Bruxism

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

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

adult

1st line – patient education and counseling

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1st line –

patient education and counseling

Patients can play an important and active role in the self-care program 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, etiology - 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.

Consider – physical therapy

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Consider –

physical therapy

Treatment recommended for SOME patients in selected patient group

Physical therapy 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 program.

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

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

Consider – biofeedback and/or cognitive behavioral therapy

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Consider –

biofeedback and/or cognitive behavioral therapy

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

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Consider –

oral appliances

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 pharmacologic 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 behavioral regimen to teach patients to avoid unnecessary tooth contact and gain awareness of their behaviors.

Consider – nonpharmacologic analgesic therapy

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Consider –

nonpharmacologic analgesic therapy

Treatment recommended for SOME patients in selected patient group

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

Consider – mild analgesics

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Consider –

mild analgesics

Treatment recommended for SOME patients in selected patient group

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

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 3200 mg/day

child

1st line – observation + parent/caregiver education and counseling

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1st line –

observation + parent/caregiver education and counseling

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

Parents or caregivers should be counseled 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, etiology - is important to reduce the potential risk for dental overtreatment.

Parents/caregivers 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.

Consider – relaxation techniques

Back

Consider –

relaxation techniques

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 – physical therapy

Back

Consider –

physical therapy

Treatment recommended for SOME patients in selected patient group

Physical therapy can also 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 program.

Along with the positive effects on pain and jaw range of motion, physical therapy 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 counseling and cognitive behavioral strategies.

A standard physical therapeutic regimen has not been established.

sleep bruxism

adult

1st line – patient education and counseling

Back

1st line –

patient education and counseling

Patients can play an important and active role in the self-care program 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, etiology - are important to reduce the potential risk for dental overtreatment.

Given the importance of psychologic factors in the onset and maintenance of clenching activities, counseling 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 – physical therapy

Back

Consider –

physical therapy

Treatment recommended for SOME patients in selected patient group

Physical therapy 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, physical therapy may be useful for helping the patient to become more conscious of the state of their jaw muscles.

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

Consider – oral appliances

Back

Consider –

oral appliances

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 reorganizing 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 pharmacologic therapy.[105]

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

Consider – short-term clonazepam

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Consider –

short-term clonazepam

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

child

1st line – observation + parent/caregiver education and counseling

Back

1st line –

observation + parent/caregiver education and counseling

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

Parents/caregivers 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 psychologic factors in the onset and maintenance of clenching activities, counseling must be directed toward 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 – physical therapy

Back

Consider –

physical therapy

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.

A standard physical therapeutic regimen has not been established.

Consider – relaxation techniques

Back

Consider –

relaxation techniques

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

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Consider –

soft occlusal splint

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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Bruxism

Treatment algorithm

awake bruxism

patient education and counseling

physical therapy

biofeedback and/or cognitive behavioral therapy

oral appliances

nonpharmacologic analgesic therapy

mild analgesics

Primary options

observation + parent/caregiver education and counseling

relaxation techniques

physical therapy

sleep bruxism

patient education and counseling

physical therapy

oral appliances

short-term clonazepam

Primary options

observation + parent/caregiver education and counseling

physical therapy

relaxation techniques

soft occlusal splint