Teeth Grinding (nocturnal bruxism) – Hypnotherapy in Glasgow
International Journal of Clinical and Experimental Hypnosis
This article describes a case study of a hypnotherapeutic treatment of nocturnal bruxism. The author saw the client for a total of 7 sessions. Hypnotherapy was interspersed with an exploration of tacit and initially denied hostility in the client’s life as well as aspects of a somewhat difficult childhood. At the end, the bruxism had disappeared. Follow-up 1 year later indicated that the bruxism had not returned, and the client had become more assertive in her relations with others and had more exploratory activities in her life directions. The latter had not been dealt with in therapy. Thus, there appeared to be a “ripple effect” of successful therapy from one part of her life into its other aspects.
Bruxism is a subcategory of temporomandibular disorders (TMD) and is defined as an involuntary grinding or clenching of the teeth, either nocturnal or daytime (Biondi & Picardi, 1998; Lobbezoo, van der Zaag, & Naeije, 2006). As measured by electromyography (EMG) recordings during sleep, there are two distinctly different behaviors: high amplitude, brief, and rhythmic EMG bursts that can vary in duration and that are associated with grinding, gnashing, or tapping; and arrhythmic, high amplitude activity (typically of short duration) associated with clenching. Grinding usually occurs at night whereas clenching may occur during the day or night (Glaros, 2006).
Bruxism is more common in the adult population than one might think. It has been estimated as comprising between 5% and 10% (Biondi & Picardi, 1998), about 8% for sleep bruxism (Glaros, 2006) and about 10% of all adults (Lobbezoo et al., 2006).
Causes of Bruxism
The causes of bruxism have been somewhat controversial. For years it was thought to be caused mainly by malocclusion of the jaw (Lobbezoo et al., 2006; Simon & Lewis, 2000). It has also been thought that TMD in general could be related to a specific personality type (Simon & Lewis, 2000), but this hypothesis has not been well supported. Some personality studies of bruxers suggest that they may be shy, rather stiff, cautious, or aloof, may have difficulty expressing themselves and may be worry-prone (Glaros, 2006). Simon and Lewis also suggest that some proportion of TMD patients might have experienced some form of physical, emotional, or sexual abuse earlier in life. There is some evidence that bruxism may be caused by sleep disturbances, such as snoring and obstructive sleep apnea syndrome (e.g., Sjoholm, Lowe, Miamoto, Fleetham, & Ryan, 2000).
Taken together, this evidence suggests that bruxers may be especially anxious and stress-prone, and, indeed, that seems to be the case. Orlando, Manfredini, Salvetti, and Bosco (2007) reported evidence that TMD patients in general possessed higher levels of anxiety, depression, and somatization than patients in general. Lobbezoo et al. (2006) reported that cross-sectional studies indicated bruxers showed greater levels of hostility and depression and greater stress sensitivity. Glaros (2006) argued that bruxism may be linked to aggression and anger.Zarren and Eimer (2002) stated that referral sources indicate bruxers have trouble relaxing.
Treatment of Bruxism
It should be stated at the outset that the therapeutic treatment approach depends on the medical and dental history of the patient. There are medical/dental options available, such as the use of an occlusal splint, the reduction of early contact during dynamic and static occlusion, and physiotherapy and orthopedic treatments. Medical and dental causes of bruxism must be ruled out before a therapy focusing only on psychological or hypnotherapeutic treatment is begun.
Orlando et al. (2007) conducted a comprehensive evaluation of studies demonstrating the effectiveness of a variety of biobehavioral therapies in treating temporomandibular disorders. These included EMG biofeedback, relaxation techniques, cognitive-behavior therapy, as well as hypnosis. They concluded that all forms of biobehavioral therapies showed some effectiveness. They noted that hypnotic techniques were not as time consuming as EMG biofeedback or relaxation techniques but commented on the need to compare it directly with other treatments. They recommended that future researchers directly compare biobehavioral treatments with occlusal appliance therapies.
