How to stop bruxism in a patient with a history of stress, anxiety, and potential sleep disorders?

How to Stop Bruxism

Begin with conservative behavioral interventions and oral appliances as first-line treatment, specifically hard full-coverage stabilization splints fitted by a dentist trained in temporomandibular disorders, combined with stress management techniques and patient education about jaw clenching awareness. 1, 2

First-Line Treatment Approach

Oral Appliance Therapy

• Obtain a hard full-coverage stabilization splint from a qualified dentist with training in sleep medicine and temporomandibular disorders. 2 This is the most common and evidence-based dental intervention for bruxism, primarily protecting teeth from grinding damage. 2
• Understand that splints reduce tooth damage and grinding sounds but have only transient effects on the actual muscle activity of bruxism. 2, 3
• Be aware that temporomandibular discomfort from the appliance is usually transient and decreases with continued use; mandibular exercises can help during the adaptation period. 2
• Schedule regular dental evaluations to monitor treatment efficacy and potential side effects, including changes in bite alignment. 2

Behavioral and Psychological Interventions

• Implement stress management techniques as the primary behavioral strategy before considering medications. 1 The American College of Psychiatry emphasizes this as first-line treatment given the strong association between psychological factors (stress, anxiety, depression) and bruxism. 1
• Practice self-observation to develop awareness of jaw clenching behaviors, particularly during waking hours. 1, 4
• Consider cognitive behavioral therapy if stress management alone is insufficient, as the combination of occlusal splint plus cognitive behavioral therapy produces significantly greater muscle relaxation than splint alone (P < 0.05). 5

Physical Therapy Techniques

• Apply massage to the masticatory muscles to reduce tension. 2
• Use heat and/or cold application to affected jaw areas for symptom relief. 2
• Engage in specialized physiotherapy to improve muscle tension, pain, and restricted jaw movement. 6

Second-Line Treatment Options

Pharmacological Management

When behavioral interventions and oral appliances provide insufficient relief:

• Consider amitriptyline for patients with significant anxiety or depression, as it has shown benefit in open-label studies for bruxism. 1, 2
• Use muscle relaxants for acute episodes when muscle pain is prominent. 1, 2
• Prescribe NSAIDs for pain management as needed. 1, 2
• Exercise caution with medications that may impair cognitive function, especially in elderly patients. 1

Addressing Underlying Psychological Factors

The American College of Psychiatry recommends systematically assessing and treating stress, anxiety, depression, and anger, as these strongly influence bruxism severity. 1

• Screen for moderate-to-severe depression (present in approximately 18% of bruxism patients) using both self-report and clinical observation. 1
• Evaluate thought patterns for rumination, worry, or obsessive thinking that may contribute to jaw clenching. 1
• Provide patient education about the stress-bruxism connection, as emotional excitation including rage, fear, and embarrassment can trigger or worsen bruxism. 1

Interventions to Use Cautiously or Avoid

Use With Extreme Caution

• Botulinum toxin injections may reduce bruxism frequency but have concerns regarding adverse effects; one RCT showed no benefit for temporomandibular disorders. 2 Reserve this only for severe secondary bruxism in neurological disorders where bruxism interferes with speaking, chewing, or swallowing. 3
• Biofeedback has limited evidence and is conditionally recommended against by some authorities. 2
• Low-level laser therapy has insufficient evidence to support its use. 2

Strongly Avoid

• Never pursue irreversible occlusal adjustments (permanent alterations to tooth structure), as these have no evidence basis and are strongly contraindicated. 1, 2
• Never consider discectomy (surgical removal of the articular disc). 2

Sleep Hygiene and Lifestyle Modifications

Given that stress and sleep disturbances are major risk factors for bruxism 4:

• Maintain a consistent sleep-wake schedule, including weekends. 7
• Avoid heavy meals, alcohol, caffeine, and nicotine near bedtime. 7
• Ensure exposure to bright light during daytime hours to regulate circadian rhythms. 7
• Engage in regular exercise, preferably in the morning or afternoon. 7
• Reduce consumption of tobacco, alcohol, and coffee, which are recognized risk factors. 4

Specialist Referral Algorithm

Refer to a dentist with training in temporomandibular disorders and sleep medicine as the primary specialist. 2 Provide complete medical history including:

• All current medications 2
• Associated conditions like sleep apnea or movement disorders 2
• Psychological comorbidities including anxiety, depression, or stress-related disorders 2

Consider secondary referrals to:

• Pain management specialist if intractable pain is unresponsive to dental interventions 2
• Sleep medicine specialist for complex sleep-related bruxism requiring specialized oral appliance fitting 2
• Psychologist or psychiatrist if significant anxiety, depression, or stress requires specialized treatment 1

Critical Clinical Pitfalls

• Do not assume bruxism can be "cured" or "stopped" permanently; management focuses on tooth protection, reduction of bruxism activity, and pain relief. 8
• Recognize that bruxism is regulated centrally (by pathophysiological and psychosocial factors) rather than peripherally (by dental occlusion), so focusing solely on dental factors will be insufficient. 8
• Assess for comorbid conditions including temporomandibular disorders, headaches, chronic pain syndromes, and sleep apnea, as these require coordinated treatment. 1, 2
• Differentiate between awake bruxism and sleep bruxism, as management strategies may differ. 3