What is the best course of treatment for a patient experiencing bruxism (teeth grinding)?

Treatment of Bruxism (Teeth Grinding)

Start with occlusal splints fitted by a qualified dentist as first-line therapy, combined with stress management and physical therapy techniques—this conservative approach protects teeth from damage while addressing underlying muscle tension without irreversible interventions. 1

Initial Management Strategy

First-Line Conservative Treatments

• Occlusal splints (mouth guards) are the cornerstone of bruxism management, specifically hard full-coverage stabilization splints that account for proper occlusion to prevent tooth damage from grinding and clenching. 1

• These appliances must be fitted by qualified dental personnel with training in sleep medicine and/or temporomandibular disorders to avoid adverse events like unwanted tooth movement. 1, 2

• Patient education about the condition and avoidance of aggravating activities (such as chewing gum, biting pens, or daytime clenching) should be provided immediately. 1

Physical Therapy Techniques

• Massage of the masticatory muscles (masseter, temporalis) helps reduce muscle tension and pain. 1

• Heat and/or cold application to affected jaw areas provides symptomatic relief. 1

• Mandibular exercises may improve discomfort, particularly during adaptation to oral appliances. 2

Behavioral and Psychological Interventions

• Stress management techniques and behavioral strategies should be implemented as these address the psychological factors strongly associated with bruxism, including anxiety, depression, and emotional stress. 3

• Teaching awareness of jaw clenching behaviors, particularly during waking hours, helps patients develop conscious control. 3

• Relaxation exercises can improve bruxism symptoms. 4

Second-Line Pharmacological Options

When conservative measures provide insufficient relief:

• NSAIDs for pain management during symptomatic periods. 1

• Muscle relaxants for acute episodes when muscle pain is prominent. 1, 3

• Amitriptyline may be considered for patients with significant anxiety or depression, as it has shown benefit in open-label studies. 1, 3

Interventions to Use Cautiously

• Botulinum toxin injections to masticatory muscles may reduce grinding frequency but have concerns regarding possible adverse effects and should be reserved for refractory cases. 1 One case report showed complete resolution of post-anoxic bruxism with 200 units to each masseter and temporalis, 5 but an RCT showed no benefit for temporomandibular disorders. 1

• Biofeedback has limited evidence and is conditionally recommended against by some authorities. 1

Interventions to Avoid Completely

• Irreversible occlusal adjustments (grinding down teeth) have no evidence basis and permanent alterations to dentition are strongly contraindicated. 1, 3

• Surgical interventions like discectomy are strongly recommended against. 1

Special Populations and Considerations

Sleep-Related Bruxism

• Candidates for mandibular repositioning appliances require adequate healthy teeth, no significant temporomandibular joint disorder, adequate jaw range of motion, and manual dexterity to insert/remove the appliance. 2

• Regular dental follow-up at 6 months for the first year and at least annually thereafter is necessary to monitor for dental complications including decreases in overbite/overjet and changes in incisor position. 2

Bruxism Associated with Movement Disorders

• Dopaminergic agents may be considered when bruxism is associated with movement disorders like Parkinson's disease, as they can help normalize oral motor function. 1

• Awake bruxism is more frequent in hyperkinetic movement disorders, particularly those with stereotypies (Rett syndrome 97%, Down syndrome 42%, autism spectrum disorders 32%). 6

When Bruxism Coexists with TMD

• Treatment must address both conditions simultaneously using the same conservative approach. 1

• TMD issues related to oral appliances are usually transient, with pain decreasing with continued use. 2

Referral Pathway

• Primary referral should be to a dentist with training in temporomandibular disorders and sleep medicine for evaluation and management. 1

• Provide complete medical history including medications, associated conditions (sleep apnea, movement disorders, chronic pain), and psychological comorbidities (anxiety, depression, stress). 1

• Consider pain management specialist referral for intractable pain unresponsive to dental interventions. 1

• Sleep medicine specialist referral may be needed for complex sleep-related bruxism requiring specialized oral appliance fitting. 1

Critical Clinical Pitfalls

• Do not prescribe anti-muscarinic medications in patients with narrow-angle glaucoma unless approved by an ophthalmologist. 1

• Exercise caution with medications that may impair cognitive function, especially in elderly patients. 1, 3

• Avoid splints that don't account for proper occlusion, as these may cause tooth movement. 1

• Children with bruxism are usually managed with observation and reassurance rather than aggressive intervention. 7