Anecdotal reports suggest that hypnosis has been used for treating bruxism for some time, althoughSimon and Lewis (2000) noted a dearth of clinical research on the topic. They found only one broader-scale study, which showed that TMD patients treated with hypnosis showed an average 27% decrease in pain scores. There were only 12 subjects in the hypnosis treatment group, however. Their study, involving 28 patients with TMD seen for six sessions, showed that the patients exhibited a significant decrease in symptoms in terms of reduced frequency, duration, and intensity of pain. The patients also showed significant improvement in their daily functioning, a sort of ripple effect. Furthermore, treatment gains were maintained at 6 months post treatment, and they exhibited significantly fewer outpatient medical visits after treatment. Simon and Lewis also discussed evidence indicating that a carefully constructed hypnotic induction with posthypnotic suggestions for symptom control would be more effective than general relaxation. They argued that hypnosis may be more effective because bruxism symptoms occur at an unconscious level, and non hypnotic treatments operate at a conscious level. Hypnosis can address the symptoms at an unconscious level.
Clarke and Reynolds (1991) published a pilot study consisting of 8 subjects with symptoms of bruxism. They called their technique suggestive hypnotherapy to distinguish it from other techniques such as uncovering or cognitive therapy. The number of sessions ranged from four to eight. The hypnotherapeutic treatment was not well described but examples were the use of the phrase, “lips together, teeth apart” and images such as hot towels on the face. Subjects were asked to let themselves drift off as in a dream. At post treatment, EMG activity was significantly lower, and subjects reported less pain at post treatment and at follow-up (ranging from 4 to 36 months). Their sleep partners also reported hearing less bruxing noise.
There have been a number of published case studies on the use of hypnosis in treating bruxism. Somer (1991) describes the treatment of a 55-year-old man who had become dependent for the last 10 years on a dental splint at night. The splint prevented the teeth from over closing. First a hypn oanalytic exploration was conducted to uncover an earlier conflict with his father that had been reactivated in his current work situation. Cognitive behavioral hypnosis was then conducted, involving suggestions that his mouth would be much more relaxed during sleep and that he would wake up if he attempted to grind his teeth. This 20-minute session was audiotaped, and the patient was instructed to play it every night before bed. Posttherapy evaluations after 1 month indicated the client had a lower level of distress, and he was able to discontinue the use of the splint. Further follow-up contacts at 3, 6, and 12 months showed the maintenance of gains.
LaCrosse (1994) described the brief hypnotic treatment of a 60-year-old woman who had a 60-year history of nocturnal bruxism. Occlusal dental treatments, including splints, had been previously unsuccessful because she ground through them in her sleep. Her husband complained he could hear her grinding at night. A pretreatment assessment indicated she suffered from social anxiety and guilt from not having more than one child. She also had eczema and described herself as a “worrier.” Prior to hypnosis the client was given the paradoxical injunction of “worrying constructively.” She was asked to spend 30 minutes each day writing about worrisome thoughts. According to the paradoxical interventions literature (e.g., Dowd & Trutt, 1988), this should have the effect of sabotaging her worry. After conducting several structured inductions, the author conducted (in a commendably detailed description) a hypnotic routine around the theme of less worry and “better” worry. He then instructed the client to immediately awaken should she feel her teeth coming together or her jaw tightening. Three days after the second session, she reported no nocturnal grinding, which was confirmed by her husband. She had stopped wearing the splint and reported she had almost nothing to worry about. Her gains were maintained at 2 years post treatment.
Wardlaw (1994) described the hypnotherapeutic treatment of a 40-year-old woman who apparently had been bruxing for 9 years. The author (a dentist) used a combination approach, including a muscle relaxant (Mersyndol), a conscious awareness exercise of tooth contact, an occlusal splint, and hypnosis to reduce anxiety by relaxation of the body and the jaw. During hypnosis, the client was instructed to concentrate on the hypnotist’s voice and let all other sensations become less and less noticeable. It was then suggested that whenever she felt herself clenching or grinding she would open her mouth slightly, allowing her jaw muscles to become loose and relaxed. Later, there were suggestions of subconscious awareness of possible tooth damage and (posthypnotic suggestion) that the splint would become part of the self. At the end of the sixth session, the client reported that she had been sleeping through the night, that her jaw was much less sore, and that she wore the splint much less. She also seemed happier.
