What are the treatment options for jaw clenching in adults with suspected stress, anxiety, or teeth grinding?

Treatment of Jaw Clenching in Adults

For adults with jaw clenching related to stress, anxiety, or teeth grinding (bruxism), cognitive behavioral therapy (CBT) with or without biofeedback should be the first-line treatment, combined with supervised jaw exercises and manual trigger point therapy, while occlusal splints should be avoided as they lack evidence for benefit. 1

Initial Assessment and Psychological Screening

• Systematically assess for stress, anxiety, depression, and anger using standardized tools (PHQ-9 for depression, GAD-7 for anxiety), as these psychological factors are strongly associated with bruxism and directly guide treatment decisions 2
• Evaluate for signs of jaw clenching including masseter muscle tenderness or hypertrophy, excessive tooth wear facets on chewing surfaces, morning jaw fatigue or stiffness, and limited jaw opening 3
• Document stress factors specifically, as stress significantly aggravates pain and complaints in patients with jaw clenching habits 4
• Screen for comorbid chronic pain conditions including headaches, temporomandibular disorders, and fibromyalgia using a biopsychosocial approach 2

First-Line Treatment Algorithm

Psychological Interventions (Highest Priority)

• Initiate CBT with or without biofeedback or relaxation therapy as the primary intervention, delivered by a licensed mental health professional using manualized protocols 1, 5
• Provide stress management techniques and behavioral strategies before considering pharmacological interventions 2
• Offer patient education about the stress-bruxism connection and teach awareness of jaw clenching behaviors, particularly during waking hours 2

Physical Therapy Interventions (Concurrent with CBT)

• Implement supervised jaw exercises and stretching combined with manual trigger point therapy, as this combination has strong evidence for benefit 1
• Provide therapist-assisted mobilization of the temporomandibular joint 1
• Prescribe supervised postural exercises to address biomechanical factors affecting the masticatory system 1

Treatment for Comorbid Anxiety or Depression

When Moderate Psychological Symptoms Present (PHQ-9: 10-14, GAD-7: 10-14)

• Start with CBT monotherapy or consider adding an SSRI (such as escitalopram) as first-line pharmacologic agent due to efficacy and favorable side effect profile 5
• Treating depression often concurrently improves anxiety and anger symptoms, which may reduce jaw clenching behavior 5

When Severe Psychological Symptoms Present (PHQ-9: ≥15, GAD-7: ≥15)

• Initiate combination therapy with both CBT and SSRI from the outset 5
• Consider amitriptyline specifically for patients with significant anxiety or depression, which has shown benefit in open-label studies for bruxism 2

Adjunctive Interventions

• Implement structured physical activity and exercise programs, which provide moderate to large reductions in depression and may reduce anxiety 5
• Consider mindfulness-based stress reduction (MBSR), which demonstrates significant improvements in both depression and anxiety 5
• Provide psychoeducation for patient and family about the connection between psychological distress and jaw clenching 5

Pharmacological Management for Pain

• Use NSAIDs for pain management as needed 2
• Consider muscle relaxants for acute episodes when muscle pain is prominent 2
• Exercise caution with medications that may impair cognitive function, especially in elderly patients 2

Treatment Monitoring and Adjustment

• Assess treatment response at 4 weeks and 8 weeks using standardized instruments (PHQ-9, GAD-7) to prevent treatment failure 5
• If symptoms are stable or worsening after 8 weeks despite good adherence, adjust the regimen immediately by adding pharmacotherapy to CBT or vice versa, changing the specific SSRI, or switching from group to individual therapy 5
• Monitor compliance monthly until symptoms subside, assessing follow-through with psychological referrals and satisfaction with treatment 1

Interventions to Avoid

• Do not use reversible or irreversible occlusal splints, as these have conditional recommendations against their use and lack evidence for benefit 1
• Avoid irreversible occlusal adjustments, as permanent dental alterations are strongly contraindicated and have no evidence basis 2
• Do not recommend arthrocentesis, botulinum toxin injection, hyaluronic acid injection, or low-level laser therapy, as these have conditional recommendations against their use 1

Multidisciplinary Referral Criteria

• Refer to a dentist with TMD and sleep medicine training as the primary specialist when significant tooth attrition, mobility, or fracture occurs, providing complete medical history including psychological comorbidities 2, 6
• Consider pain management specialist referral for intractable pain unresponsive to dental and psychological interventions 2
• Refer to sleep medicine specialist when sleep-related bruxism requires specialized evaluation or oral appliance fitting 2

Critical Clinical Pitfalls

• Recognize that jaw clenching affects both muscles and joints of the masticatory system biomechanically, resulting in muscle/joint pain that is aggravated by stress 4
• Understand that there is no effective treatment that permanently "cures" or "stops" bruxism; management is directed toward symptom reduction and protection 7
• Be aware that patients with anxiety pathology commonly avoid following through on referrals, requiring proactive monthly follow-up until symptoms subside 1