Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

awake bruxism

1st line – patient education and counselling

Back
ACUTE
|
awake bruxism
|
adult
1st line – 

patient education and counselling

Patients can play an important and active role in the self-care programme of bruxism.

Education about bruxism and its pathophysiology, as well as the potential negative clinical consequences is key.

Discussions around bruxism pathophysiology - in particular, education regarding the central, and not peripheral, aetiology - are important to reduce the potential risk for dental overtreatment.

Patients should be informed that tooth contact should only occur during chewing and swallowing, and that prolonged tooth contact (with or without bracing/thrusting of the jaw) can lead to damage.[91]​ Patients should, therefore, be advised to try to maintain teeth apart and jaw muscles relaxed when not engaging in those activities.

Given the importance of psychological factors in the onset and maintenance of clenching activities, counselling must be directed towards stress management and lifestyle modification (reduction of smoking, caffeine, and alcohol use).

Consider – physiotherapy

Back
ACUTE
|
awake bruxism
|
adult
Consider – 

physiotherapy

Additional treatment recommended for SOME patients in selected patient group

Physiotherapy can be useful in the management of jaw muscle pain and fatigue.[92]​ For example, stretching the jaw muscles by wide opening of the mouth, repeated 10 times 1 or 2 times per day, or by repeated lateral movements from right to left and vice versa, can be beneficial.

Instruction on how to relax the jaw, with a focus on creating space between the mandible and maxilla without tooth contact, is also useful as part of a self-care programme.

Along with the positive effects on pain and jaw range of motion, physiotherapy may be useful for helping patients to become more conscious of the state of jaw muscles; this actively involves the patient in the treatment regimen, and enhances counselling and cognitive behavioural strategies.

A standard physiotherapeutic regimen has not been established, and different protocols seem to be associated with similar effectiveness.[93]

Consider – biofeedback and/or cognitive behavioural therapy

Back
ACUTE
|
awake bruxism
|
adult
Consider – 

biofeedback and/or cognitive behavioural therapy

Additional treatment recommended for SOME patients in selected patient group

The potential benefit of biofeedback and cognitive behavioral treatment (CBT) to manage bruxism has always been advocated in the clinical setting, but there is a lack of evidence to support their effectiveness.[94][95]​

CBT may be performed in conjunction with psychologists.

It aims to help patients control emotional and psychosocial factors that may be associated with bruxism onset and perpetuation.

Consider – oral appliances

Back
ACUTE
|
awake bruxism
|
adult
Consider – 

oral appliances

Additional treatment recommended for SOME patients in selected patient group

Oral appliances, such as occlusal splints, may be indicated to protect the teeth from bruxism-related trauma. However, one systematic review investigating the efficacy of occlusal splints in bruxism treatment found insufficient evidence that splints provide benefit over no treatment, other oral appliances, transcutaneous electrical nerve stimulation (TENS), or pharmacological therapy.[105]

The use of oral appliances during the day is often limited by patient compliance and psychosocial considerations.

Oral appliances are indicated in patients with severe and progressing tooth wear and/or repeated fractures or failures of dental restorations to protect teeth and restorations from trauma. Full-arch appliances should be used since long-term use of anterior contact appliances, even if potentially useful for symptom reduction, may be associated with unwanted side effects related to dental occlusion changes.[106][107]​ Likewise, 24-hour appliance use is not recommended due to the risk of creating iatrogenic changes in occlusal contact patterns.

Oral appliances may be used as part of a cognitive behavioural regimen to teach patients to avoid unnecessary tooth contact and gain awareness of their behaviours.

Consider – non-pharmacological analgesic therapy

Back
ACUTE
|
awake bruxism
|
adult
Consider – 

non-pharmacological analgesic therapy

Additional treatment recommended for SOME patients in selected patient group

For patients with significant jaw muscle pain, non-pharmacological approaches include: TENS, acupuncture, and heat or cold packs, but the level of evidence supporting these approaches is modest.[111]

Consider – mild analgesics

Back
ACUTE
|
awake bruxism
|
adult
Consider – 

mild analgesics

Additional treatment recommended for SOME patients in selected patient group

There is a paucity of evidence to document the effect of pharmacological treatments in awake bruxism; however, in patients with significant jaw muscle pain that does not respond to other treatments, short-term mild analgesics may be used to alleviate symptoms.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

1st line – observation + parent/carer education and counselling

Back
ACUTE
|
awake bruxism
|
child
1st line – 

observation + parent/carer education and counselling

Given the natural history of bruxism in children, an observation-only approach may be appropriate in some cases.