Zarren and Eimer (2002) presented the treatment of nocturnal bruxism and almost constant headaches in a 46-year-old bank president. The problem was cured in two sessions. The therapist created a “healing place” by helping the client to relax deeply, then feeling very comfortable, and moving beyond the discomfort into positive, comfortable feelings while deeply relaxed in hypnosis. He instructed her to practice this exercise as a form of self-hypnosis before work each day. After work, the client was asked to conduct this exercise again and to relax deeply before bed. Suggestions were also made that she would experience much less pressure at work. By the second visit, the problem had largely disappeared.
The Case of A. B.
The literature just reviewed indicates that hypnotherapy is an effective treatment for bruxism. The hypnotic interventions have not usually been described in detail, but it appears that direct suggestions for unclenching and jaw muscle relaxation were more commonly used. Only LaCrosse (1994) seemed to use more indirect suggestions around themes related to (and possibly causative of) bruxism rather than the bruxism itself. In the following case study, I will describe the treatment of a 33-year-old woman who had been bruxing for many years. The hypnotic-treatment focus largely dealt with the psychological aspects of the bruxism, not the bruxism itself.
History and Psychological Assessment
A. B. went through the comprehensive intake process in the Psychology Clinic at Kent State University. She reported that she had been bruxing for more than 20 years, only at night. The result had been a sore jaw most mornings and consistent sleep interruption. She has worn a mouth guard to prevent tooth damage but has worn each of those out in 6 months or less. She even had oral surgery at one point on one jaw, which was marginally helpful. She seemed somewhat aware that her symptoms might be stress related and said she had done a variety of things to help manage her stress. She was not able to determine if her bruxing was related to daily events. Her dentist finally told her there did not appear to be a medical or dental reason for her problem, which was why she sought psychological help. She expressed three goals for treatment: (a) decrease the amount of grinding and clenching, (b) experience less jaw pain, and (c) sleep better as a result of less pain.
A. B. did not experience any other significant problems in her life. She was happily married with two small children. She reported good relations with her parents and her one brother. She was described by the intake worker as high functioning with a circumscribed problem, non defensive and engaged in the intake process. She was given an Axis I diagnosis of 799.9 (deferred), Axis II of 71.09 (no diagnosis), Axis III as Temporal Mandibular Joint Pain, Axis IV as caregiver for two young children (and temporarily her younger brother), and Axis V as 78 Global Assessment of Functioning.
A. B. also completed a series of psychological tests. These indicated that she was not currently experiencing psychological turmoil in her life and was free of disabling anxiety and depression. She appeared to have a positive self-concept and to be confident of herself and her abilities. There were hints of an earlier excessive use of alcohol and other substances but not currently. However, she exhibited a tendency to minimize her problems and to present an overly positive self-concept that might prevent her from admitting any problems she might be having. There was also an indication that she was suppressing anger.
I first conducted a medical and dental “rule out,” which is important before beginning psychological treatment. About a year earlier, A. B. had jaw surgery that did reduce the pain somewhat and allowed her to open her mouth wider, but it had only a temporary effect on the bruxism. Her physician ruled out fibromyalgia and said she might have “restless jaw” syndrome. She was prescribed Klonopin that did eliminate her sore jaw but not the bruxism. Valium was not helpful. She stated she did not want to be on drugs. Her pain was only in the left jaw and sometimes she had headaches. The pain was worse while chewing and as a result she had given up eating meat.
A. B. was hesitant about discussing anxiety in her life but she did say she felt anxious about keeping everything in her life in order. She was anxious about time and her ability to do everything, as well as about having to give up her way of doing things after marriage and children. She was able to reduce her anxiety by making lists of things to do even if she didn’t do everything. She also tended to reduce anxiety by smiling. When asked about anger in her life, A. B. stated she had none. Upon further discussion, she stated she did sometimes feel anger toward her husband but preferred to call it frustration. A. B. reported she had no aggression in her life. Rather, when things don’t go well for her she feels “deflated” (drained).
During her childhood, she felt loved but reported her parents had a volatile relationship that scared her. She described her role in the family as the “peacemaker” and she now considers herself as the one who “has it all together” in the family. Her brother was always the baby, and she said he was very “needy.” She said her relationship with her husband was good and that they complemented each other well.
