⫾ 4.1.
There was a mean decrease in the duration (s/event) from 10.6 ⫾ 1.4 to 9.1 ⫾ 2.5 and the total event time
(s/hour) was reduced from 41.7 ⫾ 22.4 to 23.2 ⫾ 11.0. Among these measures, bruxism events with and
without stimulation were compared, and only the duration of individual bruxism events (s/event) showed a
significant change (P⫽.038). Finally, no subject reported being awakened from sleep by the stimulation.
Conclusion. The reductions in bruxism events were noteworthy, especially considering that stimulation was
delivered for only half of the sleeping period. (J Prosthet Dent 2003;89:412-7.)

CLINICAL IMPLICATIONS
On the basis of the data from this pilot study, contingent electrical lip stimulation for bruxism
appears to be a promising method for temporarily suppressing this disorder. The long-term effects
of contingent electrical stimulation are not yet determined.

D epending on the practitioner’s concept of the

causes of bruxism, a variety of treatment methods have
been proposed.1,2 These methods include occlusal ad-
justment,3,4 occlusal splint,5 massed practice,6-8 aversive
conditioning,9 psychological counseling,10 relaxation
training,11 medications,12 contingent auditory feed-
back,13-20 and, most recently, contingent vibratory feed-
back.21 For almost all methods, the literature shows
weak positive results, and no long-term effective method
has yet been shown to prevent bruxism. For example,
Kardachi and Clarke15 used contingent auditory feed-
back on 9 subjects with sleep bruxism. They reported
that the number of bruxism events during sleep was not
reduced by this feedback, but the duration and total
a
Assistant Professor, Department of Fixed Prosthodontics, Tokushima
University.
b
Private Practice, Onsen-gun, Ehime, Japan.
c
Assistant Professor, Department of Fixed Prosthodontics, Tokushima
University.
d
Professor, Oral Biology and Medicine, University of California at
Los Angeles.
activity were significantly less. Rugh and Johnson18 re-
ported similar results with the use of a similar electro-
myographic (EMG) activated contingent auditory feed-
back system in treating 5 patients with bruxism. Finally,
Pierce and Gale20 evaluated the masseter muscle activity
during sleep in 100 patients with bruxism before, dur-
ing, and after 5 different experimental treatments. They
reported that both the EMG-measured frequency of
bruxing episodes and the duration of bruxing activity
decreased significantly for contingent-auditory-feed-
back and occlusal splint therapy, but not for the other 2
treatments examined (massed negative practice, and
daytime muscle relaxation-feedback) or the no-treat-
ment control group. Finally they reported that the
2-week treatment effects were transient, and bruxing
activity generally returned to baseline levels when the
treatment was withdrawn.
Although the suppression induced by auditory stim-
ulation is interesting, a consistent return to pretreatment
bruxism levels has been reported in all studies that have
monitored bruxism after stopping the feedback. An-

