What are the treatment options for a patient with nocturnal bruxism (nighttime teeth grinding)?

Treatment Options for Nighttime Teeth Grinding (Nocturnal Bruxism)

Conservative, non-invasive approaches including oral appliances, behavioral strategies, and physical therapy should be your first-line treatment for nocturnal bruxism, with occlusal splints being the most common and protective intervention. 1

First-Line Treatment Approach

Occlusal Splints (Primary Protective Device)

• Hard full-coverage stabilization splints are the most effective oral appliance option, designed primarily to protect teeth from grinding damage rather than "cure" the bruxism itself 1
• These appliances must be fitted by qualified dental personnel with training in sleep medicine and/or sleep-related breathing disorders to ensure proper occlusion 1
• Splints that don't account for proper occlusion may cause adverse events like unwanted tooth movement, so proper fitting is critical 1
• While evidence for "stopping" bruxism is limited, splints provide clear benefit for preventing tooth wear and protecting dental restorations 2
• Transient temporomandibular discomfort may occur initially but typically decreases with continued use; mandibular exercises can help during this adaptation period 1

Behavioral and Physical Therapy Interventions

• Patient education about the condition and avoidance of aggravating activities (stress, caffeine, alcohol before bed) is essential 1
• Massage of masticatory muscles (masseter, temporalis) provides symptomatic relief 1
• Heat and/or cold application to the jaw and temple areas can reduce muscle tension and pain 1
• Sleep hygiene improvements including regular sleep schedules, avoiding evening stimulants, and stress reduction techniques should be implemented 1, 3

Second-Line Pharmacological Options

When conservative measures are insufficient and pain is significant:

• NSAIDs (non-steroidal anti-inflammatory drugs) for pain management during acute flare-ups 1
• Muscle relaxants for acute episodes of severe muscle spasm or pain 1
• Amitriptyline has shown some benefit in open-label studies, though evidence is limited 1

Interventions to Use Cautiously or Avoid

Consider with Caution:

• Botulinum toxin injections to masticatory muscles may reduce grinding frequency, but concerns exist about adverse effects (muscle weakness, difficulty chewing), and it is conditionally recommended against by some experts 1
• An RCT showed no benefit for temporomandibular disorders specifically 1
• Biofeedback devices (like the Grindcare® device) may help some patients develop awareness of muscle tension through EMG monitoring and electrical impulses, with one pilot study showing 58% of patients reported major symptom reduction 4
• However, biofeedback has limited high-quality evidence and is conditionally recommended against by some authorities 1
• Low-level laser therapy has insufficient evidence and is conditionally recommended against 1

Strongly Avoid:

• Irreversible occlusal adjustments (grinding down teeth to "balance" the bite) have no evidence basis and permanent alterations to dentition are strongly contraindicated 1, 3
• Surgical interventions like discectomy are strongly recommended against 1

Special Considerations and Follow-Up

• Screen for coexisting temporomandibular disorders (TMD), as treatment should address both conditions when present 1
• Regular dental evaluations are necessary to monitor tooth wear, assess splint fit, and evaluate for potential side effects 1
• Long-term splint use may cause minor changes in overbite, overjet, and incisor position, requiring periodic adjustment 1
• Consider referral to a dentist with specific training in TMD and sleep medicine for complex cases 1
• If sleep-related breathing disorders are suspected, coordinate care with sleep medicine specialists 1

Key Clinical Pitfalls to Avoid

• Don't promise to "cure" or "stop" bruxism permanently—no treatment achieves this; management focuses on protection and symptom reduction 5
• Don't perform irreversible dental procedures based on bruxism alone—the condition is centrally regulated (stress, sleep factors), not caused by dental occlusion 5, 3
• Don't overlook underlying sleep disorders (sleep apnea, restless legs syndrome) that may contribute to or worsen bruxism 3
• Don't use anticholinergic medications in patients with narrow-angle glaucoma without ophthalmology approval 1
• Exercise caution with medications that impair cognition, especially in elderly patients 1