She said her bruxism problem began about 20 years ago, and I asked her what happened at that time. She could not think of anything so I asked her to reflect upon it and I would ask her again next time.
A. B. thought about what had happened 20 years ago and talked about her volatile parents. She never knew what would trigger her mother’s outbursts, and there was much tension. Even now she said she feels tension in her interactions with others. She traveled with her brother to visit a relative and he also thought her family role was the “peacemaker.” She also learned there had been other “clenchers and grinders” in the family about two generations ago, suggesting perhaps there was a genetic component to her problem.
I discussed the common myths about hypnosis with A. B., which I always do to disabuse clients of certain common cultural ideas, such as hypnosis will magically remove their problem without effort on their part. An initial assessment of hypnotic susceptibility (or trance capacity) indicated she was moderately susceptible. Based on the results of her psychological tests and the first session, I conducted a hypnotic routine with A. B. around themes of allowing herself to “let go” and to learn new things about herself. I suggested that her “unconscious mind” (a metaphor, following Milton Erickson) would begin to learn new ways of acting in the world. During our subsequent discussion of her hypnotic experience, A. B. became quite emotional and cried. I encouraged her to feel the emotionality and to describe it. She said she has wanted to let go for some time but hadn’t quite been able to put it into words. She has devoted much of her life to “having it all together” and the idea of letting go makes her feel very vulnerable. She reported she wanted to be vulnerable but is scared of it at the same time. I suggested she might be afraid of being hurt by others and that “having it all together” can indeed avoid hurt but can also create much stress in her life. Given her tendency to work hard at everything, I mentioned the paradoxical difficulty of letting go by trying to accomplish it and suggested she simply allow it to happen (Dowd & Trutt, 1988). She said she would try to “wrap her mind around” this difficult (for her) concept.
A. B. reported with excitement that “something worked!” Specifically, she reported that she did not wake up during the last week with a sore jaw and was sleeping better. She also reported that the pain in her jaw had lessened. In addition, during the week she had a revelation: She wanted to shed her peacemaker role. She had realized that she was unable or unwilling to express her own opinions while under stress. She simply “shut down.”
I conducted a hypnotic routine organized around themes of shedding old roles in life and old discomforts and pains. While she was in trance, I suggested that her strategy in life so far had been conservational, in that she was protecting herself. She could now begin to adopt a strategy of being transformational. I likened it metaphorically to adding new rooms to an existing house; the central core of the house (herself) remains the same, while new rooms (representing new actions, new ways of looking at things, new ideas) undergo significant change. The same person grows and develops while remaining centrally the same. I used the phrase “growing and developing; developing and growing” repeatedly in the routine. I suggested she could allow her unconscious mind to find new ways of being, new ways of thinking, and new ways of developing.
Afterward, A. B. reported that during the trance she felt “not in her body,” that her mind was partially detached from her body. She remembered my use of the word “transformational” and we discussed what she would like to be. She said she wanted to be more assertive and more an advocate for herself.
We discussed areas in her life in which she wished to practice this and it was first with her mother. She has learned to avoid stress with her mother by never disagreeing, because of her mother’s volatile and reactive nature. I asked her to practice disagreeing with her mother during the next week. Upon further discussion, A. B. became quite emotional. She was afraid she would turn out to be just like her mother, especially with regard to her daughter. We discussed A. B.’s attempt to be the opposite of her mother and the cost to her. She had countered her mother’s reactivity by being completely nonreactive.
A. B. came in quite excited because she had slept 10 hours last night. She reported the following new developments:
|•||Therapy is really going fast, which pleases her.|
|•||She was able to stand up to her mother on an issue and her mother backed off. Previously she would have second-guessed her own ideas.|
|•||During the last week, she dreamed about clenching and grinding three nights but in the morning she had no jaw pain at all. Only two mornings did she experience and jaw pain.|
|•||A coworker with whom she has a good relationship told her she puts up walls. This was new for her.|
|•||She was able to let go of control in a small situation and felt a release in doing so. In fact, she could feel tension escaping.|
We discussed from what the walls were protecting her. She struggled for an answer but finally said, “Afraid of being hurt; afraid of others seeing who I really am; afraid of receiving from others.” She did say she had been hurt by people earlier in her life with whom she no longer has contact.
