What non‑benzodiazepine medication can be used to treat bruxism?

Non-Benzodiazepine Medications for Bruxism

Buspirone is the most effective non-benzodiazepine medication for treating bruxism, with demonstrated efficacy in reducing symptoms by approximately 65% in both awake and sleep bruxism. 1

First-Line Pharmacological Options

Buspirone (Primary Recommendation)

• Start at 5 mg twice daily and titrate up to a maximum of 20 mg three times daily 2
• Demonstrated mean bruxism reduction of 65% across multiple cases of both sleep and awake bruxism 1
• Particularly effective when anxiety is a contributing factor 1
• May require 2-4 weeks to become fully effective 2
• Well-tolerated with minimal side effects compared to benzodiazepines 1

Gabapentin (Alternative First-Line)

• Initiate at 100-300 mg at bedtime, increase by 100-300 mg every 1-7 days as tolerated 3
• Maximum dose: 3600 mg/day in divided doses 3
• Particularly useful for bruxism that disturbs sleep 4
• Successfully treated antidepressant-induced bruxism with complete resolution 5
• Requires dose adjustment in renal insufficiency 3
• Common side effects include dizziness and sedation, which can be minimized with slow titration 3
• An adequate trial may require 2 months or more 3

Second-Line Options

Low-Dose Quetiapine

• Start at 25-50 mg daily at bedtime 6
• Effective for SSRI-induced bruxism and mandibular dystonia through 5-HT2 receptor antagonism 6
• Improvement typically occurs within a few days 6
• Particularly useful when bruxism is medication-induced 6

Hydroxyzine

• Dose: 10-25 mg at night 7
• Demonstrated significant reduction in bruxism severity in pediatric cases 7
• May be considered for adult patients, though evidence is primarily from pediatric studies 7
• Well-tolerated with minimal adverse effects reported 7

Mirtazapine

• Effective for bruxism secondary to neurological conditions 8
• Bruxism resolution typically occurs within 3 weeks 8
• Consider when other agents (gabapentin, clonazepam, clonidine, baclofen, buspirone, propranolol) have failed 8
• Dual benefit if patient has comorbid depression or chemotherapy-related side effects 8

Antidepressants for Comorbid Conditions

Tricyclic Antidepressants (TCAs)

• Nortriptyline or desipramine: start 25 mg at bedtime, increase by 25 mg every 3-7 days as tolerated 3
• Maximum dose: 150 mg/day 3
• Secondary amines (nortriptyline, desipramine) better tolerated than tertiary amines 9
• Consider when bruxism coexists with chronic pain or depression 3
• Anticholinergic effects (dry mouth, urinary hesitancy) may limit use 9

SSRIs/SNRIs

• Duloxetine: 30 mg once daily, increase to 60 mg after 1 week 3
• Venlafaxine: 37.5 mg once or twice daily, increase by 75 mg weekly to 225 mg/day 3
• Use with caution as SSRIs can paradoxically induce or worsen bruxism 5, 6
• If SSRI-induced bruxism occurs, consider adding buspirone, quetiapine, or gabapentin rather than discontinuing the antidepressant 1, 5, 6

Clinical Algorithm

1. Initial assessment: Determine if bruxism is primary or secondary to medications (particularly SSRIs/SNRIs) 5, 6

2. For primary bruxism with anxiety: Start buspirone 5 mg twice daily, titrate to effect 2, 1

3. For sleep-predominant bruxism: Start gabapentin 100-300 mg at bedtime, titrate slowly 3, 4

4. For SSRI-induced bruxism: Add low-dose quetiapine 25-50 mg at bedtime or gabapentin 5, 6

5. If first-line agents fail: Consider mirtazapine or hydroxyzine 8, 7

6. For refractory cases: Combination therapy or referral for botulinum toxin consideration 10

Important Caveats

• Avoid benzodiazepines for chronic bruxism management due to tolerance, addiction risk, cognitive impairment, and paradoxical agitation in 10% of patients 2
• Gabapentin and pregabalin require renal dose adjustment 3
• SSRIs/SNRIs may worsen bruxism in some patients; monitor closely when initiating these medications 5, 6
• Psychological factors (stress, anxiety, depression) strongly influence bruxism and should be addressed concurrently 11, 12
• Mindfulness-based interventions may reduce bruxism frequency and duration, particularly in individuals with dispositional mindfulness 12
• All pharmacological treatments should be accompanied by behavioral interventions and patient education about sleep hygiene 4, 13