Is amitriptyline (tricyclic antidepressant) effective for treating bruxism?

Amitriptyline for Bruxism: Evidence-Based Recommendation

Amitriptyline is not recommended for treating bruxism, as high-quality evidence shows no benefit over placebo for reducing bruxism frequency or associated pain. 1

Evidence Against Amitriptyline Use

The strongest evidence comes from a Cochrane systematic review that specifically evaluated pharmacotherapy for sleep bruxism:

• Three randomized controlled trials found no difference between amitriptyline and placebo for masseteric EMG activity (standardized mean difference -0.28,95% CI -0.91 to 0.34), pain intensity, or sleep duration 1

• The results were statistically imprecise and consistent with benefit, no difference, or harm—meaning amitriptyline failed to demonstrate efficacy 1

• Adverse effects were frequent: 50% of patients (5/10) experienced drowsiness, difficulty awakening, insomnia, or dry mouth compared to 0% in the placebo group 1

Additional Supporting Evidence

A 2020 overview of systematic reviews examining chronic pain related to bruxism confirmed these findings:

• No difference in pain or bruxism frequency when amitriptyline was compared to placebo 2

• The review concluded there is no evidence to support drug therapy (including amitriptyline, bromocriptine, clonidine, propranolol, or levodopa) for sleep bruxism 2

What Actually Works for Bruxism

Based on the most recent BMJ guidelines (2023) and supporting evidence, effective treatments include:

First-line conservative approaches:

• Supervised jaw exercises and stretching provide significant pain relief (approximately 1.5 times the minimally important difference) 3
• Manual trigger point therapy provides substantial pain reduction (approaching twice the minimally important difference) 3
• Cognitive behavioral therapy with or without biofeedback provides substantial pain reduction 3

Second-line options with evidence:

• Botulinum toxin type A shows significant pain and bruxism frequency reduction at 6 and 12 months compared to placebo or conventional treatment 2
• Occlusal splints combined with muscle massage show some benefit for pain reduction 2

Interventions to avoid:

• Occlusal splints alone (without other interventions) have limited evidence despite common use 3
• Biofeedback therapy alone shows no difference versus inactive control 2

Critical Context: When Amitriptyline IS Appropriate

While amitriptyline fails for bruxism itself, it may be indicated for temporomandibular disorders (TMD) with chronic pain:

• The 2023 BMJ guidelines recommend neuromodulatory medications including amitriptyline for TMD management 4
• The Royal College of Dental Surgeons of Ontario (2019) lists tricyclic amines as first-line options for TMD 4
• Start at 10 mg once daily and titrate slowly to maximum 30-50 mg once daily 4

Important Pitfall to Avoid

Do not confuse bruxism with TMD-related chronic pain—these are distinct conditions requiring different treatment approaches:

• Bruxism is involuntary teeth grinding/clenching during sleep 1
• TMD is a broader pain disorder affecting the temporomandibular joint and muscles of mastication 4
• Amitriptyline has no role in bruxism but may help TMD-associated chronic pain 4, 1

Additional Caution: SSRIs Can Worsen Bruxism

If your patient is on antidepressants, be aware that:

• SSRIs (fluoxetine, sertraline, paroxetine) can induce or exacerbate nocturnal bruxism within 2-4 weeks of initiation 5, 6, 7
• This SSRI-induced bruxism may respond to buspirone addition or SSRI dose reduction 5, 7
• Consider alternative antidepressants in patients with pre-existing bruxism 6