Parents or carers should be counselled about bruxism. Discussions around bruxism pathophysiology, as well as the potential negative clinical consequences is key. In particular, education regarding the central, and not peripheral, aetiology - is important to reduce the potential risk for dental overtreatment.

Parents/carers should be informed that tooth contact in their child should only occur during chewing and swallowing, and that prolonged tooth contact (with or without bracing/thrusting of the jaw) can lead to damage.[91]​ Advise that their child try to maintain teeth apart and jaw muscles relaxed when not engaging in those activities.

Given the importance of psychological factors in the onset and maintenance of clenching activities, counselling must be directed towards stress management and lifestyle modification (reduction in caffeinated drinks).

Consider – relaxation techniques

Back
ACUTE
|
awake bruxism
|
child
Consider – 

relaxation techniques

Additional treatment recommended for SOME patients in selected patient group

Psychosocial and muscular relaxation techniques may be the best option for young children (<6 years), but more robust studies are needed to support this recommendation.​[112][113][114]​​​[115]​​

Consider – physiotherapy

Back
ACUTE
|
awake bruxism
|
child
Consider – 

physiotherapy

Additional treatment recommended for SOME patients in selected patient group

Physiotherapy can be useful in the management of jaw muscle pain and fatigue. For example, stretching the jaw muscles by wide opening of the mouth, repeated 10 times once or twice per day, or by repeated lateral movements from right to left and vice versa, can be beneficial. Instruction on how to relax the jaw, with focus on creating space between the mandible and maxilla without tooth contact, is also useful as part of a self-care programme.

Along with the positive effects on pain and jaw range of motion, physiotherapy may be useful for helping patients to become more conscious of the state of jaw muscles; this actively involves the patient in the treatment regimen, and enhances counselling and cognitive behavioural strategies.

A standard physiotherapeutic regimen has not been established.

sleep bruxism (SB)

1st line – patient education and counselling

Back
ACUTE
|
sleep bruxism (SB)
|
adult
1st line – 

patient education and counselling

Patients can play an important and active role in the self-care programme of bruxism.

Education about bruxism and its pathophysiology, as well as the potential negative clinical consequences is key.

Discussions around bruxism pathophysiology - in particular, education regarding the central, and not peripheral, aetiology - are important to reduce the potential risk for dental overtreatment.

Given the importance of psychological factors in the onset and maintenance of clenching activities, counselling must be directed towards stress management and lifestyle modification (reduction of smoking, caffeine, and alcohol use), as well as sleep hygiene instruction (e.g., sleep environment management, light and noise reduction, sleeping on a comfortable mattress, late-evening work or exercise avoidance).[90]

Consider – physiotherapy

Back
ACUTE
|
sleep bruxism (SB)
|
adult
Consider – 

physiotherapy

Additional treatment recommended for SOME patients in selected patient group

Physiotherapy can be useful in the management of jaw muscle pain and fatigue. For example, stretching the jaw muscles by wide opening of the mouth, repeated 10 times once or twice per day, or by repeated lateral movements from right to left and vice versa, can be beneficial. Along with the positive effects on pain and jaw range of motion, physiotherapy may be useful for helping the patient to become more conscious of the state of their jaw muscles.

