What is the first-line treatment for bruxism?

Treatment for Bruxism

Conservative, non-invasive approaches with occlusal splints as the primary dental intervention should be the first-line treatment for bruxism, protecting teeth from grinding damage while addressing behavioral and physical factors. 1, 2

First-Line Conservative Management

Occlusal Splints (Primary Dental Intervention)

• Hard full coverage stabilization splints are the most effective dental device, designed primarily to protect teeth from damage rather than eliminate bruxism itself 1, 2
• Splints must be fitted by qualified dental personnel with training in sleep medicine and/or sleep-related breathing disorders 1, 2
• Critical warning: Splints that don't properly account for occlusion may cause adverse events like unwanted tooth movement 1, 2
• Transient TMD issues related to oral appliances usually decrease with continued use; mandibular exercises may improve discomfort during adaptation 1, 2

Behavioral and Physical Interventions

• Patient education about the condition and avoidance of aggravating activities (stress reduction, limiting caffeine, improving sleep hygiene) is essential 1, 2
• Massage of masticatory muscles provides relief of associated muscle tension 1, 2
• Heat and/or cold application to affected areas helps manage symptoms 1, 2
• Cognitive behavioral therapy (CBT) provides substantial pain reduction and should be considered, especially when combined with occlusal splints 3
• A study demonstrated significantly greater muscle relaxation improvement when occlusal splints were combined with CBT compared to splints alone 3

Second-Line Pharmacological Options

Pain and Muscle Management

• NSAIDs are recommended for pain management associated with bruxism 1, 2
• Muscle relaxants are appropriate for acute episodes of muscle spasm 1, 2
• Amitriptyline has shown some benefit in open-label studies for chronic cases 1, 2

Specialized Medications

• TRPV1 agonists (capsaicinoids) have shown some efficacy in improving oral motor control in select patients 1, 2
• Dopaminergic agents may be considered when bruxism is associated with movement disorders 1, 2
• Treatment decisions must be individualized based on careful risk-benefit analysis, as most medications have limited evidence specifically for bruxism 1, 2

Interventions to Use Cautiously

• Botulinum toxin injections to masticatory muscles may reduce bruxism frequency, but concerns exist regarding possible adverse effects and it is conditionally recommended against by some experts 1, 2
• An RCT showed no benefit of botulinum toxin for TMD 1, 2
• Biofeedback may help patients develop awareness of muscle tension but has limited evidence and is conditionally recommended against 1, 2
• Low-level laser therapy has insufficient evidence to support its use and is conditionally recommended against 1, 2

Interventions to Avoid

• Irreversible occlusal adjustments have no basis in evidence for managing bruxism, and permanent alterations to dentition are strongly recommended against 1, 2, 4
• Discectomy (surgical removal of the articular disc) is strongly recommended against 1, 2

Specialist Referral Pathway

Primary Referral

• Patients should be referred to a dentist with training in temporomandibular disorders and sleep medicine as the primary specialist for evaluation and management 2
• Provide the dentist with complete medical history including medications, associated conditions (sleep apnea, movement disorders, chronic pain), and psychological comorbidities (anxiety, depression, stress) 2

Secondary Referrals

• Consider pain management specialist or multidisciplinary pain team when patients have intractable pain unresponsive to dental interventions 2

Diagnostic Assessment Points

Clinical Examination Findings

• Look for excessive wear facets on teeth (indicating bruxism) 1
• Assess for muscle hypertrophy of mastication muscles 1
• Check for temporomandibular joint crepitus 1
• Evaluate for jaw joint locking or clicking 1

Patient History Elements

• Assess clenching/bruxing habits 1
• Evaluate impact on sleep, mood, and quality of life 1
• Screen for depression and chronic pain comorbidities 1

Common Pitfalls to Avoid

• Proceeding to invasive procedures before exhausting conservative options 1, 2
• Performing irreversible dental procedures without clear indication 1, 2
• Neglecting the biopsychosocial approach needed for successful management, including assessment of depression and chronic pain comorbidities 1
• Using NSAIDs with opioids, which carries significant risk without clear additional benefit 1
• Relying on occlusal splints as the only treatment without addressing behavioral factors 5

Monitoring and Follow-Up

• Regular dental evaluations are necessary to assess treatment efficacy and potential side effects 1, 2
• Long-term dental side effects of oral appliances may include decreases in overbite and overjet, and changes in incisor position 1, 2
• When bruxism coexists with TMD, treatment should address both conditions simultaneously 1, 2