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NISHIGAWA ET AL THE JOURNAL OF PROSTHETIC DENTISTRY

other disadvantage of contingent auditory feedback is

that it probably requires an awakening or at least a sleep-
stage elevation of the subject.22 This means that subjects
are potentially showing reduced deep-stage sleep during
the training period and may become sleep deprived. The
question is whether a different type of feedback, direct
afferent stimulation to the trigeminal nerve, for exam-
ple, can be used to suppress the bruxism response and
yet not induce waking. Watanabe et al21 reported on a
single subject who used contingent vibratory stimula-
tion delivered to the maxillary teeth via an occlusal
splint. The vibration was triggered by tooth-to-splint
contact above a low-level threshold. The subject used
Fig. 1. Maxillary and mandibular occlusal orthotics with
the contingent vibration system for 4 months without
switch and opposing contact platform mounted anterior to
difficulty or a report of subjective sleep disturbance. The
splint.
subject also exhibited a significant decrease in the num-
ber of events/hour (25% reduction) and the duration of
each event (44% reduction).
lected. The inclusion criteria for the subjects were that
One potentially stronger form of afferent stimulation
they (1) had evidence of tooth attrition such that at least
is low-level electrical shock of the trigeminal nerve.
1 tooth (usually canine) had dentin exposure as a result
Godaux and Desmedt23 reported that single electrical
of the attrition; (2) had frequent (more than once per
stimulation to the gums and mucosa inside the mouth
week) jaw pain in the morning and demonstrated mod-
suppressed the masseter and temporalis muscles activity
erate to severe tenderness in 2 or more sites in their jaw
in normal waking subjects. In an attempt to decrease the
closing (masseter and temporalis) muscles; (3) were self-
number of sleep apnea episodes, Miki et al24 reported
aware of the fact that they were clenching or grinding
that a percutaneous electrical stimulation of the genio-
their teeth at night because of either frequent (more
glossus muscles did not cause sleep state arousal. Con-
than once per week) tooth soreness or jaw muscle stiff-
sidering these data, it may be possible to use these other
ness on awakening; (4) were in good health; and (5) had
forms of stimulation (electrical shock or vibration) to
tried in the past, but were currently not actively using an
suppress bruxism for longer periods of time. Whether
occlusal orthotic and were planning no other active
the behavior could eventually be extinguished and feed-
treatment during the experimental period. The above
back could be discontinued after cessation is yet to be
muscle tenderness ratings were elicited via the applica-
seen. The purpose of this study was to evaluate the effect
tion of 1.8 kg of pressure to the muscle for 2 seconds
of contingent afferent stimulation (mild noxious electri-
with a hand held pressure algometer device (Pain Diag-
cal shock) applied to the maxillary division of the trigem-
nostics and Thermography Corp, New York, N.Y.). Ex-
inal nerve on the skin portion of the lip in bruxism
clusion criteria for these subjects were as follows: (1) use
subjects during sleep. The null hypothesis tested in this
of any prescription medication or daily alcohol; (2) re-
demonstration-of-concept study was that contingent
port of a clearly fragmented (multiple awakenings) sleep
electrical stimulation would not produce a suppression
pattern or substantial difficulty getting to sleep (on the
of the bruxism response.
basis of self-report); and (3) inability to sleep with re-
MATERIAL AND METHODS cording devices attached.
Overview of study design
Subjects and stimulation parameters
An on-off switch was mounted between maxillary and
mandibular orthotics to trigger a battery-powered elec- There were 7 subjects (5 men and 2 women) who
trical stimulator. This stimulator delivered slightly nox- completed all aspects of the protocol. Their mean age
ious electrical pulses to the subject’s lip. Stimulation was (⫾1 SD) was 32.4 ⫾ 3.8 years. The intensity of stimu-
delivered in 1-hour blocks for half of each sleep period. lation actually used for the subjects ranged between 0.79
Recordings of masseter muscle activity were performed and 2.05 mA. This level was individually adjusted so that
over 5 experimental nights in 7 subjects. it was at the level of being a slightly painful.

Subjects Electrical stimulation

Subjects with acknowledged bruxism and visually ob- In this study, all switch closure events (above thresh-
vious dental attrition, who responded to an advertise- old force), which will henceforth be called bruxism
ment request for subjects in the campus newspaper and events, were detected by use of a small on-off switch
satisfied the inclusion and exclusion criteria were se- mounted anterior to 2 occlusal orthotics covering the

