What is the best medication for an adult patient with no significant medical history who experiences teeth clenching (bruxism) when talking, possibly due to anxiety?

Treatment of Teeth Clenching (Awake Bruxism) Associated with Anxiety

First-Line Pharmacological Approach

For an adult patient with teeth clenching during talking (awake bruxism) likely related to anxiety, initiate treatment with an SSRI (escitalopram 10-20 mg daily or sertraline 50-200 mg daily) as first-line therapy, targeting the underlying anxiety disorder that drives the bruxism behavior. 1

Rationale for SSRI Selection

• SSRIs demonstrate high-quality evidence for treating anxiety disorders, with moderate to high strength of evidence showing improvement in primary anxiety symptoms, response to treatment, and remission rates 1
• Awake bruxism shows a positive and statistically significant relationship with anxiety levels (p < 0.05), with increased trait anxiety associated with greater masseter muscle activity and intensity of clenching episodes 2, 3
• The intensity of awake bruxism episodes is directly proportional to anxiety severity, with high trait anxiety individuals showing masseter activity of 10.23% maximum voluntary contraction compared to 7.97% in low anxiety individuals 2

Specific SSRI Recommendations

Start with escitalopram 5-10 mg daily or sertraline 25-50 mg daily, titrating gradually to minimize initial anxiety/agitation 1:

• Escitalopram: Increase by 5-10 mg increments every 1-2 weeks, targeting 10-20 mg/day by weeks 4-6 1
• Sertraline: Increase by 25-50 mg increments every 1-2 weeks, targeting 50-200 mg/day 1
• Expected timeline: Statistically significant improvement by week 2, clinically significant improvement by week 6, maximal benefit by week 12 or later 1

Critical Monitoring Parameters

• Monitor for suicidal thinking and behavior, especially in the first months and following dose adjustments (pooled risk 1% vs 0.2% placebo, NNH = 143) 1
• Common side effects include nausea, sexual dysfunction, headache, insomnia, which typically emerge within the first few weeks and resolve with continued treatment 1
• Assess response using standardized anxiety rating scales (e.g., HAM-A) at regular intervals 1

Alternative Pharmacological Option: Pregabalin

If SSRIs are ineffective, not tolerated, or contraindicated, consider pregabalin 375 mg daily, which has demonstrated complete resolution of awake bruxism in anxiety patients 4:

• A 21-year-old female with generalized anxiety disorder experienced complete disappearance of awake bruxism at 375 mg daily, with recurrence upon dose reduction 4
• Pregabalin is recommended as a second-line option when first-line SSRIs/SNRIs are ineffective or not tolerated for generalized anxiety disorder 1
• This medication addresses both the anxiety disorder and has direct effects on bruxism behavior 4

Non-Pharmacological Interventions (Essential Adjuncts)

Combine medication with cognitive behavioral therapy (CBT) targeting anxiety patterns for optimal outcomes, as combination treatment provides superior results compared to either modality alone 1:

• Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness (Hedges g = 1.01 for GAD) 1
• Structured duration of 12-20 CBT sessions is recommended to achieve significant symptomatic and functional improvement 1
• Psychological techniques including directed muscular relaxation have shown effectiveness in reducing bruxism signs with statistical significance (p < 0.05) 5

Specific Anxiety Management Strategies

Implement these evidence-based techniques alongside pharmacotherapy 1:

• Breathing techniques and progressive muscle relaxation
• Grounding strategies and visualization
• Cognitive restructuring to challenge anxiety-related distortions
• Regular cardiovascular exercise (moderate to large reduction in anxiety symptoms)
• Psychoeducation about the anxiety-bruxism connection

Treatment Algorithm

Step 1: Initial Assessment

• Confirm awake bruxism diagnosis through patient report of teeth clenching during waking hours, particularly during talking 2, 3
• Assess anxiety severity using validated scales to determine if symptoms meet criteria for an anxiety disorder (must persist ≥6 months for GAD diagnosis) 1
• Rule out medical causes: medication-induced anxiety, substance use, other medical conditions 1
• Screen for comorbidities: approximately one-third of anxiety patients have comorbid depression or other psychiatric disorders 1

Step 2: Initiate First-Line Treatment

• Start SSRI (escitalopram 5-10 mg or sertraline 25-50 mg daily) with gradual titration 1
• Refer for individual CBT concurrently, as combination therapy provides superior outcomes 1
• Educate patient about expected timeline (6-12 weeks for full response) and common side effects 1

Step 3: Monitor Response (Weeks 2-12)

• Assess anxiety symptoms at weeks 2,6, and 12 using standardized scales 1
• Monitor bruxism frequency and intensity through patient self-report
• Evaluate tolerability and adjust dose as needed within therapeutic range 1

Step 4: If Inadequate Response After 8-12 Weeks

• Switch to different SSRI (e.g., sertraline to escitalopram or vice versa) 1
• Consider SNRI (venlafaxine 75-225 mg/day or duloxetine 60-120 mg/day) as alternative 1
• Ensure CBT is optimally implemented with anxiety-specific techniques 1

Step 5: If Still Inadequate Response

• Consider pregabalin 375 mg daily as alternative agent with direct anti-bruxism effects 4
• Reassess diagnosis for comorbid conditions or alternative explanations 1
• Refer to psychiatry for complex cases requiring specialized management 1

Medications to Avoid

Do not use benzodiazepines as first-line treatment due to risks of abuse, dependence, cognitive impairment, and withdrawal 6, 1:

• Benzodiazepines should be time-limited in accordance with established psychiatric guidelines 6
• Reserve benzodiazepines only for short-term use in severe cases while establishing definitive treatment 1

Special Considerations and Pitfalls

Common Pitfalls to Avoid

• Do not abandon treatment prematurely: Full SSRI response may take 12+ weeks, and patience in dose escalation is crucial 1
• Do not escalate doses too quickly: Allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window 1
• Do not use medication alone: Combining pharmacotherapy with CBT provides optimal outcomes for anxiety-related bruxism 1
• Do not ignore the anxiety-bruxism connection: Treating anxiety is essential, as awake bruxism intensity correlates directly with anxiety severity 2, 3

When to Consider Botulinum Toxin

Botulinum toxin-A injections (200 units to each masseter and temporalis) may be considered for refractory cases where anxiety treatment alone is insufficient, with complete resolution reported 2 days after injection 7:

• This represents a symptomatic treatment rather than addressing the underlying anxiety disorder 7
• Should be reserved for cases where pharmacological and psychological interventions for anxiety have been optimized but bruxism persists
• Requires specialized administration by trained practitioners 7

Monitoring for Treatment Success

• Reduction in anxiety symptoms should correlate with decreased bruxism intensity and frequency 2, 3
• Patient-reported outcomes regarding clenching episodes during talking and daily activities
• Dental examination findings showing reduced tooth wear and masseter hypertrophy over time 7
• Quality of life improvements in social and occupational functioning related to reduced anxiety and bruxism 1