What is the recommended treatment approach for a patient presenting with teeth grinding (bruxism) and potential underlying anxiety or sleep disorders?

Treatment for Teeth Grinding (Bruxism)

The first-line treatment for bruxism is a custom-made occlusal splint (night guard) fitted by a qualified dentist, combined with behavioral interventions including stress reduction and patient education about triggers. 1, 2

Initial Conservative Management

Start with protective and behavioral approaches:

• Custom occlusal splints are the primary dental intervention, designed specifically to protect teeth from grinding/clenching damage 2
• Hard full-coverage stabilization splints have demonstrated efficacy, while poorly designed splints that don't account for occlusion may cause adverse events like tooth movement 2
• Splints must be fitted by qualified dental personnel trained in sleep medicine and/or sleep-related breathing disorders 1, 2
• Patient education about the condition and avoidance of aggravating activities (caffeine, alcohol before bed, stress triggers) is essential 2

Physical therapy techniques to implement:

• Massage of masticatory muscles 2
• Heat and/or cold application to affected areas 2
• Mandibular exercises may improve discomfort, particularly during adaptation to oral appliances 2

When to Add Pharmacological Treatment

For pain management during acute episodes:

• NSAIDs for pain control 2
• Muscle relaxants for acute episodes 2
• Amitriptyline has shown benefit in open-label studies 2

For bruxism associated with anxiety disorders:

• Pregabalin demonstrated complete resolution of awake bruxism at 375 mg daily in a patient with generalized anxiety disorder, though more studies are needed 3
• Address underlying anxiety or sleep disorders as these are dominant contributing factors 4

Interventions to Use Cautiously or Avoid

Consider with caution:

• Botulinum toxin injections to masticatory muscles may reduce bruxism frequency but have concerns about adverse effects and are conditionally recommended against by some experts 2
• One case report showed complete resolution of post-anoxic bruxism with 200 units BTX-A to each masseter and temporalis 5
• Biofeedback has limited evidence and is conditionally recommended against 2

Strongly avoid:

• Irreversible occlusal adjustments have no evidence basis and permanent dental alterations are strongly contraindicated 2
• Discectomy (surgical disc removal) is strongly recommended against 2

Follow-Up and Monitoring

Establish regular dental surveillance:

• Follow-up at 6 months for the first year, then at least annually thereafter for patients using oral appliances 1, 2
• Monitor for dental complications including tooth movement, temporomandibular joint discomfort, hypersalivation or dry mouth, dental pain, and gingival irritation 1
• Long-term side effects may include decreases in overbite and overjet, and changes in incisor position 2

Special Considerations

When bruxism coexists with sleep disorders:

• Screen for obstructive sleep apnea, as these conditions frequently overlap 6
• Patients with sleep-related bruxism may require evaluation by a sleep specialist 1
• TMD issues related to oral appliances are usually transient, with pain decreasing with continued use 2

Common pitfall: The evidence for occlusal splints preventing bruxism events during sleep is weak—they primarily protect teeth from damage rather than stopping the grinding behavior itself 7. Set realistic expectations with patients that the splint protects dentition but may not eliminate the grinding sensation or sounds.