What are the treatment options for a patient with bruxism?

Treatment of Bruxism

Start with a hard full-coverage stabilization splint fitted by a dentist trained in temporomandibular disorders and sleep medicine—this is your primary intervention to protect teeth from grinding damage. 1, 2

First-Line Conservative Management

Occlusal Splint Therapy

• Hard full-coverage stabilization splints are the most effective dental intervention, designed primarily to protect teeth from damage rather than eliminate bruxism itself 1, 2
• The splint must be fitted by qualified dental personnel with specific training in sleep medicine and sleep-related breathing disorders 1, 2
• Critical warning: Splints that don't properly account for occlusion can cause adverse events including unwanted tooth movement 1, 2
• Transient temporomandibular disorder symptoms related to oral appliances typically decrease with continued use 1, 2
• Mandibular exercises can improve discomfort during the adaptation period 2

Behavioral and Physical Interventions

• Patient education about stress-bruxism connection and avoidance of aggravating activities (stress reduction, limiting caffeine, improving sleep hygiene) is essential 1, 2
• Massage of masticatory muscles provides relief of associated muscle tension 1, 2
• Heat and/or cold application to affected areas helps manage symptoms 1, 2

Second-Line Pharmacological Options

When conservative measures are insufficient, consider medications in this order:

• NSAIDs for pain management associated with bruxism 1, 2
• Muscle relaxants for acute episodes of muscle spasm 1, 2
• Amitriptyline has shown benefit in open-label studies for chronic cases, particularly when anxiety or depression coexist 1, 2, 3
• TRPV1 agonists (capsaicinoids) have shown efficacy in improving oral motor control in select patients 1, 2
• Dopaminergic agents may be considered when bruxism is associated with movement disorders 1, 2

Important caveat: Most medications have limited evidence specifically for bruxism, so treatment decisions must be individualized based on careful risk-benefit analysis 1, 2

Interventions to Use Cautiously (Generally Not Recommended)

• Botulinum toxin injections to masticatory muscles may reduce bruxism frequency, but concerns exist regarding possible adverse effects and it is conditionally recommended against 1, 2, 4
• A randomized controlled trial showed no benefit of botulinum toxin for temporomandibular disorders 1, 2
• Biofeedback may help develop awareness of muscle tension but has limited evidence and is conditionally recommended against 1, 2
• Low-level laser therapy has insufficient evidence and is conditionally recommended against 1, 2

Interventions to Absolutely Avoid

• Irreversible occlusal adjustments are strongly contraindicated—permanent alterations to dentition have no evidence basis for managing bruxism 1, 2, 3, 4
• Discectomy (surgical removal of the articular disc) is strongly recommended against 1, 2

Specialist Referral Algorithm

Primary Referral

• Refer to a dentist with training in temporomandibular disorders and sleep medicine as the primary specialist for evaluation and management 2, 3
• Provide complete medical history including medications, associated conditions (sleep apnea, movement disorders, chronic pain), and psychological comorbidities (anxiety, depression, stress) 2, 3

Secondary Referrals (When Indicated)

• Consider pain management specialist or multidisciplinary pain team when patients have intractable pain unresponsive to dental interventions 2, 3
• Consider sleep medicine specialist for sleep-related bruxism requiring specialized oral appliance fitting 2
• Psychiatric evaluation is warranted when stress, anxiety, depression, or anger are prominent, as these psychological factors are strongly associated with bruxism 3

Diagnostic Assessment Details

Clinical Examination Findings

• Look for excessive wear facets on teeth (indicating grinding) 1
• Assess for muscle hypertrophy of mastication muscles 1, 4
• Check for temporomandibular joint crepitus 1
• Evaluate for tooth fractures, hypersensitive teeth, and loss of periodontal support 4

History Taking

• Assess clenching/bruxing habits during waking and sleeping hours 1
• Document jaw joint locking or clicking 1
• Evaluate impact on sleep quality, mood, and quality of life 1
• Screen for stress, anxiety, depression, and anger systematically 3
• Assess for comorbid chronic pain conditions including headaches, temporomandibular disorders, and fibromyalgia 3

Common Pitfalls to Avoid

• Never proceed to invasive procedures before exhausting conservative options 1
• Never perform irreversible dental procedures without clear indication 1, 3
• Do not neglect the biopsychosocial approach—assess for depression and chronic pain comorbidities 1, 3
• Avoid using NSAIDs with opioids, which carries significant risk without clear additional benefit 1
• Do not use anti-muscarinic medications in patients with narrow-angle glaucoma unless approved by an ophthalmologist 2
• Exercise caution with medications that may impair cognitive function, especially in elderly patients 2, 3

Long-Term Monitoring

• Regular dental evaluations are necessary to assess treatment efficacy and potential side effects 1, 2
• Long-term dental side effects of oral appliances may include decreases in overbite and overjet, and changes in incisor position 1, 2
• When bruxism coexists with temporomandibular disorders, treatment should address both conditions simultaneously 1, 2