A standard physiotherapeutic regimen has not been established, and different protocols seem to be associated with similar effectiveness.[93]​

Consider – oral appliances

Back
ACUTE
|
sleep bruxism (SB)
|
adult
Consider – 

oral appliances

Additional treatment recommended for SOME patients in selected patient group

Oral appliances, such as occlusal splints, may be indicated to protect the teeth from bruxism-related trauma. However, evidence and clinical experience indicate that their true efficacy to reduce SB activity is, at best, transient, with no long-term effects.[99][100]

Various oral appliances have been shown to have some level of efficacy in reducing SB activity, suggesting a placebo effect related to transient reduction in sleep-time masticatory muscle activity, possibly due to the need for reorganising motor unit recruitment.[101][102][103]​​​ A placebo-effect hypothesis supports the observation that intermittent oral appliance use is more effective at reducing SB than continued use.[104]​ However, one systematic review investigating the efficacy of occlusal splints in bruxism treatment found insufficient evidence that splints provide benefit over no treatment, other oral appliances, TENS, or pharmacological therapy.[105]

Oral appliances are indicated in patients with severe and progressing tooth wear and/or repeated fractures or failures of dental restorations to protect teeth and restorations from trauma. Full-arch appliances should be used since long-term use of anterior contact appliances, even if potentially useful for symptom reduction, may be associated with unwanted side effects related to dental occlusion changes.[106][107]​ Likewise, 24-hour appliance use is not recommended due to the risk of creating iatrogenic changes in occlusal contact patterns.

In patients with concurrent sleep-disordered breathing, prescription of appliances should be discussed with a sleep medicine consultant, especially considering the risk that obstructive sleep apnoea may be induced or worsened with a stabilisation appliance.[108][109]

Consider – short-term clonazepam

Back
ACUTE
|
sleep bruxism (SB)
|
adult
Consider – 

short-term clonazepam

Additional treatment recommended for SOME patients in selected patient group

May reduce SB compared with placebo. Clonazepam can be used as a short-term option; however, due to possible dependency it should not be used in the long-term management of sleep bruxism.[110]​​

Primary options

clonazepam: 1 mg orally once daily at bedtime

1st line – observation + parent/carer education and counselling

Back
ACUTE
|
sleep bruxism (SB)
|
child
1st line – 

observation + parent/carer education and counselling

Given the natural history of bruxism in children, an observation-only approach may be appropriate in some cases.

Parents or carers should be counselled about bruxism. Discussions around bruxism pathophysiology, as well as the potential negative clinical consequences is key. In particular, education regarding the central, and not peripheral, aetiology - is important to reduce the potential risk for dental overtreatment.

Parents/carers should be reassured that sleep bruxism in children decreases progressively after the age of 9 to 10 years, and that most children with bruxism do not continue bruxing in adolescence or adulthood.[11]

Given the importance of psychological factors in the onset and maintenance of clenching activities, counselling must be directed towards stress management and lifestyle modification (reduction in caffeinated drinks), as well as sleep hygiene instruction (e.g., sleep environment management, light and noise reduction, sleeping on a comfortable mattress, late-evening exercise avoidance).[90][114]

Consider – physiotherapy

Back
ACUTE
|
sleep bruxism (SB)
|
child
Consider – 

physiotherapy

Additional treatment recommended for SOME patients in selected patient group

Can be useful in the management of jaw muscle pain and fatigue. For example, stretching the jaw muscles by wide opening of the mouth, repeated 10 times once or twice per day, or by repeated lateral movements from right to left and vice versa, can be beneficial.

Along with the positive effects on pain and jaw range of motion, physiotherapy may be useful for helping patients to become more conscious of the state of jaw muscles; this actively involves the patient in the treatment regimen, and enhances counselling and cognitive behavioural strategies.

A standard physiotherapeutic regimen has not been established.

Consider – relaxation techniques

Back
ACUTE
|
sleep bruxism (SB)
|
child
Consider – 

relaxation techniques

Additional treatment recommended for SOME patients in selected patient group

Psychosocial and muscular relaxation techniques may be the best option for young children (<6 years), but more robust studies are needed to support this recommendation.​[112][113][114]​​​[115]

Consider – soft occlusal splint

Back
ACUTE
|
sleep bruxism (SB)
|
child
Consider – 

soft occlusal splint

Additional treatment recommended for SOME patients in selected patient group

Treatment with soft occlusal splints is indicated in selected cases with significant and progressive tooth wear. Close monitoring is required to avoid changes in occlusion.​

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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