mini-review
J. Stomat. Occ. Med. (2008) 1: 5157
DOI 10.1007/s12548-008-0010-8
Printed in Austria
Springer-Verlag 2008
The masticatory organ and stress management
S. Sato1 , R. Slavicek2
1
Department of Craniofacial Growth and Development Dentistry, Division of Orthodontics,
Kanagawa Dental College, Yokosuka, Japan
2
Danube University Krems, Austria
Received September 20, 2008; Accepted October 1, 2008
In humans, the strong grinding and clenching function of the
masticatory muscles known as bruxism has been thought
to play an important role in mitigating stress-induced psy-
chosomatic disorders by down-regulating the limbic system,
the autonomic nervous system, and the hypothalamic-pitui-
tary-adrenal axis. Experimental research results showed that
bruxism-like activity has benecial effects on stress-induced
reactions such as increasing expression of Fos protein, neu-
ronal nitric oxide synthase, phosphorylated extracellular sig-
nal-regulated kinase 1/2, corticotropin-releasing factor, and
free radicals in the paraventricular nucleus of hypothalamus,
alterations in the blood neutrophil/lymphocyte ratio and
adrenocorticotropic hormone level, and stomach ulcer for-
mation in animal studies, as well as increasing amygdala
neuronal activity and salivary chromogranin A level in human
studies. All of these ndings strongly suggest that bruxism-like
activity of the masticatory organ has the ability to decrease
stress-induced allostatic overload. The health of the mastica-
tory organ depends critically on occlusion, which must be of
sufcient quality to successfully carry out its important role in
managing stress. Occlusion and the brain must function in
harmony. For these reasons, we must integrate the study of
occlusion into the broader scope of medical science; in so
doing, we will meaningfully advance the state of the art of
dental care and general health care.
Keywords: Bruxism, stress, masticatory organ, brain,
allostasis
Introduction
The human body is a set of parts so related and interconnected
as to form an organic whole. It is considered a functioning
organism with a number of bodily organs acting together to
perform all of the functions necessary for life and health. The
masticatory organ is a unique system in the body from
physiological and psychosomatic points of view. The normal
process of mastication consists of a series of highly coordinat-
ed movements of the lower and upper jaws, lips, cheeks,
tongue, temporomandibular joints, and other oral and peri-
Correspondence: Sadao Sato, Research Center of Brain and Oral Science,
Kanagawa Dental College, 82 Inaoka-Cho, Yokosuka 238-8580, Japan.
E-mail: satos@kdcnet.ac.jp
J. Stomat. Occ. Med.
oral structures. In addition to mastication, the masticatory
organ plays essential roles in speech, respiration, swallowing,
maintaining posture, and stress management through the
clenching and grinding of bruxism. Therefore, dentists must
observe more than just the static t of upper and lower teeth as
they diagnose and treat stomatognathic disorders, and they
must recognize that they are custom-tailoring treatments to
the complex physiological system of each individual.
The masticatory organ is closely related to the brains
limbic system and to express emotions as a functional unit.
Therefore, we look forward to the day when dental practi-
tioners view stress medicine and dental occlusion as two parts
of an integrated whole a eld of study in which two concepts
play central roles: the concept of a centrally regulated feed-
back control system and the concept of the stress bruxism
axis. The role of the masticatory organ as a stress release valve
must be recognized as the most important component of
occlusion dentistry [13].
Aggression and the masticatory organ
The limbic system has been described in reference to emo-
tionally related areas of the brain and the pathway that
interconnects them. These areas are generally composed of
sites that function to alter emotions. Therefore, the mastica-
tory organ is considered to be directly or indirectly related to
the limbic system. Modern humans retain this connection;
however, this organ is more frequently used for the expression
of aggression in the form of sleep bruxism, because the newly
developed brain cortex suppresses aggressive behavior in
modern humans.
Interestingly, according to phylogenesis, many animal
species grind their teeth as a component of their response to a
threatening or stressful situation. Every [4, 5] proposed that
animals use their teeth and jaws as weapons to bite and kill,
and as tools to divide, hold, and snarl. The primitive hominoid,
particularly in the pre-tool era, would have immediately
extruded his mandible laterally when facing an appropriate
stress situation. Although this action in civilized Homo sapiens
has been apparently eliminated as instinctual, it nevertheless
occurs during sleep.