A. B. had found the previous hypnosis sessions to be quite valuable. Accordingly, I conducted another around themes of making new connections among her thoughts, feelings, and actions as she grows and develops. I suggested these connections will go around, under, through, and over her walls, gradually crumbling them and making them more permeable and transparent. I further suggested that as she continues to grow and develop she will no longer need her old ways of coping and the discomfort to her mind and body (metaphorically the jaw pain) they have produced.
After the hypnotic session, A. B. reported she felt very energized and positive. She learned that she can eliminate “old things” and find where she is comforted. She wanted to find what brings her joy and wanted to be more self-assured and confident.
We discussed her relationship with her father, and she has no issues with him as she has with her mother because he is more predictable than her mother, who is volatile and unpredictable. With other people, she does a considerable amount of “spectatoring” (i.e., watching her reactions in the encounter rather than focusing on the other person). This is stressful for her and reduces her spontaneity. I asked her to continue being more assertive with her mother.
A. B. reported that she enjoys the therapy process, and things are becoming clearer for her. For example, she has noticed that she “spectators” when she thinks she will be judged by others. She has even noticed “spectatoring” during e-mail and phone conversations that she uses to protect herself from being fully present with another.
Her jaw pain was noticeable three mornings last week, an increase from the previous week but was not as severe (a decrease). Last week was an especially stressful week for her. She described in some detail some friends earlier in her life that treated her quite badly and with whom she eventually broke off contact. Her interactions with them had left her thinking she was never a good enough friend, because they constantly found fault with her. She realized they still had an impact on her life.
I discussed the Minnesota Multiphasic Personality Inventory (MMPI) with her, particularly her social anxiety, high need for affection, and inhibition of aggression. She was surprised about the last item, and I reminder her she had denied at first feeling angry or aggressive. After a short hesitation and with some emotion, she said, “I really AM angry!” She has been afraid to admit it because she might become like her mother. For the next session, I asked her to do something different for herself and to meditate briefly each day on her anger.
I suspected this session would be unusually long and intense, so I set aside 2 hours in the Psychology Clinic. But even I did not suspect the intensity of the resulting 1½ hour session. We began by discussing A. B.’s homework assignments. She had combined them and created a large double-sided drawing. On one side were all the aspects she thought typified her, good and bad. Most were positive and many of the negative had some positive features. On the other side were all the things that made her angry.
A. B. described these in great detail, and my response was to encourage her to continue and to offer clarifications. Two themes were especially prominent: her lack of assertion (at least in her relationships) and the fear that governed this part of her life. I asked her who she really was and she said she didn’t know. I repeatedly pushed her to feel and express her anger rather than deny it. She responded well, although at times she was clearly uncomfortable expressing strong negative emotion. Most of the session was characterized by a high level of emotionality on A. B.’s part.
Near the end of the session, I conducted a hypnotic routine around themes of “letting go” (multifaceted), and I connected letting go of her fear with letting go of the pain in her jaw (phrased as discomfort). Afterwards she reported very little jaw pain during the last week and said she can now eat nuts, which she couldn’t before.
Whereas the previous session had been unusually long, this one was quite short. A. B. reported she has learned many things. She has learned how much anger she had at herself and is breaking down the walls separating her from others. During the last week, she was irritated for two days (for reasons she could not discern) with some jaw pain. She was then relaxed for the rest of the week and her pain disappeared.
Most important, she has learned to let go of her anger and feels good about it. She has discovered the connection between her emotional states and her jaw pain. Her relations with her mother have improved and she is able to be more assertive with her. She no longer feels exhausted and her husband has remarked she is more playful. We agreed to terminate with the understanding she could return later if necessary. Her final comment was, “I’ve learned so much about myself!”
I conducted a final hypnotic routine in which I spoke to her “unconscious mind” and repeatedly suggested she could let go of her fear and her anger because she no longer needed them. She could let go of her jaw “discomfort” because she no longer needed it either. They were, I suggested, elements of her past she has now outgrown. As in past hypnosis sessions, A. B. could not recall the details of the routine after coming out of the trance.