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THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 2. Detection switch and opposing contact platform at-
tached to lips of subject.
patients’ teeth (Fig. 1). The switch was closed by clench-
ing of the teeth with a force greater than 220 g.
When the switch was triggered, a constant current
electrical pulse stimulation was given to the lip until the
bruxing stopped, the mouth opened, or until an alarm
sounded. The stimulation device was designed so that if
it were activated for more than 30 seconds, an alarm that
was loud enough to awaken the subject would be acti-
vated. When the alarm sounded the lip stimulation was
shut off and the alarm stayed on until the subject man-
ually turned it off. The electrical pulse stimulation was
1 ms in width and was applied at a 10-Hz frequency to
the lip skin through a 2-mm diameter electrode fixed to
the external surface of the lip (Fig. 2).
Experimental procedures
A portable analog tape– based monitoring system was
used in this study (HR-10J cassette data recorder;
TEAC, Tokyo, Japan). This recorder monitored masse-
ter muscle and switch-triggered closures. Miniature bi-
polar surface electrode pairs were fixed over the subject’s
right or left masseter muscle. The actual stimulation
signal was recorded directly from a battery-powered
constant current electric pulse generator that was acti-
vated when the switch was triggered. Before the actual
5-night recording session, the subjects used the orthot-
ics (to which the switch was attached) for 2 weeks to
familiarize themselves with these devices during sleep.
Recordings were performed in the subjects’ home for 5
consecutive nights. The experimenter typically attended
the home of each subject for 1 hour on the evening of a
recording session to attach the sensors and evaluate the
operation of the system. The subject detached the sen-
sors the next morning and returned it to the author’s
laboratory for data download and evaluation. The first
night involved recording without electrical stimulation.
Four additional nights of recording with electrical stim-
414
NISHIGAWA ET AL
Fig. 3. Recorded RMS-converted EMG signal trace. Straight
line slightly above EMG signal is 3% MVC threshold level.
ulation were also performed. During the second to the
fifth nights of recording, the contingent electrical stim-
ulation was randomly turned on and off in one-hour
segments. This meant the stimulation was applied for
only 50% of each night in a random schedule. A timer
was then programmed to turn the stimulation on and off
for 1-hour blocks of operation in random sequence.
Data reduction and analysis
Analog tape records were played back on a second
device (MR-10 cassette data recorder; TEAC) with a
reproducing tape speed which was 8 times faster than
recording, and data were acquired by computer. Prior to
acquisition, the raw EMG signal was converted to a root
mean square (RMS) signal (SA-414 Analog Processor;
SA Instrumentation Co., San Diego, Calif.). The sam-
pling rate for the EMG signal was 250 Hz. The switch-
triggered events were detected using a window discrim-
inator and then converted to a 10 ms 5-volt square wave
pulse. This event was then acquired at the sampling rate
of 2000 Hz by an 8-bit A/D converter and acquisition
system (Intelligent DATA; Intelligent DATA Acquisi-
tion System Inc, Los Angeles, Calif). The amplitude of
the EMG signal was quantified in terms of the subjects’
100% maximum voluntary contraction (MVC) level.
The MVC for each subject was recorded at the begin-
ning and end of each night with 5 brief (2 seconds)
maximum voluntary contraction efforts. Analysis was
done automatically with custom computer programs
with the following strategy. All bruxism events were
detected and described (number, amplitude, duration)
with an custom automated computer detection software
program (Bruxism Analysis Program, UCLA, Los An-
geles, Calif.) that used the EMG criteria previously de-
scribed.25 In this study the lower, 3% MVC, criteria was
used rather than a 10% level of MVC contraction criteria
for the EMG amplitude needed to detect a bruxism
event. This was done because the triggering switch was
triggered with a force level that was determined to be
closer to 3% MVC rather than 10% MVC. Figure 3
shows the short segment of a single subject’s recording
and an example of a bruxism event on the basis of EMG
with the amplitude and duration criteria. The area below
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NISHIGAWA ET AL THE JOURNAL OF PROSTHETIC DENTISTRY

Table I. Bruxism event data with and without stimulation

Baseline: (1st night) Stimulation: 2nd-5th night

Bruxism event data (n ⴝ 7) (mean ⴞ SD) (mean ⴞ s.d.) P value

Number (no./hour) 3.87 ⫾ 2.01 2.42 ⫾ 0.78 .107

Amplitude (%MVC) 28.73 ⫾ 20.04 17.59 ⫾ 4.06 .145
*
Switch-triggered amplitude (%MVC) 3.93 ⫾ 0.37 2.32 ⫾ 0.28 N/A
Duration (s/event) 10.61 ⫾ 1.42 9.08 ⫾ 2.48 .038
Total time of all events (s/hour) 41.67 ⫾ 22.38 23.24 ⫾ 11.03 .063
*
Partial data set (n ⫽ 4).