The human masticatory organ has evolved over a long
period into an organ for emotional management, having
The masticatory organ and stress management 1/2008 51
 mini-review
passed through stages in which the organ was used predomi-
nantly as a tool or as a weapon for expressing aggression. It
was suggested that modern humans still use the masticatory
organ when they are psychologically stressed to express
aggression, but it has evolved from a direct expression of
aggression to an indirect expression such as clenching or
grinding the teeth.
Extensive research has shown that psychic stress and
occlusal disharmony are related to bruxism [611]. From a
psychosomatic point of view, unresolved psychic problems
are transferred to the level of organs. Utilizing the masticatory
organ as a stress outlet organ is an efcient and risk-free
solution to the problem of stress management.
From this point of view, the functions of the masticatory
organ are intimately connected with functions of the brain,
both somatically and psychically. The masticatory organ ap-
pears to be basic and necessary to the entire organism and its
role within its environment.
Bruxism and oral disease
Bruxism is dened as a diurnal or nocturnal parafunctional
activity including clenching, grinding, and gnashing of the
teeth. Because sleep bruxism occurs in most humans, sleep
bruxism is a physiological activity that may be a necessary
function or behavior of the human body [1215]. Lavigne et al.
[16] reported that the rhythmic masticatory muscle activity
during sleep was related to certain sleep-related physiological
functions, including autonomic activation. Results clearly
showed that rhythmic masticatory muscle activity was not
associated with the disruption of nocturnal sleep, further
suggesting that this motor activity is a natural activity occur-
ring during sleep. Because sleep bruxism with excessive
muscle activity may damage the oral tissues and cranioman-
dibular system, it has become an important research subject
in clinical dentistry.
Tremendous occlusal forces from bruxism activity,
which may be signicantly greater than those of conscious
efforts by an individual during waking hours, are applied
to teeth and periodontal tissues during sleep bruxism. Con-
sequently, signicant loads are distributed to the dentition,
the periodontal supporting structures, and the temporo-
mandibular joint (TMJ).
A new classication of dental hard tissue lesions was
introduced as abfraction, which is used to designate stress-
induced lesions that result from hyperfunction and parafunc-
tion [1723]. Both tensile and shearing forces contribute to
the loss of hydroxyapatite crystals in the cervical region during
active lesion formation. The location and distribution of
abfractive lesions support this tensile stress-induced bio-
mechanical theory. Drum [24] reported that traumatizing
parafunction played a dominant role in the development of
periodontal diseases. Bruxism activity is also considered to be
a signicant contributing factor to repetitive overloading of
the structures of the TMJ [25]. In the eld of dental research,
however, there have long been controversial discussions
regarding the relationships between occlusion and oral dis-
eases such as TMJ disorders and periodontal diseases.
Because it was clear that tremendous occlusal forces were
exerted by parafunctional bruxism activity, which very much
depends upon the occlusion schemes [2629], contemporary
52 1/2008 The masticatory organ and stress management
concepts of occlusion slowly shifted to concepts based on the
parafunctions of masticatory organ, grinding and clenching
[30]. Therefore, it must be considered that these loads con-
tribute to many oral diseases [31, 32]; that is, excessive loads
cause periodontal breakdown in some cases, and hard tissue
breakdown or temporomandibular disorders in other cases.
In this context, it is necessary to investigate the inuences
of bruxism with excessive masticatory muscle activity on the
following three components: tooth structure (non-carious
cervical lesions, hypersensitivity, wear, and cracks); periodon-
tal tissue (attachment level, mobility, bleeding on probing,
and exostosis); and craniomandibular structure (muscle and
TMJ). It is also crucial to determine the conditions that cause
damage to specic structures or tissues.
Mehta et al. [33] documented the inter-relationship
among indices of periodontal breakdown (Russell Periodontal
Index) [34], temporomandibular dysfunction (Helkimo Dys-
function Index) [35], tooth wear assessment, and parafunc-
tional activity based on the reports of sleep bruxism. About
90% of subjects with moderate and severe bruxism scores had
a high index in only one of the three parameters, suggesting
that the weakest component of the oral system is selectively
affected by strong parafunctional activity. They called it the
Weak Link Theory. Current results [36, 37] also suggested
that bruxism with molar contacts was responsible not only
for the diseases affecting the teeth and periodontal structures,
but also for TMJ dysfunction, which partly supports the Weak
Link Theory.