About a year later, I called A. B. and asked her about the treatment outcome. She reported that the jaw pain had not returned. Furthermore, her relationship with her husband and especially her mother had continued to improve. She had even made plans to return to school for an advanced degree and said, “I don’t think I would have done that before.”
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This case was a treatment success. The client demonstrated the pattern of psychological symptoms noted in the literature: that bruxers may be especially anxious and stress-prone. It also is in line with Lobbezoo et al. (2006), who found bruxers to show greater levels of hostility and stress sensitivity, and Glaros (2006), who argued that bruxers may show aggression and anger. In A. B.’s case, becoming aware of her anger and aggression seemed to be a catalyst for symptom reduction.
This was also a brief treatment, consisting of only eight sessions including intake. A. B. was basically an intact, psychologically healthy young woman, whose problem was relatively circumscribed and who did not possess major personality disturbances developed over many years. Such clients are usually able to make gains relatively quickly. She had a supportive family with whom she was close. The major problem appeared to be her somewhat conflicted relationship with her mother whose interactions might be considered mildly emotionally abusive at times, thus providing another condition for the development of bruxism (Simon & Lewis, 2000). However, A. B.’s relationship with her mother was also characterized by a great deal of empathy and understanding for her mother’s own life issues. Their relationship was not seriously strained. In addition, there had been earlier problematic relationships with a few friends. Some of these problems may represent the ordinary struggles of life we all face on occasion.
This case also illustrates the usefulness of comprehensive psychological assessment prior to psychological therapy as well as the necessity of eliminating medical or dental causes before beginning psychological treatment. The MMPI and other instruments quickly identified the suppressed (and unacknowledged) anger A. B. felt. It is likely I could have discovered it in the sessions themselves, but it might have taken longer. The assessment also identified A. B.’s relatively nondefensive nature, thus allowing me to proceed more quickly.
The reader should be able to see some differences between the hypnotic suggestions in the case studies described earlier (although details of the hypnotic suggestions were often quite sparse) and my own style of hypnotic routine construction. I usually do not use direct suggestions for symptom reduction or elimination because they may increase client resistance and thereby damage the therapist’s credibility. Rather, I tend to follow the model developed by Milton Erickson who advocated utilizing or bypassing resistance (e.g., Erickson & Rossi, 1979, 1981), often by speaking to the “unconscious mind” (although that is a metaphor) and using metaphor itself and stories to avoid arousing resistance. It can be easier to accept a story ostensibly about someone else rather than about one’s own self. Lankton (1982) indeed advocated various resistance-bypassing strategies, both within and outside of the hypnotic trance, of a paradoxical and accepting nature. I often construct these hypnotic routines around cognitive processing distortions and cognitive structural themes I discover in the client’s internal mental life. These cognitive themes are what experimental psychologists call tacit or implicit knowledge, Aaron T. Beck and Judith S. Beck call core cognitive beliefs, and Freud might have called the unconscious (see Dowd, 2006, for more details). In my bookCognitive Hypnotherapy, I provide a more extended description of these cognitive phenomena as well as a number of descriptions and illustrations of hypnotic routines addressing several clinical disorders (Dowd, 2000).
Then there is the question of whether hypnosis itself added significantly to the outcome of this case. Might standard psychotherapy, without the hypnotic routines, have performed just as well? Without conducting dismantling studies, this question is difficult to answer. LaCrosse (1994) discussed this problem and tentatively concluded that hypnosis provided value-added therapeutic power beyond that provided by motivation, readiness to change, high expectations for change, and (in the case of A. B.) a basically intact, psychologically healthy person with circumscribed problems. In addition, Lynn, Kirsch, Barabasz, Cardeña, and Patterson (2000) documented the effectiveness of hypnosis in treating a wide variety of medical and psychological disorders. Kirsch (1990) and Kirsch, Montgomery, and Sapirstein (1995) found that the addition of hypnosis enhanced the effectiveness of psychodynamic and cognitive-behavioral therapy. Thus, it appears that the use of hypnosis in treating clinical problems adds significantly to the achieved outcome.
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