Bruxism: Causes and Treatment
Causes of Bruxism
Bruxism is primarily a centrally-regulated condition driven by stress, psychosocial factors, and genetic predisposition rather than peripheral dental factors like occlusion. 1, 2
Primary Contributing Factors
- Psychological stress and emotional tension are the dominant factors leading to increased masticatory muscle tension and bruxism activity 3, 4, 5
- Anxiety syndromes contribute significantly to the development and persistence of bruxism 3
- Genetic disposition plays a role in susceptibility to developing bruxism 3
- Sleep-related factors including sleep positioning and potential protective mechanisms for airway maintenance or saliva flow stimulation 1, 4
Secondary Factors
- Allergies may contribute to bruxism development 4
- Movement disorders may be associated with bruxism in some cases 6
Important Caveat
- Occlusal disorders (bite problems) are NOT a primary cause of bruxism despite historical beliefs—this is why irreversible occlusal adjustments have no evidence basis and should never be performed 6, 1
Treatment Algorithm
Step 1: First-Line Conservative Management (Start Here for All Patients)
Begin with occlusal splints fitted by qualified dental personnel combined with behavioral strategies and physical therapy. 6
Dental Protection
- Hard full-coverage stabilization splints are the primary dental intervention to protect teeth from grinding damage 6
- Splints must account for proper occlusion to avoid adverse events like tooth movement 6
- Fitting must be performed by dental personnel trained in sleep medicine and/or sleep-related breathing disorders 6
- Regular dental evaluations are necessary to monitor treatment efficacy and side effects 6
Behavioral Interventions
- Patient education about the condition and avoidance of aggravating activities 6
- Stress reduction therapy to address the underlying psychological drivers 4
- Improvement of sleep hygiene and alteration of sleep positioning 4
- Cognitive behavioral therapy (CBT) provides substantial pain reduction when pain is present 7
Physical Therapy Techniques
- Massage of masticatory muscles 6, 7
- Heat and/or cold application to affected areas 6, 7
- Supervised jaw exercises and stretching provide significant pain relief (approximately 1.5 times the minimally important difference) 7
- Manual trigger point therapy provides one of the largest reductions in pain severity 7
Step 2: Pharmacological Management for Acute Episodes
Use these medications when conservative measures are insufficient or for acute symptom management:
- NSAIDs for pain management 6
- Muscle relaxants for acute episodes 6
- Amitriptyline has shown some benefit in open-label studies 6
- TRPV1 agonists (capsaicinoids) may help with oral motor control in some patients 6
- Dopaminergic agents may be considered when bruxism is associated with movement disorders 6
Step 3: Interventions to Use Cautiously (Only After First-Line Failure)
These have limited or conflicting evidence and should be approached with caution:
- Botulinum toxin injections to masticatory muscles may reduce bruxism frequency but have concerns about adverse effects; one RCT showed no benefit for TMD 6
- Biofeedback may help develop awareness of muscle tension but has limited evidence and is conditionally recommended against by some authorities 6, 7
- Acupuncture is conditionally recommended and may provide relief for some patients 7
- Low-level laser therapy has insufficient evidence and is conditionally recommended against 6, 7
Step 4: Specialist Referral Pathway
Refer to a dentist with training in temporomandibular disorders (TMD) and sleep medicine as the primary specialist. 6
When to Refer
- Significant tooth attrition, mobility, or fracture 4
- Intractable pain unresponsive to initial interventions 6
- Need for specialized oral appliance fitting 6
Secondary Referrals
- Pain management specialist when pain is intractable despite dental interventions 6
- Sleep dentist for sleep-related bruxism requiring specialized oral appliances 6
Critical Interventions to AVOID
Never perform irreversible occlusal adjustments or permanent alterations to dentition—these have no evidence basis and are strongly contraindicated. 6, 1
- Discectomy (surgical disc removal) is strongly recommended against 6
- Reversible occlusal splints alone are conditionally recommended against despite common use 7
- NSAIDs combined with opioids carry significant risk without clear additional benefit 7
Special Considerations
When Bruxism Coexists with TMD
- Treatment must address both conditions simultaneously 6
- TMD issues related to oral appliances are usually transient, with pain decreasing with continued use 6
- Mandibular exercises may improve discomfort during adaptation to oral appliances 6
Long-Term Monitoring
- Watch for decreases in overbite and overjet with long-term oral appliance use 6
- Monitor for changes in incisor position 6
- Regular dental follow-up is essential 6
Medication Precautions
- Avoid anti-muscarinic medications in patients with narrow-angle glaucoma unless approved by ophthalmologist 6
- Use caution with medications impairing cognitive function in elderly patients 6
Common Pitfalls to Avoid
- Do not rely solely on occlusal splints without addressing behavioral and stress-related factors 7
- Do not proceed to invasive procedures before exhausting conservative options 7
- Do not assume occlusal problems cause bruxism—this outdated concept leads to inappropriate irreversible treatments 1, 2
- Do not neglect patient education about self-management strategies 7
- Remember that no treatment permanently "cures" or "stops" bruxism—management focuses on protection, symptom reduction, and pain relief 2