Effects of bruxism-like activity in animal studies
During the process of evolution, animals have long used the
masticatory organ as an emotional outlet besides its use as a
simple tool for chewing food [4, 5]. In evolution to primates,
there is found a dramatic change in Quantitative comparison
of the amygdala in insectivores and primates [38]. The aggres-
sive zentromedian parts are strongly reduced in comparison
with the Centro-basic-lateral parts of N. amygdale (pleasure
oriented). Therefore, the conscious life-defensive aggres-
sive patterns are more and more reduced to unconscious
movements like clenching and bruxing.
Many animal species grind their teeth as a component
of their response to a threatening or stressful situation. It
has been suggested that modern humans still use the
masticatory organ to express aggression if they are over-
whelmed psychologically. Utilizing the masticatory organ
as a stress outlet is an efcient, risk-free solution to the
problem of stress management [13]. Several pieces of evid-
ence using animal models were proposed in recent years,
in which an activity of the masticatory organ showed an
attenuating effect on stress-induced neurophysiological
events as described below.
Stress-induced tissue reactions
It has been found that experimental rats grind their teeth
spontaneously as a component of their response to a re-
strained stress condition [38], and many research results
showed that bruxism-like activity (BLA) prevented stress-
induced stomach ulcer formation [3944], suggesting the use
of the masticatory organ to relieve stress (Fig. 1).
J. Stomat. Occ. Med.

Fig. 1: Hypothetical model of stress management using the masticatory
organ. The masticatory organ can be used as a tool for emotional outlet,
by whose transferences the unresolved psychic problems to the somatic
system are prevented. Utilizing the masticatory organ for stress man-
agement is relatively free of risk
In rats, the plasma adrenocorticotropic hormone level
was increased 30 min after undergoing restraint stress, while
BLA attenuated the adrenocorticotropic hormone level.
The neutrophil/lymphocyte ratio was reversed only 240 min
after restraint stress application, which might be caused by a
damage to the internal organs such as the stomach, thymus,
and spleen [4547]. All these stress-induced alterations of
physiological parameters were attenuated by BLA in a dura-
tion-dependent manner. The results suggested that the reac-
tions of the hypothalamus-pituitary-adrenal (HPA) axis and
the sympathetic nervous system to the stress were regulated
by BLA of the masticatory organ.
Another animal study with rats to investigate the effects
of BLA on high blood pressure, increasing core temperature,
and chemical mediator accumulation in the serum induced
by restraint stress showed that BLA during restraint sig-
nicantly reduced these parameters compared with those
of rats that did not perform BLA [48]. Differences in body
temperature were visible in infrared thermal images of the
restraint-only and restraint-with-BLA rats (Fig. 2). Biochem-
ical analysis revealed that biting signicantly suppressed
plasma interleukin-1b, interleukin-6, and leptin and that it
signicantly increased thyroid-stimulating hormone. These
data suggest that BLA is a possible behavioral coping skill
that enables an organism to reduce allostatic load.
Fos expression in brain
Animal experiments have shown that BLA signicantly at-
tenuates stress-induced increases in noradrenaline (norepi-
nephrine) turnover in the hypothalamus, limbic areas, and
amygdala [4953]. Moreover, nonfunctional masticatory ac-
tivity attenuates the increase in striatal dopaminergic activity
caused by stressors [8, 11]. It has been shown that psycho-
logical stress such as restraint or immobilization of the
animals induces the activation of c-fos and the expression
of the Fos protein in subsets of neurons in the central nervous
system [54]. It was of particular interest whether masticatory
J. Stomat. Occ. Med.
mini-review
Fig. 2: The effects of BLA on core temperature rise caused by restraint
stress. Thermal infrared images were compared to visualize the changes
in the surface temperature in stressed and stress-BLA rats. BLA attenu-
ates stress-induced increasing body temperature
activity, such as biting a wooden stick (simulated BLA), might
affect restraint-induced Fos protein expression in the rat brain
stem.
Using immunohistochemical methods to detect Fos pro-
tein, the effects of acute restraint stress and BLA on the
neuronal circuits in the rat central nervous system were shown
[55]. Results showed that the restraining rats in the supine
position for 1060 min invariably induced rapid expression of
Fos protein in subsets of neurons in the somatosensory and
motor cortices, paraventricular hypothalamic nucleus (PVN),
locus coeruleus (LC), medial amygdaloid nucleus, and ante-
rior portion of the paraventricular thalamic nucleus. The
suppression of Fos immunoreactivity by BLA during restraint
provides further support for the assumption that parafunc-
tional masticatory activity attenuates adverse effects of psy-
chological stress on the central nervous system.
Corticotropin-releasing factor
Stress-induced activation of the HPA axis is characterized by
enhanced expression of corticotropin-releasing factor (CRF)
in the PVN and the consequent increases in adrenocortico-
tropic hormone and adrenal glucocorticoid in the plasma.
Thus, the CRF expressed in the hypothalamus plays an
important role in mediating behavioral responses to stres-
sors. The number of CRF-expressing neurons in the PVN
increased signicantly after a short-time restraint (30 or 60
The masticatory organ and stress management 1/2008 53
 mini-review
min) followed by a 180-min postrestraint period. BLA during
the restraint stress signicantly suppressed the restraint-
induced enhancement of CRF expression in the PVN [56].
Therefore, it is speculated that the suppression of central
noradrenergic transmission, including the afferent pathway
mediated by LC, might be the mechanism by which CRF is
suppressed by BLA.
Neuronal nitric oxide synthase
Nitric oxide modulates the activity of the endocrine system in
the behavioral response to stress. The effect of restraining the
body of an animal on the expression of neuronal nitric oxide
synthase (nNOS) in the PVN of the hypothalamus and the
inhibitory effect of BLA on restraint-induced nNOS expres-
sion were investigated [57]. An increase in nNOS mRNA
expression and nNOS-positive neurons in the rat hypothala-
mus was observed after 30 or 60 min of restraint stress. BLA
during bodily restraint decreased nNOS mRNA expression in
the hypothalamus. In addition, the number of nNOS-positive
neurons was signicantly reduced in the PVN of the hypo-
thalamus. These observations clearly suggest a possible anti-
stress effect of BLA and how this mechanism might be
unconsciously operating during exposure to psychological
stressors.
Phosphorylation of extracellular signal-regulated protein
kinase 1/2
As described above, acute immobilization stress induces Fos
expression, which is generally used as a marker for neuronal
activity. It has been suggested that Fos expression may be
linked to the phosphorylation of extracellular signal-regulated
protein kinase 1/2 (pERK1/2) in the hypothalamic PVN. An
immunohistochemical study was designed to determine
whether acute immobilization stress induces pERK1/2 in the
PVN and if the stress-induced pERK1/2 is attenuated by
simultaneous BLA behavior [58]. Acute immobilization stress
in up to 15-min increments produced detectable amounts of
pERK1/2 that were proportional to the duration of the stress.
BLA during the acute immobilization stress signicantly re-
duced the amount of detectable pERK1/2. These results
suggest that BLA during acute stress inhibits pERK1/2 in this
region of the brain. It is feasible that the neuronal cellular
response to acute stress is regulated, in some part, by pERK1/2
inhibition due to biting.
Free radicals in the brain
Free radical reactions are involved in oxidative stress mediat-
ed alterations in various physiological conditions. Because
electron spin resonance (ESR) has been recognized as
one of the most powerful techniques for detecting free radicals
in biological tissues and cells, an ESR-based technique was
developed to detect free radical reactions in vivo. In vivo
ESR spectroscopy and ESR imaging can be used to
investigate redox status in living organisms noninvasively and
in real time.