Fig. 4. Switch-triggered EMG plots with and without stimu-

lation from single subject with bruxism. Amplitude is shown
in vertical axis and time on horizontal axis. Top trace dis-
plays average EMG elevation seen with 44 switch closures
(no stimulation applied) collected on single baseline night.
Bottom trace displays average EMG elevation seen with 110
switch closures (stimulation applied) collected over 4 nights.

the elevated EMG signal marked with a solid double line

shows when the EMG data satisfied the criteria and was
counted as a bruxism event. As shown by Ikeda et al,25
bruxism events could be detected with high reliability
and reproducibility from masseter EMG activity.
Bruxism event analysis
Bruxism event data was collected and separated into
those events that occurred in the baseline night and
events occurring during the treatment period (second to
fifth nights). Each subject was questioned each morning
regarding the number of times they were awakened (if at
all) from sleep by the lip stimulation. Baseline and stim-
ulation data were then submitted to a match paired t test
analysis to evaluate for differences. These analytic pro-
cedures were done with the JMP-In version 4.0 software
program (SAS Institute Inc, Campus Drive, Cary,
N.C.). An alpha of 0.05 as the level of statistical signif-
icance was used in this analysis. For each analysis the P
value and a power calculation were performed and re-
ported.
Fig. 5. Two 3-dimensional plots showing 2 entire nights of
EMG data from single heavy force bruxism subject. A, First
night. B, Fourth treatment night. Oblique repeating lines
represent EMG signal amplitude (each oblique data line rep-
resents 30 minutes of recording). Small horizontal lines rep-
resent bruxism events that satisfied EMG criteria.
RESULTS
Resulting stimulation level
The mean level (⫾1 SD) for the sensory detection
threshold for the 7 subjects was 0.69 ⫾ 0.09 mA, the
mean level for first pain detection was 1.11 ⫾ 0.30 mA
and the mean stimulation level used was 1.46 ⫾ 0.41
mA. It is interesting to note that although asked about
this every day, no subject reported being awakened by
the stimulation during the experimental nights, and the
30-second alarm button was never triggered during the
study.

