Psychiatric Medications for Bruxism
For bruxism, tricyclic antidepressants (specifically amitriptyline) and anticonvulsants (gabapentin) are the recommended neuromodulatory medications, while SSRIs should be avoided as they can induce or worsen bruxism. 1
First-Line Psychiatric Medication Approach
Recommended Agents
Tricyclic antidepressants and anticonvulsants are the preferred psychiatric medications for bruxism management. 1 The 2023 BMJ guideline specifically identifies amitriptyline and gabapentin as neuromodulatory medications for temporomandibular disorders associated with bruxism. 1 The Royal College of Dental Surgeons of Ontario (2019) similarly recommends tricyclic amines and anticonvulsants as first-line pharmacologic options. 1
- Amitriptyline is the most commonly recommended tricyclic antidepressant for bruxism, particularly when associated with TMD pain 1
- Gabapentin serves as an alternative anticonvulsant option with neuromodulatory properties 1
Medications to Avoid
SSRIs should be avoided in patients with bruxism as they can induce or exacerbate teeth-grinding. 2, 3 Research demonstrates that SSRIs are considered aggravating factors for bruxism, and chronic SSRI treatment does not improve—and may worsen—both sleep and awake bruxism. 2 This is particularly problematic because SSRI-induced bruxism can further exacerbate temporomandibular joint disorders. 3
Special Considerations for Comorbid Psychiatric Conditions
When Depression or Anxiety Coexists
If a patient with bruxism requires treatment for comorbid depression or anxiety, alternative antidepressant classes should be prioritized over SSRIs. 3
- Buspirone is effective for treating both anxiety and SSRI-induced bruxism when SSRIs cannot be discontinued 3
- Dopamine agonists are currently the most effective medications to treat SSRI-induced bruxism side effects 3
- Pregabalin (375 mg daily) has shown complete resolution of awake bruxism in a patient with generalized anxiety disorder 4
Anxiety-Related Bruxism
The severity of social phobia and anxiety directly predicts the presence of oral parafunctional activity including bruxism. 2 When anxiety is the primary driver:
- Pregabalin at 375 mg daily demonstrated complete disappearance of awake bruxism in a patient with generalized anxiety disorder 4
- Effective treatment of the underlying anxiety disorder may mitigate bruxism symptoms 2
- Muscle relaxants are listed as first-line options by the Royal College of Dental Surgeons 1
Critical Pitfalls to Avoid
Never prescribe SSRIs (fluoxetine, sertraline, paroxetine, escitalopram, fluvoxamine) as first-line treatment in patients with existing bruxism. 1, 2, 3 Common SSRI side effects include bruxism, which can manifest as teeth-grinding and jaw clenching. 1
Do not rely solely on medication without addressing behavioral and mechanical factors. 1 Psychiatric medications should be part of a conservative, reversible treatment approach that includes occlusal appliances, jaw exercises, and cognitive behavioral therapy. 1
Avoid benzodiazepines for chronic anxiety management in bruxism patients, particularly in children, due to concerns about disinhibition and the risk of tolerance and addiction. 1
Clinical Algorithm for Medication Selection
If bruxism is the primary concern without psychiatric comorbidity: Start with amitriptyline or gabapentin as neuromodulatory agents 1
If generalized anxiety disorder coexists: Consider pregabalin (titrate to 375 mg daily) which addresses both anxiety and bruxism 4
If depression coexists: Avoid SSRIs; consider tricyclic antidepressants (amitriptyline) which treat both depression and bruxism 1, 3
If patient is already on SSRIs with new-onset bruxism: Add buspirone or a dopamine agonist to counteract SSRI-induced bruxism, or switch to a non-SSRI antidepressant 3
If social phobia is the underlying driver: Treat the anxiety disorder effectively, as this may reduce bruxism without specific anti-bruxism medications 2
Monitoring Considerations
Screen for both dental and psychiatric symptoms concurrently, as this dual approach improves prognosis for both conditions. 2 Patients on tricyclic antidepressants require monitoring for anticholinergic side effects, cardiac effects, and sedation. 1 Those on anticonvulsants need monitoring for cognitive dulling, sedation, and mood changes. 1
Stress sensitivity and anxious personality traits are responsible for bruxism activities that lead to temporomandibular pain, which is then modulated by psychosocial factors. 5 Therefore, addressing the underlying psychiatric condition is essential for long-term bruxism management.