A bloodbrain barrier-permeable nitroxyl spin probe,
3-methoxycarbonyl-2,2,5,5,-tetramethylpyrrolidine-1-oxyl (MC-
PROXYL), was administered to rats, after which L-band ESR
54 1/2008 The masticatory organ and stress management
and ESR-computed tomography (ESR-CT) imaging were
used to show that the decay rate of MC-PROXYL in the
hypothalamus of isolated brain after 30 min of restraint
stress was more rapid than in unrestrained control rats, which
would suggest that restraint was associated with oxidative
stress [59]. BLA suppresses oxidative stress induced by
restraint stress and the anti-stress effect of BLA is important
for reducing the adverse effects associated with exposure to
psychological stressors.
The effect of BLA during restraint stress on nitric oxide
levels in the hypothalamus was examined using a nitric oxide
selective electrode [60]. The levels of nitric oxide were in-
creased by restraint stress and this increase was prevented by
BLA for 30 min, suggesting that there is an anti-stress effect of
BLA.
Brain-derived neurotrophic factor (BDNF)
Brain-derived neurotrophic factor (BDNF) is the most abun-
dant neurotrophin in the central nervous system, and it is
closely involved in survival, maintenance, and neural trans-
mission in neural cells. Acute restraint stress for 60 min
signicantly increased the level of plasma BDNF [61], and it
was suggested that the salivary gland is a primary source of
plasma BDNF in the condition of acute stress [62]. The BLA
also increased BDNF mRNA and plasma BDNF, suggesting
that BDNF derived from the salivary gland provides protective
effects against damage from acute stress [63]. It was also
reported that BLA inuences the alterations in BDNF levels
induced by acute stress in rat hippocampus [64].
Table 1 illustrates the results from animal studies that
have used rats as a stress model.
Effects of bruxism-like activity in human studies
Functional magnetic resonance imaging
A close relationship between the masticatory function and the
brain hippocampus activity and stress events has been de-
scribed [6568]. The amygdala is reported to trigger physio-
logical changes in response to a stressful situation [51, 55]. If
this is true, when the subject encounters a stressful situation,
the amygdala should be activated. To test this hypothesis, an
auditory stimulus (a warning sound) was delivered to the
subject through an earphone and blood oxygenation level
dependent (BOLD) signals were measured using functional
magnetic resonance imaging (fMRI) [69]. Because a stressor
may be perceived differently by different individuals, it was
conrmed that the warning sound was, in fact, stressful to the
subjects. When the BOLD signals were statistically analyzed at
P 0.01, the amygdala was markedly activated and reactive
by this stimulus. However, when the subject chewed gum or
clenched the teeth (BLA) under the same stress condition,
stress-induced activation was mostly avoided. Because the
major efferents of the amygdala include projections to the
septum and hypothalamus, providing not only a subcortical
link for integrating limbic evaluative functions but also the
switched HPA axis. Chewing is also associated with a similar
response but reduced to stress in the amygdala, thereby
decreasing stress-stimulated hormonal activity.
J. Stomat. Occ. Med.
 mini-review

Tab. 1. Summary the effects of BLA studies have identied selective localization of CgA in sympa-
on the stress-induced alterations thetic nerves and radioimmunoassays measuring the secre-
of Allostatic parameters tion of CgA in saliva have been used to evaluate stress
conditions [70, 71]. Strong immunoreactivity of CgA in human
Parameters Change Effect Refs. salivary glands has been observed in the saliva matrix of ductal
by stress of BLA cavities and CgA has been shown to be produced predomi-
Brain nantly by serous cells and secreted into saliva [72].
In a study using 44 healthy adult volunteers, salivary CgA
Fos (PVN)1 increase attenuation [55] was measured by an enzyme-linked immunosorbent assay
(LC)2 increase attenuation [55] (ELISA) using antibody against synthetic human CgA [73]. The
results demonstrated the possibility of evaluating stress levels
(Thalamus) increase attenuation [55]
of individuals by measuring salivary CgA. Salivary CgA re-
(Amygdala) increase attenuation [55] sponds to psychosomatic stress. Bruxism-like grinding activity
3
CRF (PVN) increase attenuation [56] prevented a stress-induced increase in salivary CgA, suggest-
4
ing that the reaction of the parasympatheticadrenomedullary
nNOS (PVN) increase attenuation [57]
system is regulated by the BLA of the masticatory organ.
Free radicals increase attenuation [59]
ERK1/25 increase attenuation [60]
Allostasis and the masticatory organ
6
NO (Hippocampus) increase increase [58]
Allostasis refers to the adaptive processes that protect the body
BDN F7 increase increase [64] by responding to internal and external stress through systems
(Hippocampus)
such as the autonomic nervous system, the hypothalamic-
Blood pituitary-adrenal (HPA) axis, and immune systems [74, 75]. In
Lymphocyte decrease increase [4244] these allostatic processes, epinephrine, cortisol, and other
chemical messengers not only promote adaptation during the
Neutrophiles increase attenuation [4244] aftermath of acute stress, but also contribute to allostatic
ACTH8 increase attenuation overload the wear-and-tear on the body and brain that
results from being stressed. This conceptual framework has
Leptin increase attenuation [48]
created the need to know how to improve the efciency of the
IL1-b increase attenuation [48] adaptive response to stressors while minimizing overactivity
IL-6 increase attenuation [48] of the same systems, because such overactivity results in many
of the common diseases of modern life.
TSH9 increase attenuation [48]
The terms allostasis and allostatic overload allow a
10
ADR increase attenuation [4244, 52] more restricted, precise description instead of the overused
Cortisol increase attenuation [4244]
word stress and provide a view of how the essential protec-
tive and adaptive effects of physiological mediators that main-
Organ tain homeostasis are involved in the cumulative effects of daily
Spleen atrophy prevention [4244] life when they are overloaded. Inactivation of challenge nor-
mally returns the systems to baseline levels; however, if there
Thymus atrophy prevention [4244]
is over-exposure to stress, cumulative changes that lead to
Stomach ulcer formation prevention [3944, 52] potential overloading of the body and brain occur and may
Salivary Cg A 11
increase attenuation [73] result in different patho-physiological consequences.
The experimental results presented here suggest that the
Salivary BDNF increase increase [63] masticatory activity plays a major role in affecting the stress-
Body temperature increase attenuation [48] induced psychosomatic disorders by down-regulating the
limbic system, the HPA axis, the autonomic nervous system,
Blood pressure increase attenuation [48]
and the immune system. Therefore, the occlusion of the
Blood glucose increase attenuation [4244] masticatory organ contributes signicantly to the individuals
ability to manage allostasis. Bruxism in proper dentition can be
1
PVN Paraventricular nucleus, 2LC locus coeruus, 3CRF corticotropin releasing
factor, 4nNOS neuronal nitric oxiide synthese, 5ERK1/2 extracellular signal- recognized as a prophylactic system for stress-related diseases
regulated protein kinase 1/2, 6NO nitric oxide, 7BDNF brain-derived neuro- (allostatic overload). At the same time, we should keep in mind
trophic factor,8 ACTH adrenocorticotrophic hormone, 9TSH thyroid stimulating that the masticatory organ has long been directly related to the
hormone, 10ADR adrenaline,11chromogranine A limbic system and is used to express aggression; thus, this
organ is strongly related to the emotional state of human life.

Salivary chromogranin A
Chromogranin A (CgA) is a 48-kDa acidic, hydrophilic protein
that was originally isolated from chromafn granules of the
bovine adrenal medulla. Later, CgA was found ubiquitously
in the secretory vesicles of neuroendocrine cells. Previous
Conclusion
This overview and the research ndings presented here em-
phasize that the masticatory organ integrates a broad range of
biological functions. The health of the masticatory organ

J. Stomat. Occ. Med. The masticatory organ and stress management 1/2008 55
 mini-review
depends signicantly on occlusion, which must be of suf-
cient quality to successfully carry out its important role of
managing stress. Occlusion and the brain must function in
harmony. Thus, with an understanding of the bruxing function
of the masticatory organ, practitioners will be better equipped
to fully diagnose dental diseases and to design effective
therapies to treat those diseases. For these reasons, we must
integrate the study of occlusion into the broader scope of
medical science; by doing this, we will meaningfully advance
the state of the art of dental care and general health care.
Acknowledgements
This work was performed in Research Institute of Occlusion
Medicine and Research Center of Brain and Oral Science,
Kanagawa Dental College and supported by grant-in-aid for
Open Research from the Japanese Ministry of Education,
Culture, Sports, Science and Technology.
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