What are the treatment options for nocturnal teeth grinding (bruxism)?

Treatment of Nocturnal Teeth Grinding (Bruxism)

Begin with a hard full-coverage occlusal splint fitted by a dentist trained in temporomandibular disorders, combined with patient education about stress reduction and avoidance of aggravating activities. 1

First-Line Conservative Management

Occlusal Splints (Primary Intervention)

• Hard full-coverage stabilization splints are the most effective dental intervention, designed primarily to protect teeth from grinding damage rather than eliminate the behavior itself 1
• The splint must be fitted by qualified dental personnel with training in sleep medicine and/or temporomandibular disorders to ensure proper occlusion 1
• Splints that don't account for proper occlusion can cause adverse events including unwanted tooth movement 1
• Transient temporomandibular discomfort may occur initially but typically decreases with continued use; mandibular exercises can help during the adaptation period 1
• Long-term monitoring is necessary as splints may cause decreases in overbite/overjet and changes in incisor position over time 1

Behavioral and Physical Therapy Approaches

• Patient education about the condition is essential, including awareness that stress, sleep positioning, and oral parafunctions are contributing factors 1, 2
• Massage of masticatory muscles provides symptomatic relief 1
• Heat and/or cold application to affected jaw areas reduces muscle tension and pain 1
• Sleep hygiene optimization: avoid evening caffeine, alcohol, and stimulants; maintain regular sleep-wake schedules 1

Second-Line Pharmacological Options

For Acute Episodes and Pain Management

• NSAIDs are recommended for pain management when masticatory muscle pain or headaches are present 1
• Muscle relaxants are appropriate for acute episodes of severe grinding or clenching 1
• Amitriptyline has shown some benefit in open-label studies, though evidence is limited 1

Specialized Pharmacological Considerations

• TRPV1 agonists (capsaicinoids) have shown efficacy in improving oral motor control in some patients 1
• Dopaminergic agents may be considered specifically when bruxism is associated with movement disorders to normalize oral motor function 1
• Treatment decisions require individualized risk-benefit analysis as most medications have limited evidence specifically for bruxism 1

Interventions to Use Cautiously or Avoid

Conditional Recommendations

• Botulinum toxin injections to masticatory muscles are conditionally recommended against due to concerns about adverse effects, despite some evidence of reduced grinding frequency 1
• An RCT showed no benefit of botulinum toxin for temporomandibular disorders 1
• Biofeedback has limited evidence and is conditionally recommended against by some authorities, though it may help develop awareness of muscle tension 1
• Low-level laser therapy has insufficient evidence to support its use 1

Strongly Contraindicated Interventions

• Irreversible occlusal adjustments (permanent alterations to dentition) are strongly recommended against as they have no evidence basis for managing bruxism 1
• Discectomy (surgical removal of the articular disc) is strongly recommended against 1

Special Clinical Considerations

Coexisting Obstructive Sleep Apnea

• Approximately 30-50% of adults with sleep bruxism have coexisting obstructive sleep apnea 3
• When both conditions are present, management becomes more complex as occlusal splints may compromise the oropharyngeal space 3
• Consider home sleep testing with jaw muscle EMG and cardiorespiratory variables if OSA is suspected 3
• Treatment options for co-occurring conditions include CPAP alone, CPAP with occlusal splint, or mandibular advancement device, though each has limitations 3

Coexisting Temporomandibular Disorders

• When bruxism coexists with TMD, treatment must address both conditions simultaneously 1
• TMD-related issues with oral appliances are usually transient and improve with continued use 1

Medication Precautions

• Avoid anti-muscarinic medications in patients with narrow-angle glaucoma unless approved by an ophthalmologist 1
• Use caution with medications that may impair cognitive function, especially in elderly patients 1

Referral Pathway

Primary Specialist Referral

• Refer to a dentist with specific training in temporomandibular disorders and sleep medicine as the primary specialist for evaluation and management 1
• This is the first-line referral since bruxism fundamentally requires assessment of tooth wear, occlusion, and jaw function 1

Secondary Specialist Referrals

• Consider pain management specialist or multidisciplinary pain team when intractable pain is unresponsive to dental interventions 1
• Consider sleep dentist specifically for patients requiring oral appliances fitted by personnel trained in sleep medicine 1

Information to Provide at Referral

• Complete medical history including all medications 1
• Associated conditions such as sleep apnea, movement disorders, or chronic pain syndromes 1
• Psychological comorbidities including anxiety, depression, or stress-related disorders 1
• Request from the dentist: dental diagnosis, treatment plan, assessment of modifiable risk factors, treatment response, and regular follow-up reports 1

Common Pitfalls to Avoid

• Do not perform irreversible dental procedures as there is no evidence supporting permanent occlusal adjustments for bruxism management 1
• Do not expect any treatment to permanently "cure" or "stop" bruxism; management focuses on tooth protection, reduction of activity, and pain relief 4
• Do not overlook the central (stress, psychosocial factors) versus peripheral (dental morphology) nature of the condition; current evidence suggests bruxism is regulated centrally 4
• Regular dental evaluations are mandatory to assess treatment efficacy and monitor for potential side effects of oral appliances 1