What is the recommended evaluation and management approach for bruxism?

Bruxism: Evaluation and Management

Start with conservative, non-invasive management using hard full-coverage stabilization splints as the primary intervention, combined with patient education, stress reduction, and physical therapy techniques—reserving pharmacological options like low-dose amitriptyline or NSAIDs for refractory cases with significant pain. 1, 2

Initial Evaluation

Clinical History Assessment

• Determine bruxism type: Differentiate between sleep bruxism (rhythmic or non-rhythmic grinding during sleep) versus awake bruxism (repetitive tooth contact or jaw bracing while awake) 3
• Assess frequency and severity: Document number of episodes per hour and duration of symptoms 4
• Identify triggers: Evaluate stress levels, anxiety, caffeine intake, sleep hygiene, and medication history (particularly SSRIs, which can induce or worsen bruxism) 1, 5
• Screen for comorbidities: Ask about sleep apnea, movement disorders, temporomandibular disorders (TMD), chronic pain syndromes, depression, and anxiety 2
• Evaluate impact: Assess effects on sleep quality, jaw pain, headaches, tooth sensitivity, and quality of life 1

Physical Examination Findings

• Tooth wear patterns: Look for excessive wear facets on occlusal surfaces indicating grinding activity 2
• Muscle hypertrophy: Palpate for masseter and temporalis muscle enlargement 1, 6
• TMJ assessment: Check for temporomandibular joint crepitus, clicking, or locking 1
• Dental damage: Document fractured teeth, broken restorations, or tooth hypersensitivity 6
• Soft tissue changes: Examine for tongue indentations or cheek ridging 6

Diagnostic Testing

• Polysomnography is NOT routinely needed except when sleep comorbidities (particularly sleep apnea) are suspected 7
• Electromyography can objectively measure masticatory muscle activity but is reserved for research or unclear cases 4, 3
• Self-report and clinical examination are sufficient for diagnosis in most cases 3

First-Line Management: Conservative Approaches

Occlusal Splints (Primary Dental Intervention)

• Hard full-coverage stabilization splints are the most effective intervention for protecting teeth from grinding damage 1, 2
• Critical requirement: Splints MUST be fitted by qualified dental personnel with training in sleep medicine and/or sleep-related breathing disorders 1, 2
• Important caveat: Splints that don't properly account for occlusion may cause adverse events like unwanted tooth movement—this is a common pitfall 1
• Realistic expectations: Splints protect teeth but do NOT eliminate bruxism itself; effects on reducing EMG muscle activity are transient 7
• Adaptation period: Transient TMD issues usually decrease with continued use; mandibular exercises may improve discomfort during adaptation 1, 2

Behavioral and Physical Therapy

• Patient education: Provide written information about bruxism, its triggers, and management strategies 1
• Stress reduction: Implement relaxation techniques and improve sleep hygiene 1, 6
• Lifestyle modifications: Limit caffeine intake, avoid alcohol, and address sleep disturbances 1
• Masticatory muscle massage: Provides relief of associated muscle tension 1, 2
• Heat/cold application: Apply to affected areas for symptom management 1, 2
• Myofunctional therapy: Can reduce pain intensity and bruxism episodes when performed consistently over 9 months 4

Second-Line Management: Pharmacological Options

Pain Management

• NSAIDs: First-line for pain associated with bruxism 1, 2
• Muscle relaxants: Appropriate for acute episodes of muscle spasm 1, 2
• Critical warning: Avoid combining NSAIDs with opioids—this carries significant risk without clear additional benefit 1

Neuromodulatory Medications

• Amitriptyline (low-dose): Has shown benefit in open-label studies for chronic cases, particularly when associated with TMD pain 1, 5
• Gabapentin: Alternative anticonvulsant option with neuromodulatory properties 5
• TRPV1 agonists (capsaicinoids): May improve oral motor control in select patients 1
• Dopaminergic agents: Consider when bruxism is associated with movement disorders 1
• Clonazepam: May improve sleep bruxism in patients with psychiatric comorbidities, but use is limited by lack of double-blind trials and concerns about tolerance/addiction 7, 5

Medication Pitfalls to Avoid

• Do NOT prescribe SSRIs as first-line treatment in patients with existing bruxism—they can induce or worsen the condition 5
• Avoid benzodiazepines for chronic anxiety management, particularly in children, due to disinhibition risk and addiction potential 5

Interventions to Use Cautiously

Botulinum Toxin Injections

• May reduce bruxism frequency when injected into masticatory muscles 1, 8
• Concerns exist regarding possible adverse effects 1, 6
• Conditionally recommended against by some experts 1
• One RCT showed NO benefit for TMD 1, 2
• Consider only for severe secondary bruxism in neurological disorders (cranial dystonia) interfering with speaking, chewing, or swallowing 7

Other Limited-Evidence Interventions

• Biofeedback: May help develop awareness of muscle tension but has limited evidence and is conditionally recommended against 1, 2
• Low-level laser therapy: Insufficient evidence to support use; conditionally recommended against 1, 2

Interventions to AVOID

Strongly Recommended Against

• Irreversible occlusal adjustments: Have NO basis in evidence for managing bruxism; permanent alterations to dentition are strongly contraindicated 1, 2, 6
• Discectomy (surgical removal of articular disc): Strongly recommended against 1, 2

Specialist Referral Algorithm

Primary Referral

• Refer to dentist with TMD and sleep medicine training as the primary specialist for all bruxism patients 2
• Provide complete medical history including medications, associated conditions (sleep apnea, movement disorders, chronic pain), and psychological comorbidities (anxiety, depression, stress) 2

Secondary Referrals

• Pain management specialist or multidisciplinary pain team: When intractable pain is unresponsive to dental interventions 2
• Sleep medicine specialist: When sleep-related bruxism coexists with suspected sleep apnea or other sleep disorders 2

Special Clinical Considerations

Coexisting TMD

• Treat both conditions simultaneously when bruxism coexists with temporomandibular disorders 1, 2
• TMD issues from oral appliances are usually transient and decrease with continued use 1, 2

Long-Term Monitoring

• Regular dental evaluations are necessary to assess treatment efficacy and potential side effects 1, 2
• Monitor for dental side effects of oral appliances including decreases in overbite/overjet and changes in incisor position 1, 2
• Reassess treatment response and modify approach based on progression of dental wear and orofacial pain 7

Common Pitfalls to Avoid

• Proceeding to invasive procedures before exhausting conservative options 1
• Performing irreversible dental procedures without clear indication 1
• Neglecting the biopsychosocial approach: Must assess depression, chronic pain comorbidities, and stress factors 1
• Using poorly fitted splints: Can cause unwanted tooth movement and worsen symptoms 1
• Expecting splints to cure bruxism: They protect teeth but don't eliminate the behavior 7