What treatment options are available for a patient experiencing nocturnal teeth grinding and clenching, possibly associated with sleep disturbances and jaw pain?

Treatment of Nocturnal Teeth Grinding and Clenching

For nocturnal teeth grinding and clenching (sleep bruxism), an occlusal splint fitted by a qualified dental professional is the primary treatment to protect teeth from damage, with consideration for screening and treating any underlying obstructive sleep apnea that may be contributing to the symptoms. 1

Initial Assessment and Screening

Before initiating treatment, evaluate for potential underlying sleep-disordered breathing, as sleep bruxism co-occurs with obstructive sleep apnea (OSA) in approximately 30-50% of adults. 2 Key clinical features to assess include:

• Sleep-related symptoms: Snoring, witnessed breathing pauses, daytime sleepiness, fatigue, and poor sleep quality 3
• Anatomical risk factors: Body mass index, neck circumference, retrognathia, macroglossia, and tonsillar size 3
• Bruxism indicators: Self-reported grinding sounds, awareness of clenching, jaw pain or morning headaches, and clinical evidence of tooth wear 1, 2

If OSA is suspected based on clinical probability questionnaires and assessment, refer to a sleep physician for polysomnography or home sleep testing before finalizing the treatment plan. 3 This is critical because treating bruxism alone without addressing co-existing OSA can compromise treatment outcomes and leave significant morbidity unaddressed.

Primary Treatment: Occlusal Splint Therapy

Custom-made occlusal splints are the treatment of choice for sleep bruxism, as they protect teeth from premature wear and reduce grinding noise with no reported adverse effects. 4 The American Academy of Sleep Medicine recommends that occlusal splints be fitted by qualified dental personnel trained in sleep medicine. 1

Splint Specifications and Fitting

• The appliance should be individualized and custom-made using impressions, fabricated from biocompatible materials 3
• Requires adequate healthy teeth, no significant temporomandibular joint disorder, and adequate jaw range of motion 1
• Patient must have manual dexterity to insert and remove the appliance 1

Expected Outcomes and Monitoring

Occlusal splints provide:

• Protection of tooth structure from grinding damage 1, 4
• Reduction in grinding sounds 1
• Transient reduction in masticatory muscle activity 1

However, the evidence for occlusal splints improving sleep outcomes is limited. A Cochrane systematic review found insufficient evidence that occlusal splints are effective for treating the underlying sleep bruxism itself, though they do provide benefit for preventing tooth wear. 5 This is an important caveat—the splint is primarily protective rather than curative.

Follow-up Protocol

Regular dental follow-up is mandatory to monitor for complications and adjust treatment:

• Every 6 months for the first year 3, 1
• At least annually thereafter 3, 1

Monitor for potential side effects including temporomandibular joint discomfort, dental misalignment with long-term use, hypersalivation or dry mouth, dental pain, and gingival irritation. 1

Management When OSA Co-exists

If polysomnography confirms co-occurring OSA (AHI ≥5 events/hour), the treatment algorithm changes significantly:

For Mild-to-Moderate OSA

• Mandibular advancement device (MAD) can address both conditions simultaneously 3
• MADs are custom-made, titratable devices that advance the mandible forward, widening the upper airway 3
• Success rates range from 19-75% for achieving AHI <5, with better outcomes in younger patients, lower BMI, and milder OSA 3
• The device can be used in combination with an occlusal splint if bruxism remains problematic 2

For Moderate-to-Severe OSA

• CPAP therapy is the gold standard first-line treatment 3, 6
• If CPAP is tolerated, an occlusal splint can be worn concurrently to protect teeth 2
• If CPAP is not tolerated despite optimization (mask refitting, pressure adjustments, heated humidification), consider MAD as alternative therapy 3

Adjunctive and Alternative Therapies

While occlusal splints remain primary, consider these adjuncts based on individual presentation:

Behavioral and Physical Interventions

• Myofunctional therapy can be considered as a conditional recommendation for specific cases seeking alternative treatments 3
• Relaxation exercises may improve bruxism symptoms 7
• Specialized physiotherapy can address muscle tension, pain, and restricted jaw movement 7

Pharmacological Options (Short-term Use Only)

• Clonazepam showed large effect size in reducing bruxism index, but risk of dependency limits long-term use 4
• Clonidine reduces sleep bruxism but has been linked to adverse effects 4
• Botulinum toxin treatment reduces subjective complaints during the period of action, though this is typically reserved for refractory cases 7

These pharmacological approaches should be considered only for acute cases with significant pain and are not suitable for long-term management. 4

Common Pitfalls to Avoid

• Do not assume bruxism is isolated: Always screen for OSA, as the co-occurrence rate is 30-50% and missing OSA leaves significant cardiovascular and metabolic morbidity unaddressed 2
• Do not use over-the-counter or non-custom splints: The American Academy of Sleep Medicine specifically recommends fitting by qualified dental personnel 1
• Do not delay sleep testing if OSA is suspected: Treating bruxism alone when OSA is present can compromise oro-pharyngeal space and breathing efficiency 2
• Do not prescribe MADs without proper dental assessment: Contraindications include severe periodontal disease, severe temporomandibular disorders, and inadequate dentition 6
• Do not rely on occlusal splints to cure bruxism: Set realistic expectations that the splint protects teeth but may not eliminate the grinding behavior itself 5

Treatment Algorithm Summary

1. Screen for OSA using clinical assessment and probability questionnaires 3
2. If OSA suspected: Refer for sleep study before finalizing treatment plan 3
3. If no OSA or primary snoring only: Proceed with custom occlusal splint 1, 4
4. If mild-to-moderate OSA confirmed: Consider MAD to address both conditions 3
5. If moderate-to-severe OSA confirmed: CPAP first-line, with occlusal splint for tooth protection 3, 6, 2
6. Establish regular follow-up: Every 6 months for first year, then annually 3, 1
7. Consider adjunctive therapies: Myofunctional therapy, physiotherapy, or relaxation exercises as needed 3, 7