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THE JOURNAL OF PROSTHETIC DENTISTRY
Lip stimulation effect on bruxism events
The effect of stimulation on all EMG elevations that
satisfied the EMG based criteria for the 7 subjects during
the baseline period and during the 4-night treatment
period is shown in Table I. The mean number (⫾1 SD)
of the number of events (no./h), mean event amplitude
(% MVC), mean duration of individual events (s/event),
and total time of all events (s/h) plus the matched paired
statistical test results are shown.
Mean triggered EMG amplitude
To assess the hypothesis that electrical stimulation
did not suppress bruxism, a switch closure-triggered av-
eraging of the EMG activity was performed for 4 sub-
jects (Table I). For this comparison, the all-switch clo-
sures with subsequent stimulation during the second to
fifth night were combined and contrasted to all switch
closures that occurred on the baseline night. The ampli-
tude for this partial data set demonstrated a reduction
(41%) in the mean (⫾1 SD) of the peak EMG amplitude
(% MVC) seen following switch closures. Figure 4 shows
the switch-triggered plot from a single subject’s data
that was considered representative. The top tracing in
this figure shows no stimulation and the bottom tracing
shows event under conditions of electrical stimulation.
Unfortunately, the EMG amplitude data was recorded
for only 4 subjects because the switch closures recorded
during the baseline night were not recorded for 3 of the
subjects. Because these are partial data, statistical analy-
sis was not performed.
Stimulation effect for a single subject
Figure 5 shows sample EMG data for 1 subject’s rep-
resentative data. The data are from a first (control) night
and from an experimental (stimulation applied) night.
This particular subject exhibited the highest amplitude
bruxism events with a mean amplitude on the first night
of 72.3% MVC. The entire night’s EMG data (up to 8.5
hours) are presented in this 3-dimensional computer
graph. Figure 5, A, shows a high number of strong
muscle contractions. In contrast, the EMG plot with
stimulation shown in Figure 5, B, shows relatively few
strong contractions.
DISCUSSION
In this study, a small electrical switch mounted be-
tween maxillary and mandibular occlusal coverage or-
thotics was used. Closure of this switch produced an
electrical current that allowed stimulation of the lip. In
previous research, contingent auditory feedback was
used to alter the bruxism behavior.11 Electrical stimula-
tion was used because the sound requires an awakening
of the subject to be effective and could cause sleep de-
privation. In prior research, the sound was triggered
416
NISHIGAWA ET AL
with a masseter muscle EMG amplitude change.11 One
disadvantage of this method is that surface EMG elec-
trode signal output varies with skin resistance over the
night as well as from night-to-night even though the
clenching force may be the same. In this study, a me-
chanical switch attached to the orthotics was used to
trigger the feedback. With the use of the electrical
switch, it was easy to control the threshold level and
hopefully achieve a consistent stimulation response. In
this study a random scheduled operation of the stimula-
tion was used instead of using it during the entire night.
This design was selected to evaluate the effect of stimu-
lation by comparing stimulation periods to nonstimula-
tion periods within the same night of data. A final con-
cern with the use of the occlusal orthotic electrical-
switch device as a trigger was that the orthotic itself
might modify the bruxism habit. However, in this re-
search, the subjects who participated had all worn occlu-
sal orthotics before and were still exhibiting clinical ev-
idence of bruxism. Moreover, the subjects were
requested to use the experimental orthotics for 2 weeks
to familiarize themselves with the device before experi-
ment testing.
Overall, the results of this study suggest that contin-
gent electrical lip stimulation can reduce bruxism events
during sleep without significant negative side effects.
The data agree with prior research,15,18 in that this study
also demonstrated that the number of bruxism episodes
during sleep was reduced, but not significantly, by feed-
back (P⫽.107). However, the event duration was sig-
nificantly reduced (P⫽.038). However, there are sug-
gestions in the data that for some subjects (Fig. 5) the
number of events might also decrease with electrical
stimulation of the lip. On the basis of these data the
authors feel justified in rejecting the null hypothesis that
stimulation has no effect on bruxism. In general, these
data are consistent with prior studies that have shown a
decrease in bruxism with contingent feedback. An excit-
ing aspect of the data is that the electrical lip stimulation
did not wake the subjects. Additional, more refined,
tests of sleep state using polysomnography are required.
The probable mechanism of the bruxism suppression
indicated in this experiment is a reflex inhibitory re-
sponse of the jaw closers.1,23,26 Although the data pro-
vide only a short-term demonstration-of-concept that
bruxism can be altered by electrical stimulation, it ap-
pears that there were no obvious negative side effects of
contingent mild noxious lip stimulation. These data are
consistent with a study by Miki et al24 who reported on
the effects of submental electrical stimulation during
sleep. They found that electrical stimulation during
sleep did not produce an arousal in EEG or a change in
the sleep stage, and there were no significant changes in
blood pressure or heart rate between the with and with-
out stimulation periods. An added advantage of electri-
cal stimulation is that it does not disturb a subject’s
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NISHIGAWA ET AL
spouse or roommate, whereas the nocturnal auditory
feedback method has this potential.
The amount of electrical stimulation applied is a con-
troversial issue. Lund et al26 concluded that the thresh-
old of the inhibitory reflex response is below the pain
threshold. Nevertheless, in this study the stimulation
level was set individually to be a slightly painful stimula-
tion to make its effect clear. Additional testing of thresh-
old levels would be appropriate. Finally, the actual volt-
age used for the stimulation was individually set to each
subject’s report of his or her pain threshold. This was
necessary because the threshold level for the percutane-
ous electrical stimulation varies with sex, age, weight,
emotion, lip thickness, and skin resistance. The remain-
ing question is whether any long-term extinction of the
bruxism behavior can be achieved with this method. The
limitation of this data is the small number of subjects and
that nightly recordings after the experimental simulation
stopped were not performed to determine if a return to
pre-treatment levels occurred. Power calculation of the
statistical testing ranged from a low of 42% to a high of
63%, which is inadequate for any generalization of the
data to other situations. Further investigation is neces-
sary to resolve these questions.
CONCLUSIONS
The reduction in bruxism events reported in this
study are noteworthy, especially considering that stim-
ulation was delivered for only half of the sleeping period.
On the basis of the data from this limited pilot study,
contingent electrical lip stimulation for bruxism appears
to be a promising method for controlling this disorder,
but clearly additional data and further analysis are
needed.
We thank Dr. Takashi Ikeda for his assistance in this research.
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Reprint requests to:
DR GLENN T. CLARK
ORAL BIOLOGY AND MEDICINE
UCLA SCHOOL OF DENTISTRY, CENTER FOR HEALTH SCIENCES
LOS ANGELES, CA 90095-1668
E-MAIL: glennc@dent.ucla.edu
Copyright © 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$30.00 ⫹ 0
doi:10.1067/mpr.2003.82
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