Best Medication for Nocturnal Bruxism with Co-Occurring Anxiety
Buspirone is the best medication for nocturnal bruxism with co-occurring anxiety, starting at 5 mg twice daily and titrating to 10-20 mg three times daily as needed. 1, 2
Rationale for Buspirone as First-Line
Buspirone uniquely addresses both conditions simultaneously:
- FDA-approved for generalized anxiety disorder with demonstrated efficacy in patients who have coexisting depressive symptoms, making it appropriate for complex presentations 1
- Proven effective for bruxism control in multiple case series, with patients reporting mean 65% reduction in bruxism symptoms 2
- Particularly effective for SSRI-induced bruxism, which is critical since SSRIs (the typical first-line for anxiety) can actually cause or worsen nocturnal bruxism 3, 4
- Safe in elderly patients when dosed appropriately (starting 5 mg twice daily), unlike benzodiazepines which carry significant risks 5
Dosing Algorithm
Initial dosing:
- Start 5 mg twice daily (morning and evening) 5, 1
- Increase by 5 mg every 2-3 days as tolerated 1
- Target dose: 10-20 mg three times daily 5, 1
- Maximum dose: 60 mg/day (20 mg three times daily) 5
Timeline expectations:
- Anxiety improvement requires 2-4 weeks for full effect 5, 1
- Bruxism reduction may occur within 4 days of therapeutic dosing 4
- Continue for at least 4-12 months after symptom remission for first episode 5
Critical Pitfall: Avoid SSRIs as Monotherapy
SSRIs (fluoxetine, sertraline, paroxetine) can cause or exacerbate nocturnal bruxism 3, 4:
- Bruxism typically develops 2-4 weeks after SSRI initiation 3
- Mechanism likely involves serotonergic inhibition of dopamine or SSRI-induced anxiety 4
- If SSRIs are necessary for severe anxiety or comorbid depression, buspirone must be added concurrently to prevent bruxism 3, 4
Alternative Approach: Pregabalin
If buspirone fails or is not tolerated:
Pregabalin 75-375 mg daily is a reasonable second-line option 6:
- Demonstrated complete resolution of awake bruxism at 375 mg daily in a patient with generalized anxiety disorder 6
- Effective for anxiety as a second-line agent per Canadian guidelines 7
- Requires renal dose adjustment in elderly patients 5
- Caution: Dose reduction may cause bruxism recurrence 6
Combination Therapy Strategy
For optimal outcomes, combine medication with cognitive behavioral therapy (CBT):
- CBT has the highest level of evidence for anxiety disorders across all age groups 5
- Combination therapy (buspirone + CBT) facilitates eventual medication tapering 7
- CBT addresses both anxiety and behavioral components of bruxism 5
What NOT to Do
Avoid benzodiazepines despite their anxiolytic properties 8, 5:
- Increased risk of cognitive impairment, delirium, falls, and fractures in all adults 8
- Enhanced sensitivity in elderly patients even at low doses 8
- Potential for dependence, withdrawal, and paradoxical agitation 8, 5
- If absolutely necessary for acute management, use lorazepam 0.25-0.5 mg (maximum 2 mg/24 hours) for shortest duration possible 5
Do not use muscle relaxants (cyclobenzaprine, carisoprodol, metaxalone) 8:
- High risk of CNS adverse effects including sedation 8
- Poorly tolerated in older adults 8
- No evidence of efficacy for bruxism
Monitoring Parameters
Assess at 4 weeks and 8 weeks:
- Anxiety symptom reduction using standardized scales 5
- Bruxism frequency (patient self-report and bed partner observation) 2
- Dental examination for tooth wear patterns 8
- Side effects: dizziness, nausea, headache 1
If symptoms stable or worsening at 8 weeks despite good adherence:
- Increase buspirone to maximum dose (60 mg/day) 1
- Add pregabalin 75-150 mg at bedtime 6
- Switch to pregabalin monotherapy if buspirone not tolerated 6
- Refer to dentist for occlusal splint as adjunctive therapy 8
Environmental Safety Measures
Implement protective measures regardless of medication choice 8: