Approach
Despite numerous case reports, evidence for the treatment of bruxism remains limited and there is no curative treatment.[87][88] It is important to note, however, that bruxism behaviour itself does not mandate treatment in all cases.[47]
Bruxism can be considered a risk factor for negative oral health consequences, rather than a disorder per se. The bruxism construct has evolved over the years to consider the phenomenon a motor activity that may be a sign of an underlying condition, represent a normal variation of behaviour in otherwise healthy individuals, or a protective factor associated with one or more positive health outcomes (e.g., in restoring airway patency after sleep apnoea events or releasing emotional tension).[2]
Overtreatment of sleep bruxism (SB) and awake bruxism (AB) is, therefore, a concern. Management should be guided by the presence of clinical symptoms and consequences for each motor activity.
While there is no consensus on what warrants treatment, bruxism should be treated if it causes, or threatens to cause, severe negative effects on oral health (e.g., severe tooth wear or jaw muscle symptoms) or is detrimental to general wellbeing (e.g., it is causing relationship conflicts with bed partners).[89]
Current treatment approaches are mainly symptomatic strategies which aim to control and/or prevent the clinical consequences of bruxism.[87][90] There is a lack of evidence to define a standard reference approach for SB and AB management, with the exception of oral appliance use.[87] Performing irreversible occlusal changes, when the only purpose is to reduce bruxism activities or to decrease pain symptoms in the jaw muscles and/or the temporomandibular joint (TMJ), is not recommended.[19]
Bruxism management should be based on conservative approaches, such as the multiple-P approach:[87][90]
Plates (oral appliances)
Pep talk (counseling)
Pills (drugs)
Psychology (cognitive-behavioural strategies)
Physiotherapy (exercises of the jaw muscles).
Studies of conservative management approaches are scarce; however, given the relative safety of such strategies, it is prudent to recommend their inclusion in multi-modal treatment protocols to maximise clinical benefit.
SB and AB may have very similar clinical consequences. Thus, the treatment approach to AB will be specified here only in terms of the differences (where present) with respect to SB.
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 with AB 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), as well as sleep hygiene instruction for patients with SB (e.g., sleep environment management, light and noise reduction, sleeping on a comfortable mattress, late-evening work or exercise avoidance).[90]
Physiotherapy
Physiotherapy is an important treatment option in patients with jaw muscle pain and fatigue.[92] A standard physiotherapeutic regimen has not been established, and different protocols seem to be associated with similar effectiveness.[93]
Instruction on how to relax the jaw, with a focus on creating space between the mandible and maxilla without tooth contact, is useful as part of a self-care programme, particularly for patients with AB.
Exercises may be very simple, for example stretching the jaw muscles by opening the mouth wide and repeating 10 times once or twice per day, or by repeated lateral movements from right-to-left and vice versa.
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.
Biofeedback and cognitive behavioural approaches
Biofeedback is based on the concept that bruxism can be controlled once a certain stimulus makes the patient aware of the motor phenomenon. A stimulus (e.g., auditory, visual, electrical, vibratory) instructs the patient to consciously regulate bruxism behaviours. However, existing studies are small and did not report that biofeedback is effective.[94][95] Possible explanations for the findings relate to the lack of adoption of correctional strategies, (i.e., concrete explanations on how to reverse the habits). Thus, the use of electromyographic biofeedback strategies alone, not in association with cognitive-behavioural approaches, may have important limitations for routine use.[96] One systematic review did not find evidence to support biofeedback to treat SB.[97]
CBT may be performed in conjunction with psychologists, and aims to help patients control emotional and psychosocial factors that may be associated with bruxism onset and perpetuation. More focused cognitive behavioural approaches with frequent follow-up may be indicated to reverse more chronic stress-induced bruxism and to relax the jaws.[98]
Oral appliances
Oral appliances, such as occlusal splints, are commonly used in the management of bruxism and 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] For AB, the use of oral appliances during the day is often limited by patient compliance and psychosocial considerations.
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, transcutaneous electrical nerve stimulation (TENS) or pharmacological therapy.[105]
Despite this uncertainty over their true efficacy, the use of oral appliances is 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 specialist, especially considering the risk that obstructive sleep apnoea may be induced or worsened with a stabilisation appliance.[108][109]
Oral appliances may be used as part of a CBT regimen to teach patients with AB to avoid unnecessary tooth contact and gain awareness of their behaviours.
Pharmacological treatments
Pharmacological approaches may reduce SB compared with placebo, but there are potential side effects associated with long-term use.[87][90] Therefore, drugs are not indicated as a first-line approach. Clonazepam may be used as a short-term option; however, due to possible dependency it should not be used in the long-term management of SB.[110]
There is a paucity of evidence to document the effect of pharmacological treatments in AB. However, in patients with severe jaw muscle pain that does not respond to other treatments, short-term use of mild analgesics may help to alleviate pain.
Non-pharmacological treatments
For patients with significant jaw muscle pain, non-pharmacological approaches include the use of: TENS, acupuncture, and heat or cold packs, but the level of evidence supporting these approaches is modest.[111]
Management of bruxism in children
Parents or carers should be counselled about bruxism. In particular, it is important to reassure 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]
No evidence currently exists to recommend specific therapeutic options for bruxism in children.[112][113] 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] Physiotherapy may also be considered in children with jaw muscle pain and fatigue. However, given the natural history of the condition, an observation-only approach may be appropriate in some cases.
Hard or rigid splints should not be used due to the ever-changing occlusal conditions in children. If a soft splint is used, close monitoring is required to avoid disturbing the development of the occlusion. Splints are used in selected cases of SB when there is significant and progressive tooth wear.
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